Search

Drug overdose deaths have reached record-breaking levels in North America. Drug checking services (DCS) provide localized information on the contents of drugs to individuals and communities. Depending on the design, individuals can submit drug samples for onsite "real-time" testing or offsite testing. The results can shed light on emerging drugs in the community and support ongoing prevention and surveillance efforts. We sought to describe and report aggregate outcomes of DCS operating in North America. The North American Drug Checking Survey was launched in 2022 to characterize and monitor DCS operating in the region. Sixteen organizations from the US (n = 9), Canada (n = 5), and Mexico (n = 2) responded to the survey. Each organization reported on their program's operations and provided service delivery outcomes (site- or program-level) in the aggregate. Participating organizations reported testing a total of 49,786 drug samples between 2014 and 2022. DCS were run by community-led organizations (44%), health departments (25%), universities (19%), or clinical/private laboratories (19%). The types of samples tested differed between programs (e.g., solids vs. liquids, drug paraphernalia accepted). While most organizations tested onsite using fentanyl test strips (88%) and Fourier-transform infrared (FTIR) spectroscopy (63%), many sent samples offsite for confirmatory testing (63%), most often with mass spectrometry. Common facilitators of operating a DCS included: interest of clients (69%), interest of service providers (63%), and receiving external technical assistance (63%). Barriers included: the lack of funding (81%) or staff (50%), gaps in technical expertise (38%), as well as laws banning the possession and/or distribution of illicit drug samples, drug paraphernalia, or drug checking equipment (38%). DCS are scaling up in North America. Given the evolving and localized nature of illicit drug supplies, supporting the establishment and operations of DCS could enhance the public's understanding of local drug supplies to reduce drug-related harms over time. [ABSTRACT FROM AUTHOR]

Policy PointsThis article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots.In order to successfully reduce drug‐related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. Context: Drug overdose is the leading cause of injury‐related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. Methods: In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. Findings: De‐escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. Conclusions: Without recognizing the full drug‐use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve. [ABSTRACT FROM AUTHOR]

Aims: To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW‐IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition. Design Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study. Setting: Baltimore, MD, USA Participants: One hundred and eighty FSW‐IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married. Measurements Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio‐demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural‐level factors included methods of syringe access. Findings Nearly all FSW‐IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW‐IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi‐level mixed‐effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09–4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98–4.85), being injected by others (aOR = 4.95, 95% CI = 2.42–10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94–3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21–8.90). Conclusions: Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs. [ABSTRACT FROM AUTHOR]

Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system. [ABSTRACT FROM AUTHOR]

Background: Police violence is a deleterious public health and criminal justice issue that disproportionately affects people who inject drugs (PWID). Studies documenting the prevalence and correlates of physical police violence in this population are rare. The aim of this study was to examine the correlates of past year physical police violence among an urban sample of PWID.Methods: PWID participating in the 2015 wave of the National HIV Behavioral Surveillance (NHBS) system in Baltimore City, Maryland, completed a socio-behavioral survey. Multivariable logistic regression was used to detect the socio-demographic, place-based, law-enforcement and health behavior correlates of exposure to police violence as well as knowledge of violence directed towards other PWID.Results: Enrolled PWID (N = 570) were mostly male (72%), non-Hispanic Black (77%) and daily heroin injectors (86%). Seven percent had experienced past year physical police violence (Respondent-Driven Sampling [RDS] weighted estimate: 4%), and a quarter (24%) knew someone who had experienced physical police violence in the past year (RDS-weighted estimate: 17%). Male gender, homelessness, arrest, drug paraphernalia confiscation, and receptive syringe sharing were independently associated with police violence. Knowing someone who had experienced police violence was independently correlated with selling drugs, arrest, and attending a syringe services program.Conclusion: Population differences in the extent of police violence exposure indicate that experiences of police violence are not uniform among PWID. Violent encounters with police were associated with disruptions in harm reduction strategies that can prevent HIV and HCV transmission. This study adds to the small body of public health literature on police violence and highlights the importance of monitoring and addressing this critical issue. [ABSTRACT FROM AUTHOR]

The spaces in which drug use occurs constitutes a key aspect of the "risk environment" of people who inject drugs (PWID). We aimed to add nuance to the characterization of "safe" and "unsafe" spaces in PWID's environments to further understand how these spaces amplify the risk of morbidities associated with injection drug use. PWID were recruited through the Baltimore City syringe service program and through peer referral. Participants completed a socio-behavioral survey. Multivariable logistic regression was used to identify associations between utilization of public, semi-public and private spaces with arrest, non-fatal overdose, and receptive syringe sharing. The sample of PWID (N = 283) was mostly 45 years and older (54%), male (69%), Black (55%), and heroin users (96%). Compared to PWID who primarily used private settings, the adjusted odds of recent overdose were greater among PWID who mostly used semi-public and public locations to inject drugs. We also found independent associations between arrest and semi-public spaces, and between receptive syringe sharing and public spaces (all p < 0.05). This study highlights the need for safe spaces where PWID can reduce their risk of overdose, likelihood of arrest and blood-borne diseases, and the dual potential of the environment in promoting health and risk. [ABSTRACT FROM AUTHOR]

Background: Drug overdose deaths remain the primary cause of unintentional injuries in the United States. We examined the validity of a fentanyl test strip (FTS) in detecting fentanyl and its related analogs in water-based illicit drug solutions.Methods: Illicit drugs obtained from law enforcement (N = 343) were tested using a lateral flow chromatographic immunoassay FTS (BTNX Rapid Response) and Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) at a clinical chemistry laboratory in Baltimore, Maryland.Results: The FTS assay detected fentanyl at 200 ng/ml in water, and 13 additional fentanyl analogs, but failed to detect carfentanil and furanyl fentanyl at or below 1000 ng/ml. Overall sensitivity and specificity for detecting fentanyls was 98.5 % and 89.2 %; and the false negative and positive rate was 1.5 % and 10.9 %. False negatives (n = 2) occurred in fentanyl and a fentanyl precursor. False positives (n = 23) occurred in the presence of other illicit drugs and compounds (56.5 %) or when fentanyls were present below 40 ng/ml (43.5 %). False positive/negative rates remained low when testing cocaine and prescription opioid (PO) samples.Conclusions: FTS is a valid drug checking tool, however, rapid immunoassays and other drug checking instruments that can detect a wider range of fentanyl analogs including carfentanil need to be prioritized to minimize accidental exposure to the full spectrum of fentanyls. [ABSTRACT FROM AUTHOR]

Background: Fentanyl test strip (FTS) programs are designed to promote fentanyl awareness and reduce overdose risk by providing people who use drugs (PWUD) with a method of testing drugs for the presence of fentanyl prior to use. In 2018, two large syringe services programs (SSP) in the U.S. Mid-Atlantic-one in Baltimore City, Maryland and one in the state of Delaware-began distributing FTS. We evaluated the implementation of these programs.Methods: A convenience sample of SSP clients was surveyed in Baltimore City (urban) and Delaware (urban, suburban and rural) to assess FTS utilization patterns and drug use behaviors. Data were collected and analyzed in 2019.Results: We surveyed N = 123 PWUD in Baltimore and N = 102 in Delaware. Collectively, 20,000 strips were distributed over six months. In both locations, high FTS utilization was reported (70% in Baltimore; 77% in Delaware) and clients reported testing a range of drugs including heroin, fentanyl and cocaine. Following utilization, 23% and 69% of respondents in Baltimore and Delaware adopted risk reduction behaviors (e.g., using less than intended, going slower, doing tester shot, asking someone to check on them). When asked about their level of interest in future FTS use, 49% and 74% reported being interested or very interested, respectively.Conclusion: Our findings demonstrate that FTS programs could be helpful in promoting fentanyl awareness and risk reduction among PWUD and in monitoring the evolving drug supply in areas where comprehensive community-based drug checking programs have not been established. [ABSTRACT FROM AUTHOR]

Background: U.S. research examining the illicit drug supply remains rare even though the information could help reduce overdoses. Relatively little is known regarding how often opioids are found in stimulants and whether temporal and geographic trends exist. We examined trends in fentanyl-cocaine and fentanyl-methamphetamine combinations in the national illicit drug supply.Methods: We analysed serial cross-sectional data from the National Forensic Laboratory Information System (NFLIS) collected between January 2011 and December 2016. We restricted the analysis to cocaine (N = 1,389,968) and methamphetamine (n = 1,407,474) samples and calculated proportions containing fentanyl (including 23 related analogs) over time.Results: The combined presence of fentanyl and cocaine steadily increased nationally between 2012-2016 (p = 0.01), and the number of such samples tripled from 2015 to 2016 (n = 423 to n = 1,325). Similarly, the combined presence of fentanyl and methamphetamine increased 179 % from 2015 to 2016 (n = 82-n = 272). Patterns varied widely by state; in 2016, fentanyl-cocaine samples were most common in New Hampshire (7.2 %), Connecticut (5.4 %), Ohio (2.6 %) and Massachusetts (2.1 %), whereas fentanyl-methamphetamine samples were most often in New Hampshire (6.1 %), Massachusetts (5.6 %), Vermont (2.4 %) and Maine (1.2 %).Conclusions: Although relatively uncommon, the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occuring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast. Given these trends, strengthening community-based drug checking programs and surveillance within the public health infrastructure could help promote timely responses to novel threats posed by rapid shifts in the drug supply that may lead to inadvertent exposures. [ABSTRACT FROM AUTHOR]

Background: In 2018, there were over 67,000 drug overdose deaths in the United States, with almost half involving illicit fentanyl and other synthetic opioids. While overall age-adjusted drug overdose deaths decreased by 4.6% from 2017 to 2018, synthetic opioid deaths increased 10.0%. This pilot study evaluates the impact of a brief fentanyl test strip (FTS) intervention to increase fentanyl awareness and reduce overdose risk.Methods: Female sex workers (FSW) reporting past month illicit opioid use were recruited between April 2018 through February 2019 in Baltimore City, Maryland. At baseline, they completed a baseline survey, and received tailored harm reduction messaging, 5 FTS and training, and a naloxone kit, then completed a survey after one month. McNemar's test was used to compare repeated measures.Results: Among N = 103, 54% were <40 years, 59% were white, and 24% had overdosed in the past year. Among 68 who completed follow-up, most (84%) used ≥1 FTS to test their drugs, 86% had ≥1 fentanyl-positive result, 57% were surprised by the result, and 69% engaged in harm reduction behaviors following the result (e.g., asked someone to check on them, did a tester shot, used a smaller amount). Significant pretest-posttest reductions in daily illicit opioid use (77% to 56%; p = 0.003), injection frequency (40% to 25%; p = 0.004), benzodiazepine use (22% to 7%; p = 0.008), and solitary drug use (96% vs. 68%; p < 0.001) were observed. No change in preferring drugs containing fentanyl was found. Some (18%) gave their FTS to others. All but three (96%) reported being likely to use FTS in the future.Conclusions: We found high FTS acceptability and reductions in drug use frequency and solitary drug use following FTS use among FSW who use drugs in Baltimore. These findings demonstrate that FTS-based interventions hold potential in reducing overdose risk. [ABSTRACT FROM AUTHOR]

Background: Street-based female sex workers (FSW) often cycle in and out of sex work engagement. For many FSW, substance use plays a critical role in sex work entry, continuation, and interruptions. We examined individual, interpersonal, and structural correlates of short-term interruptions of sex work among street-based FSW in an urban environment.Methods: Data were from 205 FSW in Baltimore, MD, USA followed as part of an observational prospective cohort study between April 2016-Februrary 2018. The primary outcome was short-term interruptions of sex work (stopping sex work) over the past 3 months, asked every 3 months over a 12-month follow-up. We assessed the relationship between individual, structural, and interpersonal factors for each woman's prior visit and current visit with short-term sex work interruptions. We employed modified Poisson regression with Generalized Estimating Equations to identify correlates of short-term interruptions of sex work.Results: Eighty-two women (40%) reported stopping sex work over the past 3 months at least once during follow-up. Past drug treatment (adjusted incidence rate ratio [aIRR] 1.40; 95% CI: 1.06-1.86) and not having used drugs in the past 3 months (aIRR 2.70; 95% CI: 1.96-3.71) were positively associated with short-term interruption to sex work. Past intimate partner violence (IPV) (aIRR 0.52; 95% CI: 0.31-0.86) and current homelessness (aIRR 0.61; 95% CI: 0.41-0.91) were negatively associated with short-term interruption. Results were inconclusive for the association between recent prostitution arrest and short-term interruptions to sex work (IRR 0.86; 95% CI: 0.40-1.86).Conclusion: The study suggests that similar to other professions, women leave sex work for numerous reasons. Substance use cessation and participation in drug treatment programs may contribute to short-term interruptions of sex work by reducing reliance on sex work for income among street-based FSW. Structural vulnerabilities including homelessness and IPV are driving continued street-based sex work, speaking to the need for holistic structural interventions. [ABSTRACT FROM AUTHOR]

Introduction: Despite rising morbidity and mortality from the opioid epidemic and other addictions, people who inject drugs (PWID) remain understudied regarding pain outcomes. Data among PWID regarding chronic pain and drug use, including non-medical use of opioids, is largely unknown. We examined the prevalence of chronic pain and drug use for pain in this population.Methods: Standardized surveys captured self-report of demographics, chronic pain, and non-prescription drug use in 203 PWID in an urban syringe services program between April and November 2016. Chronic pain was defined as self-report of chronic pain diagnosis or persistent pains over the past 6 months.Results: Overall, 47% (95% CI, 40%-54%) of PWID reported chronic pain, while 35% (95% CI, 29%-42%) reported non-prescription drug use of any type for pain. Among those with chronic pain, drug use to treat pain was commonly reported (76%; 95% CI, 66%-83%). Non-medical opioid use did not differ among PWID with or without chronic pain or drug use for pain. A multivariable logistic regression model showed chronic pain was more likely among non-Hispanic whites and those with arthritis, older age, and homelessness.Conclusions: Chronic pain serves as an important factor in the persistence of drug use in more than one-third of PWID in this sample. The high prevalence of chronic pain with drug use for pain suggests that proper pain management is likely to be an essential component of preventing or regressing injection drug use in PWID, with data needed on effective interventions for this population. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic disrupted healthcare and substance use services engagement, including primary and mental health services as well as residential and outpatient drug treatment. Women who inject drugs (WWID) face known barriers to healthcare and substance use service engagement, which pre-date the COVID-19 pandemic. The impact of COVID-19 on WWID's engagement with healthcare and substance use services, however, remains understudied. Methods: To explore the impact of the COVID-19 pandemic on service-seeking and utilization, we conducted in-depth interviews with 27 cisgender WWID in Baltimore, Maryland, in April–September 2021. Iterative, team-based thematic analysis of interview transcripts identified disruptions and adaptations to healthcare and substance use services during the COVID-19 pandemic. Results: The COVID-19 pandemic disrupted service engagement for WWID through service closures, pandemic safety measures restricting in-person service provision, and concerns related to contracting COVID-19 at service sites. However, participants also described various service adaptations, including telehealth, multi-month prescriptions, and expanded service delivery modalities (e.g., mobile and home delivery of harm reduction services), which overwhelmingly increased service engagement. Conclusion: To build upon service adaptations occurring during the pandemic and maximize expanded access for WWID, it is vital for healthcare and substance use service providers to continue prioritizing expansion of service delivery modality options, like telehealth and the provision of existing harm reduction services through alternative platforms (e.g., mobile services), that facilitate care continuity and increase coverage. [ABSTRACT FROM AUTHOR]

Background and aims: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). Design: A cross‐sectional qualitative study, including telephone and face‐to‐face in‐depth interviews. Setting: Baltimore City, MD, USA. Participants: Twenty‐seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April–September 2021). Measurements Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. Findings Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces. Conclusions: WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone. [ABSTRACT FROM AUTHOR]

Drug checking is a harm reduction strategy that provides greater awareness and information about the drug supply to the community. While fentanyl test strips are low-cost and available in most parts of the U.S., community-based organizations are considering using more sophisticated technologies, such as Fourier-transform infrared (FTIR) spectroscopy to test drugs. FTIR can detect multiple substances in a non-destructive manner that can be rapidly communicated to the program client by a trained technician, however implementation costs in community-based settings have not been assessed. We conducted a costing analysis of a new pilot drug checking service that employed an FTIR spectrometer, fentanyl test strips and confirmatory testing in Rhode Island from January 2023-May 2023. We used microcosting methods to determine the overall cost during this period and cost per drug checked, reflecting realistic service capacity. Among 101 drug samples that were voluntarily submitted and tested, 53% tested positive for fentanyl, 39% for cocaine, 9% for methamphetamine and 13% for xylazine, a powerful sedative. The total cost during this period was $71,044 and the cost per drug checked was $474, though sensitivity analyses indicated that the cost would rise to $78,058 - $83,058 or $544 - $593 for programs needing to pay for specialized training. These findings demonstrate feasibility and inform the resources needed to scale-up drug checking services to reduce overdose risk. • Drug checking using Fourier-transform infrared spectroscopy, test strips, and mass spectrometry cost $474 per sample • FTIR-related and confirmatory testing accounted for most of the startup costs (77%). • 53% of 101 samples submitted tested positive for fentanyl and 13% for xylazine. [ABSTRACT FROM AUTHOR]

Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland’s Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state’s response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States. [ABSTRACT FROM AUTHOR]

Substance use disorder (SUD) and infectious disease (ID) care integration may lead to improvements in SUD and ID outcomes. We assessed implementation of integrating peer-supported SUD care in an outpatient ID setting. In this implementation study, we describe REcovery in Specialty care Through medication and OutREach (RESTORE), a low-threshold SUD program implemented in a Baltimore outpatient ID clinic. Key program components were clinician training and support in SUD care, prescription of SUD treatment medications, and peer-based psychosocial support provided by peer recovery specialists. We assessed clinician adoption of RESTORE and compared patient outcomes from baseline to 6 months. Between January 2019 and January 2022, the number of ID clinicians (N=61) who prescribed buprenorphine increased eightfold from 3 (5%) to 24 (39%). Of 258 ID patients referred to RESTORE, 182 (71%) engaged, 137 consented to study participation. Mean age in the study sample was 52.1 (SD=10.4), 63% were male, 84% were Black/African-American. Among 127 (93%) who completed 6-month follow-up, fewer participants reported illicit/non-prescribed opioid use in the past 30 days at follow-up (32%) compared to baseline (52%; p<0.001). Similar reductions were noted for cocaine use (47% to 34%; p=0.006), emergency department visits (23% to 9%; p=0.002), and inpatient hospitalizations (15% to 7%; p=0.025). SUD care integration into an outpatient ID care setting using a peer-supported implementation strategy was adopted by clinicians and improved clinical outcomes for patients. This strategy is a promising approach to treating people with infectious diseases and SUD. [ABSTRACT FROM AUTHOR]

Background: The opioid crisis remains a major public health issue in the US and beyond. Despite rapid rises in fentanyl-related mortality nationally, little is known about the role of fentanyl in the occurrence of non-fatal overdose among people who use drugs. We examined the prevalence of non-fatal overdose and perceived fentanyl exposure among syringe services program (SSP) clients and modeled the correlates of non-fatal overdose. Methods: Data were drawn from a cross-sectional survey of 203 SSP clients in Baltimore, MD recruited in 2016. Logistic regression models were used to identify the correlates of experiencing non-fatal overdose in the past 12 months. Results: The majority (65%) was male, 52% were black, 41% were white, and 37% were homeless. Almost all (97%) used heroin, 64% injected heroin with cocaine (i.e., speedball), and many used other types of drugs. Half (53%) perceived fentanyl presence in their drugs either half, most or all of the time. Lifetime and past 12 month prevalence of non-fatal overdose were 58 and 31%, respectively. Independent correlates of non-fatal overdose in the past 12 months were perceiving fentanyl in drugs more than half the time (aOR = 2.79; 95% CI = 1.00–4.68), speedball injection (aOR = 2.80, 95% CI = 1.26–6.23), non-prescription buprenorphine use (aOR = 6.37; 95% CI = 2.86–14.17), and homelessness (aOR = 3.07; 95% CI = 1.28–7.39). Conclusions: These data demonstrate that SSP clients are at high-risk of overdose, some of which is likely attributable to fentanyl exposure. Addressing the rising fentanyl epidemic will require comprehensive and innovative strategies that attend to drug use patterns and structural factors such as homelessness. [ABSTRACT FROM AUTHOR]