Harm Reduction and Treatment Among People at High Risk of Overdose.

Importance: Rates of overdose deaths involving synthetic opioids remain high, increasingly involve stimulants combined with opioids, and are increasing rapidly in racially and ethnically minoritized communities, yet little is known about access to harm reduction and treatment services in these groups. Objective: To characterize access and barriers to harm reduction and treatment in a racially and ethnically diverse population of people who use drugs. Design, Setting, and Participants: A cross-sectional telephone survey of people recruited from 39 treatment, harm reduction, and social service organizations in Milwaukee County, Wisconsin; Flint and Detroit, Michigan; and statewide in New Jersey was conducted from January 30 to July 28, 2023. Adults who used cocaine, methamphetamine, or opioids in the past 30 days called a study hotline and completed an interview in English or Spanish. Exposures: Overdose experience, drug types used (opioids only, stimulants only, and polysubstance), and social risk factors (eg, financial instability and criminal legal involvement). Main Outcomes and Measures: Recent use of any harm reduction services, fentanyl test strips, naloxone possession, treatment, and self-reported barriers to services. Results: Of the total sample of 1240 adults, 486 (39.2%) were Black non-Hispanic, 183 (14.8%) were Hispanic, and 464 (37.4%) were White non-Hispanic. In the past 30 days, 826 individuals (66.6%) were polysubstance users, 135 (10.9%) used only opioids, and 279 (22.5%) used only stimulants. A total of 349 respondents (28.1%) experienced a prior-year overdose. Compared with those without a prior-year overdose, people with overdose were more likely to possess naloxone (80.7% vs 68.2%; P < .001), possess fentanyl test strips (36.8% vs 23.5%; P < .001), and use harm reduction services (63.4% vs 53.0%; P = .003), while differences in treatment use were nonsignificant (52.0% vs 46.6%; P = .24). Among stimulant-only users, 51.4% possessed naloxone compared with 77.3% of opioid-only users (P < .001) and 77.6% of polysubstance users (P < .001), with similar disparities in fentanyl test strip possession. Conclusions and Relevance: In this cross-sectional study of people who used drugs in the past 30 days, findings highlighted low use of harm reduction and treatment services among people who use stimulants. Additional communication regarding their importance may help increase the use of the services amidst a rapidly changing drug supply.

A content analysis of legal policy responses to xylazine in the illicit drug supply in the United States.

BACKGROUND: Xylazine is a veterinary sedative that is quickly spreading in the U.S. illicit drug supply and is increasingly associated with fatal overdoses and severe wounds. In response, xylazine has been deemed an emerging public health threat and several policy initiatives have been introduced to combat its spread and negative broad health impact. We aimed to synthesize trends in all-time U.S. policy responses to xylazine in the drug supply. METHODS: In April 2024, we systematically identified and categorized proposed and enacted policy initiatives that related to human xylazine consumption by searching LexisNexis and Thomas Reuters Westlaw legal databases. RESULTS: Of 58 unique policy initiatives, most were introduced in 2023 (n = 37/58, 64 %) and concentrated in Northeastern states. Penalties for xylazine possession, often tied to state drug scheduling changes, were the most common provision (n = 34/58; 59 %) and Schedule III was the most frequently proposed scheduling level (n = 17/30; 57 %). Other provisions included proposals to enhance: test strip access (n = 11/58; 19 %), public awareness and education (n = 3/58; 5 %), xylazine-specific research (n = 4/58; 7 %), and surveillance (n = 8/58; 14 %). CONCLUSION: U.S. state and federal policy responses to xylazine grew rapidly in 2023, were most concentrated in states affected most by xylazine, and scheduling was the most commonly proposed policy approach. Research measuring policy effects should be prioritized as policies are implemented.

Piloting racial bias training for hospital emergency department providers treating patients with opioid use disorder.

Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers' inequitable delivery of opioid use disorder (OUD) services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been 1 commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with OUDs in 2 hospitals in Detroit, Michigan. We conducted a 3-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to patients with OUD. Using qualitative survey response data, we found that training participants were satisfied with the content and quality of the training and especially valued the small-group discussions, motivational interviewing, and historical context.

High prevalence of hepatitis C virus infection among incarcerated persons: Results from the Louisiana Hepatitis C Elimination Plan's opt-out testing program in prisons.

In the United States, modelling studies suggest a high prevalence of hepatitis C virus (HCV) infection in incarcerated populations. However, limited HCV testing has been conducted in prisons. Through the Louisiana Hepatitis C Elimination Plan, persons incarcerated in the eight state prisons were offered HCV testing from 20 September 2019 to 14 July 2022, and facility entry/exit HCV testing was introduced. Multivariable logistic regression was used to evaluate associations with HCV antibody (anti-HCV) positivity and viremia. Of 17,231 persons in the eight state prisons screened for anti-HCV, 95.1% were male, 66.7% were 30-57 years old, 3% were living with HIV, 68.2% were Black and 2904 (16.9%) were anti-HCV positive. HCV RNA was detected in 69.3% of anti-HCV positive individuals tested. In the multivariable model, anti-HCV positivity was associated with older age including those 30-57 (odds ratio [OR] 3.53, 95% confidence interval [CI] 2.96-4.20) and those ≥58 (OR 10.43, 95% CI 8.66-12.55) as compared to those ≤29 years of age, living with HIV (OR 1.68, 95% CI 1.36-2.07), hepatitis B (OR 1.83, 95% CI 1.25-2.69) and syphilis (OR 1.51, 95% CI 1.23-1.86). HCV viremia was associated with male sex (OR 1.89, 95% CI 1.36-2.63) and Black race (OR 1.42, 95% CI 1.20-1.68). HCV prevalence was high in the state prisons in Louisiana compared to community estimates. To the extent that Louisiana is representative, to eliminate HCV in the United States, it will be important for incarcerated persons to have access to HCV testing and treatment.

Association of buprenorphine retention and subsequent adverse outcomes following non-fatal overdose: An analysis using statewide linked Maryland databases.

INTRODUCTION: Patients receiving buprenorphine after a non-fatal overdose have lower risk of future nonfatal or fatal overdose, but less is known about the relationship between buprenorphine retention and the risk of adverse outcomes in the post-overdose year. OBJECTIVE: To examine the relationship between the total number of months with an active buprenorphine prescription (retention) and the odds of an adverse outcome within the 12 months following an index non-fatal overdose. MATERIALS AND METHODS: We studied a cohort of people with an index non-fatal opioid overdose in Maryland between July 2016 and December 2020 and at least one filled buprenorphine prescription in the 12-month post-overdose observation period. We used individually linked Maryland prescription drug and hospital admissions data. Multivariable logistic regression models were used to examine buprenorphine retention and associated odds of experiencing a second non-fatal overdose, all-cause emergency department visits, and all-cause hospitalizations. RESULTS: Of 5439 people, 25% (n=1360) experienced a second non-fatal overdose, 78% had an (n=4225) emergency department visit, and 37% (n=2032) were hospitalized. With each additional month of buprenorphine, the odds of experiencing another non-fatal overdose decreased by 4.7%, all-cause emergency department visits by 5.3%, and all-cause hospitalization decreased by 3.9% (p<.0001, respectively). Buprenorphine retention for at least nine months was a critical threshold for reducing overdose risk versus shorter buprenorphine retention. CONCLUSIONS: Buprenorphine retention following an index non-fatal overdose event significantly decreases the risk of future overdose, emergency department use, and hospitalization even among people already on buprenorphine.

Medications For Opioid Use Disorder Increased Among Louisiana Medicaid Enrollees During Policy Reforms, 2018-21.

Increasing access to medications for opioid use disorder (MOUD) is a key strategy in addressing the opioid crisis. To increase MOUD access, state governments have pursued a combination of increased funding for MOUD and requirements that providers offer treatment. Louisiana has pursued multiple strategies, including a requirement that residential treatment programs offer MOUD as part of their licensure. Using Louisiana Medicaid claims data for enrollees with diagnosed OUD from the period 2018-21, we analyzed trends in MOUD between enrollees treated in residential and nonresidential settings and across demographic subgroups, and we compared trends by MOUD type. MOUD use more than tripled from 2018 to 2021 among Louisiana Medicaid enrollees diagnosed with OUD. Most of the increase in MOUD was attributable to buprenorphine use. Methadone uptake also contributed to greater MOUD use but was almost exclusively used by enrollees treated in nonresidential settings, whereas naltrexone was consistently more common in residential treatment. By 2021, differences persisted across demographic groups: MOUD use was highest among enrollees who were White, were older, had comorbidities, and lived in a metropolitan area. Policies that promote MOUD in substance use treatment programs, particularly residential programs, are critical tools for policy makers confronting a complex and unprecedented national overdose crisis.