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Fatal drug overdoses among pregnant and postpartum individuals have risen dramatically over the past 10 years. Trends in and characteristics of nonfatal drug overdoses in this population, however, remain unknown, despite the importance of this outcome for maternal and infant health. We used statewide, longitudinally linked hospital and emergency department administrative claims data from California to characterize the incidence, trends, drug type involvement, and sociodemographic disparities in pregnancy-associated drug overdose between 2010 and 2019. Generalized linear models accounting for multiple deliveries per individual were used to test for trends; descriptive statistics were used for other study analyses. Of California individuals with a live delivery between 2010 and 2018, approximately 0.2% had a pregnancy-associated drug overdose. Nonfatal overdoses were nearly 60 times more common than fatal overdoses. Incidence of overdoses involving stimulants increased in frequency, while incidence of overdoses involving sedative/hypnotic drugs and psychotropic medications decreased in frequency. Risk of overdose was substantially higher among delivering individuals who were young, non-Hispanic Black, Medicaid patients, or who lived in nonmetropolitan areas. Ongoing public health surveillance of pregnancy-associated nonfatal drug overdose events and clinical interventions to reduce these events are critical for prevention efforts., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: In Canada, the COVID-19 pandemic collided with an ongoing overdose crisis driven by a toxic unregulated drug supply. Public health guidance intended to limit transmission of COVID-19 (e.g., social distancing) directly contradicted guidance responding to the ongoing overdose crisis (e.g., never use drugs alone), exacerbating harms among people reliant on the toxic unregulated drug supply. While existing literature characterises many harms associated with consuming unregulated drugs during COVID-19, less is known about the specific impacts on women. We explored the perspectives of women who use unregulated drugs and experienced socio-economic marginalisation on how the COVID-19 environment shaped their overdose risk in British Columbia, Canada., Methods: We conducted semi-structured interviews remotely with 45 participants between May 2020 and September 2021, and analysed the data thematically using a social violence framework., Results: Participants identified contamination of the unregulated drug supply, particularly with benzodiazepines, as a significant driver of overdose and gendered violence among women who use drugs. 'Social distancing' guidelines (e.g., guest restrictions in supportive housing, reduced capacity in harm reduction services) compounded these risks and resulted in more women using drugs alone, reducing opportunities for timely overdose intervention. In response, participants practiced individualised acts of caregiving (e.g., establishing informal networks that regularly check on each other) to mitigate the risks of overdose and gendered violence for themselves and their community., Discussion and Conclusions: These intersecting health crises perpetuated individualised approaches to addressing the risks of overdose and gendered violence, rather than addressing underlying social and structural drivers of these risks., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

The overdose epidemic in the United States is evolving, with a rise in stimulant (cocaine and/or methamphetamine)-only and opioid and stimulant-involved overdose deaths for reasons that remain unclear. We conducted interviews and group model building workshops in Massachusetts and South Dakota. Building on these data and extant research, we identified six dynamic hypotheses, explaining changes in stimulant-involved overdose trends, visualized using causal loop diagrams. For stimulant- and opioid-involved overdose deaths, three dynamic hypotheses emerged: (1) accidental exposure to fentanyl from stimulants; (2) primary stimulant users increasingly using opioids, often with resignation; (3) primary opioid (especially fentanyl) users increasingly using stimulants to balance the sedating effect of fentanyl. For stimulant-only overdose deaths, three additional dynamic hypotheses emerged: (1) disbelief that death could occur from stimulants alone, and doubt in testing capabilities to detect fentanyl; (2) the stimulant supply has changed, leading to higher unpredictability and thus higher overdose risk; and (3) long-term stimulant use contributing to deteriorating health and increasing overdose risk. These hypotheses likely each explain a portion of the recent trends in stimulant-involved overdoses. However, confusion and uncertainty around the drug supply emerged as a central theme, underscoring the chaotic and unpredictable nature of the stimulant market. Our findings indicate the need for research to develop targeted public health interventions, including analyzing the extent of the effect of contamination on overdoses, reducing confusion about the stimulant supply, and examining historical stimulant use trends., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Illicitly manufactured fentanyl within the drug supply has substantially increased opioid-related overdose deaths and driven infectious disease outbreaks among people who use drugs (PWUD). Local jurisdictions often lack the data and tools necessary to detect and translate such moments into actionable and effective responses. Informed by a risk environment framework, this case study adopted a mixed-methods design spanning two rapid assessment studies with PWUD in Lowell (n = 90) and Lawrence (n = 40), Massachusetts, during an HIV outbreak (2017, Study 1) and following the outbreak (2019, Study 2). Survey responses (n = 130) were summarized by computing descriptive statistics, ethnographic field notes were reviewed, and qualitative interviews (n = 34) were thematically analyzed to contextualize quantitative findings. Study 1 participants reported constrained syringe access, high injecting frequency, syringe reuse, and unsafe syringe disposal practices, and uncovered entrenched social and structural factors exacerbating existing substance use and HIV risks: housing instability, limited harm reduction supplies and services (e.g., MOUD access), and tensions between law enforcement and PWUD. Following the outbreak and substantial local investments in harm reduction and treatment infrastructures, Study 2 participants indicated lower injection risk reporting fewer syringe reuse episodes, improved syringe disposal practices, high frequency of naloxone administration at recent overdoses, frequent testing for HIV and HCV, and greater engagement with syringe services programs. A rapid assessment approach to fentanyl's emergence and a concomitant HIV outbreak provided time-sensitive, critical insights and identified needed and local response strategies. However, unless social and structural risk factors are also addressed, community vulnerability to future HIV outbreaks remains., Competing Interests: Declarations. Ethical Approval: Approval was granted by the Institutional Review Boards of Boston University Medical Center and the Massachusetts Department of Public Health. Informed Consent: Informed consent was obtained from all study participants. Conflict of Interest: All authors of this manuscript have no conflict of interest to declare pertaining to the content of this article., (© 2024. The Author(s).)

Introduction: Prevalence estimates of opioid use disorder (OUD) at local levels are critical for public health planning and surveillance, yet largely unavailable across the US especially at the local county level., Methods: We used a Bayesian evidence synthesis approach to estimate the prevalence of OUD for 57 counties across New York State for 2017-2019 and compare rates of OUD across counties as well as assess the extent of undiagnosed OUD. We developed a generative model to assess conditional probabilistic relations between different subgroups of the OUD population defined by diagnosis, treatment, and overdose fatality., Results: Average OUD prevalence from 2017 to 2019 ranged from 2.4 % (Westchester County) to 8.3 % (Sullivan County). Overall OUD prevalence estimates were relatively stable year to year, from 4.5 % in 2018 and 4.6 % in both 2017 and 2019. The Bayesian evidence synthesis estimate is consistently higher than the percentage diagnosed in Medicaid, by age and sex. By 2019, the estimated proportion of OUD that was undiagnosed ranged from 16.7 % in Clinton County to 62.7 % in Onondaga County. Counties with relatively high overdose death rates and low buprenorphine prescription percentages had the highest estimated level of undiagnosed OUD., Conclusion: OUD prevalence varied considerably across the state. We identified counties with high OUD and overdose levels and a high proportion of undiagnosed OUD, providing insight into areas of the state in need of rapid expansion of services for people with OUD. Bayesian evidence synthesis approaches for OUD prevalence estimation represent a reliable and rigorous approach to providing local areas with information on OUD magnitude., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Katherine Keyes reports a relationship with Opioid Litigation that includes: paid expert testimony. Corresponding author on editorial board of journal to which we are submitting (Katherine Keyes). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Background: While marked gender-based differences in drug-related risk and harm between men women who use drugs have been characterized to some extent, the complex relationship between gendered socioeconomic conditions, overdose risk, and drug use patterns and behaviours remains underexplored., Methods: We conducted gender-stratified repeated measures latent class analyses (RMLCA) with data from two ongoing cohorts of people who use drugs in Vancouver, Canada to identify discrete subgroups based on socioeconomic exposures. Multivariable generalized estimating equations models weighted by the respective posterior membership probabilities were applied to estimate the associations between socioeconomic class membership and non-fatal overdose. Sub-analyses investigated whether these relationships were explained by drug use-related variables., Results: Between June 2014 and March 2020, 1723 participants provided 12120 observations. At study baseline, 1074 (62.3%) were men and 649 (37.7%) were women. In RMLCA, five distinct profiles of socioeconomic exposures emerged for men, and four emerged for women. Classes were presented in ascending order of socioeconomic disadvantage (i.e., ranging from Class 1 [least disadvantage] to Class 4/Class 5 [most disadvantage]) and were primarily distinguished by variations in income, material and housing in/security, participation in illegal/informal income generation, and criminal justice involvement. In analyses adjusting for demographic characteristics, for both men and women, progressive increases in exposure to multiple dimensions of disadvantage were positively and independently associated with non-fatal overdose when compared to the least socioeconomically disadvantaged subgroup. Subsequent analyses revealed that systematic differences in drug use patterns and behaviours across categories of socioeconomic disadvantage largely accounted for these relationships., Conclusions: Addressing multiple forms of mutually reinforcing health inequities may offer additional opportunity to mitigate non-fatal overdose in men and women who use drugs., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Non-fatal overdoses frequently precede fatal overdoses, thus identifying risk factors for non-fatal overdoses could help develop strategies to prevent substance related deaths., Aim: This study aimed to identify patterns, circumstances and risk factors leading to non-fatal substance overdose in people experiencing homelessness., Method: All recorded cases of non-fatal substance overdose from a population of people experiencing homelessness registered at a specialist homelessness primary care centre in England were identified using electronic medical records. Overdose details and patient characteristics were extracted. The heterogeneity between variables in people with and without a recorded non-fatal overdose were tested and multivariable logistic regressions were used to identify the risk factors of non-fatal overdoses., Results: From the 1221 registered patients, 194(16%) were identified as having had a non-fatal overdose with 428 overdoses between them. Half were polypharmacy events with the main substances of overdose being: heroin, paracetamol, benzodiazepines, cocaine, antipsychotics, SSRIs and synthetic cannabinoids. Risk of non-fatal overdose was greater in females, white ethnicity, ages 36-45, and in those with a recorded use of tobacco, alcohol or illicit substance use. Chronic physical and mental health conditions increased the risk of non-fatal overdose including respiratory conditions, blood borne viruses, migraines, anxiety and depression., Conclusion: With a high number of non-fatal overdoses within this population, identifying individuals at risk based on the factors identified in this research could enable primary care providers to apply prevention actions such as overdose awareness and naloxone provision to avoid drug harm and deaths. Future work should explore the role of chronic physical conditions and their treatment on non-fatal overdose risks., Competing Interests: Conflicts of interest: Vibhu Paudyal is an Associate editor of the International Journal of Clinical Pharmacy. He had no role in handling the manuscript, specifically the processes of editorial review, peer review and decision making., (© 2024. The Author(s).)

Aims: The aim of this study was to assess the validity of undertaking time-series analyses on both fatal and non-fatal drug overdose outcomes for the surveillance of emerging drug threats, and to determine the validity of analyzing non-fatal indicators to support the early detection of fatal overdose outbreaks., Design, Setting and Participants: Time-series analyses using county-level data containing fatal overdoses and non-fatal overdose counts were collected at monthly intervals between 2015 and 2021 in California and Florida, USA. To analyze these data, we used the Farrington algorithm (FA), a method used to detect aberrations in time-series data such that an abnormal increase in counts relative to previous observations would result in an alert. The FA's performance was compared with a bench-mark approach, using the standard deviation as an aberration detection threshold. We evaluated whether monthly alerts in non-fatal overdose can aid in identifying fatal drug overdose outbreaks, defined as a statistically significant increase in the 6-month overdose death rate. We also conducted analyses across regions, i.e. clusters of counties., Measurements: Measurements were taken during emergency department and emergency medical service visits., Findings: Both methods yielded a similar proportion of alerts across scenarios for non-fatal overdoses, while the bench-mark method yielded more alerts for fatal overdoses. For both methods, the correlations between surveillance evaluations were relatively poor in the detection of aberrations (typically < 35%) but were high between evaluations yielding no alerts (typically > 75%). For ongoing fatal overdose outbreaks, a strategy based on the detection of alerts at the county level from either method yielded a sensitivity of 66% for both California and Florida. At the regional level, the equivalent analyses had sensitivities of 81% for California and 77% for Florida., Conclusion: Aberration detection methods can support the early detection of fatal drug overdose outbreaks, particularly when methodologies are applied in combination rather than individual methods separately., (© 2024 The Author(s). Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Aims: To determine the contribution that variation in the unregulated drug market has on the risk of heroin overdose across individuals with different levels of personal overdose risk., Design: A retrospective cohort study of heroin injecting episodes and overdose cases were examined over a 12-month period between 30 June 2022 and 30 June 2023., Setting: The Medically Supervised Injecting Room in Melbourne, Australia., Cases: 1474 witnessed heroin overdose cases were examined amongst a cohort of 337 individuals who were predominantly male (n = 276, 81.7%) with a median age of 43.5 years (interquartile range 37.25-49.00 years, range 20-75 years)., Measurements: The daily overdose rate was used to differentiate High and Low daily overdose risk categories. The number of overdose events that an individual experienced during the study period was used to differentiate people into Standard, Moderate and High personal overdose risk categories. Each overdose case was differentiated by the personal overdose risk of the individual who experienced the overdose, as well as the overdose risk of the day that overdose occurred. A stratified overdose risk profile was then derived across the nine different daily overdose risk and personal overdose risk categories., Findings: The rate of overdose approximately doubled on High overdose risk days compared with Standard overdose risk days, increasing by a factor of 2.11, 2.41 and 2.03 times for individuals in the Standard, Moderate and High personal overdose risk groups. Conversely, the rate of overdose was also substantially reduced on Low overdose risk days to a factor of 0.17, 0.28 and 0.20, respectively., Conclusion: Among heroin users in Melbourne, Australia, there is an approximately 10-times difference in the risk of overdose on some days compared with others, which appears to be attributable to the effects of the unregulated drug market and not the effects of variation in personal overdose risk of individuals., (© 2024 The Author(s). Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Objective: Availability and accessibility of a wide range of medications may be a contributing factor to rising medication-related overdose (OD) rates. Treatment for both suicide attempts (SAs) and ODs often occurs in the emergency department (ED), highlighting its potential as a screening and intervention point. The current study aimed to identify sociodemographic and clinical characteristics of individuals who reported SA via medication OD compared to other methods and to examine how these patients' suicide severity and behaviors differed over 12-month post-ED follow-up., Methods: Data were analyzed from Phases 1 and 2 of the Emergency Department Safety Assessment and Follow-up Evaluation multicenter study (N = 1376). Participants with a history of SA (n = 987) were categorized based on whether they indicated a past medication-related SA via OD., Results: Of participants with history of SA, 62.7% (n = 619) reported medication OD for either their most serious or their most recent SA. Multivariate analyses indicated female birth sex, diagnosis of bipolar disorder, and having some college education were significantly associated with membership in the medication OD attempt group (p <0.05). Of those who attempted suicide over the 12-month follow-up, nearly 60% of participants in the medication OD attempt group reported a subsequent SA via OD over follow-up. However, nearly half (46.5%) of participants with no medication OD at baseline also reported medication OD at follow-up., Conclusions: Among patients presenting to the ED, females, individuals with bipolar disorder, and patients with a college education, respectively, may be at highest risk for SAs via medication OD. Prospectively, medication OD appears to be a frequent method, even among individuals with no prior attempt via OD, as demonstrated by the high percentage of patients who did not have a medication OD at baseline, but reported a medication OD during follow-up., (© 2024 Society for Academic Emergency Medicine.)

Background: Patient-initiated or "before medically advised" (BMA) hospital discharge is more common among people who use drugs. Transitions of care can be destabilizing and might increase the risk of subsequent illicit drug overdose., Objectives: This study sought to evaluate whether BMA discharge is associated with an increased risk of subsequent drug overdose (primary objective) and whether physician-advised discharge is associated with an increased risk of subsequent drug overdose (secondary objective)., Methods: We performed a case-crossover analysis of population-based linked administrative health data for individuals experiencing an overdose between 2016 and 2019 in British Columbia, Canada. Using conditional logistic regression, we compared the likelihood of hospital discharge in the 28 days before overdose (the "pre-overdose interval") to the likelihood of hospital discharge in two self-matched 28-day control intervals ending 26 and 52 weeks before overdose., Results: Over the 3.5-year study interval, 235 of 27,584 (0.9%) pre-overdose intervals and 189 of 55,168 (0.3%) control intervals included a BMA discharge, suggesting that BMA discharge was associated with a twofold increase in the risk of subsequent drug overdose (adjusted odds ratio [aOR], 2.08; 95% confidence interval [95% CI], 1.68-2.58; p < 0.001). Physician-advised hospital discharge was also a risk factor for subsequent overdose, occurring in 1350 of 27,584 (4.9%) pre-overdose intervals and 1625 of 55,168 (2.9%) control intervals (aOR, 1.39; 95% CI, 1.27-1.52; p < 0.001)., Conclusions: Both BMA and physician-advised hospital discharge are independently associated with transient increases in the risk of subsequent illicit drug overdose. Better in-hospital treatment of substance use disorder and novel means of post-discharge outreach should be deployed to reduce this risk., (© 2024 The Author(s). Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

This study aimed to assess the risk factors and clinical-epidemiological patterns of acute poisoning among elderly individuals to guide prevention strategies. The epidemiological, clinical data, manner and cause of poisoning, and outcome of the registered elder cases (≥ 60 years old) in the clinical toxicology department of Imam Reza Hospital of Mashhad University of Medical Silences (CTD-IRH-MUMS) were investigated for nine months. The sex and age distribution of the patients were compared with the general population of Khorasan-Razavi using direct standardization. Among the 3064 cases registered at the hospital, 124 elderly patients were included in the study. The majority (71.8%) were male, with a mean age of 69.47. Male gender was found to be a significant risk factor for poisoning among elderly individuals compared to the general population (OR = 2.62) (1.55-4.42) (p-value < 0.001), however, it was not significant for age. Substance dependency, particularly on opiates, was common among the patients (56.5%), with a higher prevalence in males. Substance overdose (35.4%) and suicide (23.3%) were the most common methods of poisoning, with varying frequencies between genders (p-value = 0.002). Male gender was identified as a risk factor for opiate intoxication (OR = 4.68, CI = 1.70-11.83, p-value < 0.05) but not for suicide attempts. The average hospital stay duration was similar between male and female patients. The mean length of hospital stay was 3.53 ± 4.02 days (median = 3.0, range = 0.5-26 days) and was similar in both sexes. In conclusion, male gender and opiate dependency were highlighted as key factors in the poisoning of elderly individuals. These findings emphasize the importance of addressing these factors in preventive measures., Competing Interests: Declarations. Ethical Approval and Consent to Participate: This statement confirms that the study was conducted using data from the medical toxicology registry of Mashhad University of Medical Science (MTR-MUMS) program. The data was obtained in full confidentiality and privacy, and all patients or their legal guardians registered in the program had signed an informed consent form allowing their data to be used for research purposes. The MTR-MUMS program has been approved by the ethical committee of MUMS, with the approval code IR.MUMS.REC.1394.726. This approval from the ethical committee also serves as an approval for publishing research results conducted using this data set. We confirmed that all methods were carried out in accordance with relevant guidelines and regulations. Consent for Publication: Not applicable. Conflict of interest: None to be declared., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This commentary explores a recent shift in British Columbia's drug policy under a novel drug "decriminalization" framework. We focus on the province's move toward "recriminalization" under this framework. In short, recriminalization was a shift in BC's drug decriminalization framework to only apply in private residences, and be removed from essentially all outdoor spaces. This policy change was completed through an agreement with the federal government amid a public health emergency. Since 2016, BC has faced a severe crisis of drug-related overdoses and poisonings, driven by a toxic and unregulated drug supply compounded by prohibitionist policies. Expert recommendations for increasing access to a regulated drug supply have repeatedly dismissed as solutions by the governing BC New Democratic Party, opting instead for measures that do not undercut the toxic drug supply. We examine the sociolegal context of the BC government decision to recriminalize drug use in 2024, including attempts to criminalize recent drug use and police suspicion of substance use. These drug law reforms, understood here as forms of biopolitical violence, reflect a broader trend of using drug policies as tools for social and spatial regulation. By analyzing the sociolegal implications of these policies, the commentary situates the BC government's actions within a framework of sanctioned biopolitical massacre, highlighting the tension between purported decriminalization efforts and the actual enforcement strategies that perpetuate harm and exclusion. This examination underscores the complex interplay between drug policy, public health crises, and state power in the context of systemic colonial and racialized control that may be adaptable to other regions considering drug law reform., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: During the summer of 2021, western Canada experienced a historic and deadly extreme heat event. Simultaneously, toxic drug use and overdoses related to high-risk use of opioids and polysubstance use continued to rise across the country. However, the combined impacts of these intersecting public health crises remain poorly understood as relevant data sources are limited in Canada., Methods: We explored news media articles (n = 86, 3%) discussing toxic drug use, overdose-related deaths and the 2021 Heat Dome which were identified in a systematic review of Canadian online news media (e.g., newspaper articles, radio broadcasts) from five subscription news databases and an extensive grey literature search (n = 2909). The analyzed articles were published before, during and after the 2021 Heat Dome, and were qualitatively coded and thematically analyzed in NVivo to identify patterns of meaning across the dataset., Results: Four main themes were identified within our media-based analysis: (I) the reported impact of toxic drug use on human thermoregulation and behavioural adaptation; (II) the reported demand of intersecting crises on the health system; (III) barriers and stigma reported to influence an individual's access to or use of heat mitigation behaviours and services; and (IV) the reported impact of extreme heat on the public health response to drug poisoning emergencies., Conclusion: With increasing temperature extremes and a rising tide of toxic drug use and overdoses, our findings illustrate that there is a need for further research to better understand the combined impacts when toxic drug use, overdose-related deaths, and extreme heat coincide., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Tetzlaff et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: More than 300 people die from an overdose each year in Norway, and the trend is rising. The proportion of suicides among overdose deaths has been 11-20 % over the past ten years, with the annual figure remaining relatively stable. The purpose of this study was to describe the demographics as well as the medications and substances used in overdose suicides., Material and Method: Data from forensic toxicology analyses performed at the Department of Forensic Medicine, Oslo University Hospital, were linked to the Cause of Death Registry. The cause and manner of death from the Cause of Death Registry were used to identify overdose suicides in Norway in the period 1 January 2016-31 December 2021., Results: A total of 1383 overdoses were recorded in the dataset, and suicide was the cause of death in 251/1383 (18.1 %) cases. The average age was 51 years (± 16 years), and 135/251 (54 %) were women. Opioids were found in 235/251 (94 %) cases, with the most common being codeine (67/251; 27 %), oxycodone (63/251; 25 %) and tramadol (60/251; 24 %). In cases where opioids were found, benzodiazepines and/or z-hypnotics were identified in 181/235 (77 %) cases. A total of 109/251 (43 %) had taken antidepressants., Interpretation: Autopsies following an overdose suicide often revealed more than one psychoactive medication with addiction potential, in addition to an antidepressant. These medications are used for chronic pain, sleep disturbances, anxiety and depression, as well as to treat substance use.

As novel psychoactive substances (NPSs) have continued to emerge over the past decade, NPS benzodiazepines have likewise increased in prevalence. They pose an evolving threat to public health and safety with regard to postmortem cases, particularly when used in combination with opioids. Bromazolam was first detected in Travis County, Texas, in April 2021. Given the recent onset of the fentanyl epidemic in this region, the international rise of bromazolam, and increased reports of "benzo-dope," a retrospective study was conducted to characterize bromazolam-positive deaths in Travis County and surrounding counties from 2021 to 2023. Bromazolam was identified in 112 deaths from 2021 to 2023, accounting for 1.57% of cases submitted for toxicology testing (n = 7129). During that interval, a 7.5-fold increase in postmortem bromazolam-related drug toxicities from 2021 (n = 7) to 2023 (n = 53) was observed. Fatalities primarily occurred in men in their early 30s. Postmortem concentrations ranged from 21 to 220 ng/mL, with mean (median) concentrations of 69.4 ± 48.4 (53.5) ng/mL. Polydrug use was present in 99% of bromazolam-positive deaths with co-occurrence with other drugs and drug classes widely varying over time. Bromazolam was attributed as the sole cause of death in one case with a postmortem blood concentration of 23 ng/mL. Polydrug use in bromazolam-related drug toxicities commonly involved fentanyl (82%), methamphetamine (41%), and cocaine (28%). Similarly, cases where bromazolam was an incidental finding and noncontributory to the cause of death often involved methamphetamine (38%), alprazolam (33%), and cocaine (33%). In light of the significant increase in fentanyl-related deaths in Travis County, the increasing prevalence of bromazolam accompanying fentanyl was particularly alarming due to the heightened risk of toxicity when used in combination. Identifying and evaluating bromazolam-related deaths clarify the impact of bromazolam on this population, promote awareness, and aid in identifying meaningful harm reduction strategies to decrease bromazolam-related morbidity and mortality., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: The opioid overdose mortality crisis in the USA is an ongoing public health epidemic. Ongoing law enforcement strategies to disrupt local unregulated drug markets can have an iatrogenic effect of increasing overdose by driving consumers towards new suppliers with unpredictable drug products of unknown potency., Methods: Cross-sectional study using point-level information on law enforcement opioid-related drug seizures from property room data, opioid-related non-fatal overdose events from emergency medical services and block group-level social determinants of health data from multiple sources. Using an endemic-epidemic spatiotemporal regression model, we estimated the degree to which exposure to drug supply disruptions triggers future overdose events within small space-time distances in Indianapolis, Indiana., Results: Neighbourhoods with more structural racism, economic deprivation or urban blight were associated with higher rates of non-fatal overdose. Exposure to an opioid-related drug seizure event had a significant and positive effect on the epidemic probability of non-fatal overdose. An opioid seizure that occurred within 250 m and 3 days, 250 m and 7 days, and 250 m and 14 days of an overdose event increased the risk of a new non-fatal overdose by 2.62 (rate ratio (RR)=2.62, 95% CI 1.87 to 3.67), 2.17 (RR=2.17, 95% CI 1.87 to 2.59) and 1.83 (RR=1.83, 95% CI 1.66 to 2.02), respectively. Similar spatiotemporal patterns were observed in a smaller spatial bandwidth., Conclusions: Results demonstrated that overdoses exhibit a community spread process, which is exacerbated following law enforcement strategies to disrupt the unregulated drug market. We discuss decriminalisation and increasing resources that promote safer drug use to combat this public health crisis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

The United States continues to suffer a drug overdose crisis that has resulted in over 100 000 deaths annually since 2021. Despite decades of attention, estimates of the prevalence of drug use at the spatiotemporal resolutions necessary for resource allocation and intervention evaluation are lacking. Current approaches for measuring the prevalence of drug use, such as population surveys, capture-recapture, and multiplier methods, have significant limitations. In a recent article, Santaella-Tenorio et al (Am J Epidemiol. 2024;193(7):959-967) used a novel joint bayesian spatiotemporal modeling approach to estimate the county-level prevalence of opioid misuse in New York State from 2007 to 2018 and identify significant intrastate variation. By leveraging 5 data sources and simultaneously modeling different opioid-related outcomes-such as numbers of deaths, emergency department visits, and treatment visits-they obtained policy-relevant insights into the prevalence of opioid misuse and opioid-related outcomes at high spatiotemporal resolutions. The study provides future researchers with a sophisticated modeling approach that will allow them to incorporate multiple data sources in a rigorous statistical framework. The limitations of the study reflect the constraints of the broader field and underscore the importance of enhancing current surveillance with better, newer, and more timely data that are both standardized and easily accessible to inform public health policies and interventions. This article is part of a Special Collection on Mental Health., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Firearm injury and poisoning, often by drug or medication overdose, account for most suicides among the general population and US veterans. In the Veterans Health Administration, the largest integrated health care system in the US, firearm and opioid access is assessed among patients at risk for suicide who complete suicide safety plans., Objective: To describe self-reported, clinician-documented access to firearms and opioids, firearm storage practices, distribution of firearm cable locks and naloxone, and counseling on firearm storage and overdose among veterans at elevated risk for suicide who completed suicide safety plans., Design, Setting, and Participants: This cross-sectional study used electronic health record data from the Veterans Health Administration from December 2021 to February 2023. Participants were veterans identified as having elevated suicide risk through routine screening with the Columbia Suicide Severity Rating Scale Screener who completed a safety plan within 30 days. Data were analyzed from March 2023 to March 2024., Exposure: Completion of a safety plan, a brief, evidence-based intervention to help prevent or de-escalate suicidal crises., Main Outcomes and Measures: Firearm and opioid access, as well as firearm storage information, were assessed via the lethal means component of the standardized safety plan note template., Results: Among 38 454 veterans identified (32 310 [84.0%] male; 15 206 participants [39.5%] aged ≥55 years; 26 960 participants [70.1%] living in urban areas), 9969 (25.9%) were Black and 23 714 (61.7%) were White and 3426 (8.9%) were Hispanic/Latine and 28 892 (75.1%) were not Hispanic/Latine. A total of 10 855 (28.2%) reported access to firearms. Approximately one-third of veterans reported storing at least 1 firearm in each of the following ways: unlocked and loaded (insecure), outside of the home or locked and unloaded (secure), or locked and loaded. Younger and middle-aged veterans, White veterans, veterans who were not Hispanic/Latine, male veterans, and rural veterans were more likely to report firearm access. A total of 2021 veterans (5.3%) reported access to opioids; older veterans, White veterans, veterans who were not Hispanic/Latine, and rural veterans were more likely to report opioid access. Clinicians reported discussing firearm storage with 10 655 veterans (98.2%) and overdose with 1589 veterans (78.6%). Only 1837 veterans (16.9%) offered firearm cable locks and 536 veterans (26.5%) of veterans offered naloxone were documented as accepting them., Conclusions and Relevance: In this cross-sectional study of electronic health record data, the prevalence of reported access to firearms was lower than expected, suggesting underreporting or underdocumentation, or a lower true prevalence among this at-risk population. Completion of a note template may have encouraged routine discussion of firearm storage and overdose risk, but acceptance of gunlocks and naloxone was low. These findings suggest that White veterans, veterans who were not Hispanic/Latine, and rural veterans may be at particular risk of harm by firearms and opioids.

Background: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies., Methods: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups., Results: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently)., Conclusions: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: This study: (1) estimated the effect of early discontinuation of medication for opioid use disorder (MOUD) on overdose probability and (2) measured the relationship between patient characteristics and early discontinuation probability for each MOUD type., Design, Setting and Participants: This was a retrospective cohort using electronic health record data from the US Veterans Healthcare Administration. Participants were veterans initiating MOUD with buprenorphine (BUP), methadone (MET) or extended-release naltrexone (XR-NTX) from fiscal years 2012-19. A total of 39 284 veterans met eligibility with 22 721 (57.8%) initiating BUP, 12 652 (32.2%) initiating MET and 3911 (10.0%) initiating XR-NTX., Measurements: Measurements (1) determined whether the veteran experienced an overdose in the 365 days after MOUD initiation (primary) and (2) early discontinuation of MOUD, defined as discontinuation before 180 days (secondary). We assumed that unobserved patient characteristics would jointly influence the probability of discontinuation and overdose. and estimated the joint distribution with a bivariate probit model., Findings: We found that 9.0% of BUP initiators who experienced an overdose above the predicted 3.9% had no veteran-discontinued BUP early; findings for XR-NTX were similar, with 12.2% of initiators overdosing above the predicted 4.5%, but this was statistically inconclusive. We found no relationship between early discontinuation and overdose for MET initiators, probably due to the high risk of both events. The patient characteristics included in our post-estimation exploratory analysis of early discontinuation varied by MOUD type, with between 14 (XR-NTX) and 25 (BUP) tested. The only characteristics with at least one level showing a statistically significant change in probability of early discontinuation for all three MOUD types were geography and prior-year exposure to psychotherapy, although direction and magnitude varied., Conclusion: Early discontinuation of buprenorphine, and probably extended-release naltrexone, appears to be associated with a greater probability of experiencing a fatal or non-fatal overdose among US veterans receiving medication for opioid use disorder (MOUD); methadone does not show the same association. There is no consistent set of characteristics among early discontinuers by MOUD type., (© 2024 The Author(s). Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Purpose: To explore people who use stimulants' (PWUS) stimulant overdose experiences and identify factors associated with calling 911 for personal and witnessed stimulant overdoses., Methods: From 2022-2023, 222 people in Massachusetts and Rhode Island with past-30-day illicit stimulant use were surveyed. Adjusted multivariable logistic regression models examined the association between sociodemographics, substance use, and stimulant overdose history and whether 911 was called for participants' last personally experienced and witnessed stimulant overdoses., Results: Overall, 42.2 % of PWUS witnessed- and 34.5 % personally overdosed on stimulants. Nearly half (48.7 %) of participants who overdosed used crack cocaine prior, 35.5 % reported extremely severe symptoms (e.g., heart attack, stroke, seizure, loss of consciousness), and 34.2 % said 911 was called at their last overdose. Among those who last witnessed a stimulant overdose, 41.5 % reported crack cocaine involvement, and 47.9 % said 911 was called (20.0 % personally called). Higher educational attainment and experiencing extremely severe symptoms were positively associated with 911 being called at participants' last stimulant overdose, whereas the number of overdoses witnessed and crack cocaine use by the person overdosing were negatively associated with 911 being called at participants' last witnessed stimulant overdose (all p-values<.05)., Conclusion: Stimulant overdoses were common. Most participants reported moderate-to-severe symptoms, yet 911 was called in less than half of personal or witnessed stimulant overdoses. Emergency help-seeking also varied by symptom severity, stimulant type, and the sociodemographics of the person overdosing. Research is needed to understand barriers to formal help-seeking and the practices PWUS engage in to prevent fatal stimulant overdoses., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Previous nonfatal overdose is a key risk factor for drug overdose death; however, current nonfatal overdose surveillance is limited to people who receive medical attention. We identified states that tracked nonfatal overdoses treated in prehospital and hospital care settings, assessed the effects of different surveillance methods on the magnitude of nonfatal overdose estimates, and estimated states' nonfatal-to-fatal overdose ratio., Methods: Two analysts independently reviewed state websites to characterize states' methods of capturing nonfatal overdose events from December 2022 through February 2023. We collected information on surveillance methods in 5 states that met the inclusion criteria, including data source, measure specification, drug(s) involved, and whether states performed deduplication or published mutually exclusive measure specifications to capture unique events across care settings. We calculated nonfatal-to-fatal overdose ratios to assess the effects of different data sources on estimates of nonfatal overdoses., Results: Illinois, Maine, North Carolina, and West Virginia used syndromic surveillance data and New Jersey used hospital discharge data to track nonfatal overdose-related emergency department visits. Illinois and West Virginia tracked nonfatal overdose-related encounters with emergency medical services. Other states tracked opioid overdoses reversed following naloxone administration by emergency medical services, law enforcement, and community members. Maine, New Jersey, and West Virginia published nonfatal overdose information by using mutually exclusive measure specifications; the number of nonfatal overdoses per fatal overdose in these states ranged from approximately 5:1 to 14:1., Practice Implications: Establishing a standard framework to combine data from existing national surveillance systems in prehospital and hospital care settings can improve nonfatal overdose estimates and enable comparisons between jurisdictions to help decision makers identify areas most in need of essential services., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Objectives: History of nonfatal overdose (NFO) is common among people who use opioids, but little is known about opioid agonist treatment (OAT) outcomes for this high-risk subpopulation. The objective of this study was to investigate the relative effectiveness of buprenorphine/naloxone and methadone on retention and suppression of opioid use among individuals with opioid use disorder (OUD) and history of NFO., Methods: Secondary analysis of a pan-Canadian pragmatic trial comparing flexible take-home buprenorphine/naloxone and supervised methadone for people with OUD and history of NFO. Logistic regression was used to examine the impact of OAT on retention in the assigned or in any OAT at 24 weeks and analysis of covariance was used to examine the mean difference in opioid use between treatment arms., Results: Of the 272 randomized participants, 155 (57%) reported at least one NFO at baseline. Retention rates in the assigned treatment were 17.7% in the buprenorphine/naloxone group and 18.4% in the methadone group (adjusted odds ratio [AOR] = 0.54, 95% CI: 0.17-1.54). Rates of retention in any OAT were 28% and 20% in the buprenorphine/naloxone and methadone arms, respectively (AOR = 1.55, 95% CI: 0.65-3.78). There was an 11.9% adjusted mean difference in opioid-free urine drug tests, favoring the buprenorphine/naloxone arm (95% CI: 3.5-20.3; p = .0057)., Conclusions and Scientific Significance: Among adults with OUD and a history of overdose, overall retention rates were low but improved when retention in any treatment was considered. These findings highlight the importance of flexibility and patient-centered care to improve retention and other treatment outcomes in this population., (© 2024 The Author(s). The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry (AAAP).)

Introduction: To investigate factors associated with suicide attempts among patients presenting after an opioid overdose., Materials and Methods: This analysis consists of patients enrolled in the Toxicology Investigators Consortium Fentalog Study, an ongoing prospective observational study of patients presenting to 1 of 10 emergency departments (EDs) for a suspected opioid overdose. Residual serum samples were analyzed to detect over 1,200 drugs and metabolites. Chart reviews were conducted to determine the patients' intentions for the opioid overdose (suicide attempt vs. unintentional overdose), medical/social history, and clinical variables. Logistic regression analyses were conducted to examine factors associated with suicide attempts., Results: Among 1,259 patients, 6.4% were classified as suicide attempts. Prescription opioids only (without illicit opioids) were associated with suicide attempts compared to unintentional overdose (OR: 1.27; 95% CI: 1.21, 1.34). Compared to unintentional overdoses, suicide attempts were not associated with an increased odds of medical interventions being provided, such as CPR, intubation, or ICU admission., Conclusions: Among patients presenting to EDs after opioid overdose, suicide attempts comprised 6% of the study population and were associated with prescription opioids rather than illicit opioids.

Importance: Medicaid programs have expanded coverage of substance use disorder treatment and undertaken many other initiatives to reduce drug overdoses among beneficiaries. However, to date, no information has been published that tracks overdose deaths among the Medicaid population., Objective: To determine the rate of drug overdose among Medicaid beneficiaries., Design, Setting, and Participants: In this cross-sectional study, US Centers for Medicare & Medicaid Services data from 2016 to 2020 that linked enrollment and demographic data from all Medicaid beneficiaries in the US with the US Centers for Disease Control and Prevention National Death Index were used to determine the rate of drug overdose death among Medicaid beneficiaries. The Medicaid population rates were compared with those of the total US population, overall and by age and sex., Exposure: Participation in the Medicaid program., Main Outcome: Death of a drug overdose., Results: In 2020, the drug overdose death rate among Medicaid beneficiaries was 54.6 per 100 000, a rate that was twice as high as the drug overdose rate among all US residents (27.9 per 100 000). In 2020, Medicaid beneficiaries comprised 25.0% of the US population but 48% of all overdose deaths (44 277 of 91 783). For each age and sex group older than 15 years, overdose deaths were higher for the Medicaid population than for the US population, with the greatest difference occurring among adults ages 45 to 64 years. From 2016 to 2020, Medicaid overdose deaths increased by 54%., Conclusions and Relevance: The results of this study suggest that more research is needed to understand why Medicaid beneficiaries have higher rates of drug overdoses than all US residents. Additionally, research is needed to understand how best to prevent overdoses among Medicaid beneficiaries. The federal government should support these efforts by routinely linking Medicaid claims and enrollment data to death records.

Background: The analysis of how people search and "navigate" the internet to obtain health-related information and how they communicate and share this information can provide valuable knowledge about the disease patterns behaviour and health habits of populations., Objective: To determine the population's interest in drug-related problems through information search trends., Method: A descriptive ecological correlational study, based on obtaining Google Trends data., Variables Studied: relative search volume (RSV), evolution over time, milestones and seasonality., Results: The most searched topic was drug overdose, with mean RSV of 56.25 ± 0.65. The highest increase occurred in the contraindication topic (R 2  = 0.87, p < 0.001). The main milestone was observed in the drug overdose topic in July 2018 (RSV = 100). A very close relationship was found between adverse drug reaction and contraindication (R = 0.89, p < 0.001). Slight seasonality was noted in the adverse drug reaction (augmented Dickey-Fuller test [ADF] = -1.96), contraindication (ADF = -2.66) and drug interaction (ADF = -1.67) topics, but did not show an epidemiological trend., Conclusions: The greatest public interest was found in the drug overdose and contraindication topics, which showed a stronger upward trend, although the seasonality study did not show any very notable data or demonstrate epidemiological information search behaviour. The main milestone observed was due to media factors related to the consumption of narcotics. There was a clear difference in English-speaking countries in the use of the drug overdose topic. A correlation between the adverse drug reaction and contraindication topics was confirmed., Competing Interests: Declarations Conflict of interest The first author, on behalf of herself and all her fellow authors, declares that there are no potential conflicts of interest related to this article., (© 2024. The Author(s).)

Background: The role of prescribed opioids and benzodiazepines as risk factors for opioid overdose are well established, however, their role as potential 'triggers' of opioid overdose has not been formally investigated., Objective: The objective of this study was to evaluate the temporal relationship between controlled substance acquisition and opioid overdose utilizing a case-crossover design., Methods: This study utilized Arkansas statewide data between 2014 and 2020. Prescription Drug Monitoring Program (PDMP) data were used to assess controlled substance acquisition and fatal and non-fatal opioid overdose were assessed using linked death certificate, inpatient discharge, and emergency department (ED) data. All persons residing in Arkansas who experienced an opioid overdose or had ≥ 1 Arkansas PDMP prescription fill(s) were included. Controlled substance characteristics were described in the 7 days prior to overdose and compared to the controlled substance characteristics in 11 weekly (7-day) control windows prior to overdose. Binary controlled substance variables indicating presence or absence of: any controlled substance, opioid, benzodiazepine, stimulant, sedative, carisoprodol, opioid and benzodiazepine, and opioid and benzodiazepine and carisoprodol were created. Additionally, total morphine milliequivalents were calculated for each time window. Conditional logistic regression models were estimated and adjusted odds ratios for each controlled substance characteristic after accounting for other controlled substance, and prior overdose, and clinical characteristics derived from ED and inpatient data are reported., Results: A total of 2,818,135 individuals with ≥1 Arkansas PDMP record(s) (45.10 % male; 39.94 mean age) were included, of which 28,670 (1.02 %) experienced ≥1 opioid overdose. There was a significant association between opioid overdose and the acquisition of a controlled substance (OR=1.785; p < 0.001), opioid (OR=1.992; p < 0.001), benzodiazepine (OR=1.379; p < 0.001), carisoprodol (OR=1.744; p < 0.001), opioid and benzodiazepine (OR=2.203; p < 0.001), and opioid and benzodiazepine and carisoprodol (OR=2.503; p < 0.001), in the 7 days prior to an opioid overdose event., Conclusion: Controlled substance prescription acquisition, particularly opioids in combination with carisoprodol and/or benzodiazepines, are potential triggers of opioid overdose., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Martin receives royalties from TrestleTree, LLC for the commercialization of an opioid risk prediction tool that used separate data sources and methods and is unrelated to this investigation., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: The COVID-19 pandemic disrupted the traditional mode of methadone maintenance treatment (MMT) delivery through the imposition of lockdowns and social distancing measures. In response, policy makers granted flexibilities to providers delivering MMT to change their practices to maintain patient participation while accommodating the measures imposed to prevent the spread of COVID-19. This study examines the utilization of MMT and overdoses of patients receiving MMT during the COVID-19 pandemic in one mid-Atlantic state., Materials and Methods: We analyzed Medicaid claims data for 2018-2020, calculating weekly trends for starts, discontinuations, and medically-treated overdoses for beneficiaries receiving MMT who had been continuously enrolled in Medicaid for the previous 12 months, to account for changes in the composition of the Medicaid population following the COVID-19 public health emergency (PHE). We completed data analyses from January to June 2022., Results: We observed countervailing trends in new starts, which experienced an immediate, non-significant dip of -22.47 per 100,000 Medicaid beneficiaries (95%CI, -50.99 to 6.04) at the outset of the pandemic followed by an increasing upward trend of 1.41 per 100,000 beneficiaries per week (95%CI, 0.37 to 2.46), and in discontinuations, which also experienced an immediate dip of -3.23 per 1000 MMT enrollees (95%CI, -4.49 to -1.97) followed by an increasing upward trend of 0.14 per 1000 MMT enrollees per week (95%CI, 0.09 to 0.19). The net result of these shifts was a stable, slowly increasing rate of MMT treatment of 0.02 % per week before and after the PHE. We also found no statistically significant association of the PHE with medically-treated overdoses among beneficiaries enrolled in MMT (trend change = 0.02 overdoses per 10,000 MMT enrollees, 95%CI, -0.05 to 0.09)., Conclusions: New Jersey achieved overall stability in MMT treatment prevalence following the pandemic's onset, while some changes in treatment dynamics took place. This outcome may reflect that the extensive flexibilities granted to providers of MMT by the state and federal government successfully maintained access to MMT for Medicaid beneficiaries through the pandemic without increasing risk of medically-treated overdose. These findings should inform policy makers developing the post-COVID-19 legal and regulatory landscape., Competing Interests: Declaration of competing interest No potential conflict of interest was reported by the authors., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The ongoing and evolving overdose epidemic highlights the need to translate research results into routine clinical practice to address urgent service delivery needs. Implementation science is a relatively new discipline intended to develop systematic, replicable, scalable strategies to accelerate this translation. This article presents a comprehensive review of implementation research funded by the National Institute on Drug Abuse (NIDA)., Methods: The study identified all NIDA-funded research grants awarded in fiscal years 2007 through 2023 in treatment services or prevention research (n = 1111) and screened them to find those with a pre-specified implementation science component (n = 248). Using the text of the grant application, two reviewers independently coded the key characteristics of each study., Results: The characteristics of these grants, and trends over time, are described, and priority gap areas are identified. NIDA's implementation research grants have demonstrated increasing rigor in design and measurement., Conclusions: Growth in the portfolio has been driven in part by NIDA's investments in research-practice partnerships in the criminal-legal system, and by recent efforts to address the overdose epidemic., Competing Interests: Declaration of competing interest Nothing to declare., (Published by Elsevier Inc.)

Objectives. To estimate children's exposure to family overdose in the United States. Methods. We used recent demographic kinship modeling advances and the Centers for Disease Control and Prevention's most recent underlying cause of death estimates to model how many children aged younger than 18 years in 2019 had lost 1 or more parents, siblings, grandparents, aunts or uncles, or cousins to overdose mortality since birth. We calculated the number and proportion of children with such exposures and considered age, cohort, and gender patterning. Results. More than 1.4 million children in the United States, mostly adolescents, experienced a family overdose death, often losing central figures like parents or grandparents. Cohort analyses suggest dramatic increases in these exposures, portending mounting prevalence. Conclusions. Attention to the large population with lives disrupted by overdose deaths should include affected children. The long-arm consequences of the overdose crisis will continue to define the public health landscape for decades. ( Am J Public Health . 2024;114(12):1394-1397. https://doi.org/10.2105/AJPH.2024.307847).

Introduction: The benefits of methadone maintenance treatment (MMT) may be compromised by the continued use of other substances during treatment. Polysubstance use has been identified as a major contributing factor to treatment discontinuation, a known risk factor for drug overdose. We examined trends in immunoassay drug positivity rates for amphetamines, benzodiazepines, cannabis, cocaine and opioids, and (2) trends in polysubstance positivity rates for drug combinations associated with increased risk of drug overdose among patients attending the national drug treatment centre in Ireland for MMT between 2010 and 2020., Methods: Repeated cross-sectional study of patients attending the national drug treatment centre (NDTC) for MMT (total N = 1942) between 2010 and 2020, focused on urine drug samples provided for testing to the NDTC clinical testing laboratory (n = 221,564). Samples were analysed using immunoassay during the study period. Mixed-effects logistic regression models evaluate time trends in drug positivity. A random intercept accounts for repeat testing of individual patients. The study reports Adjusted Odds Ratios (AOR) for time (per year) with 95 % Confidence Intervals (95 % CI)., Results: Drug positivity rates increased over time for benzodiazepines (AOR 1.02, 95 % CI 1.01-1.03, p < .0001), cannabis (AOR 1.06, 95 % CI 1.05-1.08, p < .0001) and cocaine (AOR 1.28, 95 % CI 1.27-1.29, p < .0001), with decreasing trends for opioids (AOR 0.91, 95 % CI 0.91-0.92, p < .0001). Methadone and benzodiazepines were co-detected in over two-thirds of all samples during the study period. Co-detection of methadone and benzodiazepines with cocaine was also found to be increasing (AOR 1.24, 95 % CI 1.23-1.25, p < .0001), with weighted polysubstance positivity rates reaching 29.2 % in 2020. The co-detection of methadone and benzodiazepines with opioids decreased over the study period (AOR 0.92, 95 % CI 0.91-0.92, p < .0001), ranging from 36.7 % in 2010 to 26.9 % in 2020., Conclusion: Interventions are needed to target the persistently high use of benzodiazepines among patients in receipt of methadone due to their synergistic effects with opioids on respiratory depression, enhancing the risk of overdose. The growing use of cocaine among people in MMT also needs to be addressed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: Supervised consumption service (SCS) use among people who inject drugs may reduce acute care utilization; however, prior studies have been limited by self-reported outcomes and dichotomous exposures., Methods: We conducted a prospective cohort study using linked questionnaire and health administrative data among people who inject drugs in Toronto, Canada (2018-2020). Baseline SCS use frequency was defined by a participant's self-reported proportion of injections performed at an SCS over the past six months: "all/most" (≥75 %), "some" (26-74 %), "few" (1-25 %), or "none" (0 %). Outcomes measured over the following six months included: emergency department (ED) visits; hospitalizations; ED visits or hospitalizations for opioid-related overdose; and hospitalizations for injection-related infections. The relative effects of varying SCS use levels on study outcomes were estimated using inverse-probability-weighted negative binomial regression models., Results: Of 467 participants, 25.5 %, 30.4 %, 28.7 %, and 15.4 % respectively reported "all/most", "some", "few", and "none" levels of SCS use at baseline. SCS use frequency was not significantly associated with ED visits, hospitalizations, or hospitalizations for injection-related infections. Participants reporting "some" SCS use had a higher rate of ED visits or hospitalizations for opioid-related overdose (versus "few"; rate ratio=2.30, 95 % confidence interval=1.15-4.61)., Conclusions: SCS use had little impact on objectively measured acute care utilization, which was high overall. Although preventing overdose mortality is the primary goal of SCS in Canada, resourcing sites to support their clients' acute healthcare needs may help build a continuum of care for people experiencing marginalization who inject drugs., Competing Interests: Declaration of Competing Interest SH and MJ work(ed) in organizations that provide supervised consumption services. DW is a co-founder of DoseCheck, a private company developing a mobile drug checking technology. The remaining authors have no conflicts to declare., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: To assist the state of Ohio in addressing the opioid epidemic, the Ohio Attorney General appointed experts in a variety of academic disciplines to the Scientific Committee on Opioid Prevention and Education (SCOPE). The focus of SCOPE is the application of scientific principles to the development of prevention and educational strategies for reducing substance use disorder and related harms (e.g., promoting naloxone awareness). Naloxone awareness is a step in the naloxone cascade, which is a useful model for understanding the sequential steps laypeople must take to prepare themselves to intervene using naloxone; other steps include training and previous administration experience. Prior work has explored correlates of these steps among individuals with risky substance use, but fewer studies have focused on broader populations containing potential bystanders (e.g., family and community members)., Methods: This study was a secondary data analysis of patients from three urban emergency departments. Subsamples differed across five models (n = 479-1208) and included opioid-exposed and -naïve participants. Logistic regression characterized clinically useful sociodemographic predictors (e.g., race, ethnicity, education, employment, housing status) of naloxone awareness, self-efficacy (which relates to training), and previous-overdose administration. Two additional logistic regressions tested associations between risk factors for witnessing an opioid overdose and two cascade steps (awareness and self-efficacy)., Results: Non-White race, Hispanic ethnicity, and lower education predicted not being aware of naloxone; non-White race also predicted lower naloxone self-efficacy, and older age predicted lack of previous-overdose administration. Having family members with risky opioid use was heavily associated with awareness, while personal substance-use behaviors and previous overdose witnessing were associated with both awareness and higher naloxone self-efficacy., Conclusions: Characteristics associated with lower likelihood of completing each cascade step highlight opportunities for targeted interventions. Specifically, findings indicated the importance of expanding naloxone education and training programs to more diverse populations and to family members of individuals with risky opioid use. Further, these findings demonstrate how a state-funded program such as SCOPE can have a positive impact on identifying strategies that may assist in reducing mortality associated with opioid overdose., Competing Interests: Declaration of competing interest The following authors received compensation for time spent on the parent study through awards to their institutions from the Ohio Attorney General Office (Grant Number 12545): Rob Braun, Drs. Freiermuth, Brown, Lyons, and Punches. Dr. Littlefield received compensation for the parent study through consultant payments. Authors Petrovitch, Himes, Jump, and Sprague declare that they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Among patients with opioid use disorder (OUD), high rates of overdose and death have been reported in subgroups with Hepatitis C Virus (HCV). Evidence on the comorbid effect of HCV on clinical and substance use trajectories has been limited by small sample sizes, short follow-up, and heavy reliance on administrative data which lacks granularity on important prognostic factors. Additionally, few studies include populations on substance use treatment., Aim: To establish the impact of HCV exposure (antibody positivity) on health care utilization patterns, substance use treatment response, and death in a cohort of patients with OUD on opioid agonist therapy (OAT)., Methods: This multi-center prospective cohort study recruited adult patients with OUD on OAT from 57 substance use treatment centers in Ontario, Canada. The study collected substance use outcomes, and classified patients with ≥50 % positive opioid urine screens over one year of follow-up as having poor treatment response. Additional data obtained via linkage with ICES administrative databases evaluated the relationship between HCV status, healthcare service utilization, and death over 3 years of follow-up. Multiple logistic regression models established the adjusted impact of HCV on various outcomes., Results: Among recruited participants (n = 3430), 44.10 % were female with a mean age of 38.64 years (Standard deviation: 10.96). HCV was prevalent in 10.6 % of the cohort (n = 365). Methadone was used most often (83.9 %, n = 2876), followed by sublingual buprenorphine (16.2 %, n = 554). Over the three-year follow-up, 5.3 % of patients died (n = 181). Unadjusted results reveal rates of hospitalization (all-cause, mental-health related, critical care) and emergency department visits (mental health-related), were significantly higher among HCV patients. Associations diminished in adjusted models. Active injection drug use exhibited the highest predictive risk for all outcomes., Conclusion: A high degree of acute physical and mental illness and its resulting health service utilization burden is concentrated among patients with OUD and comorbid HCV. Future research should explore the role for targeted interventions and how best to implement integrated healthcare models to better address the complex health needs of HCV populations who inject drugs., Competing Interests: Declaration of competing interest None. The authors have no declarations of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Paracetamol dosing errors can cause acute liver injury, with potentially toxic doses only slightly above the therapeutic range. This study aimed to characterise unintentional paracetamol overdose reported to an Australian poisons centre, including time trends, demographics, types of dosing errors, and outcomes., Methods: Records regarding paracetamol dosing errors for individuals aged ≥12 years were extracted from the New South Wales Poisons Information Centre database, January 2017 to June 2023. Data from 2021 underwent an in-depth screening of free text case notes to examine: dose, duration, products involved, reasons for ingestion and outcomes including hospitalisation, treatment, liver transplantations and deaths. Where possible, complete outcome data were obtained from medical records of New South Wales hospitalised cases in 2021., Results: There were 14,380 exposures due to paracetamol dosing errors (predominantly self-administered, median age 43 years, 62.6% female), with an average yearly increase of 2.5% (95% CI 1.6-3.8%; p < 0.0001). The in-depth analysis of exposures recorded during 2021 revealed 1899 exposures (median age 46 years, 63.4% female) with 26.8% requiring hospitalisation. Immediate- and modified-release formulations were highly implicated. Multiple paracetamol-containing products were ingested in approximately 20% of exposures. Hospitalised exposures were associated with paracetamol use for dental pain and ingested higher doses for longer durations. Over half of those hospitalised (52%) were treated with the antidote (N-acetylcysteine), and 6% of exposures developed hepatotoxicity., Conclusion: Paracetamol dosing errors continue to occur, with relatively high rates of hospitalisation and liver injury. Many hospitalisations involved use for dental pain. Possible preventative measures include ingredient name prominence and increased education on appropriate dosing., Competing Interests: Declarations Funding Open Access funding enabled and organized by CAUL and its Member Institutions. RC is supported by an NHMRC Investigator Grant (ID: 1196516), NAB is supported by an NHMRC Investigator Grant (ID: 2007726). RC is the recipient of an untied educational grant from Reckitt Benckiser to study over-the-counter medicine poisonings, which includes a PhD stipend for ASC. Conflicts of interest ASC is supported by a PhD scholarship funded by Reckitt Benckiser, as part of an untied educational grant awarded to RC. RC has also received conference speaker fees/honoraria from Reckitt Benckiser and The Pharmacy Guild of Australia. These funders had no role in the design, conduct, or interpretation of the study’s findings. NAB is an Editorial Board member of Drug Safety. NAB was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. FN has no conflicts of interest to be declared. Availability of data and material The data supporting this study’s findings are not publicly available due to the sensitive nature of the contents. Select data is available on request to the NSW Poisons Information Centre. For access, please email rose.cairns@sydney.edu.au Ethics approval This study was approved by the Sydney Children’s Hospitals Network Human Research Ethics Committee (2021/ETH00165). Consent for participation Not applicable. Consent for publication Not applicable. Code availability R code used for the Wilcoxon Rank Sum test is available on request. For access, please email firouzeh.noghrehchi@sydney.edu.au Author contributions RC and NAB contributed to the design of the study. Data cleaning and extraction was performed by ASC. ASC and FN performed the data analysis. The first draft of the manuscript was written by ASC and all authors commented on subsequent versions of the manuscript. All authors read and approved the final version of the manuscript., (© 2024. The Author(s).)

Introduction: The worsening life expectancy of middle-aged White Americans due to suicides and substance overdoses has been hypothesized to be caused by various societal conditions. Work is a social determinant of health, but its role in this demographic shift has not been examined. This article describes the characteristics and trends of suicides and overdose fatalities occurring in U.S. workplaces among all workers between 2011 and 2022., Methods: Data originated from the Census of Fatal Occupational Injury database. Fatality rates were calculated using the Current Population Survey. Fatality rates were calculated and compared among demographic and occupational groups. Annual rates were modeled with a first-order auto-regressive linear regression to account for serial correlation. Analyses were conducted in 2023-2024., Results: Between 2011 and 2022, the rate of workplace overdose fatality rates increased from 0.05 per 100,000 workers to 0.33-an increase of 560%. Workplace suicide rates were relatively stable (0.19 per 100,000 to 0.17). Most industries and occupations experienced significant increases in workplace overdose rates and nonsignificant decreases in workplace suicide rates. The largest workplace overdose rates occurred in the transportation and warehousing industry (0.47, 95% CI=0.27, 0.67) and farming, fishing, and forestry occupations (0.68, 95% CI=0.27, 1.08)., Conclusions: Fatal workplace suicides and substance overdoses have different trends and impact industries, occupations, and demographic groups differently. The rise in workplace overdoses deserve immediate attention., (Published by Elsevier Inc.)

Introduction: As perinatal drug overdoses continue to rise, reliable approaches are needed to monitor overdose trends during pregnancy and postpartum. This analysis aimed to determine the sensitivity, specificity, positive predictive value, and negative predictive value of ICD-9/10-CM codes for drug overdose events among people in the MATernaL and Infant clinical NetworK (MAT-LINK) with medication for opioid use disorder during pregnancy., Methods: People included in this analysis had electronic health record documentation of medication for opioid use disorder and a known pregnancy outcome from January 1, 2014, through August 31, 2021. Data were analyzed during pregnancy through 1 year postpartum. The Centers for Disease Control and Prevention's drug overdose case definitions were used to categorize overdose based on ICD-9/10-CM codes. These codes were compared to abstracted electronic health record data of any drug overdose. Analyses were conducted between May 2023 and May 2024., Results: Among 3,911 pregnancies with electronic health record-documented medication for opioid use disorder, the sensitivity of ICD-9/10-CM codes for capturing drug overdose during pregnancy was 32.7%, while specificity was 98.5%, positive predictive value was 23.4%, and negative predictive value was 99.0%. The sensitivity of ICD-9/10-CM codes for capturing drug overdose postpartum was 30.9%, while specificity was 98.4%, positive predictive value was 25.9%, and negative predictive value was 98.8%., Conclusions: The sensitivity and positive predictive value of ICD-9/10-CM codes for capturing drug overdose compared with abstracted electronic health record data during the perinatal period was low in this cohort of people with medication for opioid use disorder during pregnancy, though the specificity and negative predictive value were high. Incorporating other data from electronic health records and outside the healthcare system might provide more comprehensive insights on nonfatal drug overdose in this population., (Published by Elsevier Inc.)

After years of reductions in the rate of murder in the United States, the national murder rate has increased since 2015. The causes of this trend are generally unknown, though there is some evidence related to narcotic drugs. Arrests related to heroin and cocaine had been stable between 2010 and 2014 before a sudden increase in 2015. Likewise, the number of murders related to narcotic drugs has increased since 2013, with a jump in 2015. Increased rates of these crimes parallel recent dramatic growth in overdoses involving heroin. However, the causal relationship between the recent opioid crisis and the rise in murder rates is missing from the literature. I used OxyContin reformulation as an exogenous shock to illicit markets. OxyContin reformulation led some people who misused OxyContin to switch to illicit opioids. Previous work has shown that areas with higher rates of OxyContin misuse experienced faster growth in heroin overdoses post-reformulation. I tested whether this growth in illicit drug use caused an increase in crime. After reformulation, I find significantly greater relative increases in murder rates in states with high pre-reformulation rates of OxyContin misuse. The results support a causal link between the opioid epidemic and crime., (© 2024 The Author(s). Health Economics published by John Wiley & Sons Ltd.)

Study Objective: Addition of illicitly manufactured fentanyl to the opioid and nonopioid illicit drug supply has exacerbated the drug overdose crisis in the United States. People who use drugs are often unaware that their drugs contain fentanyl. Awareness about fentanyl adulteration may be protective against fatal overdose., Methods: We performed a cross-sectional study of a convenience sample of emergency department (ED) patients who presented with illicit drug-related complaints from April 2022 to January 2024 in New York City, NY. Patients were surveyed about their drug use and provided urine samples for fentanyl testing. Results were analyzed according to the patient's intention of using opioids versus only nonopioid substances., Results: Of 338 eligible patients, we enrolled 229 (68% acceptance, men: 78%, mean age: 43 years [SD=12.2], Hispanic/Latino: 57%), with 53% (121/229) and 47% (108/229) intending to use opioids and only nonopioid substances, respectively. Among patients who used opioids and provided urine, 89% (86/97) samples were positive for fentanyl, including 90% (27/30) fentanyl positivity among those who did not believe that they were using fentanyl. Among those intending to use only nonopioids, 24% (23/94) urine samples were positive for fentanyl., Conclusions: Many drug-related ED visits involved fentanyl exposure, even when individuals did not believe they were using fentanyl. Knowledge of fentanyl adulteration can inform people who intend to use opioid and/or nonopioid drugs about harm reduction approaches, such as distribution of fentanyl test strips and educational interventions., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The breadth of the overdose crisis is underestimated because of a lack of quantifying nonfatal overdoses. We estimate the proportion of nonfatal overdoses among all people with HIV (PWH) in British Columbia, Canada, and the prevalence of fatal overdoses among people who had a nonfatal overdose, stratified by sex. A small proportion of PWH who experienced a nonfatal overdose subsequently died of a fatal overdose, signaling opportunities for crucial interventions and treatment to prevent overdose death., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

The US opioid overdose epidemic has been a major public health concern in recent decades. There has been increasing recognition that its etiology is rooted in part in the social contexts that mediate substance use and access; however, reliable statistical measures of social influence are lacking in the literature. We use Facebook's social connectedness index (SCI) as a proxy for real-life social networks across diverse spatial regions that help quantify social connectivity across different spatial units. This is a measure of the relative probability of connections between localities that offers a unique lens to understand the effects of social networks on health outcomes. We use SCI to develop a variable, called "deaths in social proximity", to measure the influence of social networks on opioid overdose deaths (OODs) in US counties. Our results show a statistically significant effect size for deaths in social proximity on OODs in counties in the United States, controlling for spatial proximity, as well as demographic and clinical covariates. The effect size of standardized deaths in social proximity in our cluster-robust linear regression model indicates that a one-standard-deviation increase, equal to 11.70 more deaths per 100,000 population in the social proximity of ego counties in the contiguous United States, is associated with thirteen more deaths per 100, 000 population in ego counties. To further validate our findings, we performed a series of robustness checks using a network autocorrelation model to account for social network effects, a spatial autocorrelation model to capture spatial dependencies, and a two-way fixed-effect model to control for unobserved spatial and time-invariant characteristics. These checks consistently provide statistically robust evidence of positive social influence on OODs in US counties. Our analysis provides a pathway for public health interventions informed by social network structures. The statistical robustness of our primary variable of interest, deaths in social proximity, supports the hypothesis of a social network effect on OODs. Using agent-based modeling (ABM) to simulate social networks can offer an effective method to design interventions that incorporate the dynamics of social networks for maximum impact., Competing Interests: Competing interests: K.T. has been an associate specialist at Merck Sharp & Dohme LLC from May to August 2023. M.A.R. has served on the advisory committee of a vaccine confidence fund created by Meta and Merck; some of his research has also been funded by Meta. The other authors declare no competing interests., (© 2024. The Author(s).)

Background: An online mail order naloxone and harm reduction supply program was created by an interdisciplinary team at the University of Rhode Island College of Pharmacy and hosted on the university website (UNIV). The program was subsequently funded by the Rhode Island Department of Health (DOH) and added to the DOH website. This study compares demographic characteristics of the two populations submitting requests through the program's distinct access points, UNIV and DOH, to those of populations at-risk for overdose., Methods: This is a retrospective comparative analysis using voluntarily provided information from mail order request forms submitted through two websites from June 2020 through October 2023. The primary objective was to compare demographic characteristics of requesters through the two access points to those of individuals at-risk for experiencing or responding to an overdose. Descriptive statistics were used to characterize the two distinct populations. Chi-square tests were performed to determine if statistically significant differences in population demographics existed between access points. Odds ratios were estimated using a simple logistic regression model to assess the relationship between access point and demographic characteristic to determine if either access point had a greater likelihood of reaching individuals with at-risk demographics., Results: A total of 5,783 (UNIV = 1662; DOH = 4121) mail order request forms were included in the analysis. Participants who completed requests through UNIV were more likely to be 44 years old or younger and/or reside in rural areas. Participants who submitted requests through DOH were more likely to reside in non-rural and/or low-income areas, and/or identify as gender minorities. Additionally, UNIV respondents were more likely to be first-time naloxone requesters while DOH respondents were more likely to have obtained and used naloxone before., Conclusions: Results establish that different access points can reach different at-risk population subsets and support the use of multiple access points and advertising strategies to expand the reach of online mail order harm reduction programs., Study Registration: The study was retrospectively approved by the University of Rhode Island Institutional Review Board (IRB reference #2124391-2)., Competing Interests: Declarations Ethics approval and consent to participate This study uses previously captured, voluntarily-provided data and was approved by the University of Rhode Island Institutional Review Board (IRB reference #2124391-2). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Objectives: We aimed to determine the prevalence of self-reported naloxone use during pregnancy among people in the United States with a recent live birth. A secondary objective was to characterize people at increased risk of overdose who did and did not use naloxone., Methods: We analyzed data from the Pregnancy Risk Assessment Monitoring System from 26 US jurisdictions that conducted an opioid supplement survey from 2019 to 2020. Respondents with increased risk of experiencing an opioid overdose were identified based on self-reported use of illicit amphetamines, heroin, cocaine, or receiving medication for opioid use disorder (MOUD) during pregnancy. Weighted prevalence estimates and 95% confidence intervals were calculated for reported naloxone use at any point during pregnancy among people with an increased risk of overdose., Results: Naloxone use during pregnancy was reported by <1% of the overall study population (unweighted N = 88/34,528). Prevalence of naloxone use was 5.0% (95% CI: 0.0-10.6) among respondents who reported illicit amphetamine use, 15.2% (1.8-28.6) among those who reported heroin use, and 17.6% (0.0-38.1) among those who reported cocaine use. Naloxone use was 14.5% (8.4-20.6) among those who reported taking MOUD. Among people with increased risk of overdose, no significant differences in naloxone use were observed by age, race/ethnicity, education level, residential metropolitan status, or insurance status., Conclusions: Prevalence of naloxone use among people with an increased risk of overdose during pregnancy ranged from 5.0% to 17.6%. Access to naloxone, overdose prevention education, and treatment for substance use disorders may help reduce morbidity and mortality., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Drug overdose deaths increased by 50 % between 2017 and 2021 in San Francisco. Little is known about non-fatal overdose, which heralds future risk for morbidity and overdose death. We assessed non-fatal overdose, access to drug treatment, and overdose prevention service utilization among people who inject drugs (PWID) in San Francisco in 2022., Methods: Data were from the National HIV Behavioral Surveillance (NHBS), a cross-sectional survey among PWID recruited by respondent-driven sampling from June-December 2022. Participants self-reported their experience of overall overdose. Logistic regression analysis identified factors associated with non-fatal overdose., Results: Of 521 PWID, 120 (23.0 %) experienced non-fatal overdose; 207 (39.7 %) frequently injected methamphetamine and 175 (33.6 %) frequently injected heroin in the past 12 months. PWID who experienced non-fatal overdose were more likely to reside in the low-income neighborhoods (25.9 % vs. other neighborhoods 16.8 %, p = 0.022) in the past 12 months. Less than half (43.7 %) of PWID who experienced non-fatal overdose received overdose treatment. Compared to those who did not try to access treatment, adjusted odds of non-fatal overdose was 1.89 times higher among PWID who attempted to access drug treatment but were unable to (p = 0.035, 95 % CI 1.05-3.43); and 1.86 times higher among PWID who attempted to obtain medications to treat drug use but were unable to in the past 12 months (p = 0.049, 95 % CI: 1.00-3.43)., Conclusions: Non-fatal overdose was highly prevalent among PWID, including those who frequently inject stimulants. Public health surveillance will need to be vigilant in monitoring stimulant use and tracking fentanyl contamination in non-opioid drugs. PWID who were most engaged in harm reduction practices were also the most likely to experience non-fatal overdose. Expansion of substance use and overdose treatment, naloxone, fentanyl test strips, and safe drug use education are needed to reduce risk of overdose deaths among PWID., Competing Interests: Declaration of competing interest The authors have no conflicts of interest including financial or non-financial., (Copyright © 2024. Published by Elsevier B.V.)

Background: Acetaminophen and ibuprofen are the most common agents involved in adolescent self-poisoning. With increasing suicidality observed during the COVID-19 pandemic, we sought to compare overdose trends, severity, and outcomes for both agents., Methods: We performed a retrospective analysis of the National Poison Data System for acetaminophen and ibuprofen single-substance exposures in teenagers 13-19 years of age from 2017-2022. Acetaminophen and ibuprofen overdoses (per 100,000 persons) were plotted by year. Medical outcomes, clinical effects, and therapies were compared to determine if there were differences in overdose severity between the 2 agents., Results: From 2017 to 2022, US poison centers recorded 50,902 single-substance acetaminophen exposures and 41,674 single-substance ibuprofen exposures in teenagers. Cases peaked in 2021 with 40.0 versus 29.1 cases (per 100,000 persons) for acetaminophen and ibuprofen, respectively. Acetaminophen self-poisoning was significantly more likely to result in death (odds ratio, 13.92; 95% confidence interval, 2.18-581.75; P < 0.001) or inpatient admission (odds ratio, 7.38; 95% confidence interval, 7.10-7.66; P < 0.001) compared with ibuprofen. Abdominal pain and vomiting were the most common clinical effects for both agents, and unsurprisingly, acetaminophen was more likely to cause transaminitis and liver dysfunction, whereas ibuprofen was more likely to cause central nervous system depression and metabolic acidosis. For the acetaminophen group, 19 teenagers underwent organ transplantation., Conclusions: Given the increased hospitalization and treatment resources needed for acetaminophen overdoses compared with ibuprofen, it is time to implement acetaminophen packaging policy change to protect US adolescents., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: According to the U.S. Centers for Disease Control and Prevention, approximately 10.2 % of fatal overdoses in 2022 were among people experiencing homelessness or housing instability. In the United States, the majority of all drug overdoses now involve stimulants., Methods: We linked stimulant-involved fatal overdose records occurring between 2017 and 2021 from Kentucky's Drug Overdose Fatality Surveillance System to the electronic health records (EHR) of the state's largest safety-net hospital network. We used State Unintentional Drug Overdose Reporting System (SUDORS) definitions of homelessness or housing instability to establish baseline estimates before linking decedents to medical records. After linkage, we augmented SUDORS data with structured administrative billing codes, semi-structured address data, and unstructured clinical notes identifying homelessness from the EHR., Results: There were 313 individuals with stimulant-involved fatal overdoses linked to at least one medical encounter in the EHR (2017-2021). Thirty-three individuals (10.5 %) were identified as having unstable housing according to SUDORS. After linkage, 130 individuals (41.5 %) had evidence of housing instability. For this period, these 313 individuals represent 8.0 % of stimulant-involved overdoses in KY or 38.5 % of stimulant-involved overdoses from residents of the primary and secondary catchment area of our healthcare network., Conclusions: The single-site increase in observed housing instability in stimulant-involved fatal overdoses suggests that increased data linkage between state medicolegal death investigation system and EHRs would significantly improve the public health surveillance of overdoses., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024. Published by Elsevier B.V.)

Overdose fatality review teams (OFRTs) are becoming more common across U.S. communities as a means of addressing the overdose epidemic and improving local overdose prevention strategies; however, empirical examinations of the work of OFRTs are lacking. The current study seeks to characterize recommendations for local overdose prevention strategies made by county-level OFRTs across Indiana in order to understand their practices., Methods: A qualitative descriptive content analysis was conducted on recommendations made by 19 county-level OFRTs across Indiana in 2022., Results: OFRTs generated 1512 recommendations during 2022 based on case reviews of 291 overdose deaths occurring across 19 Indiana counties; of those, 26.8 % (n=405) were specific to the case reviewed, rather than relevant to the broader community, and were not further coded. The remaining 1109 recommendations were coded according to their overall scope, recommendation strategy, and target agency. The most common recommendations addressed substance use more broadly (e.g., improving substance use screening/assessment in healthcare settings), followed by recommendations directly addressing overdose risk (e.g., naloxone distribution, increasing harm reduction programs). Other common recommendations related to mental health, OFRT practices, and addressing social determinants of health. Common recommendation strategies were to implement new services or service improvements., Conclusion: Results highlight the extent of further efforts needed to improve overdose prevention and the need for further research and support of OFRTs across the United States., Competing Interests: Declaration of Competing Interest Authors have no conflict of interest to disclose., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: The United States faces an ongoing drug overdose crisis, but accurate information on the prevalence of opioid use disorder (OUD) remains limited. A recent analysis by Keyes et al used a multiplier approach with drug poisoning mortality data to estimate OUD prevalence. Although insightful, this approach made stringent and partly inconsistent assumptions in interpreting mortality data, particularly synthetic opioid (SO)-involved and non-opioid-involved mortality. We revise that approach and resulting estimates to resolve inconsistencies and examine several alternative assumptions., Methods: We examine 4 adjustments to Keyes and colleagues' estimation approach: (A) revising how the equations account for SO effects on mortality, (B) incorporating fentanyl prevalence data to inform estimates of SO lethality, (C) using opioid-involved drug poisoning data to estimate a plausible range for OUD prevalence, and (D) adjusting mortality data to account for underreporting of opioid involvement., Results: Revising the estimation equation and SO lethality effect (adj. A and B) while using Keyes and colleagues' original assumption that people with OUD account for all fatal drug poisonings yields slightly higher estimates, with OUD population reaching 9.3 million in 2016 before declining to 7.6 million by 2019. Using only opioid-involved drug poisoning data (adj. C and D) provides a lower range, peaking at 6.4 million in 2014-2015 and declining to 3.8 million in 2019., Conclusions: The revised estimation equation presented is feasible and addresses limitations of the earlier method and hence should be used in future estimations. Alternative assumptions around drug poisoning data can also provide a plausible range of estimates for OUD population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)

Objectives: The number of drug overdoses and drug-related deaths has increased across the United States in recent years. Reports of suspected opioid drug overdoses identified through emergency medical services (EMS) are valuable sources of information for shaping the public health response to drug overdoses. The objective of this study was to describe trends in the number of EMS-reported suspected opioid drug overdose events in South Carolina from 2019 through 2022., Methods: We included reports of suspected opioid drug overdoses if they met the definition of nonfatal opioid overdose syndrome in our analysis. We analyzed statewide data reported from EMS agencies to biospatial, Inc, from January 2019 through December 2022 to understand demographic trends for a statewide overdose and response program in South Carolina., Results: In 2022, a total of 11 078 suspected opioid drug overdose events, or 216.4 per 100 000 South Carolina residents, were reported by EMS. During the 4-year study period, the number of EMS-reported suspected opioid drug overdoses increased by 82%, with African American people experiencing a 133% increase and White people experiencing a 68% increase. The number of opioid overdoses increased among all age groups during the study period. Approximately 84% of opioid overdoses were reported in urban counties, but rural counties had a higher number of opioid overdose reports per capita than urban counties., Conclusions: Monitoring trends in suspected opioid drug overdoses allows decision makers to adjust resources and programs for overdose response and is essential for local coordinated response. Continued monitoring of trends is needed for an equitable response to prevent opioid drug overdoses., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.