Balancing Data Privacy With Access to Health Services and Research: Facilitating Confidential Information Sharing in US Multisystem Collaborations.

This article addresses data privacy issues as they relate to multisystem collaborations for prearrest deflection into treatment and services for those suffering from a substance use disorder. The authors explore how the US data privacy regulations pose barriers to collaboration and care coordination and how data privacy regulations affect researchers' ability to evaluate the impact of interventions intentioned to facilitate access to care. Fortunately, this regulatory landscape is evolving to strike a balance between protecting health information and sharing it for research, evaluation, and operations, including comments on the newly proposed federal administrative rule that will shape the future of deflection and health access in the United States.

The Baltic and Nordic responses to the first Taliban poppy ban: Implications for Europe & synthetic opioids today.

The 2000-2001 and the 2022-2023 Taliban opium bans were and could be two of the largest ever disruptions to a major illegal drug market. To help understand potential implications of the current ban for Europe, this paper analyzes how opioid markets in seven Baltic and Nordic countries responded to the earlier ban, using literature review, key informant interviews, and secondary data analysis. The seven nations' markets responded in diverse ways, including rebounding with the same drug (heroin in Norway), substitution to a more potent opioid (fentanyl replacing heroin in Estonia), and substitution to one with lower risk of overdose (buprenorphine replacing heroin in Finland). The responses were not instantaneous, but rather evolved, sometimes over several years. This variety suggests that it can be hard to predict how drug markets will respond to disruptions, but two extreme views can be challenged. It would be naive to imagine that drug markets will not adapt to shocks, but also unduly nihilistic to presume that they will always just bounce back with no lasting effects. Substitution to another way of meeting demand is possible, but that does not always negate fully the benefits of disrupting the original market. Nonetheless, there is historical precedent for a European country's opioid market switching to synthetic opioids when heroin supplies were disrupted. Given how much that switch has increased overdose rates in Canada and the United States, that is a serious concern for Europe at present. A period of reduced opioid supply may be a particularly propitious time to expand treatment services (as Norway did in the early 2000s).

Guiding officers to deflect citizens to treatment: an examination of police department policies in Illinois.

BACKGROUND: The U.S. overdose crisis has motivated police departments to enact policies allowing officers to directly deflect individuals to substance use disorder treatment and other services shown to reduce recidivism and subsequent overdose risk, as well as refer people who voluntarily present at police facilities with a desire for treatment. As a new way of operating, and one that relies on an officer's use of discretion for successful implementation, the practice benefits from guidance through written directives, training, and supervisory support. However, there is little information on the establishment, content, and execution of police department deflection policies, which hampers the implementation and dissemination of this promising practice. We analyzed 16 policies of Illinois police department deflection programs. Using content analysis methodology, we coded the policies for language and terminology, as well as program components and procedures. We aimed to examine how the policies were written, as well as the content intending to guide officers in their work. RESULTS: We found the policies and programs had notable differences in length, detail, terminology, and reading level. Only one policy mentioned the use of any type of addiction treatment medication, many used stigmatizing language (e.g., "abuse" and "addict"), and few mentioned "harm reduction" or training in the practice of deflection. Many policies restricted participation in deflection (i.e., no minors, outstanding warrants, current withdrawal symptoms), and critically, a majority of policies allowed police officers to exclude people from participation based on their own judgment. CONCLUSIONS: We recommend police departments consider the readability of their policies and reduce barriers to deflection program participation to engage a larger pool of citizens in need of substance use disorder treatment. Since there is limited research on police policies generally, and the field of deflection is relatively new, this study offers insight into the content of different department policies and more specifically, how officers are directed to operate deflection programs.

What and how can we learn from complex global problems for antimicrobial resistance policy? A comparative study combining historical and foresight approaches.

OBJECTIVES: To (i) develop a methodology for using historical and comparative perspectives to inform policy and (ii) provide evidence for antimicrobial-resistance (AMR) policymaking by drawing on lessons from climate change and tobacco control. METHODS: Using a qualitative design, we systematically examined two other complex, large-scale policy issues-climate change and tobacco control-to identify what relevance to AMR can be learned from how these issues have evolved over time. During 2018-2020, we employed a five-stage approach to conducting an exploratory study involving a review of secondary historical analysis, identification of drivers of change, prioritisation of the identified drivers, scenario generation and elicitation of possible policy responses. We sought to disrupt more 'traditional' policy and research spaces to create an alternative where, stimulated by historical analysis, academics (including historians) and policymakers could come together to challenge norms and practices and think creatively about AMR policy design. RESULTS: An iterative process of analysis and engagement resulted in lessons for AMR policy concerning persistent evidence gaps and uncertainty, the need for cross-sector involvement and a collective effort through global governance, the demand for new interventions through more investment in research and innovation, and recognising the dynamic relationship between social change and policy to change people's attitudes and behaviours are crucial towards tackling AMR. CONCLUSION: We draw on new methodological lessons around the pragmatism of future- and policy-oriented approaches incorporating robust historical and comparative analysis. The study demonstrates proof of concept and offers a reproducible method to advance further methodology, including transferrable policies that could tackle health problems, such as AMR.

America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms.

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include detail on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. The primary audience for this study is policymakers, but it should also be useful for foundations looking for opportunities to create change that have often been overlooked. This study can help researchers better consider the full consequences of policy changes and help members of the media identify the dynamics of interactions that deserve more attention.

Imagining a fentanyl future: Some consequences of synthetic opioids replacing heroin.

For nearly a century heroin has dominated the illegal opioid trade. The global supply of heroin is estimated to generate tens of billions of dollars in revenues a year and its illegal use has long been the source of many societal harms. The arrival of inexpensive and mass-produced synthetic opioids, such as fentanyl, to parts of North America and Europe may signal the beginning of the end of heroin's dominance. Data from several places suggest that fentanyl and other synthetic opioids can quickly supplant heroin. Taking the extreme case, we calculate the estimated wholesale revenues of heroin currently and contrast that with fentanyl prospectively in the United States and in the rest of the world if fentanyl were to supplant heroin entirely. Heroin traffickers in the United States generate about $2.5 billion in revenues; the total import value of fentanyl, after replacing heroin, could be less than $100 million. For the rest of the world we project a reduction from $6.7 billion to less than $300 million. Retailer revenues on the other hand would probably rise because individuals may consume more frequently and with greater intensity due to fentanyl's shorter duration of action and so far there has been no indication of a notable reduction in retail prices. It is unlikely that heroin will entirely disappear, but very likely that globally heroin will account for a declining share of illegal opioids. Violence and corruption may decline but opioid related mortality and morbidity, as well as property crime, are likely to rise. Policy makers will face difficult challenges. Economics provides limited help in forecasting which opioid markets are likely to convert to synthetic opioids.

The dawn of a new synthetic opioid era: the need for innovative interventions.

BACKGROUND: Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often-overlooked events in Estonia since the turn of the century. Market transitions generate important and far-reaching implications for drug policy. ARGUMENT AND ANALYSIS: The supplier-driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history. CONCLUSIONS: There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on-line distribution and new technologies aimed at improving transparency, such as point-of-use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths.

Illicit synthetic opioid consumption in Asia and the Pacific: Assessing the risks of a potential outbreak.

BACKGROUND: Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO's encroachment in markets in the Asia-Pacific region. METHODS: Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia. RESULTS: Australia reports some signs of three facilitating factors to IMPSO's emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500-5700 over a five-year period. CONCLUSIONS: This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.

Community perspectives on supervised consumption sites: Insights from four U.S. counties deeply affected by opioids.

BACKGROUND: To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities-primarily in coastal urban areas-have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature. METHODS: To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO. RESULTS: Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance. CONCLUSIONS: Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.

Prescribing diamorphine in the United States: Insights from a nationally representative survey.

BACKGROUND: Some countries allow physicians to prescribe pharmaceutical-grade diamorphine to dependent users who have previously undergone treatment but are still using street-sourced heroin; this is not allowed in the US. This study provides the first nationally representative US data concerning public support for prescribing diamorphine to dependent users. We also test the hypothesis that calling it "diamorphine" instead of "heroin" increases support for this approach. METHODS: The RAND American Life Panel is a nationally representative, probability-based survey of US adults. Of the 3345 panel members invited to take the survey, 2530 (75.6%) provided a valid response to our question module. Respondents were randomly assigned to have the question refer to the prescribed drug as either "heroin" or "diamorphine." The groups did not significantly differ on sex, age, race/ethnicity, or education. We compare the distribution of responses for the two groups and conduct Pearson's chi-squared test with the Rao-Scott correction. RESULTS: For those asked whether the US should try prescribing pharmaceutical-grade "heroin," the share answering "Yes" (20.8%) was 15 percentage points lower than those responding "No" (35.8%). When the question asked about "diamorphine," the results were nearly reversed: the share answering "Yes" (30.6%) was almost 12 percentage points higher than those responding "No" (18.9%). The distributions of responses were significantly different (p < 0.001). CONCLUSIONS: Support for prescribing diamorphine to dependent users is low in the US. While the results are consistent with the hypothesis that referring to heroin as diamorphine may reduce stigma associated with the substance and increase support for prescribing it, opinions may change as individuals learn they are different names for the same substance.

Why Sleep Matters-The Economic Costs of Insufficient Sleep: A Cross-Country Comparative Analysis.

The Centers for Disease Control and Prevention (CDC) in the United States has declared insufficient sleep a "public health problem." Indeed, according to a recent CDC study, more than a third of American adults are not getting enough sleep on a regular basis. However, insufficient sleep is not exclusively a US problem, and equally concerns other industrialised countries such as the United Kingdom, Japan, Germany, or Canada. According to some evidence, the proportion of people sleeping less than the recommended hours of sleep is rising and associated with lifestyle factors related to a modern 24/7 society, such as psychosocial stress, alcohol consumption, smoking, lack of physical activity and excessive electronic media use, among others. This is alarming as insufficient sleep has been found to be associated with a range of negative health and social outcomes, including success at school and in the labour market. Over the last few decades, for example, there has been growing evidence suggesting a strong association between short sleep duration and elevated mortality risks. Given the potential adverse effects of insufficient sleep on health, well-being and productivity, the consequences of sleep-deprivation have far-reaching economic consequences. Hence, in order to raise awareness of the scale of insufficient sleep as a public-health issue, comparative quantitative figures need to be provided for policy- and decision-makers, as well as recommendations and potential solutions that can help tackling the problem.

Antimicrobial Stewardship: The Effectiveness of Educational Interventions to Change Risk-Related Behaviours in the General Population: A Systematic Review.

RAND Europe undertook a systematic review of the evidence of effectiveness and cost effectiveness on changing the public's risk related behaviour pertaining to antimicrobial use to inform the development of a NICE public health guideline aimed at delaying antimicrobial resistance (AMR). The review considered educational interventions targeting individuals, communities or the general public delivered via any mode. Specifically, it aimed to address: 1. Which educational interventions are effective and cost-effective in changing the public's behaviour to ensure they only ask for antimicrobials when appropriate and use them correctly? 2. Which educational interventions are effective and cost-effective in changing the public's behaviour to prevent infection and reduce the spread of antimicrobial resistance? Overall, 60 studies met the inclusion criteria; 29 related to research question 1, and 36 related to research question 2 (five studies were applicable to both). The key findings are summarised in "Evidence Statements" in accordance with NICE guidelines. Evidence Statements provide a high level overview of the key features of the evidence including: the number of studies, the quality of evidence, and the direction of the estimated effect followed by a brief summary of each of the supporting studies. Studies are grouped into Evidence Statements by setting and intervention.

Treatment for Dementia: Learning from Breakthroughs for Other Conditions.

The past few decades have seen a number of medical breakthroughs that enabled the effective treatment of a range of conditions, transforming them from fatal into manageable ones. Examples include certain cancers and HIV. Conversely, progress on dementia has been limited. There are currently no treatments that will cure or even alter the progressive course of dementia, despite ongoing research investigating new therapies and care options. The UK Department of Health is interested in the potential to learn from other disease areas to better understand the particular social, economic, political, legislative and scientific contexts that have contributed to accelerating progress and breakthroughs in treatment. Such learning could helpfully inform dementia research and innovation efforts, and help identify levers for supportive policy development. This project analysed breakthroughs in the treatment of four selected conditions of ill health and seeks to identify potentially transferable lessons for the dementia context. Using evidence review and key informant interviews we sought to identify the series of "events" that eventually led to a given breakthrough, and the key milestones in the process that have helped improve understanding and potential for treatment. We also aimed to capture the temporal and causal relationships between "notable" events looking at a variety of factors implicated in the breakthrough pathway. The focus of this work was on political, economic, social, scientific and technological, and legal, regulatory and environmental factors.

Assessment of the implementation of the EU Drugs Strategy 2005-2012 and its Action Plans.

Illicit drug use continues to be an important public health and safety concern in Europe. Production, trafficking and dealing in illicit drugs constitute important criminal justice challenges in themselves, and are associated with other criminal activities. The 2005-2012 EU Drugs Strategy (as with previous strategies) was developed to complement and add value to national strategies and approaches while respecting the principles of subsidiarity and proportionality set out in the EU Treaties. The main rationale for its development was that while drugs problems vary across Member States, and are experienced at the local and national level, they are "a global issue that needs to be addressed in a transnational context." RAND Europe undertook an independent evaluation of the current Strategy and its Action Plans, addressing four research objectives: (1) to assess barriers and facilitators to the implementation of objectives and priorities at EU and Member State level, (2) to assess the relevance and influence of the Strategy with respect to national drugs policy and legislation, (3) to assess possible impact on the drugs situation in the EU, and (4) to identify key aspects and recommendations for future EU Drugs Strategies.