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Twin epidemics: The surging rise of methamphetamine use in chronic opioid users
Abstract
Background/aims: Recent supply-side efforts enacted to curb the opioid epidemic have had both positive (i.e., prescription opioid abuse is on the decline) and negative outcomes (i.e., shifts to other drugs). Given methamphetamine is notably increasing in use across the United States, we sought to understand whether use of methamphetamine has increased among opioid users and whether there is an association between these two epidemics.
Methods: Patients (N = 13,521) entering drug treatment programs across the United States completed an anonymous survey of drug use patterns from 2011 to 2017. A subset of these patients (N = 300) was also interviewed to add context and expand on the structured survey.
Results: Past month use of methamphetamine significantly increased among treatment-seeking opioid users (+82.6%, p < .001), from 18.8% in 2011 to 34.2% in 2017. The Western region had the greatest increase in past month methamphetamine use (+202.4%, p < 0.001) and the highest prevalence rate in 2017 (63.0%). Significant increases (p < .001) in methamphetamine use were seen among males (+81.8%), females (+97.8%), whites (+100.6%), urban residents (+123.0%) and rural residents (+93.7%).
Conclusions: Our studies show that there has been a marked increase in the past month use of methamphetamine in individuals with a primary indication of opioid use disorder. Qualitative data indicated that methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function “normally”. Our data suggest that, at least to some extent, efforts limiting access to prescription opioids may be associated with an increase in the use of methamphetamine.
... Data suggest the US has entered the fourth wave of the opioid overdose epidemic: a combined stimulant/opioid epidemic, [1][2][3] with a notable increase in methamphetamine use among people who use opioids in rural communities. [4][5][6][7][8][9] Polysubstance use, the practice of taking 2 or more classes of substances together or within a short time period, is common among people who use drugs (PWUD) and a driving factor of overdose deaths. [10][11][12][13] Motivations for the concurrent or sequential use of stimulants with opioids have been reported by some as a strategy to mitigate opioid overdose risk or to reduce opioid withdrawal symptoms. ...
... [14][15][16][17] Additional motivations include preferences for the simultaneous effects of both substances and increased availability and affordability of methamphetamine in local communities. 7,15,18,19 In addition, some people who use methamphetamine are unintentionally exposed to opioids, and especially fentanyl, putting them at elevated risk for overdose because they are opioid naïve. 20 In the US, there are high rates of opioid/methamphetamine polysubstance use in rural communities. ...
... 20 In the US, there are high rates of opioid/methamphetamine polysubstance use in rural communities. 7,9,21,22 Polysubstance use, especially in the form of opioid/stimulant polysubstance use, is an important contributor to negative outcomes such as overdoses among PWUD in rural areas. 10,13,23 Some PWUD have previously reported incorporating stimulants with their opioid use as a perceived way to reduce their risk of an overdose; however, evidence shows that the opposite is actually true-use of stimulants and opioids together increases the risk of an overdose. ...
Background
The United States’ (US) opioid overdose epidemic has evolved into a combined stimulant/opioid epidemic, a pattern driven in part by mitigating opioid overdose risk, variable substance availability, and personal preferences. This study aimed to investigate the association between self-reported substance preference (heroin or methamphetamine) and behavioral/health outcomes among individuals who used both heroin and methamphetamine in the rural US.
Methods
The Rural Opioid Initiative is a consortium of 8 research cohorts from 10 states and 65 rural counties that recruited individuals reporting past 30-day injection of any substance or opioid substance use by any route from 1/2018 to 3/2020. Analyses were restricted to participants ⩾18 years, who self-reported either heroin or methamphetamine as their preferred substance and past 30-day use of both heroin and methamphetamine. We examined cross-sectional associations between preferred substance (heroin versus methamphetamine) and behavioral and health outcomes using random effects meta-analysis with adjusted regression models.
Results
Among 1239 participants, 61% (n = 752) reported heroin as their preferred substance. Adjusting for age, sex, and race/ethnicity, methamphetamine preference was associated with lower prevalence ratios for current naloxone possession (adjusted prevalence ratio [aPR] = 0.68; 95% Confidence Interval [95% CI] = 0.59-0.78; P-value ⩽ .001), of ever being told they had the hepatitis C virus (HCV; aPR = 0.72; 95% CI: 0.61-0.85; P-value ⩽ .001) and a personal history of overdose (aPR = 0.81; 95% CI = 0.73-0.90; P-value ⩽ .001).
Conclusion
In our study analyzing associations between preferred substance and various behavioral and health outcomes amongst people who use both heroin and methamphetamine, a majority of participants preferred heroin. Methamphetamine preference was associated with lower prevalence of naloxone possession, ever being told they had HCV, and prior history of an overdose. This study underscores the need for targeted harm reduction services for people who prefer methamphetamine in rural areas.
... This epidemic includes the use of both substances simultaneously and the concurrent use of one substance within hours of the other. In the U.S., among persons who use opioids, the use of stimulants, particularly methamphetamine, has increased dramatically [3,4] with past-month use increasing from 9 to 44% among people who use heroin between 2015 and 2019 [4]. ...
... Our qualitative study is the largest and most regionally diverse sample of people who concurrently use stimulants and opioids in the rural U.S., corroborating findings in smaller and/or non-rural studies that have identified drivers of concurrent use, such as the desire for unique psychoactive effects [20,21,27], to offset or balance the adverse physical and psychological effects of the other drug [3,4,20,28], and to alleviate opioid withdrawal symptoms [20,27,29]. We note that three of our findings appear particularly salient to the rural U.S. context, and less prevalent in studies limited to urban populations. ...
... First, our participants described significant changes in local drug availability as a key driver for their methamphetamine use. Methamphetamine was less expensive and described as more readily available than opioids, aligning with findings from smaller rural U.S. studies [19,21] and a large national sample [3]. Second, in contrast to studies limited to urban populations, participants often described functional goals, such as "having energy and being pain free", in order to be productive in daily activities including employment, echoing findings elsewhere [21,23]. ...
Background
In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.
Methods
We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.
Results
We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.
Conclusion
In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
... The "fourth wave" of the opioid epidemic is marked by a drastic increase in opioid and illicit stimulant (mainly cocaine and methamphetamine) co-use (Ahmed et al., 2022;Ciccarone, 2021). It has been estimated that opioid and stimulant co-use has increased by over 80 % in the last decade (Ellis et al., 2018;Goodwin et al., 2021), with a recent cross-sectional study conducted in 10 states between 2018 and 2020 finding that 75 % of people with current opioid addiction reported illicit stimulant use in the past 30-days (Tsui et al., 2023). ...
... Opioid and illicit stimulant co-use has increased dramatically in the last decade (Ellis et al., 2018;Goodwin et al., 2021) and is directly associated with worse MOUD treatment outcomes (Frost et al., 2021;Russell et al., 2023). Almost half of the sample (42.8 %) tested positive for stimulants at baseline, highlighting the high prevalence of opioid and stimulant co-use among individuals initiating MOUD treatment. ...
Introduction: Illicit stimulant use among individuals initiating medication for opioid use disorder (MOUD) has significantly increased over the past decade. Co-use of these substances is associated with increased risk of mortality as well as worse treatment outcomes. This study examines the potential predictive role of stimulant urinalysis result at baseline on treatment retention and opioid and stimulant use outcomes amongst individuals
initiating MOUD treatment.
Methods: This is a cross-sectional secondary analysis of data from a multi-site randomized clinical trial (CTN-0027). A total of 1269 individuals were randomized to receive 24 weeks of buprenorphine (n=740) or methadone (n=529) treatment across nine sites. Multiple linear and logistic regressions were conducted to determine the impact of baseline stimulant urinalysis results on treatment retention, and stimulant and opioid use outcomes.
Results: Individuals initiating MOUD with a stimulant negative urinalysis result at baseline submitted more negative stimulant (β=7.8; 95 % CI 6.8–8.7) and opioid (β=2.8; 95 % CI 1.8–3.8) urinalyses during treatment, were more likely to complete treatment (aOR=1.4; 95 % CI 1.1–1.7), and had better outcomes at six-month follow-up, measured as negative urinalysis for stimulant (aOR=5.3; 95 % CI 3.6–7.7), and opioid (aOR=1.8; 95 % CI 1.3–2.6).
Conclusion: Baseline stimulant use is associated with worse MOUD treatment outcomes, underscoring the need for novel integrated interventions designed to address opioid and stimulant co-use.
... National death records in the US also indicate that the percent of overdose deaths involving both fentanyl and stimulants increased from 0.6% in 2010 to 32.3% in 2021, with the sharpest increase beginning in 2015 [7]. Although these increases may have been partially attributed to unintentional fentanyl exposure among persons who use stimulants (e.g., stimulants contaminated with fentanyl, or fentanyl-contaminated paraphernalia), there have been documented increases in the prevalence of self-reported stimulant use among those using opioids in recent years, with methamphetamine use in particular rising among increasingly diverse demographic groups and geographic regions [46][47][48][49]. Among persons seeking treatment for opioid use disorder, Ellis and colleagues [46] found that primary motivations for methamphetamine and opioid co-use included achieving a synergistic high (51.0% of respondents), balancing out the effects of opioids (38.6%), and using methamphetamine as a substitute when opioids were not available, often to manage withdrawal symptoms (12.5%). ...
... Although these increases may have been partially attributed to unintentional fentanyl exposure among persons who use stimulants (e.g., stimulants contaminated with fentanyl, or fentanyl-contaminated paraphernalia), there have been documented increases in the prevalence of self-reported stimulant use among those using opioids in recent years, with methamphetamine use in particular rising among increasingly diverse demographic groups and geographic regions [46][47][48][49]. Among persons seeking treatment for opioid use disorder, Ellis and colleagues [46] found that primary motivations for methamphetamine and opioid co-use included achieving a synergistic high (51.0% of respondents), balancing out the effects of opioids (38.6%), and using methamphetamine as a substitute when opioids were not available, often to manage withdrawal symptoms (12.5%). Others have described the use of methamphetamine as a method to manage overdose risks related to IMF. ...
Purpose of Review
As the overdose crisis evolves, it is important to monitor fentanyl consumption patterns. This review provides an overview of recent findings regarding illegally manufactured fentanyl (IMF) availability, use, and associated harms in the US.
Recent Findings
Availability of IMF has increased, especially in pill form, and the increasing adulteration of IMF with veterinary tranquilizers such as xylazine complicates overdose response. Prevalence in the general population based on self-reported IMF use is rare, and likely underestimated. Transitions from injection to smoking have been documented in recent years, particularly in the western US. Fentanyl-stimulant polysubstance use has also been observed increasingly among IMF-related overdose deaths.
Summary
Shifts in routes of administration, availability of counterfeit pills containing fentanyl, and common adulterants add complexity to the landscape of IMF use and related harms. Additional data is needed for monitoring changes in consumption patterns to inform prevention and harm reduction efforts.
... 3 There has been a marked increase in the co-use of methamphetamine with opioids in North America, with some studies suggesting a twofold increase in the past decade. 4,5 While reliable Canadian epidemiologic data is scarce, data from the United States shows that past month methamphetamine use increased among treatmentseeking adults who use opioids from 18.8% in 2011 to 34.2% in 2017. 5 Furthermore, similar increasing trends in amphetamine use have been observed in Canada. ...
... 4,5 While reliable Canadian epidemiologic data is scarce, data from the United States shows that past month methamphetamine use increased among treatmentseeking adults who use opioids from 18.8% in 2011 to 34.2% in 2017. 5 Furthermore, similar increasing trends in amphetamine use have been observed in Canada. 6,7 For example, at a psychiatric hospital in Toronto, Ontario the proportion of opioid-related emergency department visits, among amphetamine-related visits, increased from 8.4% in 2014 to 19.8% in 2021. ...
Background and Objectives
Although concurrent stimulant use is common among people with opioid use disorder (OUD), there is little evidence on its impacts on opioid agonist therapy (OAT) outcomes. This study sought to determine the impact of baseline methamphetamine/amphetamine use on discontinuation of OAT among individuals with prescription‐type OUD (POUD) initiating methadone or buprenorphine/naloxone as part of a pragmatic randomized trial in Canada.
Methods
Secondary analysis of a pan‐Canadian pragmatic trial conducted between 2017 and 2020 comparing supervised methadone versus flexible take‐home dosing buprenorphine/naloxone models of care. Cox proportional hazard models were used to evaluate the effect of baseline methamphetamine/amphetamine use (measured by urine drug test [UDT]) on two discontinuation outcomes (i.e., assigned OAT discontinuation, any OAT discontinuation).
Results
Two hundred nine (n = 209) participants initiated OAT, of which 96 (45.9%) had positive baseline methamphetamine/amphetamine UDT. Baseline methamphetamine/amphetamine use was associated with shorter median times in assigned OAT (21 vs. 168 days, hazard ratio [aHR] = 2.45, 95% confidence interval [CI] = 1.60–3.76) and any OAT (25 days vs. 168 days, aHR = 2.06, CI = 1.32–3.24). No interaction between methamphetamine/amphetamine and assigned OAT was observed for either outcome ( p > .05).
Conclusion and Scientific Significance
This study offers novel insights on the impact of methamphetamine/amphetamine use on OAT outcomes among people with POUD. Methamphetamine/amphetamine use was common and was associated with increased risk of OAT discontinuation. Supplementary interventions, including treatment for stimulant use, are needed to improve retention in OAT and optimize treatment outcomes in this population.
... The addition of cocaine to tranq dope may be of significance in the development of wounds due to its potential to increase the acidity of injected mixtures and its vasoconstrictive effects. The uptake of stimulant-type drugs among primary opioid users has been documented in many US locations in recent years (Ciccarone, 2021;Ondocsin, Holm, Mars, & Ciccarone, 2023;Ellis et al., 2018). Ethnographic comparison suggests that the use of cocaine speedballs, as well as methamphetamine ones, has become more prevalent in Philadelphia in recent years: "And ...
Introduction: ‘Tranq dope’ is a combination of xylazine and fentanyl that is increasingly common in the US. Frequently injected, its use appears related to severe skin and soft tissue wounds (SSTW) through an unknown mechanism. Previous research suggests that the high acidity of certain heroin source-forms contributes to vein damage and SSTW, however, the possibility of a role between the acidity of tranq dope and SSTW is understudied.
Methods: A convenience sample of persons who use drugs participated in semi-structured interviews (Philadelphia, Oct. 2023, n = 30). Observations of wounds/injection locations were made. We analyzed narrative data for perceptions of wound causation. Our partner lab analyzed the pH of 10 independently obtained samples, including tranq dope (n = 4), street opioids without xylazine (n = 2), xylazine alone (n = 2), and street stimulants (n = 2).
Results: Observed SSTW were extraordinarily severe. Several themes emerged related to wound etiology: 1) tranq dope injection caused burning sensations; 2) vein loss occurred rapidly following uptake of tranq dope; 3) vein loss resulted in increased injection attempts, the use of large central veins (e.g., jugular and femoral), as well as more frequent ‘skin-popping’; and 4) wounds (called ‘tranq burn’) rapidly followed vein loss. The average pH of the samples was 4, with samples containing fentanyl ranging from pH 2.1–5.9; samples containing xylazine ranging from pH 3.6–5.9; and the cocaine sample with a pH of 3.
Discussion: While this study cannot confirm a causal role, our findings of reported burning sensations and moderate to high acidity of lab-tested drugs are coherent with reported rapid vein loss following initiation of tranq injection. This, in turn, lends early support to a synergistic hypothesis of tranq-related SSTW etiology: vein loss and subcutaneous injections stem from the injection of acidic drugs followed by poor tissue perfusion from vasoconstriction due to xylazine. Possible harm reduction interventions include dilution and buffering. Stigma reduction and enhanced wound care are required in harm reduction and clinical settings.
... This issue has expanded to other illicitly used drugs, such as xylazine, a veterinary tranquilizer, with 98.4% of xylazine-involved overdoses involving fentanyl as a co-occurring drug in areas with a high number of xylazine deaths [72]. In addition to contamination, many opioid users have intentionally co-used stimulants in an effort to enhance their "high" and manage opioid withdrawal symptoms, as seen with the rise of the use of "goofballs" (the injection of both methamphetamine and heroin together) [73][74][75]. This co-use of stimulants and opioids carries numerous health consequences, including an increased risk of overdose due to masking opioid overdose symptoms, which decreases the likelihood of naloxone traffic injuries, falls, and drownings, with a nearly eightfold increase in rates of accidental injury and suicide among individuals with OUD compared to the general population [113]. ...
Purpose of Review
This review explores the epidemiology of opioid use, misuse, and opioid use disorder (OUD), exploring its risk factors, consequences, and management strategies.
Recent Findings
The rising prevalence of synthetic opioids has significantly increased overdose deaths, with the rise of polysubstance use posing a critical problem in the current phase of the epidemic. There has also been a shift in the use of opioids, with an increasing preference for smoking over injecting. Risk factors, including genetic predisposition, socioeconomic disadvantage, and mental health disorders, are strongly linked to OUD. Management strategies, such as medications for OUD, harm reduction programs, and psychosocial interventions, have proven effective but face barriers such as stigma and limited accessibility. Emerging approaches like novel therapeutics show promise in improving outcomes.
Summary
OUD remains a complex public health challenge requiring substantial and collaborative efforts. Addressing accessibility barriers, enhancing treatment retention, and integrating innovative therapies are essential to mitigating the epidemic’s impact and reducing its burden.
... Notably, the proportions of persons indicating use of opioids and methamphetamines serves as a call to action for local, state, and Federal leaders to enact evidence-based policies and programs aimed at mitigating associated harms. These data parallel trends found throughout the US and may reflect needs for holistic forms of addiction treatment that encompass opioid and stimulant dependence [56,57]. Given the scale of opioid and stimulant use in our sample and that it spans populations who self-identify as American Indian and other demographic groups, implementing an array of evidence-based programs tailored to local cultures and contexts should be prioritized. ...
Background
Reversing trends in substance use-related health inequities among Indigenous Peoples requires investments in epidemiological research anchored in community-based participatory research (CBPR) methodologies. There is scarce literature that describes how to implement population estimation methods on American Indian reservation lands.
Objective
This research describes how we leveraged CBPR throughout the implementation of a population estimation study conducted in collaboration with a Tribal Nation in the southern plains to quantify the size and characteristics of persons with histories of illicit substance use on reservation lands.
Methods
We used the capture and recapture population estimation methodology in April-May 2023 to estimate the size of the population of people who used illicit substances in the past six months in a county within the collaborating tribe’s jurisdiction. Participant recruitment occurred in areas where people who use drugs were known to congregate. Participants completed a survey that included measures pertaining to sociodemographics, substance use, harm reduction, overdose, sexual health, and cultural factors.
Results
In total, N = 501 surveys were completed by unique persons who had used illicit substances in their lifetime. A large proportion had injected drugs in the past six months or greater than six months ago (19.6% and 31.7%, respectively). There were N = 210 persons who reported having used illicit substances by at least one route of administration within the last six months. We estimated that there were 419 (95% confidence interval = 277, 562) adults who had recently used an illicit substance in the county where the study occurred.
Conclusions
This study demonstrates that population estimation methodologies can be integrated with community-based participatory research approaches to quantify the size of populations of people who use drugs. Future work should be conducted to understand the degree to which population-level needs evolve over time and in response to local initiatives.
... prcp.20240051 The rise of synthetic opioids, such as oxycodone and fentanyl, has precipitated increases in overdose-related deaths, and this concerning trend is not solely due to the opioid crisis (1,2). Concomitantly, the rise in methamphetamine use, its co-use with opioids, and lethal adulteration with fentanyl have had deleterious consequences (3,4). ...
Objective
In recent years, Black and Hispanic communities have been disproportionately impacted by growth in stimulant use disorders and overdose‐related mortality. Faith‐based institutions serve an important role in communities, and thus, community‐based interventions to enhance psychoeducation and reduce stigma are a promising area. The American Heart Association EmPOWERED to Serve program has developed health lessons through community‐based collaborations, including a video regarding stimulant use.
Methods
In collaboration with church partners, program staff and collaborators developed and implemented a 10‐min video in 12 church communities across several US states and in Puerto Rico. Implementation methods included virtual, hybrid, and in‐person forums. Six churches participated in a pre‐ and post‐video survey to assess effectiveness of the stimulant use disorder video for modifying attitudes toward substance use and for instilling knowledge about stimulant use disorders. Survey data (N = 478) were analyzed in SPSS utilizing Wilcoxon signed ranks for Likert scale responses or McNemar's tests for dichotomous data.
Results
Data suggested improvement in compassion for people with substance use and knowledge regarding stimulant use disorders. By contrast, sense of comfort in talking to loved ones with substance use and beliefs about substance use being a medical illness did not change following the video.
Conclusions
This work suggests that a brief 10‐min educational video lesson implemented by a trusted community leader is feasible and effective for reducing stigma and enhancing knowledge about substance use. Further research is required to design additional interventions and to assess for longitudinal effects.
... Opioid use disorder (OUD) affects 6.1 million Americans [1]. Among US military Veterans (USV), rates of opioid misuse have significantly increased, leading to a 53% rise in overdose deaths between 2010 and 2019 [2][3][4] and combined with rises in stimulant use in this population has led to a syndemic [5]. Parenteral opioid use is associated with increased risk for acquisition of severe injection-related infections (SIRI), including acute bacterial skin and skin structure infections, endocarditis and osteoarticular infections, as well as acquisition of HIV, hepatitis B (HBV) and C viruses (HCV) via shared injection equipment (e.g., "shared works") [6,7]. ...
Background
Injection drug use (IDU) may lead to negative health outcomes and increased healthcare utilization. In US Veterans (USV) with opioid use disorder (OUD), there is sparse information about healthcare utilization, harm reduction prescription, and outcomes associated with IDU, including severe injection-related infections (SIRI). We assessed psychosocial factors, clinical outcomes, and harm reduction receipt in a cohort of USV with OUD, specifically focusing on persons who inject drugs (PWID).
Methods
A retrospective cohort study was performed of USV aged ≥ 18 years with a diagnosis of OUD who presented to the Northport Veterans Affairs Medical Center (Long Island, NY) between 2012 and 2022. Demographics, psychosocial factors, history of human immunodeficiency virus (HIV), hepatitis C virus (HCV) infection, and healthcare utilization were compared by IDU status. Prescription of medications for opioid use disorder, naloxone and pre-exposure prophylaxis (PrEP) for HIV were also compared by IDU status. SIRI episodes and associated sequelae were characterized in USV with IDU.
Results
A total of 502 USV with OUD were included and 216 (43%) were PWID. Mean age was 52.6 years. PWID were more likely to use multiple stimulants (14.4% PWID vs. 7.3% non-PWID, p < 0.011), be hospitalized with an infection (26.4% PWID vs. 12.2% non-PWID, p < 0.001) and had more frequent inpatient admissions (n = 5.5 PWID vs. n = 3.51 non-PWID, p = 0.003). Among PWID, 134 (62%) had a history of HCV infection, 9 (4.2%) had HIV, and 35 (16.2%) had at least one SIRI episode. PWID had a higher frequency of current (51.9% PWID vs. 38.5% non-PWID, p = 0.003) or previous MOUD use (45.8% PWID vs. 31.1% non-PWID, p < 0.001). Overall PrEP receipt in our cohort (0.46% PWID vs. 1.4% non-PWID, p = 0.4) was low.
Conclusions
USV with OUD and a history of IDU had a high prevalence of concurrent stimulant use, HCV, SIRI episodes, and were more likely to be hospitalized than USV with OUD and no history of IDU. Harm reduction strategies such as MOUD or PrEP, can help decrease the risk of infectious diseases, yet PrEP was underutilized in our population regardless of IDU status. USV with OUD would benefit from improved integration of OUD treatment, infectious diseases clinical care and harm reduction interventions.
... In this study, the majority of illicit drug toxicity deaths were ascribed to a combination of opioids and stimulants, with a smaller proportion of deaths ascribed to opioids alone or stimulants alone. This suggests the need for public health officials, health care and social service providers to pay increased attention to the role of stimulants in illicit drug toxicity deaths, and resources to improve awareness among people who use stimulants [18][19][20]. ...
Background
Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10–59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant use and detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity.
Methods
BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (N = 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type.
Results
Of the 3788 deaths, 11.1% (N = 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (N = 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (N = 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14–2.85)) and people with heart failure (2.29 (1.25–4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group.
Conclusions
Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.
... While further evidence is needed to understand acute toxicity risk by different living arrangements, prior research on polysubstance use and housing status has reported associations between couse of stimulants and opioids and unstable housing Shearer et al., 2020). Methamphetamine use may be increasing due to its high availability in the illegal drug supply and relatively low cost and may be co-used with opioids unintentionally due to contamination (e.g., methamphetamine contaminated with fentanyl) or intentionally, for example, to moderate the effects of opioids (Daniulaityte et al., 2023;Ellis et al., 2018;Hayashi et al., 2021). People who do not have stable housing, who are also at an elevated risk of assault or property theft, may be more likely to use methamphetamine to stay awake and protect themselves (Casey, 2019;Papamihali et al., 2021). ...
The aim of this study was to examine underlying patterns of substances detected among accidental acute toxicity deaths in Canada and their associations with sociodemographic characteristics, location, and substance use and health history. Data abstracted from coroner and medical examiner files for all accidental acute toxicity deaths across Canada (2016 to 2017) were analyzed. Six classes emerged from a latent class analysis conducted to characterize detected substance classes: (1) cocaine and alcohol, (2) benzodiazepines and other pharmaceutical substances, (3) pharmaceutical opioids, (4) multiple pharmaceutical and non-pharmaceutical substances, (5) methamphetamine and fentanyl or analogues, and (6) fentanyl or analogues. Differences were identified between latent classes by sex, age, marital status, location of death, place of residence, and substance use and health history. Patterns of detected substances among deaths characterized in this study emphasize the complex nature of substance-related acute toxicity deaths across Canada and can inform future research and public health action.
... This change can only be partially accounted for by concomitant opioid use. Notably, overdose rates involving stimulants and other drug classes like opioids, as well as overdoses from stimulants alone, have increased (Ahmed et al., 2022;Ellis et al., 2018;Hedegaard et al., 2020;Vivolo-Kantor et al., 2020). Nationally, overdose deaths involving stimulants have increased from 12,122 in 2015 to 53,495 in 2021 (National Institute on Drug Abuse, 2023). ...
Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.
... The crisis was further compounded by the COVID-19 pandemic, which saw approximately 3700 drug poisoning deaths in 2019 escalate to over 7300 fatalities in 2022. A key characteristic of the crisis is the prevalence of multi-drug toxicity, with combinations of drugs including opioids, stimulants and benzodiazepines being detected in drug-related fatalities [2][3][4][5][6][7]. In 2022, 46% of opioid toxicity deaths in Canada also involved other psychoactive substances [1]. ...
Introduction
We aimed to describe rates and toxicological findings of unintentional opioid and stimulant toxicity deaths, 2012–2021.
Methods
The dataset included accidental deaths determined by the Coroner to be due to opioids or stimulants. We calculated annual crude mortality rates and described combinations of drugs identified in toxicological examinations of these deaths. We described temporal trends in the detection of specific opioids, stimulants, benzodiazepines (including novel benzodiazepines), gabapentinoids and z‐drugs in deaths due to opioids and stimulants.
Results
Mortality rates increased over time, reaching their peak in 2020 and remaining high in 2021. In deaths due to opioids, there was a decline in the proportion of deaths involving pharmaceutical opioids after 2019, and a corresponding increase in the proportion of deaths with fentanyl detected. Benzodiazepines were often present in deaths due to opioids, with novel benzodiazepines increasing rapidly from 2019 onwards. Cocaine was the most frequently detected drug in deaths due to stimulants, but amphetamine/methamphetamine was detected in around half of all stimulant deaths from 2016 onwards.
Discussion and Conclusions
Despite availability of a multitude of overdose prevention interventions, mortality rates due to drug toxicity have increased in Québec. Toxicological findings of these deaths suggest concerning shifts in the illicit drug market, with Québec potentially having entered a new era of elevated overdose mortality. Intervention scale‐up is essential, but unlikely to be sufficient, to reduce drug‐related mortality. Policy reform to address the root causes of drug toxicity deaths, including an unpredictable drug supply, strained health systems and socio‐economic precarity, is essential.
... Another concerning finding was how commonly used was methamphetamine, widely known by users as "ice," which was reported by 58% of participants. Previous research expected its rise as an affordable alternative to heroin and reported a recent increase in overdose deaths attributed to methamphetamine and other psychostimulants (Ellis et al., 2018;Seth et al., 2018). ...
... This is unfortunate as the combination actually increases the risk for an overdose death. There is some evidence that people also use stimulants, specifically methamphetamine, when they are unable to procure opioids such as fentanyl [7]. Stimulants and opioids are not cross-tolerant, but people can easily become dependent on both substances. ...
Methamphetamine use has seen a marked increase nationwide over the last decade. Highly potent forms of methamphetamine are currently internationally illicitly manufactured in great quantities. Methamphetamine is typically very inexpensive and widely available throughout the United States.
... 23 Studies also show that the use of methamphetamine among treatment-seeking opioid users has increased worldwide. 24,25 A previous study in the region reported that individuals preferred to use ATSs to increase productivity. 11 There could be various reasons for the concomitant use of ATSs and heroin. ...
Background
South Asia generally reports low levels of amphetamine-type stimulant (ATS) use, with few studies on the pattern of ATS use. We assessed the pattern of ATS use and associated high-risk behavior in Manipur, a north-eastern state of India.
Methods
209 adult male ATS users (mean age 28.8 years) from three districts of Manipur were interviewed. Data were collected on the patterns of high-risk behavior with ATS use, health consequences, and help-seeking. The severity of use with various substances was assessed using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Depression and anxiety were assessed by the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scale, respectively.
Results
The mean duration of ATS use was 3.7 years (SD 2.3). The majority used ATS almost daily (88%) and depended on ATS (77%). Methamphetamine (99.5%) was the most used ATS orally. Around 87% also suffered from opioid dependence. About 76% injected drugs, most commonly heroin. Almost three-fourths (78%) used ATS before their sexual intercourse, 31% of whom did not use condoms. Most reported physical problems with ATS and had above-cut-off scores on PHQ-9 and GAD-7. The majority (95%) reported that they could procure ATS easily. Also, the majority (93%) had thought of quitting ATS use.
Discussion
Most ATS users start using ATS at a young age and have comorbid other drug use, including heroin. ATS use is associated with various physical and psychological problems. Focusing on ATS use in India and developing strategies to address this problem is essential.
Jurisdictions across Canada are experiencing high and increasing numbers of drug toxicity (overdose) deaths. To effectively respond to this crisis, a recognition and adaptation to shifting substance use patterns is needed. People may use one or more modes of consumption (e.g. injection, inhalation, snorting, oral, rectal), with different modes of consumption presenting different opportunities and challenges for public health education and intervention. In recent years, inhalation has increasingly been identified as a major mode of consumption for unregulated substances. We discuss the implications and what is needed to respond. We argue that (1) more research and evidence focused specifically on services for people who smoke unregulated substances is needed; (2) inhalation services that have an acceptable evidence base, even if incomplete, should be implemented and rigorously monitored, to be responsive to an ongoing public health crisis; and (3) there is a need to be mindful of the implications of delays in services for people who inhale drugs. We acknowledge the efforts of public health decision-makers to learn from the context of public health emergencies when it comes to upholding evidence-based practice standards. In this context, it will be important for decision-makers to remain agile in responding to complex public health issues that are characterized by ongoing and acute harms, political tensions, and a growing yet incomplete body of evidence, such as the evolving drug toxicity crisis.
Purpose of Review
The prevalence of substance use disorder (SUD) has increased substantially around the world. These increases are associated with severe medical and socioeconomic consequences. Moreover, the simultaneous use of opioids and stimulants among patients with SUD has complicated the treatment and outcomes of treatment approaches.
Recent Findings
Misuse of these two classes of substances occurs in order to overcome sedative effects of opioids, attenuate the stimulatory responses to stimulants, prolong the clinical effects of both classes of substances, and to experience their synergistic psychoactive effects. In this review, we aim to provide a detailed overview of the co-morbid use and misuse of opioids and stimulants as reported in human. Towards that end, we have included results from studies that have identified the influences of co-opioids and stimulants use on behaviors, cognitive processes, and their effects on physiological aspects and treatment strategies. Finally, the review highlighted the potential significance of identifying these issues when planning behavioral and pharmacotherapeutic approaches against substance use disorders.
Summary
Future studies will need to pay more attention on identifying genetic causes for co-morbidity as well as structural and neuroplastic changes in the brains of patients who use opioids and stimulants.
Importance
The lack of representative research on homelessness risks mischaracterizing and misrepresenting the prevalence of illicit substance use.
Objective
To estimate the population prevalence and patterns of illicit substance use, treatment, nonfatal overdose, and naloxone possession among people experiencing homelessness in 1 US state.
Design, Setting, and Participants
This representative survey study of adults experiencing homelessness from October 2021 to November 2022 in 8 California counties used multistaged probability-based sampling and respondent-driven sampling. Eligible individuals were 18 years or older and met the federal definition of homelessness.
Main Outcomes and Measures
The primary outcome measures included lifetime and past–6-month illicit substance use and substance type (methamphetamine, nonprescription opioids, or cocaine). Lifetime and current substance use treatment, unmet treatment need, types of treatments received, nonfatal overdose (lifetime and current episode of homelessness), and current possession of naloxone were measured. Population prevalence estimates with 95% Wald CIs were calculated using survey replicate weights.
Results
Of 3865 individuals approached, 3042 (79%) participated and an additional 158 participants were recruited through respondent-driven sampling. Among 3200 participants, the mean age was 46.1 (95% CI, 45.3-46.9) years, 67.3% (95% CI, 65.2%-69.3%) were cisgender male, and there were similar proportions of Black and African American, Hispanic and Latine, and White participants. Overall, an estimated 65.3% (95% CI, 62.2%-68.4%) of participants used illicit drugs regularly (≥3 times per week) in their lifetime; 41.6% (95% CI, 39.4%-43.8%) began using regularly before their first episode of homelessness and 23.2% (95% CI, 20.5%-25.9%) began using regularly after. In the past 6 months, an estimated 37.1% (95% CI, 32.9%-41.3%) of participants reported regular use of any drug; 33.1% (95% CI, 29.4%-36.7%) reported use of methamphetamines, 10.4% (95% CI, 7.9%-12.9%) reported use of opioids, and 3.2% (95% CI, 1.8%-4.6%) reported use of cocaine. In their lifetime, an estimated 25.6% (95% CI, 22.8%-28.3%) injected drugs and 11.8% (95% CI, 9.8%-13.8%) injected drugs in the past 6 months. Among those with any regular lifetime use, an estimated 6.7% (95% CI, 3.8%-9.5%) of participants were currently receiving treatment. Of those with any regular use in the last 6 months, an estimated 21.2% (95% CI, 17.9%-24.5%) reported currently wanting but not receiving treatment. An estimated 19.6% (95% CI, 17.4%-21.8%) of participants had a nonfatal overdose in their lifetime and 24.9% (95% CI, 21.3%-28.5%) currently possessed naloxone.
Conclusion and Relevance
In a representative study of adults experiencing homelessness in California, there was a high proportion of current drug use, history of overdose, and unmet need for treatment. Improving access to treatment tailored to the needs of people experiencing homelessness could improve outcomes.
Aims
We measured the association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy (OAT) for opioid use disorder.
Design
Retrospective cohort study using the British Columbia Provincial Overdose Cohort, a linked administrative database.
Setting
We used data from British Columbia, Canada, from January 2015 through February 2020.
Participants
In total, 9395 individuals contributed 18 273 person‐years of follow‐up while dispensed OAT.
Measurements
We examined the association between stimulant prescription (primary exposure) and fatal or non‐fatal overdose (primary outcome, allowing for recurrent events) after adjusting for potential confounders including sociodemographic characteristics and substance use patterns. As a secondary analysis, we evaluated type of OAT (full agonists involving methadone or slow‐release oral morphine versus partial agonist involving buprenorphine/naloxone alone) as a potential effect modifier.
Findings
There were 1746 overdose events; 37 (2.1%) were fatal. Overall, there was no increased risk of overdose among individuals dispensed a stimulant medication while on OAT [adjusted Cox regression hazard ratio (AHR) = 1.13, 95% confidence interval (95% CI) = 0.86–1.49, P = 0.39]. When analyzed by type of OAT medication, for individuals on buprenorphine, dispensation of a stimulant medication was associated with a reduced risk of overdose (AHR = 0.47, 95% CI = 0.23–0.96, P = 0.037) while, for individuals on full agonist OAT, dispensation of a stimulant medication was associated with an increased risk of overdose (AHR = 1.51, 95% CI = 1.09–2.07, P = 0.012).
Conclusions
There does not appear to be an overall increased risk of overdose for individuals co‐prescribed a stimulant medication with opioid agonist therapy (OAT). There appears to be a reduced risk of overdose for individuals dispensed buprenorphine with a stimulant medication compared with those dispensed buprenorphine alone, and an increased risk of overdose for individuals dispensed full agonist OAT (methadone or slow‐release oral morphine) with a stimulant medication compared with those dispensed full agonist OAT alone.
Introduction
: Pre-pandemic data suggests that methamphetamine-related mortality and opioid co-involvement have been increasing in the United States (US). However, there was a staggering number of US drug overdose deaths in 2020 and 2021, particularly among males. An updated examination of sex-specific trends in methamphetamine-related mortality, the extent to which these deaths may be driven by the heroin and fentanyl co-involvement, and whether this co-involvement might explain the disproportionate number of male methamphetamine deaths is warranted.
Methods
We leveraged final and provisional data from the CDC WONDER multiple causes of death database to examine deaths involving methamphetamine (i.e., psychostimulants with abuse potential, ICD-10 code T43.6) and methamphetamine-related deaths that co-involved heroin and/or synthetic opioids excluding methadone (ICD-10 code T40.4; e.g., fentanyl) among US residents aged 15 – 74 years. We plotted age-adjusted methamphetamine mortality rates by sex and year and quantified the proportion of deaths with heroin/synthetic opioid co-involvement. Finally, we used joinpoint regression models to quantify sex-specific trends in methamphetamine mortality and the proportion of deaths with heroin and/or synthetic opioid co-involvement.
Results
From 1999 to 2021, the methamphetamine-related mortality rate increased 58.8-fold among males (0.33 per 100,000 to 19.74 per 100,000) and 65.3-fold among females (0.12 per 100,000 to 7.96 per 100,000), with the greatest increases occurring between 2019 and 2021. The proportion of these deaths that co-involved heroin and/or synthetic opioids increased among both males (13.1% to 61.5%) and females (7.7% to 63.1%) from 1999 to 2021.
Conclusions
Increasing methamphetamine-related mortality among males and females has been accompanied by a dramatic increase in the proportion of heroin and/or synthetic opioid co-involvement among both sexes. Robust harm reduction efforts are needed to mitigate these increases, particularly for people who co-use stimulants and opioids.
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.
Substance use disorders pose significant health risks and treatment challenges due to the diverse interactions between substances and their impact on physical and mental health. The chemical effects of multiple substance use on bodily fluids are not yet fully understood. Therefore, this study aimed to investigate the chemical changes induced by a combination of substances compared to a control group. Analysis of FT-Raman spectra revealed structural alterations in the amide III, I, and C = O functional groups of lipids in subjects treated with opioids, alcohol and cannabis (polysubstance group). These changes were evident in the form of peak shifts compared to the control group. Additionally, an imbalance in the amide-lipid ratio was observed, indicating perturbations in serum protein and lipid levels. Furthermore, a 2D plot of two-track two-dimensional correlation spectra (2T2D-COS) demonstrated a shift towards dominance of lipid vibrations in the polysubstance use groups, contrasting with the predominance of the amide fraction in the control group. This observation suggests distinct molecular changes induced by multiple substance use, potentially contributing to the pathophysiology of substance use disorders. Principal Component Analysis (PCA) was utilized to visualize the data structure and identify outliers. Subsequently, Partial Least Squares Discriminant Analysis (PLS-DA) was employed to classify the polysubstance use and control groups. The PLS-DA model demonstrated high classification accuracy, achieving 100.00 % in the training dataset and 94.74 % in the test dataset. Furthermore, receiver operating characteristic (ROC) analysis yielded perfect AUC values of 1.00 for both the training and test sets, underscoring the robustness of the classification model.
This study highlights the quantitative and qualitative changes in serum protein and lipid levels induced by polysubstance use groups, as evidenced by FT-Raman spectroscopy. The findings underscore the importance of understanding the chemical effects of polysubstance use on bodily fluids for improved diagnosis and treatment of substance use disorders. Moreover, the successful classification of spectral data using machine learning techniques emphasizes the potential of these approaches in clinical applications for substance abuse monitoring and management.
Introduction
The co‐use of stimulants and opioids, including opioid agonist treatment (OAT), is very prevalent worldwide. A large body of data exists on the association between stimulant use and its health complications, and on OAT effectiveness among people with opioid use disorder. However, few data exist on stimulant‐opioid co‐use among people receiving OAT. Using data from the COSINUS cohort study, we investigated the association between the type of OAT and problematic stimulant use among persons who inject drugs (PWID).
Methods
COSINUS is a 12‐month French cohort study of 665 PWID. Data were collected in face‐to‐face interviews at enrolment, at 6 and 12 months. We defined problematic stimulant use as daily use of and/or injecting stimulants. We used Bayesian model averaging (BMA) to identify factors associated with problematic stimulant use.
Results
At baseline, 76% ( n = 505) of the participants reported problematic stimulant use. The optimal model from the BMA estimation showed that, after adjusting on social precarity and daily injection, participants on prescribed morphine sulfate as an OAT (compared with methadone) and those who use daily unprescribed buprenorphine were less likely to report problematic stimulant use.
Discussion and Conclusions
Our work highlights the high prevalence of problematic stimulant use among PWID in France but also the potential association between the type of OAT taken and stimulant use, by suggesting a protective effect of morphine sulfate on stimulant use. Since it has a higher intrinsic activity than other opioids, PWID on this OAT may be less interested in stimulants. Our findings warrant further investigation in clinical studies.
Objectives
Identifying demographic risk and protective factors for continued substance use in late life may identify groups in need of health care resources. Here, we assess demographic risk factors of past-year cannabis, stimulants, opioid, and tranquilizer use in young and older adults from a United States sample as well as lifetime use in older adults to contextualize generational differences.
Methods
Weighted samples were created with respondents to the National Survey on Drug Use and Health from 2015-2019 (N=214,415). The youngest (ages 18–25) and oldest (ages 65+) adult groups were selected (n=88,621). Demographic covariables were chosen according to their plausibility in the medical literature. Data were coded as categorical variables and analyzed with logistic regression models with dichotomous drug use (yes/no) as the dependent variable.
Results
Younger and older males were more likely than females to report past-year use of most substances (ranging OR=1.23 for nonmedical opioids in 18–25; OR= 8.33 for cocaine in 65+). Younger and older adults who identified as homosexual or bisexual were nearly twice as likely as heterosexual individuals to report cannabis and nonmedical tranquilizer past-year use. Younger and older adults who identified as bisexual more likely to report non-medical opioid use. In older adults, ethnicity did not emerge as a key predictor for past-year substance use.
Conclusion
Our findings suggest that male sex and sexual minority identity remain key predictors of substance use in older adults; these demographic groups may require special consideration in the delivery of substance use interventions.
Objectifs
L'identification des facteurs démographiques de risque et de protection pour la consommation continue de substances illicites chez les adultes plus agés peut permettre d'identifier les groupes ayant besoin de ressources en soin de santé. Nous évaluons ici les facteurs de risque démographiques de la consommation de cannabis, de stimulants, d'opioïdes et de tranquillisants au cours de l'année écoulée d'un échantillon de jeunes adultes et d’adultes plus âgés provenant des États-Unis, ainsi que la consommation chez des adultes plus âgés qui ont consommés toute leur vie afin de contextualiser les différences générationnelles.
Méthodes
Des échantillons pondérés ont été créés à partir des répondants à l'enquête nationale sur la consommation de drogues et la santé de 2015 à 2019 (N=214 415). Les groupes d'adultes les plus jeunes (18-25 ans) et les plus âgés (65 ans et plus) ont été sélectionnés (n=88 621). Les covariables démographiques ont été choisies en fonction de leur plausibilité dans la littérature médicale. Les données ont été codées sous forme de variables catégorielles et analysées à l'aide de modèles de régression logistique, la variable dépendante étant la consommation dichotomique de médicaments (oui/non).
Résultats
Les hommes jeunes et âgés étaient plus susceptibles que les femmes de déclarer avoir consommé la plupart des substances au cours de l'année écoulée (RC = 1,23 pour les opioïdes non médicaux chez les 18-25 ans; RC = 8,33 pour la cocaïne chez les 65 ans et plus). Les jeunes adultes et les adultes plus âgés qui s'identifient comme homosexuels ou bisexuels sont presque deux fois plus susceptibles que les hétérosexuels de déclarer avoir consommé du cannabis et des tranquillisants à usage non médical au cours de l'année écoulée. Les jeunes adultes et les adultes plus âgés qui s'identifient comme bisexuels sont plus susceptibles de déclarer une consommation d'opioïdes à des fins non médicales. Chez les adultes plus âgés, l'origine ethnique n'est pas apparue comme un facteur prédictif clé de la consommation de substances psychoactives au cours de l'année écoulée.
Conclusion
Nos résultats suggèrent que le sexe masculin et l'identité sexuelle minoritaire restent des prédicteurs clés de la consommation de substances chez les adultes plus agés; ces groupes démographiques pourraient nécessiter une attention particulière dans la mise en œuvre d'interventions en matière de consommation de substances.
Background:
Co-use of stimulants and opioids is often deliberate. However, the possibility remains that some people are unintentionally consuming fentanyl. To advance understanding of overdose risk, we examined the rate of concordance between self-reported fentanyl use and corresponding urine toxicology screen results.
Methods:
Between August 2022-August 2023, 411 participants (adults who reported any non-medical drug use in the past three months) in Nevada and New Mexico completed a cross-sectional survey, of whom 64% (n = 270; the analytical sample) also completed a urine toxicology screen, which detects fentanyl use in the past three days. Positive predictive value, negative predictive value, sensitivity, and specificity were calculated using self-reported past three-day fentanyl use (yes/no) and urine toxicology screen results for the presence of fentanyl (positive/negative).
Results:
Of the 270 participants who provided a urine sample, 268 are included in the descriptive statistics (two with inconclusive urine toxicology screen results were excluded). Of the 268 participants, 146 (54.5%) had a fentanyl-positive urine toxicology screen result, 122 (45.5%) had a fentanyl-negative urine toxicology screen result, 137 (51.1%) reported past three-day fentanyl use, and 130 (48.5%) reported no past three-day fentanyl use. Only 6.9% of those with a fentanyl-positive urine toxicology screen did not report recent fentanyl use. The sensitivity of self-reported fentanyl use was 93%, specificity was 97%, positive predictive value was 97%, and negative predictive value was 92%.
Discussion:
The rate of unanticipated exposure to fentanyl (that is, positive urine screen and negative self-report) in this sample was low, at 6.9%. This runs counter to the national narrative that there is widespread unknown contamination of fentanyl in the drug supply.
Conclusion:
Future research is needed to further explore how people who use multiple substances interpret their overdose risk and what harm reduction methods they employ.
The current study aimed to understand motivations of high-risk polysubstance use. Semi-structured interviews were conducted in New York City with 20 individuals with frequent recent polysubstance use. Two analysts coded the interviews (κ = 93.97). Five themes related to motivation for polysubstance use were found: (1) balance, prolong, or enhance effects, (2) self-medicate physical ailments, (3) cope with emotional distress, (4) drug-induced cravings, and (5) responding to social contexts. Individuals reported simultaneous or sequential co-use to balance, prolong or enhance a ‘high’ (theme 1). Participants engaged in polysubstance use to alleviate withdrawal symptoms, to induce sleep and self-medicate physical pain (theme 2) and to provide relief from emotional distress (theme 3). Other themes included drug-induced cravings (theme 4) and responding to social contexts (theme 5) including both social situations and economic availability. Motivations for polysubstance use may provide important insight into harm reduction and treatment settings solutions.
Purpose
The correctional system continues to face challenges with responding to and managing methamphetamine use among incarcerated individuals. This study aims to uncover what resources and policies could better help correctional workers deal with these challenges. The authors also examined methamphetamine’s impact on correctional work and staff well-being.
Design/methodology/approach
An online survey was distributed to correctional workers ( n = 269) in Manitoba, Canada, featuring questions about their experiences related to methamphetamine use in populations under their care, what supports are needed to adequately address the concern, and the potential effects on self and their occupational responsibilities. Using NVivo software, survey responses were analysed using an emergent theme approach.
Findings
Correctional workers believed policies and protocols for managing methamphetamine use and withdrawal are currently inadequate. Correctional workers reported having monthly contact with incarcerated individuals experiencing methamphetamine withdrawal, posing safety concerns to them and other incarcerated individuals. Respondents proposed more education and training on managing incarcerated people withdrawing from methamphetamines, related to the symptoms of use and withdrawal and how to support persons detoxing. Increased human and material resources were reported as being needed (e.g. more nurses onsite and better screening devices). Respondents also desired more medical intervention, safe living spaces for methamphetamine users and programming to support addiction.
Originality/value
The current study unpacks correctional workers’ perspectives, support desires and their experiences managing methamphetamine use amongst incarcerated people. The authors discuss the required knowledge to respond to gaps in prison living, re-entry and related policy needs.
Objective: The prevalence of polysubstance use is known to be high among individuals who use/misuse drugs. This study aims to extend existing research by (a) measuring polysubstance use through objective drug testing rather than fallible self-reports, (b) determining the most frequent three- and four-substance combinations instead of being limited to typical two-substance combinations, and (c) examining a comprehensive panel of substances beyond those commonly studied.
Method: Participants were a convenience sample of individuals applying for methadone maintenance treatment in 11 clinics across 7 states (n = 1098, 43.2% female). Participants voluntarily provided oral fluid and urine specimens for the study during clinic intake that were tested for 22 types of substances using liquid chromatography/tandem mass spectrometry (LC-MS-MS).
Results: Polysubstance use was high (89.6%), with the mean number of substances used by participants = 3.3, up to a maximum of 11. There were 10 three-substance combinations with prevalences of 5% or greater, the most frequent being opiates, fentanyl, and cocaine (10.5%). There were nine four-substance combinations with prevalences of 2% or greater, the most frequent being opiates, fentanyl, cocaine, and cannabis (4.5%). Many of these combinations can produce serious and even life-threatening interactions and side effects. The combination with perhaps the most severe potential consequence of concurrent use is the combination of opiates, fentanyl, and tramadol (5.1%), which all have sedative or central nervous system (CNS) depressive effects.
Conclusion: Clinicians should consider that symptoms of substance use are likely due to diverse combinations of substances, not only problematic use of a single presenting “substance of choice.”
Introduction
There has been a significant increase in methamphetamine/amphetamine use in North America, particularly among people who use opioids. Despite its association with several negative health consequences, the population of people who use methamphetamine/amphetamine with opioids is not well characterised. The aim of this study was to investigate correlates of methamphetamine/amphetamine use among adults with prescription‐type opioid use disorder (POUD) starting methadone or buprenorphine/naloxone as part of a pragmatic randomised treatment trial in Canada.
Methods
Multivariable logistic regression analyses were used to determine factors associated with baseline methamphetamine/amphetamine use (measured by urine drug test [UDT]) among participants of a pan‐Canadian pragmatic trial conducted between 2017 and 2020 comparing supervised methadone versus flexible take‐home dosing buprenorphine/naloxone models of care in people with POUD (e.g., licit or illicit, including fentanyl, prescribed or not).
Results
The sample included 269 participants, of which 142 (52.8%) had positive baseline methamphetamine/amphetamine UDT. In the multivariable model, positive fentanyl UDT (adjusted odds ratio [AOR] 13.21, 95% confidence interval [CI] 6.45, 28.30), non‐fatal overdose in the last 6 months (AOR 2.26, CI 1.01, 5.17) and a lifetime history of opioid agonist therapy exposure prior to study entry (AOR 2.30, CI 1.09, 4.87) remained positively associated with baseline methamphetamine/amphetamine use.
Discussion and Conclusions
In this sample of people with POUD, methamphetamine/amphetamine use was associated with markers of complex and severe OUD, including overdose risk. This suggests the need for targeted interventions to optimise treatment outcomes and prevent future overdoses in this population.
Clinical Trial Registration: Available at: ClinicalTrials.gov NCT03033732.
Introduction:
The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.
Areas covered:
In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.
Expert opinion:
Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.
This report summarizes the epidemiology of overdose deaths from 2015–2016, highlighting the key findings of this health crisis.
Preliminary estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016 (1,2). Illicitly manufactured fentanyl, a synthetic opioid 50-100 times more potent than morphine, is primarily responsible for this rapid increase (3,4). In addition, fentanyl analogs such as acetylfentanyl, furanylfentanyl, and carfentanil are being detected increasingly in overdose deaths (5,6) and the illicit opioid drug supply (7). Carfentanil is estimated to be 10,000 times more potent than morphine (8). Estimates of the potency of acetylfentanyl and furanylfentanyl vary but suggest that they are less potent than fentanyl (9). Estimates of relative potency have some uncertainty because illicit fentanyl analog potency has not been evaluated in humans. This report describes opioid overdose deaths during July-December 2016 that tested positive for fentanyl, fentanyl analogs, or U-47700, an illicit synthetic opioid, in 10 states participating in CDC's Enhanced State Opioid Overdose Surveillance (ESOOS) program.* Fentanyl analogs are similar in chemical structure to fentanyl but not routinely detected because specialized toxicology testing is required. Fentanyl was detected in at least half of opioid overdose deaths in seven of 10 states, and 57% of fentanyl-involved deaths also tested positive for other illicit drugs, such as heroin. Fentanyl analogs were present in >10% of opioid overdose deaths in four states, with carfentanil, furanylfentanyl, and acetylfentanyl identified most frequently. Expanded surveillance for opioid overdoses, including testing for fentanyl and fentanyl analogs, assists in tracking the rapidly changing illicit opioid market and informing innovative interventions designed to reduce opioid overdose deaths.
Background:
Prescription opioid-related overdose deaths increased sharply during 1999-2010 in the United States in parallel with increased opioid prescribing. CDC assessed changes in national-level and county-level opioid prescribing during 2006-2015.
Methods:
CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns in 2010 and 2015.
Results:
The amount of opioids prescribed in the United States peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015. Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country. County-level factors associated with higher amounts of prescribed opioids include a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan status (i.e., town/city; nonmetro); and higher unemployment and Medicaid enrollment.
Conclusions and implications for public health practice:
Despite reductions in opioid prescribing in some parts of the country, the amount of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level. Given associations between opioid prescribing, opioid use disorder, and overdose rates, health care providers should carefully weigh the benefits and risks when prescribing opioids outside of end-of-life care, follow evidence-based guidelines, such as CDC's Guideline for Prescribing Opioids for Chronic Pain, and consider nonopioid therapy for chronic pain treatment. State and local jurisdictions can use these findings combined with Prescription Drug Monitoring Program data to identify areas with prescribing patterns that place patients at risk for opioid use disorder and overdose and to target interventions with prescribers based on opioid prescribing guidelines.
Background:
These studies were carried out to examine whether the onset and progression of an opioid substance use disorder (SUD) differed in those who first used opioids to get "high" compared to those who received a prescription from a doctor to relieve pain (Non-Rx vs. Rx groups, respectively).
Methods:
A subset of patients (N=214) from an ongoing larger study of patients entering one of 125 drug treatment programs for opioid use disorder across the country agreed to give up their anonymity and participate in structured and open-ended online interviews examining drug abuse patterns.
Results:
With the exception that the Non-Rx group began their opioid abuse at a younger age than the Rx group and more quickly evolved from initial exposure to regular opioid abuse, there were relatively few differences in the characteristics, patterns and trajectories of opioid abuse. The vast majority of patients in both groups, most of whom had serious, antecedent psychiatric disorders, indicated that they used opioids to self-medicate psychological problems (67-73%) and/or stated that opioids provided a means to "escape" from the stresses of everyday life (79-85%). As the SUD progressed, for many individuals any "positive" attributes of opioids waned and avoidance of withdrawal became the overriding concern, often serving as the impetus for treatment.
Conclusions:
Our results suggest that self-treatment of co-morbid psychiatric disturbances is a powerful motivating force to initiate and sustain abuse of opioids and that the initial source of drugs-a prescription or experimentation-is largely irrelevant in the progression to a SUD.
Objective:
Although persons who inject drugs (PWID) in the western United States-Mexico border region are known to inject both heroin and methamphetamine, little is known about the prevalence and risks associated with co-injection of this depressant-stimulant combination (also known as "goofball" and "Mexican speedball").
Method:
Baseline data from parallel cohort studies of PWID conducted concurrently in San Diego, CA, and Tijuana, Mexico, were used to estimate the prevalence and identify correlates of heroin-methamphetamine co-injection. PWID older than 18 years of age who reported injecting illicit drugs in the past month (N = 1,311; 32.7% female) were recruited in San Diego (n = 576) and Tijuana (n = 735) and completed interviewer-administered questionnaires. Bivariate and multivariable logistic regression analyses were used to identify correlates of heroin-meth-amphetamine co-injection.
Results:
The prevalence of co-injection in the past 6 months was 39.9% overall and was higher in Tijuana (55.8%) than in San Diego (19.8%). In multivariable analyses adjusting for study cohort, distributive syringe sharing, purchasing syringes prefilled with drugs, finding it hard to get new syringes, reporting great or urgent need for treatment, and younger age were independently associated with co-injection. Past-6-month overdose was significantly associated with higher odds of co-injection in San Diego than in Tijuana.
Conclusions:
These findings indicate that heroin-methamphetamine co-injection is more common in Tijuana than in San Diego, yet this practice was only associated with overdose in San Diego. Heroin-methamphetamine coinjection was also independently associated with HIV-associated injection risk behaviors. Overdose-prevention interventions should address co-injection of depressants and stimulants.
There is an epidemic of opioid abuse. This article discusses the history of opioid use. Abusers of opioids are at great risk of harm. There have been increasing legislative efforts to curb this abuse and we present a review of the current state of these laws. Naloxone has made a profound impact in the care of these patients if they present for medical care early enough. This paper discusses naloxone pharmacodynamics, its use in the medical setting, and how its use is now being expanded to include nontraditional providers with take home naloxone programs.
A large fraction of heroin users now report that they formerly used prescription opioids nonmedically, a finding that has led to restrictions on opioid prescribing. Nevertheless, only a small fraction of prescription-opioid users move on to heroin use.
The purpose of this study is to extend the research on contextual factors that influence the initiation and continued use of methamphetamine (meth) by women on the U.S.-Mexico border. At present, a minimal body of literature exists that explores meth use on the Mexico-U.S. border. A purposeful sample of 20 women who were active meth users aged ≥18 years was recruited by trained outreach workers from a variety of meth-user networks in Ciudad Juárez, Mexico, the city bordering El Paso, Texas. Respondents participated in in-depth, semi-structured interviews including questions on users’ perceived familial, social, and environmental influences of meth use. Gender-based themes emerged from the analysis: (1) patterns of meth use; (2) places where drugs were used; (3) effects of relationship networks on meth use; (4) differential access to drugs; (5) trading sex for drugs; (6) perceived class differences; and (7) long-term drug use and its consequences. Respondents reported a preference for using meth as powder or pills as opposed to smoking or injecting the drug. They reported being introduced to meth by men they trust and relying on men for drug acquisition in spaces less accessible and more dangerous to women. They described how the drug changed their lifestyle and their behavior towards family members and friends, including instances of physical and psychological violence. Interventions for women on the Mexico-U.S. border should be developed based on users’ social networks to target social processes to prevent initiation and to bring active meth users into treatment.
In an effort to reduce wide-scale abuse of the proprietary oxycodone hydrochloride formulation OxyContin, an abuse-deterrent formulation (ADF) was introduced in 2010. Although the reformulation produced an immediate drop in abuse rates, a definite ceiling effect appeared over time, beyond which no further decrease was seen.
To examine the factors that led to the initial steep decline in OxyContin abuse and the substantial levels of residual abuse that have remained relatively stable since 2012.
We used data from the ongoing Survey of Key Informants' Patients program, part of the Researched Abuse, Diversion and Addiction-Related Surveillance system that collects and analyzes postmarketing data on misuse and diversion of prescription opioid analgesics and heroin. For our survey study, patients with a DSM-V diagnosis of opioid use disorder and primary drug of abuse consisting of a prescription opioid or heroin (N = 10 784) at entry to 1 of 150 drug treatment programs in 48 states completed an anonymous structured survey of opioid abuse patterns (surveys completed from January 1, 2009, through June 30, 2014). A subset of these patients (n = 244) was interviewed to add context and expand on the structured survey.
In addition to key demographic measures, past-month abuse of opioids was the primary measure in the structured surveys. In the interviews, the effect of the introduction of the ADF on drug-seeking behavior was examined.
Reformulated OxyContin was associated with a significant reduction of past-month abuse after its introduction (45.1% [95% CI, 41.2%-49.1%] in January to June 2009 to 26.0% [95% CI, 23.6%-28.4%] in July to December 2012; P < .001; χ2 = 230.83), apparently owing to a migration to other opioids, particularly heroin. However, this reduction leveled off, such that 25% to 30% of the sample persisted in endorsing past-month abuse from 2012 to 2014 (at study end [January to June 2014], 26.7% [95% CI, 23.7%-29.6%]). Among the 88 participants who indicated experience using pre-ADF and ADF OxyContin, this residual level of abuse reflects the following 3 phenomena: (1) a transition from nonoral routes of administration to oral use (38 participants [43%]); (2) successful efforts to defeat the ADF mechanism leading to a continuation of inhaled or injected use (30 participants [34%]); and (3) exclusive use of the oral route independent of formulation type (20 participants [23%]).
Abuse-deterrent formulations can have the intended purpose of curtailing abuse, but the extent of their effectiveness has clear limits, resulting in a significant level of residual abuse. Consequently, although drug abuse policy should focus on limiting supplies of prescription analgesics for abuse, including ADF technology, efforts to reduce supply alone will not mitigate the opioid abuse problem in this country.
Importance
Over the past several years, there have been a number of mainstream media reports that the abuse of heroin has migrated from low-income urban areas with large minority populations to more affluent suburban and rural areas with primarily white populations.Objective
To examine the veracity of these anecdotal reports and define the relationship between the abuse of prescription opioids and the abuse of heroin.Design, Setting, and Participants
Using a mixed-methods approach, we analyzed (1) data from an ongoing study that uses structured, self-administered surveys to gather retrospective data on past drug use patterns among patients entering substance abuse treatment programs across the country who received a primary (DSM-IV) diagnosis of heroin use/dependence (n = 2797) and (2) data from unstructured qualitative interviews with a subset of patients (n = 54) who completed the structured interview.Main Outcomes and Measures
In addition to data on population demographics and current residential location, we used cross-tabulations to assess prevalence rates as a function of the decade of the initiation of abuse for (1) first opioid used (prescription opioid or heroin), (2) sex, (3) race/ethnicity, and (4) age at first use. Respondents indicated in an open-ended format why they chose heroin as their primary drug and the interrelationship between their use of heroin and their use of prescription opioids.Results
Approximately 85% of treatment-seeking patients approached to complete the Survey of Key Informants’ Patients Program did so. Respondents who began using heroin in the 1960s were predominantly young men (82.8%; mean age, 16.5 years) whose first opioid of abuse was heroin (80%). However, more recent users were older (mean age, 22.9 years) men and women living in less urban areas (75.2%) who were introduced to opioids through prescription drugs (75.0%). Whites and nonwhites were equally represented in those initiating use prior to the 1980s, but nearly 90% of respondents who began use in the last decade were white. Although the “high” produced by heroin was described as a significant factor in its selection, it was often used because it was more readily accessible and much less expensive than prescription opioids.Conclusion and Relevance
Our data show that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.
In the United States, per-capita opioid dispensing has increased concurrently with analgesic-related mortality and morbidity since the 1990s. To deter diversion and abuse of controlled substances, most states have implemented electronic prescription drug monitoring programs (PDMPs). We evaluated the impact of state PDMPs on opioid dispensing.
We acquired data on opioids dispensed in a given quarter of the year for each state and the District of Columbia from 1999 to 2008 from the Automation of Reports and Consolidated Orders System and converted them to morphine milligram equivalents (MMEs). We used multivariable linear regression modeling with generalized estimating equations to assess the effect of state PDMPs on per-capita dispensing of MMEs.
The annual MMEs dispensed per capita increased progressively until 2007 before stabilizing. Adjusting for temporal trends and demographic characteristics, implementation of state PDMPs was associated with a 3% decrease in MMEs dispensed per capita (p=0.68). The impact of PDMPs on MMEs dispensed per capita varied markedly by state, from a 66% decrease in Colorado to a 61% increase in Connecticut.
Implementation of state PDMPs up to 2008 did not show a significant impact on per-capita opioids dispensed. To control the diversion and abuse of prescription drugs, state PDMPs may need to improve their usability, implement requirements for committee oversight of the PDMP, and increase data sharing with neighboring states.
The United States is in the midst of a devastating opioid misuse epidemic leading to over 33,000 deaths per year from both prescription and illegal opioids. Roughly half of these deaths are attributable to prescription opioids. Federal and state governments have only recently begun to grasp the magnitude of this public health crisis. In 2016, the Centers for Disease Control and Prevention released their Guidelines for Prescribing Opioids for Chronic Pain. While not comprehensive in scope, these guidelines attempt to control and regulate opioid prescribing. Other federal agencies involved with the federal regulatory effort include the Food and Drug Administration (FDA), the Drug Enforcement Agency (DEA), and the Department of Justice. Each federal agency has a unique role in helping to stem the burgeoning opioid misuse epidemic. The DEA, working with the Department of Justice, has enforcement power to prosecute pill mills and physicians for illegal prescribing. The DEA could also implement use of prescription drug monitoring programs (PDMPs), currently administered at the state level, and use of electronic prescribing for schedule II and III medications. The FDA has authority to approve new and safer formulations of immediate- and long-acting opioid medications. More importantly, the FDA can also ask pharmaceutical companies to cease manufacturing a drug. Additionally, state agencies play a critical role in reducing overdose deaths, protecting the public safety, and promoting the medically appropriate treatment of pain. One of the states' primary roles is the regulation of practice of medicine and the insurance industry within their borders. Utilizing this authority, states can both educate physicians about the dangers of opioids and make physician licensure dependent on registering and using PDMPs when prescribing controlled substances. Almost every state has implemented a PDMP to some degree; however, in addition to mandating their use, increased interstate sharing of prescription information would greatly improve PDMPs' effectiveness. Further, states have the flexibility to promote innovative interventions to reduce harm such as legislation allowing naloxone access without a prescription. While relatively new, these types of laws have allowed first responders, patients, and families access to a lifesaving drug. Finally, states are at the forefront of litigation against pharmaceutical manufacturers. This approach is described as analogous to the initial steps in fighting tobacco companies. In addition to fighting for dollars to support drug treatment programs and education efforts, states are pursuing these lawsuits as a means of holding pharmaceutical companies accountable for misleading marketing of a dangerous product.
The current narrative describing the national opioid epidemic as the result of overprescribing opioid pain medicines fails to capture the full dimensions of the problem and leads to inadequate and even confounding solutions. Overlooked is the fact that polysubstance use is nearly ubiquitous among overdose deaths, demonstrating that the opioid overdose death problem is bigger than opioids. The foundation of the nation’s opioid overdose crisis – and the totality of the nation’s drug epidemic – is widespread recreational pharmacology, the use of drugs for fun or “self-medication.” The national focus on opioid overdose deaths provides important new opportunities in both prevention and treatment to make fundamental changes to the way that substance use disorders and related problems are understood and managed.
The first-ever US Surgeon General’s report on addiction provides a starting point for systemic changes in the nation’s approach to preventing, treating and managing substance use disorders as serious, chronic diseases. New prevention efforts need to encourage youth to grow to adulthood not using alcohol, nicotine, marijuana or other drugs for reasons of health. New addiction treatment efforts need to focus on achieving long-term recovery including no use of alcohol, marijuana and other drugs.
Heroin is a highly abused opioid and incurs a significant detriment to society worldwide. In an effort to expand the limited pharmacotherapy options for opioid use disorders, a heroin conjugate vaccine was developed through comprehensive evaluation of hapten structure, carrier protein, adjuvant and dosing. Immunization of mice with an optimized heroin-tetanus toxoid (TT) conjugate formulated with adjuvants alum and CpG oligodeoxynucleotide (ODN) generated heroin ‘immunoantagonism’, reducing heroin potency by >15-fold. Moreover, the vaccine effects proved to be durable, persisting for over eight months. The lead vaccine was effective in rhesus monkeys, generating significant and sustained anti-drug IgG titers in each subject. Characterization of both mouse and monkey anti-heroin antibodies by surface plasmon resonance (SPR) revealed low nanomolar antiserum affinity for the key heroin metabolite, 6-acetylmorphine (6AM), with minimal cross reactivity to clinically-used opioids. Following a series of heroin challenges over six months in vaccinated monkeys, drug-sequestering antibodies caused marked attenuation of heroin potency (>4-fold) in a schedule-controlled responding (SCR) behavioral assay. Overall, these preclinical results provide an empirical foundation supporting the further evaluation and potential clinical utility of an effective heroin vaccine in treating opioid use disorders.
Groups advocating quick fixes to the opioid-misuse epidemic seek regulations limiting opioid availability, but prescriber education is a more finely tuned approach, allowing us to individualize care appropriately after a careful benefit-risk assessment.
Typical abused drug-induced behavioral changes are ordinarily mediated by the mesolimbic dopaminergic systems even the phenotypes of behavior are different from each other. However, the mechanisms that underlie the behavioral changes induced by these abused drugs have not yet been elucidated. The present study was designed to investigate the mechanisms that underlie how abused drugs induce distinct behavioral changes using neurochemical as well as behavioral techniques in rats. Methamphetamine (2 mg/kg) more potently increased dopamine release from the striatum more than those from the nucleus accumbens. In contrast, the administration of morphine (10 mg/kg) produced a significant increase in the release of dopamine from the nucleus accumbens, but not the striatum, which is accompanied by a decrease in the release of GABA in the ventral tegmental area. These findings indicate that morphine and methamphetamine differentially regulate dopaminergic systems to produce behavioral changes, even though both drugs have abuse potential through activation of the mesolimbic dopaminergic system.
The use of prescription opioid medications has increased greatly in the United States during the past two decades; in 2010, there were 16,651 opioid-related deaths. In response, hundreds of federal, state, and local interventions have been implemented. We describe trends in the diversion and abuse of prescription opioid analgesics using data through 2013.
We used five programs from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System to describe trends between 2002 and 2013 in the diversion and abuse of all products and formulations of six prescription opioid analgesics: oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol. The programs gather data from drug-diversion investigators, poison centers, substance-abuse treatment centers, and college students.
Prescriptions for opioid analgesics increased substantially from 2002 through 2010 in the United States but then decreased slightly from 2011 through 2013. In general, RADARS System programs reported large increases in the rates of opioid diversion and abuse from 2002 to 2010, but then the rates flattened or decreased from 2011 through 2013. The rate of opioid-related deaths rose and fell in a similar pattern. Reported nonmedical use did not change significantly among college students.
Postmarketing surveillance indicates that the diversion and abuse of prescription opioid medications increased between 2002 and 2010 and plateaued or decreased between 2011 and 2013. These findings suggest that the United States may be making progress in controlling the abuse of opioid analgesics. (Funded by the Denver Health and Hospital Authority.).
Prescription drug abuse has reached an epidemic level in the United States. The prevalence of prescription drug abuse escalated rapidly beginning in the late 1990s, requiring a significant increase in research to better understand the nature and treatment of this problem. Since this time, a research literature has begun to develop and has provided important information about how prescription drug abuse is similar to, and different from the abuse of other substances. This introduction to a special issue of the Journal of Substance Abuse Treatment on prescription drug abuse provides an overview of the current status of the research literature in this area. The papers in this special issue include a sampling of the latest research on the epidemiology, clinical correlates, treatment, and public policy considerations of prescription drug abuse. Although much has been learned about prescription drug abuse in recent years, this research remains in early stages, particularly with respect to understanding effective treatments for this population. Future research priorities include studies on the interaction of prescription drugs with other licit and illicit substances, the impact of prescription drug abuse across the lifespan, the optimal treatment for prescription drug abuse and co-occurring conditions, and effective public policy initiatives for reducing prescription drug abuse.
Abuse of prescription analgesics in the USA is increasing. The epidemic has been driven by many factors, including marketing strategies, incorrect prescribing practices, a variety of legal and illegal drug sources, belated governmental responses and increases in the number of prescriptions written.
Data sources including surveys, emergency room visits, treatment admissions, overdose deaths, toxicology laboratory findings and journal articles were examined to identify trends.
The surveys and emergency department visits show use lowest among young teenagers and highest among older teenagers and young adults, with significant increases among those aged 55 and older. The length of time between initial use of an opioid other than heroin and admission to treatment is shortening. Mortality data and toxicology exhibits confirm the increases and show the variation in the prevalence of various drugs across the USA.
Abuse is increasing, with varying patterns of use by high-risk groups and different geographic preferences. Prescription drug monitoring programs are being developed in each of the US states to deter 'doctor shopping'; the Food and Drug Administration has increased authority over manufacturers; and options for proper disposal of leftover medications exist. There is increased emphasis on responsible prescribing including risk assessments, prescribing agreements, treatment plans, and training for clinicians, as well as monitoring the interactions with benzodiazepines. However, unless these efforts decrease diversion, abuse and addiction, clinicians may lose the ability to use some of these opioids for effective pain management or so many barriers will be raised that pain will go undertreated or untreated.
OBJECTIVE. Beginning in the late 1990's a marked increase in abuse of OxyContin emerged, which led to the development and establishment of a proactive surveillance program to monitor and characterize abuse, named the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS) System. The main goal of RADARS was to develop proactive, timely and geographically sensitive methods to assess the abuse and diversion of OxyContin, along with a number of other Schedule II and III opioids with the aim of using this information to guide risk reduction interventions. Thus, its major focus was the detection of abuse of OxyContin and other commonly prescribed opioid analgesics at the three-digit ZIP code level across the country utilizing a number of different detection systems.
The detection systems selected were: (1) Quarterly-surveys of drug abuse experts who are knowledgeable about cases of prescription drug abuse; (2) Surveys of law enforcement agencies that detect diversion of prescription drugs; and (3) Poison Control Center reports of intentional misuse or abuse of prescription opioids. Collectively, the three systems provide overlapping coverage of over 80% of the nation's 973 three-digit ZIP codes.
Preliminary results indicate that prescription drug abuse is prevalent nationwide, but it seems to be heavily localized in rural, suburban and small urban areas. Our results also indicate that hydrocodone and extended and immediate release oxycodone products are by far the most widely abused drugs in the country, but the abuse of all prescription opioids seems to have grown over the 14 quarters since the inception of RADARS.
The next step in these studies is to develop regionally specific, risk-minimization-strategies, which is the goal of all risk-management programs. If successful, RADARS will serve as a prototype of such programs for any new drug approved that has measurable abuse potential.
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In the Shadow of the Opioid Crisis, Meth Has Roared Back into Minnesota
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Meth, the Forgotten Killer, is Back. And It's Everywhere. Retrieved from. The New York Times
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