Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore,MD

Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This article investigates heroin injectors’ perceptions and experiences of changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently facing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore’s heroin market is divided between two types: “Raw,” believed to be Colombian in origin and relatively pure, and the more adulterated “Scramble” (raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action, and effect. Some considered that Scramble was no longer “heroin,” but was heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines, and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users’ lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions, and acceptance.     

Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore,Boston and Providence

BackgroundNorth America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD).MethodsThrough FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson’s χ² and logistic regression determined factors associated with drug checking intent.ResultsOverall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3–1.8); homelessness (aOR: 0.6, 95% CI: 0.5–0.7); being non-white (aOR: 2.0, 95% CI: 1.0–4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1–2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1–3.1).ConclusionsThe majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.     

Concerns that an opioid antidote could “make things worse”: Profiles of risk compensation beliefs using the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale

Abstract

Background and aims: As opioid overdose death rates reach epidemic proportions in the United States, the widespread distribution of naloxone is imperative to save lives. However, concerns that people who use drugs will engage in riskier drug behaviors if they have access to naloxone remain prevalent, and the measurement scales to assess these risk compensation concerns remain under researched. This study aims to examine the validity of the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale and to understand the effect of overdose education and naloxone distribution (OEND) training on risk compensation beliefs across demographic and professional populations. Methods: A total of 1424 participants, 803 police officers, 137 emergency medical services (EMS)/fire personnel, and 484 clinical treatment and social service providers were administered surveys before and after attending an OEND training. Survey items measured the endorsement of opioid overdose knowledge and attitudes, as well as risk compensation beliefs. Results: Police and EMS/fire personnel expressed greater endorsement of risk compensation beliefs than clinical treatment and social service providers at both pre- and post-OEND training. Although endorsement of risk compensation beliefs was significantly reduced in each of the 3 groups after the training, reductions were greatest among EMS/fire personnel, followed by providers, then police. Moreover, younger, male, and black participants endorsed greater beliefs in risk compensatory behaviors as compared with their older, female, and white counterparts. Conclusion: This study validated a novel measure of naloxone-related risk compensation beliefs and suggests participating in OEND trainings decreases beliefs in naloxone-related risk compensation behaviors. OEND trainings should consider addressing concerns about naloxone “enabling” drug use, particularly in law enforcement settings, to continue to reduce stigma surrounding naloxone availability.     

The Risk of Emergency Room Treatment Due to Overdose in Injection Drug Users

ABSTRACT

This cohort study was conducted to identify risk factors for lifetime emergency room treatment due to overdose in injection drug users. Data of 1049 patients on admission for opioid detoxification were analyzed. More than every third injection drug user (34.7%) experienced emergency room treatment due to an overdose. Using multiple logistic regression not living with a significant other drug user (odds ratio [OR] = 1.78, P = .002), history of suicide attempt (OR = 3.0, P = .000), daily use of barbiturates (OR = 2.17, P = .006) and cannabis (OR = 1.89, P = .001) were independently associated with emergency room treatment, whereas shorter duration of opioid use (OR = 0.23, P = .001) was independently associated with lack of emergency room treatment. Suicidal thoughts and multiple use of central nervous system depressants should be considered in injection drug users entering the emergency room due to an overdose. Emergency rooms should be seen as important places for offering further assistance (e.g., counselling) or referral to an addiction unit to drug users.     

International patent applications for non‐injectable naloxone for opioid overdose reversal: Exploratory search and retrieve analysis of the PatentScope database

Issues. Non‐injectable naloxone formulations are being developed for opioid overdose reversal, but only limited data have been published in the peer‐reviewed domain. Through examination of a hitherto‐unsearched database, we expand public knowledge of non‐injectable formulations, tracing their development and novelty, with the aim to describe and compare their pharmacokinetic properties. Approach. (i) The PatentScope database of the World Intellectual Property Organization was searched for relevant English‐language patent applications; (ii) Pharmacokinetic data were extracted, collated and analysed; (iii) PubMed was searched using Boolean search query ‘(nasal OR intranasal OR nose OR buccal OR sublingual) AND naloxone AND pharmacokinetics’. Key Findings. Five hundred and twenty‐two PatentScope and 56 PubMed records were identified: three published international patent applications and five peer‐reviewed papers were eligible. Pharmacokinetic data were available for intranasal, sublingual, and reference routes. Highly concentrated formulations (10–40 mg mL⁻¹) had been developed and tested. Sublingual bioavailability was very low (1%; relative to intravenous). Non‐concentrated intranasal spray (1 mg mL⁻¹; 1 mL per nostril) had low bioavailability (11%). Concentrated intranasal formulations (≥10 mg mL⁻¹) had bioavailability of 21–42% (relative to intravenous) and 26–57% (relative to intramuscular), with peak concentrations (dose‐adjusted C_max = 0.8–1.7 ng mL⁻¹) reached in 19–30 min (t_max). Implications. Exploratory analysis identified intranasal bioavailability as associated positively with dose and negatively with volume. Conclusion. We find consistent direction of development of intranasal sprays to high‐concentration, low‐volume formulations with bioavailability in the 20–60% range. These have potential to deliver a therapeutic dose in 0.1 mL volume. [McDonald R, Danielsson Glende Ø, Dale O, Strang J. International patent applications for non‐injectable naloxone for opioid overdose reversal: Exploratory search and retrieve analysis of the PatentScope database. Drug Alcohol Rev 2017;00:000‐000]     

Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients

Background: Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. Methods: The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Results: Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Conclusions: Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.     

A Cross-Sectional Study on Prevalence of Non-Fatal Drug Overdose and Associated Risk Characteristics Among Out-of-Treatment Injecting Drug Users in North Vietnam

In a community-based cross-sectional survey among out-of-treatment male opiate injecting drug users (IDU) aged 18–45, data on non-fatal overdose were collected using a semi-structured questionnaire. From August to September 2003, 299 IDU were recruited in two districts of Bac Ninh, a semi-urban province in North Vietnam. Prevalence of lifetime and recent non-fatal overdose were 43.5 and 83.1%, respectively. Logistic regression analyses showed associations between non-fatal overdose and younger age, unemployment, residence in the provincial township, frequency of injecting, injecting heroin mixed with valium, and history of drug treatment. While recognizing the limitations of this study, it is the first in Southeast Asia to report on prevalence of drug use–related overdose. Future research is recommended on occurrence of fatal overdose in this population.     

Perceived Severity of and Susceptibility to Overdose Among Injection Drug Users: Relationships With Overdose History

Background: Overdose is relatively common among injection drug users (IDUs) yet little is known about how overdose-related health beliefs influence overdose experiences or risk reduction. Objectives: This study examines the association of perceived susceptibility to and perceived severity of nonfatal overdose with overdose history among IDUs attending needle exchange programs (NEPs) to inform prevention efforts. Methods: In 2009–2010, IDUs (N = 91) attending NEPs completed self-report surveys. Negative binomial regression modeled the association between demographics, age of injection initiation, length of time attending the NEP, perceived severity of overdose, and perceived susceptibility to overdose with lifetime history of nonfatal overdose. Results: Over half (55%) of participants reported lifetime overdose, with a mean of 2.9 overdoses. A multivariable negative binomial regression model revealed that younger current age, older age of first injection, non-Caucasian race, higher perceived severity of overdose, and lower perceived susceptibility to overdose were significantly correlated with fewer lifetime overdoses. Conclusions: Although our methodology precludes causal inferences, these findings are consistent with the hypothesis that perceived severity and perceived susceptibility are among several factors associated with IDUs' use of protective behaviors, which could influence the likelihood of overdose. Future prospective research to explore the impact of this and other health beliefs on risk behaviors and overdose could help improve the effectiveness of behavioral interventions.     

The willingness of people who inject drugs in Boston to use a supervised injection facility

ABSTRACT

Background: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. Methods: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). Results: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9–15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8–14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2–21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6–14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9–18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2–14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2–14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2–10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3–8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2–8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2–7.4; P = .02). Conclusions: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.     

The Association between Intentional Overdose and Same-Sex Sexual Intercourse in a Cohort of People who Inject Drugs in Melbourne,Australia

Background: People who inject drugs (PWID) are at disproportionately high risk of suicidal behaviors, as are individuals who report same-sex attraction or experience. However, there is little evidence of compounded risk of suicide for individuals who report same-sex sexual intercourse (SSI) and are PWID. Objectives: To explore the associations of lifetime intentional overdose amongst a cohort of PWID, with particular attention to those reporting SSI. Methods: The sample included 529 participants, from an ongoing cohort of 757 PWID. An “ever” SSI variable was created for participants who reported sexual intercourse with a same-sex partner at any longitudinal interview. We explored the adjusted associations between SSI and lifetime intentional overdose using logistic regression. Results: Ninety-one (17%) participants reported ever experiencing an intentional overdose. Forty-one (8%) participants reported SSI at any interview. Three hundred and sixty (68%) participants reported diagnosis of a mental health condition. Diagnosis of a mental health condition (AOR = 2.02, 95% CIs: 1.14, 3.59) and SSI (AOR = 2.58, 95% CIs: 1.22, 5.48) significantly increased the odds of lifetime intentional overdose. Conclusions/Importance: We found a heightened risk of intentional overdose amongst PWID reporting SSI, after controlling for diagnosis of a mental health condition. Services need to be aware of this heightened risk and target interventions appropriately.