Characterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study.

We understand the current crisis of overdose deaths to be driven by widespread opioid use, characterized by distinct 'waves' of drug use. The first wave was driven by prescription opioids, the second by heroin, and the third by illicit, non-pharmaceutical fentanyl and fentanyl analogues (henceforth, fentanyl). The purpose of this study is to describe opioid initiation within each of the three waves from the perspective of people who use illicit opioids, with a focus on emerging pathways into fentanyl use. The authors recruited sixty people reporting past-30-day illicit opioid use in Dayton, Ohio. Participants completed a brief survey and a semi-structured in-depth qualitative interview, conducted from March to November 2020 with a total of 13 in-person and 47 virtual interviews. The qualitative interviews were transcribed in their entirety and analyzed thematically using NVivo 12. We noted supply-side changes as influencing trajectories in all three waves. However, we also noted differences in the experiences of prescription opioid and heroin initiation, with these trajectories influenced by pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peers. In comparison, most participants were unaware that they were initiating fentanyl, and many reported overdosing with their first use of fentanyl. We identified a trajectory into fentanyl with limited to no prior heroin use among a few participants. The increased risk of overdose with initiation into fentanyl use further emphasizes the need for an expansion of naloxone distribution and the implementation of more comprehensive measures, such as overdose prevention centers, drug testing, and a safer supply. Further research on the dynamics of the ongoing overdose death crisis in the era of fentanyl and the 4th wave of the overdose crisis is critical in developing responsive prevention and intervention strategies.

Pandemic response across Ohio's public universities: Novel approaches, emergent challenges and future opportunities.

Objective: We describe and analyze case investigation and contact tracing (CICT) efforts across Ohio's public universities in response to COVID-19 to distill challenges and lessons learned and suggest future opportunities for universities to mobilize in the face of emergent public health crises. Participants: Faculty, staff, and graduate students from Ohio's fourteen public universities. Methods: In-depth, semi-structured interviews were conducted with representatives from nine of the 14 universities; representatives from the remaining five universities completed a brief questionnaire. Interviews were transcribed in their entirety and thematically analyzed. Results: Emergent themes include the significance of local relationships for implementing locally tailored solutions; the presence of discrete challenges in doing CICT work with university and local communities, and the importance of university students in pandemic response. Conclusions: There are unique challenges associated with disease control across university populations and surrounding communities, but students from diverse academic background are a potential source of assistance.

Lay knowledge and practices of methamphetamine use to manage opioid-related overdose risks.

AIM: Methamphetamine use has increased among individuals with opioid use disorder. The key aims of this study are to detail and contextualise lay knowledge, attitudes, and behaviours related to methamphetamine use in relation to opioid overdose risks in an area dominated by non-pharmaceutical fentanyl-type drugs (NPF). METHODS: The study recruited 41 individuals in Dayton, Ohio, who reported past 30-day use of methamphetamine and heroin/fentanyl. Interviews included structured and qualitative questions. Urine toxicology analysis was conducted to identify NPFs and other drugs. Open-ended interview sections were audio-recorded, transcribed, and analysed qualitatively using NVivo. RESULTS: The mean age was 38.3 years, 51% were female, and 100% non-Hispanic white. Participants described an exceedingly unpredictable local opioid market that became saturated with NPFs. The sample tested positive for 10 NPFs, including fentanyl (100%), acetyl fentanyl (61%), tetrahydrofuran fentanyl (29%), and carfentanil (12%). Most participants believed that methamphetamine could help prevent and/or reverse an opioid-related overdose. Nearly half had personally used it to help manage overdose risks related to NPF. These beliefs were embedded in a lay understanding of how methamphetamine works to stimulate the cardiovascular system. They were acted upon in the context of last resort situations that were determined by a lack of immediate access to naloxone, ambiguities surrounding overdose symptomatology, and easy access to plentiful and inexpensive methamphetamine. CONCLUSION: Lay efforts to rely on methamphetamine to manage NPF-related overdose risks highlight the need for a continuing expansion of take-home-naloxone programs and implementation of other novel harm reduction approaches in communities affected by NPFs.

Exploring the Impacts of Alcohol and Other Drug Use on HIV Care Among Older African American Adults in Kentucky: A Constructivist Grounded Theory Study.

ABSTRACT: This grounded theory study examined the use of alcohol and other drugs (AOD) on the management of HIV disease among 27 older African Americans (≥50 years). Interview transcripts were analyzed using constructivist grounded theory analytic techniques. Participants reported facing (a) environmental impacts of AOD use and (b) discrimination from the health care system. The analysis revealed six phases of AOD use, occurring at various stages of the HIV care continuum: (a) linking AOD use as the cause of HIV diagnosis, (b) having AOD use facilitate denial of HIV, (c) experiencing problematic use as a barrier to care engagement, (d) "testing the waters," (e) relying on AIDS service organizations and medical providers, and (f) changing or maintaining patterns of AOD use to maintain engagement with care. Recommendations include assessing a patient's AOD use in relationship to the care continuum to evaluate patients' experiences and barriers within systems of care.

Visualizing a Calculus of Recovery: Calibrating Relations in an Opioid Epicenter.

This article uses participatory photography to explore the relationships animating efforts towards recovery from opioid use disorder (OUD) in the Dayton, Ohio area, an epicenter of illicit opioid use and overdose death. A photo-elicitation project was conducted with thirteen people who met the DSM-5 criteria for OUD. Photographs were used as prompts during qualitative interviews, which were thematically analyzed. Analysis of both visual and textual data demonstrated the ways in which recovery became an unfolding process of calculation as participants made strategic choices to navigate relations and encounters with things, people, and places. Relationships across each of these domains could, under some circumstances, serve as supports or motivators in the recovery process, but, in alternate settings, be experienced as "triggers" prompting a resumption of problematic drug use or, at the very least, a reckoning with the feelings and emotions associated with painful or problematic aspects of personal histories and drug use experiences. Findings highlight the importance of understanding recovery as a calibration of the ambiguous relations animating experiences of everyday life. We argue for continued emphasis on recovery as an active performance and ongoing practice of calculation-of risks and benefits, of supports and triggers, of gratification and heartbreak-rather than a goal or static state.

Exploring the Interactions between Non-Medical Methamphetamine Use and Prescribed Buprenorphine or Naltrexone in Opioid Use Disorder Treatment Retention.

OBJECTIVES: Our objectives were to examine the impact of methamphetamine use on opioid use disorder (OUD) treatment retention in patients prescribed either buprenorphine/buprenorphine-naloxone (BUP-NX) or naltrexone/extended-release naltrexone (XR-NTX), while also exploring the role of other risk factors that may modify the impact of methamphetamine use. METHODS: We conducted an exploratory retrospective study examining OUD treatment retention in 127 patients in Ohio (USA). Patients were prescribed either BUP-NX or naltrexone/XR-NTX. Cox proportional hazard regression was used to compare time to dropout of treatment between patients positive and negative on screening for methamphetamines at intake, estimate the association between other risk factors and time to dropout, and test interactions between risk factors and methamphetamine status. RESULTS: Among patients prescribed naltrexone/XR-NTX, those positive for methamphetamines had almost three times the risk of treatment dropout (AHR = 2.89, 95% CI =1.11, 7.07), significantly greater (interaction p = .039) than the methamphetamine effect among those prescribed BUP-NX (AHR = 0.94, 95% CI = 0.51, 1.65). Early in treatment, being prescribed BUP-NX was strongly associated with a greater risk of treatment dropout (at baseline: AHR = 2.90, 95% CI = 1.33, 7.15), regardless of baseline methamphetamine use status. However, this effect decreased with time and shifted to greater risk of dropout among those prescribed naltrexone/XR-NTX (non-proportional hazard; interaction with time AHR = 0.66, 95% CI = 0.49, 0.86), with the shift occurring sooner among those positive for methamphetamine at baseline. CONCLUSIONS: Additional support should be provided to patients who use methamphetamines prior to starting OUD treatment.

"It's Crazy What Meth Can Help You Do": Lay Beliefs, Practices, and Experiences of Using Methamphetamine to Self-Treat Symptoms of Opioid Withdrawal.

BACKGROUND: Across the U.S., methamphetamine use is expanding among people who use illicit opioids (PWUIO). Motives for methamphetamine use must be contextualized within the experiences of PWUIO, who may use methamphetamine not only to achieve euphoria, but also as a tactic of self-management. The overall aim of this study is to contextualize lay beliefs, practices, and experiences of methamphetamine use as a form of self-treatment of symptoms related to chronic opioid use among PWUIO in the Dayton Metro Area of Southwest Ohio, an epicenter of the ongoing opioid crisis. METHODS: This paper draws on two phases of interviews conducted with 38 individuals who use both heroin/fentanyl and methamphetamine. This paper primarily analyzes qualitative data but includes supplementary information from the structured interview component. Qualitative interview sections were transcribed in their entirety and thematically analyzed. RESULTS: Participants described learning about methamphetamine as a tactic to treat opioid withdrawal symptoms through social networks and through personal experimentation. Many participants suggested that methamphetamine was helpful in relieving exhaustion, alleviating some acute physical symptoms of opioid withdrawal, and providing a psychological distraction, although some admitted that methamphetamine use could incur additional health risks. To effectively use methamphetamine as a tactic of self-treatment, participants emphasized the importance of timing and dosing. DISCUSSION: Among PWUIO in the Dayton area, methamphetamine use as a tactic to self-manage opioid withdrawal must be studied in relation to historical and evolving patterns of illicit opioid use and associated risks. More research is needed to understand the long-term health impacts of this emergent practice of polydrug use.

A Second Chance: Reenactment and Recovery Narratives in a Peruvian Drug Rehabilitation Center.

The following article discusses a collaborative, reenactment film made with the residents of a drug rehabilitation center in Iquitos, Peru. In so doing, it raises questions about narratives of recovery from addiction, and the tensions that emerge between these narratives and the often-ambivalent feelings of the people who tell them. Practices of filmmaking and reenactment generate a collaborative theorization of lived experience-in this case, the multifaceted natures of both addiction and recovery. At the same time, these practices are also attentive to the embodied memories and complex feelings of the film's actors. Further engagement with the filmic materials demonstrates how the film became an active exploration of the ongoing nature of recovery, complicating the therapeutic trajectories of a group of actors struggling to reconcile ambivalent feelings as they attempt to craft new narratives of self.

Methamphetamine Use and Its Correlates among Individuals with Opioid Use Disorder in a Midwestern U.S. City.

Background: U.S. is experiencing a surging trend of methamphetamine use among individuals who use opioids. More research is needed to characterize this emerging "twin epidemic." Objectives: The study aims to identify social and behavioral characteristics associated with methamphetamine use among individuals with opioid use disorder (OUD) in the Dayton, Ohio, area, an epicenter of the opioid crisis and an emerging frontier of methamphetamine epidemic. Methods: 357 adult individuals with current OUD were recruited using targeted and respondent-driven sampling. Structured interviews collected information on social and drug use characteristics. Multivariable Logistic Regression was used to identify characteristics associated with the past 6-month use of methamphetamine. Results: 49.7% were female, and 88.8% were non-Hispanic whites. 55.6% used methamphetamine in the past 6-months, and 84.9% reported first use of methamphetamine after initiation of illicit opioids. Methamphetamine use was associated with homelessness (aOR = 2.46, p = .0001), lifetime history of diverted pharmaceutical stimulant use (aOR = 2.97, p < .001), injection route of heroin/fentanyl use (aOR = 1.89, p = .03), preference for fentanyl over heroin (aOR = 1.82, p = .048), lifetime history of extended-release injectable naltrexone (Vivitrol)-based treatment (aOR = 2.89, p = .003), and more frequent marijuana use (aOR = 1.26, p = .04). Discussion: The findings point to the complexity of motivational and behavioral pathways associated with methamphetamine and opioid co-use, ranging from self-treatment and substitution behaviors, attempts to endure homelessness, and greater risk taking to experience euphoria. More research is needed to understand the causal relationships and the association between methamphetamine and Vivitrol use. Public health responses to the opioid crisis need to be urgently expanded to address the growing epidemic of methamphetamine use.

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

BACKGROUND: Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period. METHODS: Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use. RESULTS: Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis. DISCUSSION: The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.

On my own terms: Motivations for self-treating opioid-use disorder with non-prescribed buprenorphine.

INTRODUCTION: The opioid overdose crisis in the United States has prompted an expansion of treatment services, including pharmacotherapy with buprenorphine. However, many people who use illicit opioids (PWUIO) self-treat their opioid-use disorder (OUD) with non-prescribed buprenorphine (NPB) in lieu of attending formal treatment. The present study aims to qualitatively understand motivations of people who are self-treating their OUD with NPB. METHODS: Qualitative study designed to supplement and contextualize quantitative findings from natural history study of buprenorphine diversion, self-treatment, and use of substance use disorder treatment services. Interviews were audio-recorded, transcribed, systematically coded and analyzed via Iterative Categorization. STUDY SETTING: The Dayton, Ohio metropolitan area in the midwestern United States; a site previously characterized as high impact in the national opioid overdose crisis. PARTICIPANTS: Sixty-five individuals (35 men and 30 women) who met the DSM-5 criteria for OUD (moderate or severe) and had used NPB at least one time in the six months prior to their intake interview. RESULTS: Participants described four key motivators for self-treating with NPB: perceived demands of formal treatment, the desire to utilize non-prescribed buprenorphine in combination with a geographic relocation, to self-initiate treatment while preparing for formal services, and to bolster a sense of self-determination and agency in their recovery trajectory. CONCLUSIONS: Use of NPB is a recognized self-treatment modality among PWUIO, with some PWUIO transitioning into sustained recovery episodes or enrollment in formal treatment. Understanding the motivations for opting out of treatment is crucial for improving forms of care for people with OUD.

"Everything is not right anymore": Buprenorphine experiences in an era of illicit fentanyl.

BACKGROUND: Conducted in the Dayton Metropolitan area of Southwestern Ohio, this qualitative study explores the self-treatment practices of people who use illicit opioids (PWUIO) amidst the new risk environment produced by illicit, non-pharmaceutical fentanyl (NPF). We explore local perceptions of the presence of NPF in the Dayton area, and how this has both positively and negatively impacted practices of non-prescribed buprenorphine use among PWUIO. METHODS: This study analyzes qualitative data from 63 interviews conducted between October 2018 and June 2019. Participants were selected from a larger longitudinal study on non-prescribed buprenorphine use among individuals with opioid use disorder. Qualitative interviews were transcribed in their entirety, and their transcriptions were analyzed using NVivo software, drawing on a mix of thematic and inductive coding. RESULTS: Interview respondents ranged from 19 to 70 years old, with a mean age of 38.9 years. 54% of them were male, and 85.7% identified as non-Hispanic White. 98.4% of the sample had used heroin, and 93.7% of the sample reported use of NPF. Participants agreed NPF dominated the illicit opioids market in the area, and was perceived as both dangerous and desirable. The domination of NPF and associated overdose experiences prompted some to seek positive change and initiate self-treatment with non-prescribed buprenorphine. For others, NPF sabotaged established practices of harm reduction, as unanticipated experiences of precipitated withdrawals prompted some participants to give up non-prescribed buprenorphine use as a tactic of self-treatment. DISCUSSION: The changing nature of heroin/NPF necessarily gives rise to new beliefs surrounding self-treatment attempts, treatment seeking behaviors, and harm reduction practices. While buprenorphine treatment continues to offer promising results for treating opioid use disorders, it is urgent to reconsider how the unpredictable biochemical mixture of NPFs circulating on the streets today may impact the initiation and success of treatment.