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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).)

In the last decade, the opioid overdose epidemic has been exacerbated by the emerging drug of abuse, xylazine. This veterinary anesthetic, an alpha-2 agonist, not only potentiates the fatal effects of opioids but also causes toxic endothelial effects. This review aims to assess the impact of xylazine use and overdoses within the context of the opioid crisis as a public health issue. The research used data from scientific publications, state health reports, and analyses from the Institute of Forensic Sciences of Puerto Rico. The databases PubMed, Google Scholar, and Scopus were searched for relevant publications. The search strategy employed two groups of terms: the drug of interest (xylazine) and types of exposure (drug use, overdose, substance abuse, etc.). The initial search in PubMed was then extrapolated, and the search terms were adjusted for appropriate database syntax. According to the most recent publications and CDC data in the USA, approximately 95 % of fentanyl overdose cases involve xylazine, while the other 5 % of overdose cases are attributed solely to xylazine, predominantly administered intravenously. In the last four years, more than 4000 overdose deaths have been related to xylazine use; the northeastern United States had reported the most significant number of deaths. This number changes daily as reanalysis results and new data are published. Less than 50 % of states perform tests for xylazine detection or maintain statistical monitoring of overdoses related to this drug. The absence of testing impedes emergency room physicians from making accurate diagnoses, increasing the likelihood of fatal overdoses. This review highlights five major concerns: (1) The recognition of intoxication as a primary concern and the unavailability of alpha-2 antagonists for treatment. (2) The challenges in the clinical setting linked to xylazine abuse and its co-administration with substances like fentanyl and its analogs. (3) The necessity for robust government statistical resources for the unification and dissemination of critical overdose and emerging drug abuse detection information. (4) The need for effective rehabilitation programs, including psychosocial support and treatment interventions, to respond to this public health crisis. (5) The urgency for further research to understand the prevalence, toxic effects of chronic or acute use, and the clinical implications in xylazine users, including the development of alpha-2 antagonists for treatment. We conclude that addressing these concerns is crucial to working with the xylazine abuse situation., Competing Interests: Declaration of competing interest The authors report no conflict, this study was not grant awarded., (Copyright © 2024 Elsevier Ltd and Faculty of Forensic and Legal Medicine. 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.)

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: Illicitly manufactured fentanyl accounts for a majority of overdose fatalities in the US. Research has demonstrated that fentanyl test strips (FTS) help people who use drugs (PWUD) avoid unintended exposure to fentanyl and overdose. This study assesses characteristics associated with FTS use among PWUD in Rhode Island. Such findings may shed light on whether there are subgroups of PWUD who are less likely to be using FTS and therefore may benefit from their use., Methods: From September 2020 - February 2023, participants were recruited to participate in RAPIDS, a clinical trial assessing whether FTS provision can reduce overdose rates. Baseline data were used to assess correlates of lifetime FTS use through bivariable and multivariable analyses. We also examined drug testing patterns relating to FTS use in the past month., Results: Of 509 people enrolled, 376 (73.9 %) had heard of FTS before enrollment. Among this group, 189 (50.3 %) reported lifetime FTS use and 98 (26.1 %) reported use in the last month. In bivariable analyses, lifetime injection drug use, responding to an overdose, and drug selling were associated with FTS use. Solitary drug use was not associated with FTS uptake. In the multivariable analysis, gender and lifetime naloxone administration were associated with FTS use. Of those who used FTS in the past month, 76.5 % had at least one test that was positive for fentanyl., Conclusions: We found high uptake of FTS use among PWUD in Rhode Island. Our results also suggest a need for targeted outreach to increase FTS uptake among sub-groups of PWUD., Clinical Trial Registration: The Rhode Island Prescription and Illicit Drug Study is a registered clinical trial, NCT043722838., Competing Interests: Declaration of Competing Interest No conflict declared, (Copyright © 2024 Elsevier B.V. All rights reserved.)

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. To examine drug overdoses in Colombia by type of substance, sex, age, and intent using data from a health surveillance system from 2010 to 2021. Methods. We characterized data by year, type of substance, and sociodemographic variables. We calculated age-adjusted overdose rates by substance type, sex, age groups, and intent. We used Poisson regression models to examine trend differences across sex and age groups. Results. Age-adjusted rates of drug overdoses increased from 8.51 to 40.52 per 100 000 during 2010 to 2021. Men, compared with women, had higher overdose rates for every substance, except for opioids and psychotropics. Drug overdose rates involving cannabis and stimulants increased steadily until 2017 but decreased afterward. Overdose rates involving psychotropic medication increased greatly during 2018 to 2021, mainly because of intentional overdoses in young women. Conclusions. Overdoses involving illegal drugs decreased in recent years in Colombia; however, the continuous increase in intentional psychotropic overdose rates highlights the need for prevention efforts to curb this trend. Health surveillance systems are an important tool that can guide overdose prevention efforts in countries with limited data resources. ( Am J Public Health . 2024;114(11):1252-1260. https://doi.org/10.2105/AJPH.2024.307786).

Background: Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs., Methods: People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression., Results: Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88)., Conclusion: Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids., 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.)

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: 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: 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 and Objectives: More knowledge is needed to identify and reach those at overdose risk with preventive measures. We examined past 12-month health service utilization, identified the most frequently utilized service, explored this utilization in more detail, and examined correlates of overdose death., Methods: A population-based nested case-control registry study including all drug overdose deaths (1 January 2010 to 31 December 2018) in Norway through the Cause of Death Registry (n = 2388). The year-, age- and gender-matched controls included through a population registry (n = 21,465). Data cross-linked with population and patient registries. Multivariable conditional logistic regression analyses estimated the likelihood of overdose death., Results: The cases (vs. controls) attended a higher median number of services (3 vs. 1). The General Practitioner (GP) was the most utilized service. The majority (55.7%) of cases had 11-50 encounters, while the majority (60.7%) of the controls had 1-5 encounters. No high school diploma, no employment, urban living, social welfare benefits/disability pension, single-person household, recent incarceration, multiple health service utilization and frequent GP encounters, as well psychological and certain physical diagnoses were correlates of overdose death among the GP attenders., Discussion and Conclusions: The cases had utilized more services than the controls and the GP was the most frequently utilized service. In addition to low socioeconomic status, psychological and certain physical diagnoses were correlates of overdose death., Scientific Significance: This is the first national case-control registry study to document the high utilization of multiple primary and secondary health care services before drug overdose death, as well as reasons for attendance and correlates of overdose death., (© 2024 The Author(s). The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry (AAAP).)

Xylazine, a veterinary sedative, has emerged as a concerning element in the landscape of substance use in the United States. This integrative review synthesizes evidence from a systematic examination of 14 selected studies conducted between 2008 and 2023. The primary objective is to comprehensively understand the epidemiology and prevalence of xylazine use, particularly its involvement in drug-related deaths, regional variations, national impact, co-occurrence with opioids, and challenges associated with detection and intervention. The results underscore stark regional disparities in xylazine prevalence. West Virginia and Miami-Dade County have experienced alarming surges in xylazine-involved drug-related deaths. Nationally, its influence extends beyond regional boundaries, predominantly affecting white males in the Northeast. The co-occurrence of xylazine with opioids, especially fentanyl and heroin, significantly amplifies the risks of fatal overdoses. Detecting xylazine presents formidable challenges due to its frequent presence alongside other substances, necessitating enhanced surveillance and more effective detection methods. User perspectives emerge as pivotal, emphasizing the importance of user-informed harm reduction strategies. In conclusion, this review has significant policy implications. Tailored, region-specific strategies are imperative to address the diverse prevalence of xylazine use. A nationwide response is indispensable, prioritizing harm reduction initiatives, enhanced detection methods, and active user engagement. The multifaceted nature of the xylazine issue requires comprehensive approaches to mitigate its profound risks effectively. Policymakers are urged to consider regional disparities and the co-occurrence of xylazine with opioids when crafting targeted interventions. Immediate, user-informed harm reduction is vital to address the evolving landscape of xylazine use in the United States.

This pilot study explores the utilization of the Overdose Detection Mapping Application Program (ODMAP) as a tool for enhancing collaboration between the public health and public safety sectors to address the overdose epidemic in the United States. Through qualitative interviews with ODMAP users, key themes emerged, including the role of data sharing in facilitating collaboration, challenges posed by divergent data privacy standards, and the need for clearer guidance on cross-sector data sharing. Findings highlight ODMAP's potential to integrate data for targeted interventions at individual and population levels. Future research directions include overcoming data sharing barriers, strategically utilizing data across sectors, and rigorously evaluating the impact of cross-sector partnerships on overdose morbidity and mortality. Overall, this study underscores the importance of ODMAP in fostering coordinated responses to the overdose crisis and provides valuable insights for improving overdose surveillance and intervention efforts., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

For the past decade, illicitly manufactured fentanyl has been a primary contributor in drug overdose deaths regardless of age. The pediatric population is particularly vulnerable to fentanyl exposure, yet there are limited case reports involving this population. Postmortem cases from 2019 to 2023 were retrospectively analyzed to determine the prevalence of fentanyl in decedents between 0 and 12 years of age. Over this time frame, the fentanyl positivity rate increased from 2.6 to 6.2% (n = 632). The most commonly reported age group was 0-4 years, with a peak around 1 year of age for toddlers. Fentanyl concentrations in blood (n = 573) ranged from 0.19 to 360 ng/mL (mean 18 ng/mL, median 6.9 ng/mL). Polydrug use was present in 428 cases; midazolam (n = 96) and methamphetamine (n = 66) were the most common drugs found concurrently in blood with fentanyl, followed by markers of illicitly manufactured fentanyl, such as xylazine (n = 23), para-fluorofentanyl (n = 18), and acetyl fentanyl (n = 17). This report contrasts the differences in postmortem pediatric fentanyl toxicology results for three groups of case histories: likely medical intervention (n = 113), pregnancy/birth related (n = 136), and inadvertent/intentional exposure (n = 196). Overall, this study provides a retrospective review of postmortem pediatric fentanyl concentrations in a variety of biological matrices and highlights the need for comprehensive toxicology testing in postmortem pediatric casework., (© 2024 American Academy of Forensic Sciences.)

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.

Background: The development of drug policies has been a major focus for policy-makers across North America in light of the ongoing public health emergency caused by the overdose crisis. In this context, the current study examined stakeholders' experiences and perceptions of power and value in a drug policy-making process in a North American city using qualitative, questionnaire, and social network data., Methods: We interviewed 18 people who participated in the development of a drug policy proposal between October 2021 and March 2022. They represented different groups and organizations, including government (n = 3), people who use drugs-led advocacy organizations (n = 5), other drug policy advocacy organizations (n = 5), research (n = 3) and police (n = 2). Most of them identified as men (n = 8) and white (n = 16), and their ages ranged between 30 and 80 years old (median = 50). Social network analysis questionnaires and semi-structured qualitative interviews were administered via Zoom. Social network data were analysed using igraph in R, and qualitative data were analysed using thematic analysis. The analyses explored perceptions of value and power within a drug policy-making network., Results: The policy-making network showed that connections could be found across participants from different groups, with government officials being the most central. Qualitative data showed that inclusion in the network and centrality did not necessarily translate into feeling powerful or valued. Many participants were dissatisfied with the process despite having structurally advantageous positions or self-reporting moderately high quantitative value scores. Participants who viewed themselves as more valued acknowledged many process shortcomings, but they also saw it as more balanced or fair than those who felt undervalued., Conclusions: While participation can make stakeholders and communities feel valued and empowered, our findings highlight that inclusion, position and diversity of connections in a drug policy-making network do not, in and of itself, guarantee these outcomes. Instead, policy-makers must provide transparent terms of reference guidelines and include highly skilled facilitators in policy discussions. This is particularly important in policy processes that involve historical power imbalances in the context of a pressing public health emergency., (© 2024. The Author(s).)

Importance: The US is experiencing a protracted drug overdose crisis primarily associated with exposure to illicitly manufactured fentanyl (IMF), methamphetamine, and cocaine. Overdose risk and treatment responses may be directly affected by absolute drug exposure concentrations and drug use prevalence., Objective: To quantify changes in absolute drug exposure concentrations from 2013 to 2023., Design, Setting, and Participants: This cross-sectional study analyzed urine drug testing (UDT) results from urine specimens collected between January 1, 2013, and August 22, 2023, in 49 states and the District of Columbia. Urine specimens were obtained from patients aged 18 years or older who presented to substance use disorder treatment clinics. The UDT was ordered by clinicians based on medical necessity., Exposures: Urine specimens were analyzed for the following drugs or metabolites (analytes tested in parentheses): fentanyl (fentanyl), heroin (6-monoacetylmorphine), cocaine (benzoylecgonine), and methamphetamine (methamphetamine) using liquid chromatography with tandem mass spectrometry., Main Outcomes and Measures: Relative concentrations of fentanyl, heroin, cocaine, and methamphetamine. Creatinine-normalized drug concentration values were log-transformed prior to visualization and statistical analyses. The Mann-Kendall trend test was performed to examine trends over time. To estimate the geospatial and temporal patterns of drug concentration, a second series of models (1 for each drug) with an interaction effect for clinic location and collection year were fit., Results: A total of 921 931 unique UDT samples were collected from patients (549 042 males [59.6%]; median [IQR] age, 34 [27-44] years). The adjusted fentanyl concentration in urine specimens was 38.23 (95% CI, 35.93-40.67) ng/mg creatinine in 2023 and 4.61 (95% CI, 3.59-5.91) ng/mg creatinine in 2013. The adjusted methamphetamine concentration was 3461.59 (95% CI, 3271.88-3662.30) ng/mg creatinine in 2023 and 665.27 (95% CI, 608.51-727.32) ng/mg creatinine in 2013. The adjusted cocaine concentration was 1122.23 (95% CI, 1032.41-1219.87) ng/mg creatinine in 2023 and 559.71 (95% CI, 524.69-597.06) ng/mg creatinine in 2013. The adjusted heroin concentration was 58.36 (95% CI, 48.26-70.58) ng/mg creatinine in 2023 and 146.59 (95% CI, 136.06-157.92) ng/mg creatinine in 2013. Drug concentrations varied across US Census divisions., Conclusions and Relevance: This cross-sectional study found that absolute concentrations of fentanyl, methamphetamine, and cocaine in urine specimens increased from 2013 to 2023, with a decrease in heroin concentration during that period. The findings suggest that exposure to these substances, as well as the illicit drug supply, has fundamentally changed in many parts of the US, highlighting the need to reinforce surveillance initiatives and accelerate efforts to treat individuals with IMF and/or stimulant exposure.

Background: Our goal in this report was to quantify the degree to which opioid prescription rates and socioeconomic correlates of income inequality predicted overdose deaths in the 1055 U.S. Midwest counties. The study follows up a state-level analysis which reported that opioid prescription rates, social capital and unemployment explained much of the variance in opioid overdose death rates (Heyman, McVicar, & Brownell, 2019)., Methods: We created a data set that included drug overdose death rates, opioid prescription rates, and correlates of income inequality. Given that the variables of interest varied at the state and county level, multilevel regression was our statistical approach., Results: From 2006 to 2021, Midwest overdose drug deaths increased according to an exponential equation that closely approximated the equation that describes the increases in overdose deaths for the entire U.S. from 1978 to 2016 (e.g., Jalal et al., 2018). Retail opioid prescription sales increased from 2006 to 2012, but then declined so that by 2017 they were lower than in 2006. The regression analyses revealed that intergenerational income mobility was the strongest predictor of overdose deaths. The other consistently statistically significant predictors were opioid prescription rates, social capital, and unemployment rates. Together these predictors, plus pupil teacher ratios, single parent families, and attending college accounted for approximately 47 % of the variance in overdose death rates each year. In keeping with the decline in opioid prescription rates, the explanatory power of opioid prescription rates weakened over the course of the study., Conclusions: Overdose deaths increased at a constant exponential rate for the years that it was possible to apply our regression model. This occurred even though access to legal opioids decreased. What remained invariant was the predictive strength of intergenerational income mobility; each year it was the predictor that explained the most variance in overdose deaths., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution., Methods: 2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution., Results: SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties., Conclusions: Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Understanding opioid overdose risk perception may inform overdose prevention strategies., Methods: We used baseline data from a randomized overdose prevention trial, in San Francisco, CA, and Boston, MA, among people who used nonprescribed opioids, survived an overdose in the past 3 years, and had received naloxone. Participants were asked how likely they were to overdose in the next 4 months. We combined "extremely likely" and "likely" (higher risk perception) and "neutral," "unlikely," and "extremely unlikely" (lower risk perception). We performed bivariate analyses and separate multivariable logistic regression models of risk perception across (1) sociodemographic, (2) substance use, and (3) overdose risk behavior measures. Covariates were selected a priori or significant in bivariate analyses., Results: Among 268 participants, 88% reported at least 1 overdose risk behavior; however, only 21% reported higher risk perception. The adjusted odds ratio (AOR) of higher risk perception was 2.41 (95% confidence interval [CI]: 1.10-5.30) among those unhoused in the past 4 months, 2.06 (95% CI: 1.05-4.05) among those using opioids in a new place, and 5.61 (95% CI: 2.82-11.16) among those who had overdosed in the past 4 months. Living in Boston was associated with higher risk perception in all 3 models (AOR = 2.00-2.46, 95% CI: 1.04-4.88)., Conclusions: Despite prevalent risk behaviors, a minority of participants perceived themselves to be at higher risk of overdose. Nonetheless, some known risk factors for overdose were appropriately associated with risk perception. Fentanyl has been prevalent in Boston for longer than San Francisco, which may explain the higher risk perception there., 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.

Background: Federal, state, and municipal governments in the United States have been reluctant to authorize overdose prevention centers (OPCs), which are evidence-based approaches for preventing overdose deaths and blood-borne pathogen transmission., Methods: From July 2022 to February 2023, we explored how stigma manifests in OPC policymaking by conducting in-depth interviews with 17 advocates, legislators, service providers, and researchers involved with OPC advocacy and policymaking in Rhode Island, California, Pennsylvania, and New York., Results: We found that although jurisdictions differed in their OPC policymaking experiences, stigma manifested throughout the process, from planning to authorization. Participants described OPCs as a tool for destigmatizing overdose and substance use, yet confronted institutionalized stigma and discriminatory attitudes toward people who use drugs (PWUD) and harm reduction from multiple sources (eg, politicians, media, and members of the public). Opposition toward OPCs and harm reduction approaches more broadly intersected with public discourse on crime, homelessness, and public disorder. Employed stigma-mitigation strategies included humanizing PWUD, publicizing the benefits of OPCs to the wider community, and strategically engaging media., Conclusion: These findings illustrate the importance of understanding stigma at different stages of the policymaking process to better facilitate authorization and eventual implementation of OPCs in the United States., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JNP served as a technical consultant on a US Food and Drug Administration grant (U01FD00745501). The remaining authors have no conflicts of interest to disclose.

Background: Adolescents and young adults with risk factors for opioid misuse and opioid use disorder are at elevated risk for overdose. We examined prior non-fatal overdose experiences among at-risk adolescents/young adults to inform prevention efforts., Methods: Adolescents/young adults (ages 16-30) in two US emergency departments self-reporting past year opioid misuse or opioid use plus a misuse risk factor completed a baseline survey as part of an ongoing randomised controlled trial. We describe baseline factors associated with (a) overall non-fatal overdose experiences and (b) groups based on substance(s) used during the worst overdose experience., Results: Among 771 participants (27.9% male), 40.7% reported a non-fatal overdose experience. Compared with those without a prior overdose experience, those with prior overdose experience(s) were less likely to be heterosexual, and more likely to report a prior suicide attempt and greater peer substance misuse. Regarding the worst overdose experience, substance(s) included: 36.6% alcohol only, 28.0% alcohol and cannabis, 22.6% alcohol with other substance(s) and 12.7% other substance(s) only (eg, opioids). Compared with the alcohol only group, the alcohol and cannabis group were younger and less likely to be heterosexual; the alcohol with other substance(s) group were older and had greater peer substance misuse; and the other substance(s) only group were more likely to be male, receive public assistance, screen positive for anxiety and less likely to be heterosexual., Conclusions: Among at-risk adolescents/young adults, findings support the need for tailored overdose prevention efforts based on substance(s) used, with consideration of sexuality, mental health and peer substance use., Trial Registration Number: NCT04550715., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Growing evidence from pharmacovigilance data and postmortem toxicology reports highlights the misuse potential of gabapentinoids. This study aimed to investigate the risk of serious adverse outcomes (drug misuse, overdose, major trauma), and their risk factors, in primary care patients who are prescribed gabapentinoids. Using the UK Clinical Practice Research Datalink, a matched cohort study calculated adverse event rates separately for gabapentinoid-exposed and unexposed cohorts. In the exposed cohort, event rates for exposure to a range of potential risk factors were calculated. Event rates were compared using Cox proportional hazards models, adjusted for age, sex, deprivation, previous mental health diagnosis, and coprescribing with potentially interacting medicines. Substance misuse (gabapentin adjusted hazard ratio [95% CI]: 2.40 [2.25-2.55]), overdose (2.99 [2.56-3.49]), and major trauma (0-2.5 years: 1.35 [1.28-1.42]; 2.5 to 10 years: 1.73 [1.56-1.95]) were more common among patients prescribed gabapentinoids than matched individuals who were not. The association with overdose was stronger for pregabalin than gabapentin. All adverse outcomes were significantly associated with smoking, history of substance misuse, overdose, or a mental health condition and prescription of opioids, benzodiazepines, antidepressants, and Z-drug hypnotics (eg, gabapentin hazard ratios for association of concurrent opioid use: misuse 1.49 [1.47-1.51]; overdose 1.87 [1.78-1.96]; major trauma 1.28 [1.26-1.30]). Our findings highlight the importance of careful patient selection when prescribing gabapentinoids and the need to educate prescribers about the risks of these drugs, particularly in combination with other central nervous system depressants., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Introduction: While randomized-controlled trials have shown that heroin-assisted treatment (HAT) is superior to methadone maintenance alone in treatment of refractory clients, little is known about client factors associated with retention in HAT in routine care., Methods: This retrospective cohort study assessed predictors of retention in first treatment episode among a consecutive cohort of clients admitted to HAT in Denmark from 2010 to 2018, who could be matched to the Danish population register and for whom a Short Form Health Survey (SF-36) was available at admission (N = 432). The study derived predictors from client self-reports at intake and administrative data available in national registers. Cox proportional hazards regression modelled retention in treatment., Results: The one-year retention rate was 69.63 % (95 % CI 65.06 %-73.74 %), and the median time in treatment was 2.45 years (95 % CI, 1.83-3.12). Bivariate analyses showed that retention was lower for clients who had recent cocaine or benzodiazepine use and among those who had experienced an overdose in the year prior to enrollment in HAT. Age below 40, recent illegal activity, poorer emotional wellbeing, previous residential treatment experience, and previous intensive outpatient treatment were also predictors of dropout from HAT., Conclusions: This observational study found that retention in HAT in routine care was similar to rates observed in randomized-controlled trials conducted in other countries. The results suggest that addressing polysubstance use as part of the HAT program may promote long-term retention, as may directing resources to certain subgroups identified at intake, including clients under 40 years and those who report recent criminal activity, emotional problems, or overdoses. The findings that previous residential treatment and intensive outpatient treatment were associated with dropout were unexpected., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives. To examine trends in overdose deaths by intent and drug category to better understand the recent decrease in overdose suicides amid the overdose epidemic. Methods. We examined trends in rates of overdose deaths by intent (unintentional, suicide, or undetermined) across 9 drug categories from 1999 to 2022 using US National Vital Statistics System mortality data. Results. Unintentional overdoses involving synthetic opioids, polydrug toxicity involving synthetic opioids, psychostimulants, and cocaine increased exponentially with annual percentage changes ranging from 15.0% to 104.9% during 2010 to 2022. The death rates also increased for suicides involving these drugs, especially for psychostimulants (annual percentage change = 12.9% for 2010-2022; P  < .001). However, these drugs accounted for relatively small percentages of overdose suicides. The leading drug categories among suicides were antidepressants, prescription opioids, and benzodiazepines, though these deaths have decreased or leveled off in recent years. Conclusions. Different drugs commonly involved in suicides and unintentional overdoses may contribute to their divergent trends. Public Health Implications. Amid the overdose epidemic, safe storage of medications remains a crucial strategy to prevent overdose suicides. The large increases in suicides involving psychostimulants warrant monitoring. ( Am J Public Health . 2024;114(10):1081-1085. https://doi.org/10.2105/AJPH.2024.307745).

Fentanyl has emerged as the leading cause of fatal drug overdoses in the U.S. Individuals misusing drugs may not always be aware of exposure to fentanyl., To determine the prevalence of fentanyl use and extent of awareness of fentanyl exposure among a national sample of treatment-seeking individuals with opioid use disorder ( n  = 1098)., Participants provided oral fluid and urine specimens, which were tested for drugs by liquid chromatography/tandem mass spectrometry. Participants also provided self-reports of fentanyl use., 49.5% tested positive for fentanyl in oral fluid, urine, or both. Of those testing positive for fentanyl, 29.8% were unaware that they had been exposed to fentanyl. Participants testing positive for opioids methadone, and specifically 6-monoacetylmorphine (6-MAM), a unique metabolite of heroin, were significantly more likely to be unaware of fentanyl exposure than participants testing negative for these substances, with a similar trend for oxycodone and tramadol., These findings may be due to fentanyl's effect being difficult to distinguish from that of other opioids, whereas when other types of drugs are adulterated with fentanyl, the differences in effects are likely to be readily discernable. These results support the importance of expanded drug-checking services.

Background: Scholarship on how fentanyl affects the complexities of correctional settings is limited in Canada, as scholars have focused on the prevalence of opioid use and overdose in prisons, as well as community treatment and access following release. Fentanyl constitutes a continuing challenge both in prisons and broader society., Results: The current qualitative, interview-based empirical study examines how fentanyl is interpreted by correctional officers (COs, n = 99) across federal prisons in Canada, some of whom have worked in institutions with a high presence of fentanyl, while others have less exposure to the drug. We found that while many COs had responded to an overdose during their first or second year on the job, most COs who had did not perceive the event to be psychologically traumatic nor were concerned about the presence and availability fentanyl in their work environment, or they were indifferent. Yet this finding competes with the 41.4% of officers who did express concern about the presence of fentanyl - suggesting both a "normalization" of fentanyl as a workplace hazard as well as an underpinning social concern., Conclusions: We discuss the implications of these complicated findings in relation to reducing workplace stressors and countering misinformation that, in addition to other potential occupational factors, may be responsible for the concerns of COs tied to the presence of fentanyl., (© 2024. The Author(s).)

Background: A substantial number of hospital admissions end in patient-initiated departure before medical treatment is complete. Whether "before medically advised" (BMA) discharge increases the risk of subsequent drug overdose remains uncertain., Methods: We performed a retrospective cohort study using administrative health data from a 20% random sample of residents of British Columbia, Canada. We focused on nonelective, nonobstetric hospital stays occurring between 2015 and 2019. We used survival analysis to compare the rate of fatal or nonfatal illicit drug overdose in the first 30 days after BMA discharge versus the rate after physician-advised discharge., Results: Overall, 6440 of 189 808 (3.4%) hospital stays ended in BMA discharge. Among 820 overdoses occurring in the first 30 days after any hospital discharge, 755 (92%) involved patients with a history of substance use disorder. Unadjusted overdose rates were 10-fold higher after BMA discharge than after physician-advised discharge, and BMA discharge was associated with subsequent overdose even after adjustment for potential confounders (crude incidence, 2.8% v. 0.3%; adjusted hazard ratio [HR] 1.58; 95% confidence interval [CI] 1.31-1.89). Before medically advised discharge was associated with increases in subsequent emergency department visits (adjusted HR 1.92; 95% CI 1.83-2.02) and unplanned hospital readmissions (adjusted HR 2.07; 95% CI 1.96-2.19), but there was no significant association with the uncommon outcomes of fatal overdose and all-cause mortality., Interpretation: Before medically advised departure is associated with an increased risk of drug overdose in the first 30 days after discharge. Improved treatment of substance use disorder, expanded access to overdose prevention services, and new means of postdeparture outreach should be explored to reduce this risk., Competing Interests: Competing interests:: Jeffrey Brubacher reports receiving grants from the Canadian Institutes of Health Research (CIHR), Public Safety Canada, Transport Canada, British Columbia Ministry of Public Safety and Solicitor General, and Saskatchewan Government Insurance. Alexis Crabtree is an employee of the BC Centre for Disease Control, an agency of the BC Provincial Health Services Authority. Jessica Moe reports receiving grants or contracts from the Vancouver Physician Staff Association, the Canadian Association of Emergency Physicians/Schwartz-Reisman Emergency Medicine Institute, the Health Canada Substance Use and Addictions Program, CIHR (team grant: Partnerships for Cannabis Policy Evaluation; project grants: Opioid Overdose-Related Cardiac Arrest, Evaluating Microdosing in Emergency Departments, and Drug Overdose after Departure from Hospital Against Medical Advice; training grants: Clinical Trials Training Platforms), and the BC Centre for Disease Control (STARTS grant). Dr. Moe has also received the Vancouver Coastal Health Research Institute Mentored Clinician Scientist Award. Amanda Slaunwhite reports receiving project grant funds from Health Canada, CIHR, the Public Health Agency of Canada, the Community Action Initiative, the province of British Columbia, and Michael Smith Health Research BC (all payments made to the University of British Columbia or Provincial Health Services Authority for staff, trainee, or other project costs). Dr. Slaunwhite has also served on the Board of Directors of Unlocking the Gates and Moms Stop the Harm (unpaid). John Staples reports receiving salary support from a Michael Smith Health Research BC Health Professional–Investigator Award and the UBC Division of General Internal Medicine’s Academic Investment Fund. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Fentanyl is increasingly pervasive in the unregulated drug supply and is a driver of drug overdose deaths in the United States. The aims of this study were to characterize and identify correlates of fentanyl preference among people who use drugs (PWUD) in Rhode Island (RI)., Methods: Using bivariate analysis, we examined associations between fentanyl preference and sociodemographic and psychosocial characteristics at baseline among participants enrolled in the RI Prescription Drug and Illicit Drug Study from August 2020-February 2023. Fentanyl preference was operationalized based on responses to a five-point Likert scale: "I prefer using fentanyl or drugs that have fentanyl in them." Participants who responded that they "strongly disagree," "disagree," or were "neutral" with respect to this statement were classified as not preferring fentanyl, whereas participants who responded that they "agree" or "strongly agree" were classified as preferring fentanyl., Results: Among 506 PWUD eligible for inclusion in this analysis, 15% expressed a preference for fentanyl or drugs containing fentanyl as their drug of choice. In bivariate analyses, preference for fentanyl was positively associated with younger age, white race, lifetime history of overdose, history of injection drug use, past month enrollment in a substance use treatment program, past month treatment with medications for opioid use disorder, and preferences for heroin and crystal methamphetamine (all p < 0.05). Descriptive data yielded further insight into reasons for fentanyl preference, the predominant having to do with perceived effects of the drug and desire to avoid withdrawal symptoms., Conclusions: Only a relatively small subset of study participants preferred drugs containing fentanyl. Given the increased prevalence of fentanyl contamination across substances within the unregulated drug market, the result for PWUD is increasingly less agency with respect to choice of drug; for example, people may be forced to use fentanyl due to restricted supply and the need to mitigate withdrawal symptoms, or may be using fentanyl without intending to do so. Novel and more effective interventions for PWUD, including increased access to age-appropriate harm reduction programs such as fentanyl test strips and overdose prevention centers, are needed to mitigate fentanyl-related harms., (© 2024. The Author(s).)

We examined a natural history of opioid overdose deaths from 1999-2021 in the United States to describe state-level spatio-temporal heterogeneity in the waves of the epidemic. We obtained overdose death counts by state from 1999-2021, categorized as involving prescription opioids, heroin, synthetic opioids, or unspecified drugs. We developed a Bayesian multivariate multiple change point model to flexibly estimate the timing and magnitude of state-specific changes in death rates involving each drug type. We found substantial variability around the timing and severity of each wave across states. The first wave of prescription-involved deaths started between 1999 and 2005, the second wave of heroin-involved deaths started between 2010 and 2014, and the third wave of synthetic opioid-involved deaths started between 2014 and 2021. The severity of the second and third waves was greater in states in the eastern half of the country. Our study highlights state-level variation in the timing and severity of the waves of the opioid epidemic by presenting a 23-year natural history of opioid overdose mortality in the United States. While reinforcing the general notion of three waves, we find that states did not uniformly experience the impacts of each wave., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Noa Krawczyk receives consulting fees for expert witness testimony in ongoing opioid litigation., (Copyright: © 2024 Kline 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.)

There has been an overall increase in the number of suspected suicide attempts by self-poisoning among the adolescent population. Incidences of self-poisoning have increased since the coronavirus 2019 pandemic, particularly among patients age 10 to 19 years. Common agents used in self-poisoning include over-the-counter and prescription medications. It is crucial to identify adolescent patients with risk factors and provide appropriate resources to reduce the likelihood of intentional toxic ingestion. This article aims to summarize the current state of intentional toxic ingestions by adolescents, provide an overview of the most common agents implicated in self-poisoning, and discuss the best practices in screening patients. [ Pediatr Ann . 2024;53(9):e330-e336.] .

Introduction: Adolescent overdoses have been rising over the past decade. Emergency department (ED) visits for both acute overdoses and for adolescents in opioid withdrawal have risen post-COVID. Urine drug screens have poor utility in the ED but are routinely obtained for medical clearance and in the management of patients with substance use disorder. Our primary goal was to measure the sensitivity of the opiate urine drug assay over time in opioid-related presentations to the ED., Methods: We reviewed ED presentations at all EDs within our health system that were directly related to opioids from 1/1/2014 to 12/31/2022. For each patient included over the time frame, we identified whether a urine drug screen was obtained and the results from this screen. The urine drug screen available at all sites was an enzyme-multiplied immunoassay with an opiate screen (morphine antibody), but no fentanyl screen. The percent positivity for each drug category on enzyme multiplied immunoassay technique testing was calculated. Chi-squared tests were used to compare positivity rates between years., Results: Opiate positivity declined over the last 9 years. Positivity rates from 2020 to 2022 were 5% ± 2% vs 82% ± 6% from 2014 to 2019 ( P < 0.001) Performance of UDS also declined over time (76% from 2014 to 2019 vs 46% from 2020 to 2022; P < 0.001). UDS was more likely to be performed in patients after a suicide attempt or when presenting after illicit use (66% vs 38%; P = 0.004)., Conclusion: Opiate screen positivity decreased the last 9 years and may reflect wider use of fentanyl among this population starting in 2020., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Over the past two decades methamphetamine-related harms have increased in Australia. Previous analysis of methamphetamine-related deaths has covered limited timeframes, and largely focused on drug-toxicity deaths. This paper examines long-term trends in methamphetamine-related deaths over 20 years, including deaths due to a range of specific causes., Methods: Descriptive analyses were conducted on Australian methamphetamine-related deaths (2001-2023) by cause, extracted from the National Coronial Information System, an online database containing deaths reported to coroners in Australia and New Zealand. Joinpoint trend analyses were used to assess changes over time between 2001 and 2020 (with data from 2021 to 2023 likely incomplete and thus excluded)., Results: Unintentional drug toxicity was the cause of 49.8 % of methamphetamine-related deaths, intentional self-harm (including toxicity) 23.3 %, unintentional injury 15.1 %, natural causes 9.6 %, and assaults 2.3 %. Between 2001 and 2020, joinpoint analysis showed three trend change points among all-cause methamphetamine-related mortality rates, resulting in four distinct periods: two periods where they increased (2001-2006 - annual percentage change (APC) = 15.4 %; 2009-2016 - APC 25.5 %), and two where they decreased (2006-2009 - APC = -11.8 %; 2017-2020 - APC = -2.9 %). Similar patterns were evident among rates of intentional self-harm and unintentional injury. Deaths caused by unintentional drug toxicity saw two trend change points (2011, 2016), and rates increased across all three periods. Natural cause deaths had three trend change points (2007, 2010, 2015), and rates continued to rise after 2015, largely driven by increases in circulatory diseases., Conclusion: Cause-specific models highlighted diverse trends. Recent trends show unintentional drug toxicity deaths have slightly increased, intentional self-harm stabilised, and unintentional injury and assault deaths have declined. Deaths from natural causes involving methamphetamine continued to increase, highlighting a public health concern and a potential need for early circulatory disease screening among people who use methamphetamine., 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: Tricyclic antidepressants often cause drug-induced QRS complex prolongation in overdose but are now less commonly prescribed. We sought to determine, among a contemporary cohort of patients, the pharmaceuticals independently associated with QRS complex prolongation in acute overdose., Methods: We performed secondary analysis of data from the Toxicology Investigators Consortium (ToxIC) Core Registry. We included adult patients presenting from January 2016 through March 2023 with acute or acute-on-chronic pharmaceutical exposures. The primary outcome was QRS complex prolongation >0.12 s. Secondary outcomes included cardiac arrest, death, ventricular dysrhythmia, intensive care unit admission, initiation of vasopressors, and treatment with sodium bicarbonate. We used a multivariable logistic regression model with QRS complex prolongation as the outcome and individual pharmaceuticals of interest as independent variables. We assessed yearly trends of the contribution of relevant pharmaceuticals to QRS complex prolongation since 2016., Results: Of 11,945 patients in the total cohort (median age 37 years, 6,652 [55.7%] female), 366 (3.1%) developed QRS complex prolongation. Of 9,417 patients included in the model, 290 (3.1%) developed QRS complex prolongation. Amitriptyline, nortriptyline, doxepin, imipramine, noxiptiline, bupropion, flecainide, carvedilol, propranolol, diphenhydramine, and lamotrigine poisonings were independent predictors of QRS complex prolongation. Flecainide poisoning conferred the greatest odds of QRS complex prolongation (OR 574.1; 95% CI: 88.3-12,747). The contribution of tricyclic antidepressants to QRS complex prolongation decreased from 38.8% to 17.6% of all patients with QRS complex prolongation from 2016 to 2022. In 2022, the proportion of QRS complex prolongation from diphenhydramine (20.6%) surpassed that of tricyclic antidepressants., Discussion: This study provides insights into contemporary pharmaceutical poisoning associated with QRS complex prolongation. Tricyclic antidepressants remain clinically relevant exposures but are no longer the most common cause of drug-induced QRS complex prolongation., Conclusions: Bupropion, diphenhydramine, and antidysrhythmics are increasingly common causes of QRS complex prolongation, each associated with numerous severe outcomes in poisoning. Greater safety measures to protect patients from cardiovascular toxicity from these pharmaceuticals are warranted.

Background: Pharmacy has an important role in combating the opioid epidemic. However, there is a need for more consistency of programs and evidence-based practices across the country., Objectives: To describe how an evidence-based opioid misuse and overdose prevention program that originated in North Dakota was implemented in West Virginia and to compare program results between the two states including pharmacist interventions and patient screening for opioid misuse and overdose., Practice Description: This advancement in practice took place in participating North Dakota and West Virginia community pharmacies., Practice Innovation: An evidence-based program that originated in North Dakota was implemented in West Virginia. The details of this collaboration are outlined in this manuscript., Evaluation Methods: Program screening and pharmacist intervention data were collected using DocStation, an online pharmacy patient management platform., Results: Thirty-four pharmacies in West Virginia implemented the program. Between April 2022 and September 2023, a total of 34 West Virginia pharmacies conducted 449 documented screenings compared to 12,105 screenings by 81 pharmacies in North Dakota over the same time. There were differences between the states with regard to the proportion of individuals screened as high-risk for opioid use disorder and individuals at risk of accidental opioid overdose likely attributable to different demographics., Conclusion: An opioid misuse and prevention program was successfully implemented in two states, which can serve as a model to implement similar programs in other pharmacies across the United States., Competing Interests: Disclosures The authors declare no relevant conflicts of interest or financial relationships., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: The spread of illicitly manufactured fentanyl is driving steep increases in US overdose deaths. Fentanyl seizures are correlated with state-level opioid-related mortality; however, more granular seizure surveillance information has the potential to better inform overdose prevention and harm reduction efforts., Methods: Using data on fentanyl pill and powder seizures from High Intensity Drug Trafficking Areas (HIDTA), we tested associations between seizure prevalence and overdose mortality, from 2013 to 2020. The primary exposure-seizure burden-was constructed by identifying counties having high (above the median) prevalence of pill, powder, or combined pill/powder seizure burden per 100,000 population. Poisson models accounted for county demographic, law enforcement and time trends., Results: During the timeframe, there were 13,842 fentanyl seizures in 606 US counties. In adjusted models, counties with a high burden of pill or powder fentanyl seizures, or both (combined pills/powder) exhibited higher total overdose mortality than non-high burden counties (pills adjusted prevalence ratio [aPR]: 1.10 [95 % confidence interval [CI]: 1.08, 1.12]; powder aPR 1.12 [CI: 1.11, 1.13]; combined pills/powder aPR: 1.27 [CI: 1.25, 1.29]). A similar pattern of associations with fentanyl seizure burden was noted for overdose deaths involving synthetic opioids (pills [aPR]: 0.99 [CI: 0.96, 1.02]; powder aPR 1.29 [CI: 1.27, 1.30]; combined pills/powder aPR 1.55 [CI: 1.52, 1.58])., Conclusions: Law enforcement data on fentanyl seizures predicts drug overdose mortality at the county-level. Integrating these data with more traditional epidemiologic surveillance approaches has the potential to inform community overdose response efforts., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier B.V.)

Abstract: The opioid crisis, particularly the "fourth wave" involving fentanyl and stimulants, has been responsible for an alarming increase in overdose deaths in the United States. Although fentanyl contamination in cocaine has gained significant attention, the converse-cocaine-adulterated fentanyl-has been largely overlooked despite its health implications. The rise in concurrent cocaine and fentanyl overdose deaths could be attributed to various factors, from intentional polysubstance use to unintentional adulterations. Cocaine-related health issues may amplify the problem. Four potential pathways for the increased risk of overdose with cocaine-adulterated opioids include enhanced drug reinforcement, potential overdose risk with switching drug samples, altered metabolism of medications used for opioid use disorder, and increased myocardial demand juxtaposed with opioid-induced respiratory depression. With these risks, the importance of drug testing becomes paramount in the unregulated drug market. As polysubstance use overdoses surge, there is an urgent need to understand how drug supplies are changing in order to effectively identify appropriate harm reduction strategies. Specifically, further research is needed evaluating complications of low-level cocaine exposure with chronic/persistent opioid use. The hazards associated with cocaine-adulterated fentanyl emphasize the significance of understanding not only fentanyl's presence in cocaine but also cocaine's role in the fentanyl supply., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)

Objective: The National Survey on Drug Use and Health (NSDUH), as the primary source of epidemiological substance use data in the United States, could illuminate trends in fentanyl use behaviors contributing to the opioid overdose crisis. We hypothesized that the trend in NSDUH prevalence of lifetime fentanyl injection would match the direction and magnitude of the trend in synthetic opioid overdose deaths., Method: Using logistic regression, we modeled the 2015-2020 trend in synthetic opioid overdose deaths as a proportion of all deaths. We modeled contemporary trends from cross-sectional NSDUH data for (a) lifetime fentanyl injection, (b) past-year prescription fentanyl misuse, (c) prescription tramadol misuse (the other synthetic opioid counted alongside fentanyl in the overdose deaths category), and (d) combined prescription fentanyl or tramadol misuse. The average annual NSDUH weighted sample size was 272,519,038 (51.5% female, 48.5% male)., Results: Synthetic opioid overdose deaths increased from 2015 to 2020 (odds ratio = 3.39, meaning that the odds of a death being from synthetic opioid overdose in 2020 were 3.39 times the odds of death from that cause in 2015, 95% CI [3.34, 3.44]). None of the substance use trends significantly increased., Conclusions: Per NSDUH data, the prevalence of fentanyl misuse did not significantly increase in tandem with synthetic opioid overdose deaths from 2015 to 2020. Scrutiny of NSDUH's approach to assessing fentanyl misuse casts doubt on the utility of NSDUH fentanyl data collection. We acknowledge recent changes to the survey and recommend two further changes to optimize a vital source of data on behaviors related to the opioid overdose crisis., Competing Interests: Ramin Mojtabai has received royalties from UpToDate. Eric C. Strain has consulted, done work for, or served on advisory boards to the following organizations: Cerevel, Fast Track Drugs and Biologics, Masimo/Innovative Health Solutions, Otsuka, Pear Therapeutics, UpToDate, and Wolters Kluwer.

Abstract: Suicide is one of the worldwide leading causes of unnatural death. Pretoria is a capital city of South Africa and is the fourth most populated city in South Africa. Between 16 and 22 suicide cases are recorded daily in South Africa.Case files from the Pretoria Medico-Legal Laboratory were reviewed between 1 January 2015 to 31 December 2021, which spanned the COVID-19 pandemic. All cases of possible and probable suicides were included. One-way analysis of variance and Pearson chi 2 tests were conducted to determine statistical significance in the observed trends.A total of 1820 possible and probable suicide cases were identified. The year following the outbreak of the COVID-19 pandemic accounted for the largest number of suicides. White males were the most heavily represented population, followed by Black males. Hanging was the most common method for males, whereas poisoning via ingestion and/or overdose was more commonly used by females.Suicides in Pretoria have increased since previous studies from 9.74% and 10.2% to 13.32%. Methods used have changed among various population groups over the past two decades. This paper examined changes in suicide trends in Pretoria compared to previous studies and highlighted correlations between suicide trends and COVID-19 lockdown measures., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Poisoning poses a worldwide public health challenge and recent data from Lebanon in 2020 revealed that over half patients presenting with acute toxicological exposure intentionally poisoned themselves, primarily with suspected suicidal intent. This study aims to assess sex disparities in intentional toxicological exposures among patients presenting to the Emergency Department, at a tertiary care centre in Lebanon. This was a secondary analysis of an existing toxicological database, including patients aged 6 years and older admitted due to acute overdose from March 2015 to August 2022. A total of 444 cases of intentional poisoning were analysed, with 302 (68.0%) women. The primary cause of intentional poisoning was suspected suicide in both sexes, significantly more common in women (85.1% versus 65.5%, P < 0.001). Specific agents exposed to patients varied by sex; sedatives/hypnotics/antipsychotics, antihistamines, and melitracen/flupentixol were significantly more prevalent in women (P < 0.001) while men showed higher prevalence for ethanol (P = 0.02), stimulants, street drugs and opioids (P < 0.001). Our study underscores substantial sex differences in intentional poisoning cases in Lebanon. Women exhibited a higher likelihood of exposures to sedatives/hypnotics/antipsychotics, antihistamines and melitracen/flupentixol, while stimulant drugs, ethanol, and opioids were prevalent in men. Developing proper and effective sex-specific measures may mitigate potential physical and psychological consequences., (© 2024 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society). Published by John Wiley & Sons Ltd.)

Background: Opioid-involved overdoses, especially those involving synthetic opioids like fentanyl, have driven increases in overdose morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) data can each provide near real-time information on trends in nonfatal opioid-involved overdoses; however, minimal data exist on the comparability of trends in these two data sources., Methods: EMS data from biospatial© and ED data from CDC's Drug Overdose Surveillance and Epidemiology system and National Syndromic Surveillance Program were queried for nine states. Counts of total encounters, opioid-involved overdose encounters, and rates of opioid-involved overdoses per 10,000 total encounters were calculated for each data source from 2020 to 2022. Trends in monthly counts and rates were assessed using Joinpoint regression., Results: On average, EMS data captured 1.8 times more monthly opioid-involved overdose encounters than ED data. Trends in the counts of opioid-involved overdose encounters were similar in both data sources with increases and decreases occurring during roughly the same periods. Overall, trends in rates of opioid-involved overdose encounters were also comparable., Conclusions: EMS and ED data provide complementary information for understanding overdose trends. Study findings underscore the importance of implementing post-overdose response protocols by both EMS and ED providers to ensure patients receive services irrespective of care setting., 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., (Published by Elsevier Inc.)

Introduction: Recognized risk factors for acetaminophen overdose include alcohol, opioids, and mood disorders. The aim of this study is to assess additional risk factors for acetaminophen overdose evaluated in the emergency department (ED)., Methods: A retrospective study was performed using the 2018 US Nationwide Emergency Department Sample (NEDS). All adult ED visits for acetaminophen overdose were included in the study group and those without it were taken as control. STATA, 16.1 was used to perform multivariable logistic regression analysis and adjusted odds ratios (ORadj) were reported., Results: We identified 27,792 ED visits for acetaminophen overdose. Relative to non-acetaminophen ED visits, this group was younger (median age 32 vs 47 years; p < 0.0001), more often female (66.1% vs 57.0%; p < 0.0001), had higher ED charges ($3,506 vs $2,714; p < 0.0001), higher proportion of alcohol-related disorders (15.8% vs 3.5%; p < 0.0001), anxiety disorders (30.2% vs 8.3%; p < 0.0001), cannabis use (8.7% vs 1.4%; p < 0.0001), hematology/oncology diagnoses (13.3% vs 10.9%; p < 0.0001), mood disorders (52.4% vs 7.9%; p < 0.0001), opioid-related disorders (4.1% vs 1.0%; p < 0.0001), and suicide attempt/ideation (12.2% vs 1.1%; p < 0.0001). Multivariable analysis showed alcohol-related disorders (ORadj 2.67), anxiety disorders (ORadj 1.24), cannabis (ORadj 1.63), females (ORadj 1.45), Income Q3 (ORadj 1.09), hematology/oncology diagnoses (ORadj 1.40), mood disorders (ORadj 10.07), opioid-related disorders (ORadj 1.20), and suicide attempt/ideation (ORadj 1.68) were associated with acetaminophen overdose., Conclusion: In addition to previously recognized risks, our study demonstrated that cannabis use and hematologic/oncologic comorbidities were more common among acetaminophen-overdose ED visits. These new findings are concerning because of rapid legalization of cannabis and the increasing incidence of cancer worldwide. Additional investigation into these risks should be a priority for clinicians, policymakers, and researchers., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Introduction: Low-threshold substance use treatment programs may help overcome barriers for marginalized individuals. The aims of this study were to 1) describe participant characteristics and treatment outcomes for a multi-site, Philadelphia-based mobile program providing street-based buprenorphine initiation, stabilization, and referral to ongoing care and 2) examine associations between patient characteristics and successful linkage., Methods: We conducted a retrospective cohort study of patients receiving buprenorphine through Prevention Point Philadelphia's mobile overdose response program from 9/2020-12/2021. We abstracted electronic medical record data, including patient characteristics, mobile program treatment, and care linkage. We used descriptive statistics to characterize the sample and assessed the association between patient characteristics and successful care linkage using multi-variable logistic regression., Results: Two hundred thirty-seven patients initiated buprenorphine in the program across six sites. Mean age was 46. Participants were majority men (67 %); 59 % identified as Black, 33 % identified as White, and 15 % reported Hispanic ethnicity. Most were publicly insured (74 %) and 30 % were unstably housed. Basedline engagement in primary care (32 %), psychiatric treatment (5 %), and counseling (2 %) were low. Most participants reported heroin or fentanyl use at intake (87 %), with high rates of IV drug use (37 %)., and co-occurring substance use and prior buprenorphine treatment experience were common.. 86 % completed ≥1 mobile follow-up visit, and 69 % completed ≥4 mobile program visits. 51 % of patients attended at least one visit at an outside site, and 30 % had ≥2 visits for buprenorphine prescriptions at an outside site. 35 % of the referrals were internal, meaning they went to University-based practices staffed by the mobile unit physicians. In a multivariable logistic regression model, internal referral was associated with significantly increased odds of effective care linkage (aOR 2.47, 95 % CI 1.20-5.09)., Conclusions: Targeted community outreach with low-threshold substance use care facilitated treatment access among marginalized individuals. Participants showed high levels of engagement with the mobile program, but rates of outside care linkage, while comparable to retention in other low-threshold models, were lower. The only predictor of effective care linkage was referral to brick-and-mortar clinics staffed by mobile unit physicians. These findings support the importance of outreach beyond traditional health care settings to engage high-risk patients with OUD., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives. To determine mortality risk among those recently released from a Minnesota jail or prison. Methods. Using linked prison, jail, and death records, our retrospective cohort study followed 99 065 people who were released from Minnesota jails and prisons between March 1, 2020, and December 31, 2021. We explored differences between jail and prison exposures regarding mortality using standardized mortality ratios. Results. Adjusting for age and gender, we estimated that the rate of overdose death for people released from jail was 15.5 times that of the Minnesota general population. Overdose death rates for people released from prison were even higher at 28.3 times the rate of the Minnesota general population. Conclusions. Drug overdose was the leading cause of death for people reentering their communities from both jail and prison in Minnesota-with opioids being the leading cause of overdoses. Overdose death relative to the general population was double the estimates from earlier studies among people leaving prison. Providing seamless access to medications for opioid use disorder during and after incarceration is important to lower the risk of death following release. ( Am J Public Health . 2024;114(9):913-922. https://doi.org/10.2105/AJPH.2024.307723).