Stigma and drug use settings as correlates of self-reported,non-fatal overdose among people who use drugs in Baltimore,Maryland

BackgroundFatalities from opioid overdose quadrupled during the last 15 years as illicit opioid use increased. This study assesses how stigma and drug use settings are associated with non-fatal overdose to identify targets for overdose risk reduction interventions and inform overdose education and naloxone distribution programs.MethodsWe surveyed 444 people who used drugs in Baltimore, Maryland, USA, from 2009 to 2013 as part of a randomized clinical trial of a harm reduction intervention. Participants reported demographic characteristics, drug use, overdose history, use of a local syringe services program, involvement in the local drug economy, and whether they experienced discrimination from others (i.e., enacted stigma) or stigmatized themselves (i.e., internalized stigma) related to their drug use. We used multinomial logistic regression models to identify correlates of experiencing a non-fatal overdose within the past year or >1 year ago relative to participants who never experienced an overdose.ResultsStigma was positively associated with experiencing a non-fatal overdose in the past year (adjusted Odds Ratio [aOR]: 1.7, 95% Confidence Interval [CI]: 1.1–2.7) and >1 year ago (aOR [95% CI]: 1.5 [1.1–2.0]) after adjustment for demographic and substance use characteristics. The association of stigma with overdose was stronger for enacted versus internalized stigma. The number of public settings (shooting gallery, crack house, abandoned building, public bathroom, outside) where participants used drugs was also positively associated with experiencing an overdose.ConclusionsStigma related to drug use and using drugs in more settings may increase overdose risk. The effectiveness of overdose prevention and naloxone training may be improved by reducing discrimination against people who use drugs in community and medical settings and diversifying the settings in which overdose prevention trainings are delivered. These efforts may be enhanced by use of peer outreach approaches in which people who use drugs diffuse prevention messages through their social networks and within settings of drug consumption outside the medical setting.     

“We don’t got that kind of time,man. We’re trying to get high!”: Exploring potential use of drug checking technologies among structurally vulnerable people who use drugs

BackgroundNovel public health interventions are being considered to address the opioid overdose epidemic, including drug checking technologies. We examined the willingness to use various drug checking technologies among structurally-vulnerable people who use drugs (PWUD).MethodsWe conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada’s Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD.ResultsOverall willingness to use drug checking technologies was low among participants. A range of factors undermined potential use of various drug checking technologies including: having to give up a drug sample; time dedication; discrepancies regarding measurements and accuracy; recourse following positive fentanyl results; ambivalence to overdose risk; and availability and accessibility of drug checking technologies.ConclusionsParticipants discussed numerous factors that undermined potential willingness to use drug checking technologies. These factors underscore the structural vulnerabilities experienced by PWUD and how they may constrain uptake of drug checking technologies. Future drug checking programming should consider these influencing factors prior to the implementation of drug checking technologies to ensure that drug checking interventions are appropriate and meeting the needs of target populations.     

A qualitative exploration of unintentional versus intentional exposure to fentanyl among people who use drugs in Austin,TX

BackgroundThe prevalence of deaths involving synthetic opioids has historically been lower in Texas than most U.S. states but more than quadrupled from January 2020 to January 2022. This paper explores the emergence of fentanyl in a drug supply where black tar heroin predominates, a factor considered protective against fentanyl adulteration, through the perspectives of people who use drugs (PWUD).ObjectivesWe describe experiences of unintentional exposure to fentanyl, illustrate how some people identify fentanyl in their supply, and present harm reduction strategies that PWUD use to avoid overdose.MethodsThirty rapid assessment interviews were conducted in July 2021 at 2 mobile outreach sites of a harm reduction organization in Austin, Texas. The brief semistructured interviews were designed to assess participant fentanyl exposure experiences.ResultsParticipants were clients who reported using heroin or fentanyl in the past week and had lived in Texas for at least 6 months. Seventeen participants identified as male, 10 as female, and 3 as nonbinary. Half identified as white; other participants were Latinx (6), black (2), American Indian (1), and mixed race (6). Two-thirds were unhoused or in transitional housing. The drug supply in Texas has evolved; most participants reported that the heroin and other drugs they obtained contain fentanyl. Participants detected differences by observing changes in the physical characteristics of the drug, experiencing unexpected effects, and using fentanyl test strips. Many had been unintentionally exposed to fentanyl and expressed concerns about fentanyl’s presence. The presence of fentanyl had negative unintended consequences for participants, including adverse effects and developing a dependence on opioids.ConclusionPWUD in Austin, Texas, report increasing prevalence of unintentional fentanyl exposure, despite the predominance of black tar heroin. Pharmacists can provide crucial supplies and education to safeguard the health of this vulnerable population.     

‘It's too much,I'm getting really tired of it’: Overdose response and structural vulnerabilities among harm reduction workers in community settings

BackgroundIn response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) – who experience social and structural vulnerabilities due to their drug use – enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.MethodsData were drawn from an ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.ResultsOEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.ConclusionOEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.     

Impact of 24-hour schedule of a drug consumption room on service use and number of non-fatal overdoses. A quasiexperimental study in Barcelona

BackgroundThe opening hours of drug consumption rooms could constitute a barrier to access among people who use drugs (PWUD). CAS Baluard is an outpatient substance use care center in Barcelona, which provides a drug consumption room in Barcelona among other services. The objectives of our study were to compare the client profile, the facility use, the drugs used, and the number of non-fatal overdose episodes between (1) a 15-hour opening period of a drug consumption room versus a 24-hour opening period; and (2) between daytime and nighttime during the 24-hour period.MethodsData from CAS Baluard was obtained from March-June (15-hour opening period) and July-October (24-hour opening period), 2018. The sociodemographic characteristics of clients were gathered in both periods and in the daytime and nighttime client groups in the 24-hour period. Finally, associations were estimated between facility use and period and between facility use and opening hours.ResultsThere were 1,089 clients in the 15-hour period and 1,262 in the 24-hour period. There were no sociodemographic differences in the clients between periods. During nighttime, there was a higher proportion of women (17%) and homeless people (47%) than during daytime (12% and 30%, respectively). Injected cocaine use was more frequent during nighttime (34%) than during daytime (25%) and injected heroin use was less frequent during nighttime (17%) than during daytime (24%). There was a non-significant increase in non-fatal overdose risk during nighttime (PR 3.9 95%CI 0.98-15.64). However, when we analyzed heroin use alone, the increase in non-fatal overdose risk was significant (PR 4.69 95%CI 1.17-18.75).ConclusionDuring nighttime, attendance at the facility was higher among women, homeless people, and people who used stimulants. Our results point to a possible increase in overdose risk during nighttime, when most drug consumption rooms are closed.     

High enhancer,downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

BackgroundBenzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular—a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.MethodsFor qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18–32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18–29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.ResultsParticipants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.ConclusionNonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.     

Editorial

The increase in the number of non-fatal opioid overdoses in Melbourne, Australia has occurred concomitantly with the emergence of street heroin dealing / using areas across different parts of Melbourne. The aim of this study was to examine the social and environmental factors that contribute to the risk of illicit drug overdose in a street heroin dealing / using setting. A detailed examination of overdose experiences, and consultations with drug users, police and shop traders, suggests that the harm related to drug overdose and the factors which contribute to the risk of overdose in a street-using / dealing environment may be significantly underestimated. The clinical definition of drug overdose may underestimate the harm associated with illicit drug use. Through not fully understanding drug user's experiences of drug overdose, and thus incorrectly defining drug overdose, significant opportunities to intervene in what is a significant medical and social problem may be lost.     

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

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

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.     

Agency in the fentanyl era: Exploring the utility of fentanyl test strips in an opaque drug market

BackgroundIn Baltimore, the emergence of fentanyl and its analogues exacerbated an existing heroin crisis and increased uncertainty about drug composition and potency. In an effort to reduce overdoses, harm reduction organizations and health departments across the U.S. began distributing fentanyl test strips, a low barrier, inexpensive drug checking strategy. Studies show that people who use drugs (PWUD) frequently suspect that their drugs contain fentanyl and are interested in using fentanyl test strips to check their drugs; however, some people question their usefulness in regions where fentanyl presence is assumed. Understanding the utility of fentanyl test strips in fentanyl-saturated markets is a priority to best tailor interventions.MethodsIn-depth interviews (N = 20) were conducted with individuals who reported recent (past 30 days) opioid use in Baltimore, MD.ResultsFentanyl was viewed as pervasive, dangerous, and difficult to avoid in the local drug supply. This dominant narrative characterized PWUD as disempowered by the heightened unpredictability of the drug market. While several strategies are used to navigate the drug market, respondents wanted more information about their drugs. In this context, fentanyl test strips were used in unique and unexpected ways to empower PWUD to be savvier market consumers, including avoiding fentanyl when there could be negative social or legal consequences, negotiating with dealers, and helping others in their social network navigate the opaque drug market.ConclusionThese findings add nuance and place fentanyl preference and use in the context of the drug market. When fentanyl presence is assumed, people used fentanyl test strips in unexpected ways to gain some control over their drug use. Novel uses for fentanyl test strips strengthen existing strategies used to navigate the drug market and mitigate overdose risk, and highlight their potential to quickly disseminate valuable information about the local drug supply.     

Transition to injection amongst opioid users in Iran: implications for harm reduction

Driven by opioid use, HIV prevalence is high (15-27%) amongst injection drug users (IDU) in Iran. Harm reduction programmes are associated with a reduction in high risk injecting behaviours; however, Iran has a large number of non-injecting opioid users not immediately targeted by harm reduction programmes. The vast majority of heroin injectors tend to have a history of several years of smoking opium or heroin before transitioning to injection, and a small fraction may even start their drug career by injection of opioids, behaviours that can undermine the effectiveness of the harm reduction programmes. In this study, we have reviewed evidence on the HIV epidemic, extent and pattern of opioid use, and correlates of the transition to injection in Iran. We have concluded that harm reduction policies should also emphasize prevention of the transition to injection amongst high-risk non-injecting opioid users as an additional strategy against the spread of HIV infection in Iran.     

Urban,individuals of color are impacted by fentanyl-contaminated heroin

The present phase of the overdose epidemic is characterized by fentanyl-contaminated heroin, particularly in the eastern United States (U.S.). However, there is little research examining how changes in drug potency are affecting urban, racial minority individuals who have been affected by both the “old” epidemic of the 1940s through 1980s, as well as the “new” present day epidemic. A focus on the drug using experiences of racial minorities is needed to avoid perpetuating discriminatory responses to drug use in communities of color, which have characterized past U.S. policies. This qualitative study was conducted from March through June 2018 to examine recent experiences of urban, individuals of color who inject drugs to assess the impact of the current overdose epidemic on this understudied population. Interviews were conducted with 25 people who reported current injection drug use. The interviews were transcribed and analyzed using a general inductive approach to identify major themes. Fifteen of 25 participants reported experiencing a non-fatal overdose in the past two years; eight suspected their overdose was fentanyl-related. Likewise, 15 had ever witnessed someone else overdose at least once. Overdoses that required multiple doses of naloxone were also reported. Participants employed several methods to attempt to detect the presence of fentanyl in their drugs, with varying degrees of success. Carrying naloxone and utilizing trusted drug sellers (often those who also use) were strategies used to minimize risk of overdose. Contaminated heroin and increased risk for overdose was often encountered when trusted sources were unavailable. This population is suffering from high rates of recent overdose. Removal of trusted drug sources from a community may inadvertently increase overdose risk. Ensuring access to harm reduction resources (naloxone, drug testing strips) will remain important for addressing ever-increasing rates of overdose among all populations affected.     

Are non-fatal opioid overdoses misclassified suicide attempts? Comparing the associated correlates

This paper aimed to determine whether non-fatal opioid overdose and suicide attempts are distinct behaviours by examining the histories of 1500 opioid-dependent individuals. This paper utilised data collected as part of a large retrospective case-control study. Unintentional non-fatal opioid overdoses were more common than suicide attempts (58% vs. 32%). Overall, the correlates associated with a history of attempted suicide only and non-fatal opioid overdose only were different. Drug-related risk behaviours (including high impulsivity, injection of opioids, sedative dependence) were associated with non-fatal opioid overdose; and a history of mental disorders (depression, anxiety disorder, and screening positive for borderline personality disorder (BPD+) were associated with suicide attempts. Additionally, those who reported a history of both behaviours had a more severe clinical profile including excessive drug use, psychological disorders and childhood trauma. The study concluded that non-fatal opioid overdose and attempted suicide are distinct clinically significant problems that require different approaches for prevention. Additionally, if both behaviours are reported a thorough assessment of underlying comorbid problems should be initiated by treatment services.     

Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia

BackgroundBetween the years 2017–2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.MethodsIn 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.ResultsData reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate—in particular structural inequalities exacerbated by decades of “War on Drugs” policies.ConclusionExisting health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.