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Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework

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Policy Points • This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. • In order to successfully reduce drug‐related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. Context Drug overdose is the leading cause of injury‐related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. Methods In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The “continuum of overdose risk” framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. Findings De‐escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. Conclusions Without recognizing the full drug‐use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.
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Original Scholarship
Situating the Continuum of Overdose Risk in
the Social Determinants of Health: A New
Conceptual Framework
JU NYEONG PARK,SABA ROUHANI,
LEO BELETSKY,LOUISE VINCENT,
BRENDAN SALONER,and SUSAN G. SHERMAN
Johns Hopkins Bloomberg School of Public Health; School of Law and Bouvé
College of Health Sciences, Northeastern University; Urban Survivors Union
Policy Points:
rThis article reconceptualizes our understanding of the opioid epidemic
and proposes six strategies that address the epidemic’s social roots.
rIn order to successfully reduce drug-related mortality over the long
term, policymakers and public health leaders should develop partner-
ships with people who use drugs, incorporate harm reduction interven-
tions, and reverse decades of drug criminalization policies.
Context: Drug overdose is the leading cause of injury-related death in the
United States. Synthetic opioids, predominantly illicit fentanyl and its analogs,
surpassed prescription opioids and heroin in associated mortality rates in 2016.
Unfortunately, interventions fail to fully address the current wave of the opioid
epidemic and often omit the voices of people with lived experiences regarding
drug use. Every overdose death is a culmination of a long series of policy failures
and lost opportunities for harm reduction.
Methods: In this article, we conducted a scoping review of the opioid litera-
ture to propose a novel framework designed to foreground social determinants
more directly into our understanding of this national emergency. The “contin-
uum of overdose risk” framework is our synthesis of the global evidence base
The Milbank Quarterly, Vol. 98, No. 3, 2020 (pp. 700-746)
© 2020 Milbank Memorial Fund

Continuum of Overdose Risk in the Social Determinants of Health 
and is grounded in contemporary theories, models, and policies that have been
successfully applied both domestically and internationally.
Findings: De-escalating overdose risk in the long term will require scaling
up innovative and comprehensive solutions that have been designed through
partnerships with people who use drugs and are rooted in harm reduction.
Conclusions: Without recognizing the full drug-use continuum and the role
of social determinants, the current responses to drug overdose will continue to
aggravate the problem they are trying to solve.
Keywords: substance use, drug use, opioids, addictive behavior.
D        
in the United States, with recent increases in overdose fatali-
ties contributing to national reductions in life expectancy over
two consecutive years.1In 2017, the United States recorded more than
70,000 drug overdose deaths, an increase of more than 30% since 2015,
and 67,367 deaths in 2018.1,2 The current epidemic has been character-
ized as consisting of three distinct opioid overdose “waves” beginning
in the 1990s: the widespread prescription, diversion, and misuse of pre-
scription opioids; their interaction with and amplification of heroin use;
and the expansion of synthetic opioids in the drug supply, including il-
licitly manufactured fentanyl.3,4 Adjacent to the dramatic rates of fatal
overdose are the rising burden of nonfatal overdose, polysubstance use,
and the health and financial costs they incur.5Given the high human
resources and monetary costs of managing this epidemic—driven by fac-
tors such as rising hospitalization costs and expenditures on treatment
and incarceration— the overall economic cost of the opioid epidemic for
2018 will likely exceed $500 billion.6,7
Despite their similar underlying social and economic causes, includ-
ing poverty and stigma, earlier waves of overdoses driven by heroin
(1970s) and crack cocaine (1980s), particularly among urban low-
income communities of color, are less often acknowledged in the pub-
lic discourse.8-10 The federal policy response since the early 1900s has
been the moral rebuke of people who use drugs (PWUD); expanded
drug criminalization laws, particularly following the declaration of the
War on Drugs by President Richard Nixon; increased funding of inter-
diction efforts; and aggressive policing, especially of urban Black com-
munities. Together these factors have led to high incarceration rates,
 J.N. Park et al.
greater overdose risk, and community violence, and have alienated many
communities.11,12 The legacy of these punitive approaches continues to
manifest today through “drug-induced homicide” laws and police drug
raids, which jeopardize public health efforts to tackle this crisis.13,14
Alternative views of drug use, based on pragmatism and driven by
grassroots activists, including PWUD, catalyzed the movement now
known globally as harm reduction. The term PWUD was in fact devel-
oped by and advocated for by organizations led by PWUD to replace
stigmatizing terms like junkie and addict and has been adopted glob-
ally. In the United States, the growing demographics of PWUD and the
sharp rise in fatalities over the past decade have also galvanized a move-
ment to reframe the overdose crisis as a medical or public health issue
rather than a criminal one. Progress has been made in tackling addiction
and overdose, such as the expansion of medications for opioid use disor-
der (OUD) and the increased availability of naloxone. Supply-reduction
strategies have reduced the number of prescription opioids dispensed,
even though the decades-long efforts to stem the flow of illicit opioids
have remained largely ineffective.
However, the current response remains too narrow for the scale and
scope of this crisis. For example, reforming opioid-prescribing practices
and holding pharmaceutical companies accountable for placing profits
over patient safety is necessary but will not be sufficient to reduce over-
dose rates over the long term because it leaves PWUD ill-equipped to
adapt to the rapidly evolving illicit drug market and to adopt safer drug
use practices.15,16 Instead, the focus must shift from reducing supply
and interdiction to recognizing, understanding, and addressing the epi-
demic’s root causes. Although the social determinants of health, defined
by the World Health Organization as “the conditions in which people are
born, grow, live, work and age … shaped by the distribution of money,
power and resources,” have been underutilized in addressing the opioid
epidemic, they could propel us forward in our response.
In this article, we propose a range of evidence-based strategies that
could be implemented to holistically address the scope and depth of
this epidemic. We introduce the “continuum of overdose risk” (COR)
framework (Figure 1) to highlight the precursors to overdose, clarify the
distinction between drug use and addiction, and identify factors that es-
calate progression, as well as six strategies that could de-escalate risk.
We developed this framework to promote a comprehensive approach
Continuum of Overdose Risk in the Social Determinants of Health 
Figure 1. The Continuum of Overdose Risk (COR) Framework Visual-
ized as a Staircase [Color figure can be viewed at wileyonlinelibrary.com]
 J.N. Park et al.
inclusive of the social determinants of health, amid new challenges posed
by synthetic opioids and polysubstance use.17-19
Higher steps represent increasing risk of a fatal overdose (red step).
Six strategies to de-escalate risk are represented by the blue doors.
The social determinants of health are more important than ever, given
the current COVID-19 pandemic, which has swept through the world
and resulted in more than a quarter of a million cases and 36,000 deaths
in less than 5 months,20 causing major and unprecedented disruptions to
the global economy. In the United States, this pandemic has exposed the
vulnerabilities that many Americans face, from inequities in health in-
surance and paid sick leave, to constraints in accessing COVID-19 test-
ing, masks, and ventilators. PWUD, with their unique set of health,
social and structural vulnerabilities, including medical comorbidities,
homelessness, food insecurity, and violence, are expected to be dispro-
portionately burdened by this pandemic. In addition to interruptions
in medications, care, and harm reduction supplies, social distancing is
nearly impossible for homeless individuals and incarcerated populations,
and detrimental to those with severe mental health disorders or who face
abuse at home. It therefore is vital that COVID-19 policies consider
PWUD in their development and implementation.
Through this work, we aim to confront the stigmatization and crim-
inalization of drug use and the abstinence-centric ideology and racism
that endures in public discourse (eg, the media) as well as in medicine,
public health, and law. Following others, we argue that these views, laws,
and policies impede access to critical opportunities to prevent drug mor-
bidity and mortality.12,21,22 A narrow understanding of drug use coupled
with punitive drug policies will continue to isolate and harm the mil-
lions of Americans who use drugs. Despite leading the development and
dissemination of harm reduction interventions (eg, community-based
naloxone, syringe services programs [SSP]), and being directly impacted
by the overdose crisis themselves, PWUD continue to be excluded from
key policy discussions at local and national levels, even though their in-
clusion could facilitate pragmatic dialogue, innovation, and action. In
later sections, we discuss six strategies to address the epidemic, such as
meaningful partnerships with PWUD, harm reduction interventions,
and legal reforms, along with the traditional strategies of prevention,
treatment, and recovery that are often the guiding framework for re-
sponding to the overdose crisis.
Continuum of Overdose Risk in the Social Determinants of Health 
The Continuum of Overdose Risk
Framework
The COR framework (Figure 1) characterizes key stages that could be
effective intervention targets in reducing drug overdose: (1) drug ini-
tiation, (2) active drug use, (3) addiction, (4) nonfatal overdose, and
(5) fatal overdose. As we will discuss later, we propose six strategies
to de-escalate progression toward higher levels of risk: (1) meaningful
partnerships with PWUD, (2) prevention, (3) harm reduction, (4) treat-
ment, (5) recovery, and (6) reversal of the criminalization of PWUD.
Because individuals can progress toward higher levels of overdose risk
and skip or jump steps, we have applied a staircase analogy in which
the stairs represent stages of risk and doors along the way symbolizing
strategies that can support the de-escalation of risk. Drug use is a com-
plex phenomenon, and accordingly, these stages capture the trajectory
for many—but not all—PWUD. Throughout this article, we apply the
following definition of harm reduction: “a set of practical strategies and
ideas aimed at reducing negative consequences associated with drug use
… harm reduction is also a movement for social justice built on a belief
in, and respect for, the rights of PWUD.”23
This framework is also informed by our review of the health and policy
literature, national guidelines on evidence-based interventions, existing
strategic plans, and our collective experiences. It recognizes a need for
shifting investment from supply-side approaches (ie, controlling pre-
scription opioids and arresting PWUD) to interventions that address
the social determinants of health. We reviewed contemporary models,
frameworks, and theories commonly applied in the health literature in
order to understand the existing views of drug use and overdose, includ-
ing conceptualizations of drug use spectrums,24 addiction as a “brain
disease,”25 harm reduction approaches to substance use,26 a public health
strategy to address the crisis,27 and the social and economic determinants
of the opioid epidemic.10 Some of the tensions among those approaches
preferred in medicine, public health, harm reduction, and the law are
highlighted. Our comprehensive focus on the entire drug use continuum
through a social determinants lens differentiates this framework from
existing approaches. We prioritized interventions implemented domes-
tically or internationally that were holistic and evidence based in order
 J.N. Park et al.
to spur cross-adoption. Throughout, we call attention to some of the im-
plementation barriers and research gaps that require urgent attention.
Unpacking the Continuum of Overdose
Risk
The next five sections describe the risk factors associated with each stage
of the COR. Strategies to address them are discussed in the second half
of this article.
Drug Initiation
The timing and nature of drug use initiation can help determine sub-
sequent trajectories of drug use and misuse. The onset of drug use
during childhood or adolescence while the brain remains plastic can
have long-lasting impacts on the modulation of desires, emotions, and
behaviors,25 which in turn influences patterns of future drug use. Early
initiation is also linked to subsequent dependence and riskier behav-
iors like injection,28,29 which can increase the likelihood of infectious
diseases, job instability, unintended pregnancies, and suicide.30-32 Stud-
ies specific to opioid initiation show similar trends, with national data
linking early initiation with subsequent risks such as poorer clinical
outcomes, greater emotional distress, and increased tolerance and with-
drawal symptoms relative to adult-onset users.33 We next look at several
elements that may influence the opioid initiation environment.
Over the last decade, trends in the licit and illicit drug supply have
received much attention.34,35 Increased marketing and a greater num-
ber of prescriptions for OUD medications have increased the supply of
prescription opioids,36,37 resulting a birth cohort of opioid users signif-
icantly more likely to initiate use with prescription opioids or nonmed-
ical prescription opioids (NMPO) than with heroin.38 The availability
of pharmaceutical opioids initially occurred in the context of shifts in
pain treatment guidelines, along with the targeted marketing and lob-
bying by pharmaceutical companies to push profits. The resulting outcry
concerning opioid dependence led to the formulation of abuse-deterrent
prescription opioids, the leveling of prescribing practices, and the use
of prescription drug–monitoring programs (PDMP). However, an unin-
tentional consequence of these interventions was a substantial resurgence
Continuum of Overdose Risk in the Social Determinants of Health 
of PWUD initiating with heroin, which became more easily available at
a lower cost, triggering a second “wave” of the epidemic.36,39,40
The emergence of synthetic opioids like illegally manufactured fen-
tanyl and its many related analogues, which was partly due to eco-
nomic pressures generated by law enforcement “crackdowns” of heroin
suppliers,4,16 critically shifted the drug supply and initiation environ-
ment for a third time.41 Fentanyl is estimated to be 50 times more po-
tent than heroin and accounts for 40% of overdose deaths.42 It is sold as
a stand-alone drug and also contaminates a range of illicit drugs includ-
ing heroin, counterfeit pills, and (in rare cases) cocaine.43-45 This makes
possible the inadvertent initiation of highly potent opioids and high risk
of overdose among low-frequency users.46-50 Given the increased supply
of illicit fentanyl in many states, it is likely that initiation patterns will
shift between the current and the future cohorts of PWUD.
Although there has been relatively less attention paid to the epi-
demic’s social roots, several social determinants that drive drug initi-
ation have been identified: (1) microsocial factors, including trauma, so-
cial exposure/access to prescription opioids and illicit drugs;34 and (2)
macrosocial factors such as structural racism, income inequality, and af-
fordable housing.10,51-54 For example, although NMPO initiation and
use is often a response to physical pain and injury, it can also be a response
to life stressors like unemployment or untreated mental illness.36 Place-
based factors have been well-documented as critical to shaping the risk of
drug initiation, with neighborhood-level measures of disadvantage such
as income inequality, low educational attainment, and racial segregation
associated with an earlier initiation of overall substance use and adminis-
tration via injection.55-58 More broadly, the concept of despair59 spread-
ing within a geographic community or particular class (eg, an especially
vulnerable labor market) is also increasingly thought to influence the
likelihood of experiencing harmful outcomes like overdose. The liter-
ature on how these factors influence the conditions and age of opioid
initiation is sparse, however. An overreliance on supply-side interven-
tions without a commensurate focus on these social determinants will
not be sufficient to curb overdose deaths.36,60,61
Finally, although the influence of individual-level factors (eg, fam-
ily history, mental illness, early use of alcohol or nicotine)62-64 on drug
initiation has been previously reviewed,28 considerably less is known
specifically about opioid initiation. The data suggest that the initia-
tion of NMPO is concentrated among those between ages 18 and 25,65
 J.N. Park et al.
and that early initiation of NMPO is associated with heroin initiation
and later-life dependence on other prescription drugs.66-70 Our recent
work71 shows that PWUD initiating with NMPO are significantly more
likely to engage in the nonmedical use of benzodiazepines—a risk behav-
ior that, in conjunction with opioid use, amplifies overdose risk—and
illustrates the greater risk of initiation with NMPO among women who
are entering the risk population in greater numbers now that NMPO
have so fully penetrated street drug markets.72 Nonetheless, there is in-
sufficient research on ways to detect and intervene73 to delay opioid ini-
tiation at the individual level, and we know very little about the initia-
tion of fentanyl. Research and surveillance to identify actionable targets
to delay opioid initiation, incorporating individual as well as the micro-
and macrosocial elements of the initiation environment, are needed.
From Initiation to Active Drug Use
What happens between opioid initiation and the development of
harmful dependent use? Although we often assume that dependence
inevitably follows opioid initiation there is a distinction between recre-
ational, nonproblematic drug use for pleasure, and persistent or uncon-
trollable drug use to relieve psychological, physical, or emotional pain,
which impairs social functioning.25,36 This is reflected in US national
statistics: In 2019, more than 11 million individuals in the United States
reported using opioids for nonmedical reasons, with only a small fraction
meeting the definition of an OUD.74 Notably, the dominant rhetoric in
the public health, medical, and legal arenas fails to acknowledge that
many people use drugs regularly without the overwhelming physical,
psychosocial, individual, and interpersonal harms characteristic of OUD
and addiction. The term PWUD has been increasingly adopted as a non-
stigmatizing term that acknowledges that drug use exists on a contin-
uum from recreational use to severe dependence, though there is less
discourse and research on this topic in the current epidemic.
At the level of individual biology, sustained and dependent patterns
of opioid use alter the neurological circuitry that produces fewer returns
per episode of consumption (ie, physical tolerance), which can result in
the altered regulation of executive processes such as decision making
and inhibitory control (ie, resisting “urges”).25 In addition, the strong
relief that opioids provide from states like despair, sadness, anxiety, or
Continuum of Overdose Risk in the Social Determinants of Health 
physical pain may be “learned” by the mind and body and compound the
craving to use them to relieve the symptoms of distress, which include
withdrawal.75 Changes in tolerance can lead to the adoption of higher-
risk practices. Examples are more frequent use and the use of several
drugs or high-risk (but more economical) routes of administration such
as injection drug use to achieve the same levels of relief.76-79 These prac-
tices also confer a greater risk of overdose, particularly during recurring
cycles of stopping and resuming use.80,81
Risk factors for progressing to harmful patterns of use overlap with
those we described in the previous section. For example, experiences of
violence and abuse, particularly during childhood, are linked with the
likelihood of increased substance use disorder (SUD).82 Upstream social
and structural segregation and economic disadvantage in both urban and
rural environments further increase the likelihood of successive adop-
tion of higher-risk practices, including binging and injection.34,53,83,84
Initiation of injection represents a critical shift in risk, as introducing
substances directly into the bloodstream increases the PWUD’s vulner-
ability to changing potency and drug formulation and amplifies the risk
of overdose85-89 and blood-borne infections. People who inject drugs
also face greater levels of stigma and discrimination, which in them-
selves are additional barriers to accessing social and medical support,
financial stability, housing, and employment and thereby compound
the risk factors for progression along the COR.22 While many of these
factors can lead to the adoption of riskier practices, they also are con-
sequences of higher-risk drug use. For example, the risk of experienc-
ing violence, eviction, or homelessness is higher for individuals pro-
gressing further along the COR, cycling through the criminal justice
system, and dealing with the ensuing mental, physical, and economic
consequences.
Alcohol research and policy clearly distinguish between recreational
use and harmful dependence, allowing for a greater focus on tailored
prevention and treatment and reserving punitive measures for circum-
stances when grave harm is caused to others (eg, drunk driving). In
contrast, studies of illicit drug use often rely on dichotomous out-
comes of success defined by abstinence, with frequency or measures of
harm caused rarely used to delineate what is “problematic.”90-92 This is
changing in the cannabis literature, as the legalization of recreational
use has created the need for more clearly defined gradations and pa-
rameters around consumption,90,93 but this delineation remains largely
 J.N. Park et al.
absent in reference to other drugs. One study has shown that a lower
frequency of heroin injection is associated with lower rates of nonfa-
tal overdose.94 A one-size-fits-all definition of opioid use ignores the
likelihood that the trajectory to overdose differs between individuals
who use drugs recreationally and those who have a harmful dependence
on them. Consequently, we need research, surveillance, and discourse
to define the distinct stages of drug use more effectively, in order to
allow greater specificity in designing interventions to avert overdose
among individuals with fundamentally different relationships to illicit
substances.
Addiction
Several theories have tried to explain the sequelae of opioid addiction.
Historically, these have varied considerably. The early 19th to late 20th
centuries saw broad shifts from the widespread social acceptance and le-
galization of heroin and morphine for medical and recreational use due
to their pain-relieving and euphoric properties, to the view that heroin
use was a moral failing requiring punishment, which still prevails in the
United States and abroad.95 This stigma-driven view fueled support for
the War on Drugs, led by the United States, which resulted in the global
mass incarceration of PWUD, particularly in communities of color and
among low-income women, frequently in breach of their constitutional
rights,11,96 as well as state-sponsored mass killings of PWUD and drug
dealers in countries like the Philippines.97 Without legal reform, barri-
ers to accessing vital services will hinder our ability to implement real
change and continue to marginalize PWUD.
The brain disease model of addiction centers on the neurobiological
and psychological changes caused by chronic opioid use.25 While this
model has been a critical tool in shifting the paradigm away from moral
judgment and stigma, its proliferation raises at least three important
concerns. First, the model supports a dichotomy that sees abstinence as
the only way to recovery and sees a return to drug use as a “relapse”
that inherently causes harm. These social norms can create the absti-
nence violation effect, a set of negative emotional and cognitive responses
that perpetuate the drug-related stigma experienced by the individual
after resuming drug use.98 The second concern focuses on biomedical
solutions to addressing opioid addiction, rather than those rooted in the
Continuum of Overdose Risk in the Social Determinants of Health 
social determinants of health that characterize the lives of many PWUD.
Third, by popularizing the idea that addiction “highjacks the brain,” the
model threatens to undermine harm reduction efforts by eroding the le-
gal constructs of agency and self-determination among PWUD. This is
already apparent in the proliferation of statutes authorizing involuntary
commitment for substance use and the rising number of states actively
deploying these mechanisms in order to institutionalize PWUD against
their will.
Microsocial factors such as lacking social integration or the support
of family and friends, and exposure to interpersonal trauma have been
conceptualized as risk factors for addiction and may operate through
similar neural pathways as the opioid addiction process does.99 Adverse
childhood experiences (ACE) and traumatic experiences are consistently
associated with mental illness and SUD. Substance use may be an at-
tempt to “self-medicate” from these stressful experiences,100,101 and such
maladaptive coping behaviors are hypothesized to drive addiction and
relapse.102 Previous studies corroborating this hypothesis have shown
that trauma and mental illness are more likely to occur before rather than
after the onset of SUD among women101,103 and to aggravate symptoms
over the long term.104 Stressful life events among individuals in recovery
who have developed learned associations between opioid use and relief
from negative mental states over time may trigger drug relapse and sus-
tain drug addiction.75
Stressful life events that place populations at risk of addiction of-
ten operate at the macrosocial level. Examples of these life events
are homelessness, unemployment, concentrated disadvantage, structural
racism, trauma, and hopelessness, which have been discussed in rela-
tion to the opioid crisis.10 In addition to needing to escape the phys-
ical effects of drug withdrawal to being triggered by social cues asso-
ciated with drug use (eg, seeing a dealer), research on drug cessation
and relapse shows that patients often develop learned associations be-
tween opioid use and relief from the negative mental impact of life
stressors. These associations may make it difficult to break the cy-
cle of addiction without broader intervention addressing macrosocial
triggers,75 which may help explain why many people resume using
drugs after a period of abstinence.105 Taken together, this body of liter-
ature highlights that overreliance on the brain disease model may serve
to disempower affected communities by pathologizing drug use and
 J.N. Park et al.
undercutting the role of individual agency and contextual factors that
may lead to addiction.
Nonfatal Drug Overdose
Nonfatal drug overdose, affecting 17% to 68% of PWUD, is a signifi-
cant risk factor for a fatal overdose and also is associated with a range of
health (eg, cognitive and muscular dysfunctions), social (eg, “compas-
sion fatigue”), and economic (eg, emergency room costs) consequences,
marking it as a critical target for intervention.106-110 The literature on
risk factors exhibits high heterogeneity in the types of nonfatal overdoses
examined (eg, any drug versus opioids), the target population (eg, in-
jectors versus noninjectors), and their historical, sociopolitical, and eco-
nomic contexts. However, several individual-level risk factors of nonfatal
overdose have endured over time, recently highlighted in a systematic
review.106
The risk of a nonfatal overdose is high after periods of abstinence
(eg, recent release from detoxification or incarceration without access
to MAT) because the tolerance to opioids is lower than normal.111 Poly-
substance use (also known as polydrug use and concomitant use), par-
ticularly between multiple opioids, or opioids in combination with
depressants such as alcohol or benzodiazepines, can increase over-
dose risk owing to the compounding effects on the body’s metabolic
systems.108,110,111 Injection drug use is also a strong risk factor for
a nonfatal overdose.112-115 Documented risk factors include fentanyl
injection116 and the assumption that drugs contain fentanyl.49 Some
studies also point to underlying mental illness, including suicidal be-
haviors and other medical comorbidities.108 More research is required to
elucidate the risk factors of nonfatal fentanyl overdose among noninjec-
tors, although many risk factors are expected to be comparable for the
two populations.106,112
Although the social determinants of nonfatal overdose receive com-
parably less attention, emerging evidence has documented higher risks
associated with incarceration, unstable housing,49,83,111 and drug use in
public settings116-118 (which often accompanies homelessness). Home-
less PWUD who rely on public spaces to use drugs are at a heightened
risk of robbery, stigmatization, and harassment from community mem-
bers and interactions with police, and these factors can lead to rushed
and unsafe levels of drug use and overdose.117,119,120
Continuum of Overdose Risk in the Social Determinants of Health 
Broader place-based and macrosocial factors have been explored as
important drivers of overdose risk in urban and rural communities at
different periods in history, such as deindustrialization, stagnation of
economies, population loss, and despair.121,122 Community poverty en-
dures as a condition that elevates the risk of overdose. A recent analysis
of overdose hospitalizations in 17 states from 2002 to 2014 found that
zip code–level poverty was associated with increased heroin overdose
hospitalizations in urban areas.123 Paradoxically, drug criminalization
laws may increase overdose rates among PWUD by creating an environ-
ment where safe drug preparation and use is compromised and rushed
in order to avoid police harassment, arrest, and incarceration.111,124,125
The availability and regulation of opioids also contribute to overdose
risk.108 In settings where the manufacturing, distribution, and market-
ing of drugs are criminalized and thus unregulated, illegal drug markets
may contain products of unknown or unpredictable purity and doses that
pose a high risk of fatal and nonfatal overdose, as we describe more fully
below.10,108,126
Fatal Drug Overdose
Beyond individual-level factors such as polysubstance use80,127,128 and
reduced opioid tolerance following abstinence-based treatment81 or
incarceration,80,127-132 broader risk factors contribute to the lethality
of the current epidemic. The major challenge with the current syn-
thetic opioid epidemic is the infusion of illicit fentanyl and related
analogues.4,19 These potent drugs come in the form of powders, tablets,
and liquids. In the absence of regulation and drug checking programs,
the high potency and rapid absorption properties of fentanyl narrow the
window of opportunity to revive someone using naloxone and render
the drug highly lethal even among chronic opioid users.126 The pen-
etration of fentanyl into heroin markets has resulted in high rates of
overdose mortality among heroin users who may unknowingly use fen-
tanyl that is marketed to them as heroin or who are unaware that the
product is contaminated with fentanyl.46,48,49 Even among those who
knowingly use fentanyl, the purity is often unknown, which makes safe
dosing a challenge. Alarmingly, synthetic opioids are involved in deaths
attributable to prescription opioid pills (24%), cocaine (40%), benzodi-
azepines (31%), psychostimulants (14%), and other drugs (27%).133
 J.N. Park et al.
A growing number of studies at multiple levels have examined risk
factors other than supply-side factors, although these enduring and fun-
damental determinants of overdose have received less attention.10,127 For
example, PWUD who are witnesses to fatal overdoses frequently state
their fear of police arrest as a reason for delaying or refusing to call emer-
gency medical services (EMS). Unsurprisingly, geographic areas with
higher rates of police activity (ie, arrest) exhibit higher population-level
overdose mortality, which may be driven by fear of calling for medi-
cal help among bystanders.132 Naloxone coverage remains low among
PWUD, many of whom have seen their family and friends die of an
overdose. Notably, no national surveillance data are available on nalox-
one coverage among PWUD and others at a higher risk of witnessing an
overdose.134 Solitary drug use, which is practiced by an estimated 58%
of PWUD, lowers the chances of EMS being called or naloxone being
administered.135-137 State-level income inequality has been shown to be
highly correlated with drug overdose deaths in the early 2000s.127,131,138
The roles of race, sex, drug, time, geography, and urbanicity in rela-
tion to overdose risk require further attention.122 For example, the dis-
aggregation of national mortality trends has shown that age-adjusted
mortality among women in the southern United States continued to
grow between 2000 and 2013, whereas among men it peaked by the
mid-2000s.139 Urban areas in 2017 faced a higher burden of mortality
from heroin, synthetic opioids, and cocaine, but rural areas faced higher
mortality from prescription opioids and methamphetamines.140 In re-
gard to racial disparities, cocaine was the largest contributor of deaths
among Black men and women between 2000 and 2015 but not among
whites.141 From 2014 to 2016, mortality among whites from drug over-
dose was highest in urban areas and associated with both socioeconomic
and opioid supply factors.142 Whether all these trends can be attributed
to “despair” or other factors needs further investigation. In any case, tai-
lored interventions that account for these factors will likely be required
at the local level.143
Although the demographic, socioeconomic, and drug supply factors
warrant further examination, our review suggests that the risk fac-
tors along the COR are multifaceted and necessitate a comprehensive,
evidence-based strategy that is attentive to local needs. We next look at
several of these strategies.
Continuum of Overdose Risk in the Social Determinants of Health 
Opening Doors to De-escalate Risk: Six
Strategies
Given the nature of the risk factors that drive drug use and overdose (ex-
amined in the previous section), we identified and grouped interventions
that together could de-escalate risk over the long run and address drug-
related morbidity and mortality. Our findings are organized around six
strategies: (1) meaningful partnerships with PWUD, (2) prevention, (3)
harm reduction, (4) treatment, (5) recovery, and (6) reversal of the crimi-
nalization of PWUD. We chose interventions that are most likely to have
a population-level impact on addiction and overdose burden, keeping in
mind that the implementers should be responsive to local place-based
needs. Many strategies have already been successful in several states,
while others have been evaluated internationally. Ensuring that these
approaches are applied through a racial, gender, and class equity lens
will be critical, given the disproportionate effects of decades of punitive
policies and broader economic forces on these populations.
Meaningful Partnerships with People
Who Use Drugs
PWUD have been the driving force behind the international harm re-
duction movement.144,145 In the Netherlands, early SSP, peer education
programs, and treatment policies were driven by drug user unions.146
The emergence of HIV/AIDS, which appeared among US PWUD in
New York City in 1981, as well as significant activism by PWUD and
their allies, propelled the adoption of SSP as a public health measure
against HIV and viral hepatitis transmission in some parts of the country
and, later, the scale-up of community-based naloxone and other impor-
tant risk reduction programs.145,147 Nonetheless, despite their pivotal
historical role, PWUD are often sidelined in the present-day develop-
ment of programs, policy, and research.
Central to a harm reduction approach are the experiences and voices
of PWUD when developing opioid strategies. The most direct method
involves including PWUD in positions of leadership and decision
making21,148 because their involvement brings expertise and humanity,
and therefore relevance, to the design and implementation of programs,
policies, and laws. Even though PWUD have provided critical input
 J.N. Park et al.
for global health issues such as HIV/AIDS, they have been systemati-
cally excluded from influencing drug policy. This includes measures like
felon disenfranchisement laws, prison gerrymandering, and other efforts
to deprive people who are incarcerated or have a history of incarceration,
specifically people of color, from participating in the political process.
A key measure to sensible and humane drug policies is dismantling the
barriers to political participation for those who are most directly im-
pacted by drug policy.
Throughout history, PWUD have also had a pivotal role in the de-
velopment and delivery of outreach services, including SSP, naloxone
programs, HIV education, counseling, and recovery support.144,149 Peer-
based interventions have been shown to improve harm reduction educa-
tion and supply distribution and to reduce injection and sexual risk be-
haviors among PWUD. However, many are precluded from federal and
state employment, even though their community relationships and cul-
tural competencies could help these programs succeed. Legal protection
from discrimination, like the Americans with Disabilities Act (ADA),
which covers individuals with alcohol use disorder, have often not been
successful in SUD cases, especially in view of the “illegal use” exception
to this statute (42 U.S.C.A. § 12114[b]). Eliminating this exception
would provide some legal protections from discrimination.
Being convicted of drug charges and labeled as a felon create far more
barriers than most people fully comprehend. These barriers often in-
clude, but certainly are not limited to, an inability to obtain gainful em-
ployment. Although “ban the box” legislation would prevent employers
from investigating past drug convictions and would mitigate future dis-
crimination, these efforts would not fully prevent discrimination because
of public criminal records. Even in places where PWUD are engaged in
paid work, they risk being arrested if their drug use (past or present)
is discovered. In addition, universities regularly bar people with crimi-
nal records from employment and often prevent PWUD from receiving
student loans and access to college grants and scholarships. Many em-
ployment credentials and certifications are not accessible to felons. Drug
convictions also pose a barrier for housing and food in the United States,
with landlords regularly denying housing applications for people with
criminal records, and many states denying government assistance like
food stamps to people with drug convictions.
Stigma is another factor that adds to the marginalization of
PWUD.27,150 In a national survey, most respondents reported
Continuum of Overdose Risk in the Social Determinants of Health 
stigmatizing views toward OUD patients (eg, blaming them for hav-
ing a disorder).151 Another study found that stigmatizing terms were
used to describe PWUD in half of all news stories examined from 2008
to 2018.152 In addition, the media’s negative portrayal of racial minor-
ity PWUD, in contrast to holding white suburbanites blameless, has
been observed.153 The enduring stigma towards PWUD in the health
care sector also remains a barrier to seeking and receiving compassionate
and quality health care.154 Despite their own lack of experience, most
policymakers and academics fail to see PWUD as experts. Although
many organizations are led by PWUD (eg, Urban Survivors Union, New
England User Union, Bmore POWER, International Network of Peo-
ple Who Use Drugs, Women and Harm Reduction International Net-
work), few researchers and policymakers take the time to create real
buy-in when engaging in opioid work. Albeit rare, participatory ap-
proaches in research that draw on the expertise of PWUD can decrease
stigmatization and researcher bias. Fostering meaningful partnerships
with PWUD to address the opioid response holds great potential in en-
suring that policy and research priorities are appropriate and effective.
Prevention
Prevention is a broad term that encapsulates a range of interven-
tions across the life span. Many evidence-based prevention programs
exist,150ranging from early education to public mass-media campaigns.
However, these programs focus heavily on drug use prevention or absti-
nence rather than overdose prevention, as reflected by the outcomes typ-
ically reported in their evaluation. In fact, as the narrative moves away
from the “white” prescription opioid crisis, it is reverting to a campaign
of scare tactics and misinformation resulting in a revitalization and com-
mitment to America’s war on drugs. This is exemplified by the recent
rhetoric and policy promoting harsher penalties for the possession or sale
of fentanyl, for example, than for other opioids, as well as drug-induced
homicide laws.13,16 Limiting prevention efforts to the deterrence of opi-
oid use rather than harm reduction reflects long-standing stigma toward
PWUD, equating abstinence with recovery, as well as policies aiming for
a “drug-free society” that punishes those who use drugs. Such views and
policies continue to hamper prevention efforts by fueling the stigma and
marginalization of PWUD.
 J.N. Park et al.
We argue that society must shift from the model of judgment and
punishment of PWUD to one accepting that drug use will likely per-
sist (as it has throughout history). To improve the health of and social
outcomes for future generations, interventions should also target the full
COR, from initiation to overdose, and follow harm reduction principles.
For example, the integration of educational information about opioid
awareness, naloxone, Good Samaritan laws, and OUD treatment into
existing drug education programs may better equip individuals to pre-
vent drug-related harms, like overdose, rather than focusing on averting
drug use altogether. Avoiding stigmatizing terms like drug abuse and
addict in the narrative characterizing PWUD could help shift some key
barriers to safer drug use and access to treatment.
Prevention efforts targeting factors upstream of the drug initiation,
informed by the social determinants of health model, are an impor-
tant avenue for research and evaluation. For example, efforts to allevi-
ate neighborhood-level poverty or blight and the promotion of access to
education, employment, and housing would likely bolster overdose pre-
vention efforts. These are often de-prioritized, however, owing to their
scope and the many years before “returns on investment” are measurable,
and they therefore lack a solid evidence base.
Increased oversight of opioid prescribing through PDMPs and
providers’ greater awareness and restriction of the illegal marketing of
opioids through lawsuits have been successful in reducing the supply
of pharmaceutical opioids.106,155 But tackling the upstream policy en-
vironment that enables poor opioid stewardship, including laws that
permit pharmaceutical companies to pay doctors both directly and in-
directly and to advertise their products to consumers through the me-
dia, is another reform that has not yet been pursued. These approaches
also do not address the needs of already opioid-dependent individuals.
Moreover, research suggests that the reduction of prescription opioid
supplies through PDMPs may have inadvertently led to increased rates
of heroin overdose deaths.106,155 These supply-based approaches also fail
to help those who initiate opioid use through heroin or fentanyl, espe-
cially among underserved urban communities of color who have been
suffering the effects of this crisis for decades.
Continuum of Overdose Risk in the Social Determinants of Health 
Harm Reduction
Naloxone and Good Samaritan Laws. It has been almost 50 years since
the US Food and Drug Administration (FDA) approved the use of nalox-
one, a medication that can reverse the course of an overdose by strongly
binding to opioid receptors in the brain in the place of opioids and effec-
tively blocking their effects. Unlike other interventions, naloxone is the
only tool that directly prevents fatal overdoses. Although fatal overdoses
often occur in the presence of bystanders, the majority do not administer
naloxone, indicating a missed opportunity for intervention.136 Even so,
tens of thousands of overdoses have been reversed through the distribu-
tion of naloxone in the community.147
The Centers for Disease Control and Prevention (CDC), among oth-
ers, recommends that the scale-up of naloxone programs should target
those people who are most likely to experience or witness an overdose,
including active PWUD (eg, at SSP, emergency rooms, drug treatment
facilities, recovery programs, infectious disease and mental health clin-
ics, and jails/prisons), first responders (eg, EMS and police), and service
providers (eg, outreach staff and clinicians).136,156 Training potential by-
standers (eg, family and friends of PWUD) has been successful and could
have a substantial impact on overdose rates if such programs were scaled-
up.147 The implementation of coprescribing policies, as well as stand-
ing orders permitting over-the-counter dispensing of naloxone without
a prescription has increased access in some states, like Maryland. Given
the current fentanyl crisis, it is imperative that individuals receive at
least three doses of naloxone in case a higher dose is required.
The limitations of naloxone programs also should be noted. First,
naloxone does not address nonfatal overdoses, which account for a large
proportion of social and economic burden, and thus other interventions
are always needed. Second, the fear of police involvement often keeps
bystanders from calling EMS and intervening. Naloxone programs need
to be coupled with a federal Good Samaritan law to provide legal pro-
tections to those who try to intervene in the case of an overdose, and
implemented effectively.156,157 Third, because of fentanyl’s lipophilic
nature, overdoses occur rapidly, so waiting for EMS may not be an
option.21,36 Finally, even though solitary drug use is common, it is of-
ten not addressed.37 Preventive interventions are needed that target the
earlier stages of the overdose trajectory.
 J.N. Park et al.
Overdose Prevention Sites. Overdose prevention sites (OPS), also
known as safe consumption spaces and supervised injection facilities,
are places in which PWUD can use previously purchased drugs under
trained supervision.158-160 If scaled-up, OPS could address many issues
regarding naloxone, bystanders, and police. There are more than 110
OPS in 66 cities worldwide. Evidence on the impacts of OPS demon-
strates their significant association with reducing overdose fatalities,
HIV and HCV transmission, syringe sharing, public injection, ambu-
lance usage, and crime.161-164 Furthermore, OPS increase entry into drug
treatment, have never housed a fatal overdose, and have been found to
be cost-effective.165-167 There is one unsanctioned OPS documented in
the United States,168 although many more likely exist, and a number of
US jurisdictions, including Maryland, are considering legislation to le-
galize these potentially lifesaving spaces. In Philadelphia, the nonprofit
Safehouse was established with support from the mayor, health commis-
sioner, and private donors. Despite a civil lawsuit (21 U.S.C. §856[a]),
a US district judge ruled in favor of Safehouse. Even though they are
currently underutilized, OPS hold great potential for saving lives in the
United States, particularly in areas of concentrated poverty, drug use,
and overdose.
Drug Checking. Drug checking programs enable PWUD, without
the risk of arrest, to have their drugs chemically analyzed for the pres-
ence of substances like fentanyl and its analogues and for their purity,
thereby allowing for more informed decisions about subsequent drug
use.169-172 These programs, which were pioneered in Europe and are in-
clusive of laboratory-based and point-of-care models, have the potential
to promote product safety in the illicit drug supply in the United States,
where its use has been limited to testing drugs at music festivals and
some SSP and community-based organizations. Such services are needed
in the context of a large unregulated illicit market in which the quantity
and purity of illicit drugs (eg, heroin) remain uncertain. We, among oth-
ers, have found a high level of interest in drug checking programs among
urban PWUD and associated behavior change (eg, obtaining naloxone,
using in the presence of others).72,173-175
Legal barriers will need to be overcome in order to scale-up drug
checking programs. The Controlled Substances Act (CSA) prohibits
the possession of controlled substances, which includes community-
based collection of drug samples. Consequently, there are barriers to
implementing drug checking programs in the community, and the
Continuum of Overdose Risk in the Social Determinants of Health 
current drug surveillance system relies heavily on drug testing data from
law enforcement that may not fully represent the broader drug supply.
Reforming the CSA would enable the direct testing of samples collected
from the community to strengthen surveillance, improve awareness, and
promote safety.
Treatment
The provision of methadone and buprenorphine to manage OUD
(also known as medication-assisted treatment) is an important aspect of
a comprehensive overdose reduction strategy.154,176,177 The gold stan-
dard medical treatment for OUD is maintaining patients on either
methadone or buprenorphine/naloxone. As opioid agonists, these drugs
reduce cravings, treat withdrawal symptoms, and stabilize the patient.
Methadone and buprenorphine/naloxone can be considered harm reduc-
tion tools insofar as many patients, despite continuing to take opioids,
still receive important health benefits from treatment. A third FDA-
approved drug approved for OUD treatment is extended-release naltrex-
one. While opioid agonists occupy the same receptors in the brain that
illicit opioids stimulate, naltrexone blocks receptor activity and is there-
fore an antagonist. Building on decades of evidence, a 2019 report from
the National Academies of Science, Engineering, and Medicine con-
cluded that OUD medications are effective at reducing overdoses and
promoting recovery and yet are massively underprovided in the United
States.154
Opioid agonists reduce overdose risk by causing people to use il-
licit opioids less frequently and to stop injecting opioids (and conse-
quently reduce their risk of acquiring infectious diseases) and ultimately
to abstain from using illicit opioids.178 Their protective effect has been
demonstrated in clinical trials and cohort studies.179 Moreover, because
patients receiving agonist treatments do not completely lose their tol-
erance, they also make it less likely that people will overdose if they
return to using drugs, compared with medication-free treatments.180
For this reason, even though naltrexone is more commonly used in cor-
rectional settings, its use for preventing overdoses and providing other
health benefits has been demonstrated to be far inferior to opioid agonist
treatment.181
The current paradigm for delivering treatment is fundamentally
failing. Most OUD patients are not receiving treatment, and fewer
than half the treated patients are receiving agonist medication.182
 J.N. Park et al.
Moreover, when they do receive treatment, it is often inadequately short
and fragmented.183 Access to treatment is particularly difficult for the
most vulnerable, such as people in the criminal justice system, in which
only one in twenty individuals receive OUD medications.184 Comor-
bidities such as underlying mental illness (eg, stemming from trauma)
are often left untreated as well, even though more than 60% of OUD
patients suffer from mental illness and high levels of trauma.185 Limited
access to OUD treatment likely reflects the stigma toward PWUD and
OUD medications, including the perception that medications merely
“substitute one drug for another.”186 Drug-related stigma is pervasive
in all sectors—among doctors, law enforcement, and in many segments
of the recovery community.187
Stigma reinforces, and is reinforced by, burdensome regulations that
ironically make it more difficult to access OUD treatment than ad-
dictive opioid pain relievers. Specifically, since the 1970s, access to
methadone has been restricted to certified opioid treatment programs,
which themselves are often subject to additional regulation and discrim-
inatory zoning rules. In Canada, Australia, and the United Kingdom, by
contrast, methadone can be accessed through primary care.188 Although
buprenorphine is available in primary care settings in the United States,
it is limited to providers who have obtained a federal waiver. The num-
ber of providers has grown somewhat in recent years, but many areas
still do not have an adequate supply of providers,189 and most treatment
is not “on demand.”190
Expanding treatment across the United States that could achieve
widespread public health benefits would require substantial change. It
would require the confluence of at least three elements: stigma reduc-
tion, increased financing, and regulatory change.
Stigma reduction would focus on normalizing opioid agonist treat-
ment and making OUD a mainstream medical issue, much as diabetes
is considered a chronic disease that is appropriately managed in primary
care. In particular, stigma reduction in the context of treatment deliv-
ery would necessitate fundamental changes in the training of medical
professionals and other first responders. Currently, medical profession-
als receive little to no education in addiction medicine and are some-
times professionally socialized to see people with addiction issues as un-
trustworthy, dangerous, and unsuitable for treatment in primary care.191
Creating stronger expectations for medical professionals about how they
interact with PWUD and measuring patient satisfaction, as well as
Continuum of Overdose Risk in the Social Determinants of Health 
promoting further research on this topic in partnership with PWUD
will be necessary in addressing the stigma of PWUD in health care.
Much of the current treatment for OUD is derived from public
sources, especially Medicaid, which has grown as a payer after the Afford-
able Care Act (ACA) was passed.192 The ACA established that covering
OUD and mental health services is essential and reinforced that bene-
fits should have parity with other medical conditions. While the growth
of funding has been important, available funding is currently failing to
meet needs in several ways. First, many states do not comprehensively
cover treatment costs or limit the duration of time that publicly insured
individuals are able to remain in treatment.192 Second, many providers
still do not accept publicly insured patients, which may reflect the lower
reimbursement offered by Medicaid and administrative hurdles, such as
prior-authorization rules.190 Third, supplemental federal funds (eg, the
21st Century Cures Act) have opened new treatment slots but are time
limited without further funding.
Finally, regulatory changes are needed. The long-term objective
should be dismantling the burdensome regulatory framework dating
back to such antiquated drug control policies as the 1914 Harrison Nar-
cotics Act, the federal law that forbade doctors from prescribing opi-
ates (including, ultimately, methadone and buprenorphine) to people
known to be addicted to drugs.193 In the shorter term, smaller regulatory
changes could boost access to treatment, including removing the patient
cap for physicians who prescribe buprenorphine, providing prescribing
authority to all prescribers with a DEA license (along with a revamped
addiction curriculum), and providing more options for methadone pro-
vision offered at nontraditional locations such as mobile vans or jails.
The cumulative effect of these policy changes would be a new frame-
work to treat OUD that combines the resources for treatment with the
enabling regulations and a workforce that is more motivated to care for
these patients. The ultimate test of this treatment’s effectiveness would
be measured by the increased number of patients who initiate and stay
in treatment and ultimately by fewer overdose deaths.
Recovery
Recovery programs are often included in national and state strate-
gic plans, yet most of them implicitly or explicitly conflate the term
 J.N. Park et al.
recovery with abstinence from drug use. As noted in the Surgeon Gen-
eral’s report, it is possible to be in recovery and still use opioids,
whether they are medically supervised (eg, MAT) or not (eg, con-
trolled safe use).150 The federal definition offered by SAMHSA (Sub-
stance Abuse and Mental Health Services Administration) demonstrates
that recovery involves more than a person’s drug use and consists
of “a process of change through which people improve their health
and wellness, live self-directed lives, and strive to reach their full
potential.”
Many laws, policies, and strategic plans, however, do not reflect
this definition of recovery, which paradoxically poses major hurdles for
PWUD who seek long-term recovery. Addressing the social determi-
nants of health (eg, employment, housing), and structural barriers such
as the integration of services targeting SUD, along with mental health
and general health services, would go a long way in supporting recov-
ery programs. Examples of specific changes are (1) expunging low-level,
nonviolent, drug-related offenses; (2) instituting a federal “ban the box”
law; (3) including PWUD in broader discrimination laws like the ADA
to reduce employment discrimination; (4) banning drug testing when
it is unrelated to the candidate’s ability for the job; (5) creating afford-
able housing opportunities that are not contingent on maintaining ab-
stinence; and (6) treating SUD as a chronic condition and providing
wraparound services (prevention, harm reduction, and mental health ser-
vices in addition to drug treatment) that are not contingent on main-
taining abstinence. Prioritizing interventions based on geography may
be warranted in accordance with local needs. For example, homelessness,
violence reduction, and structural racism may be more urgent to address
in urban areas, whereas health insurance, and treatment of injury-related
pain may be more appropriate in rural areas with economies reliant on
mining.123,142
In order to maximize the impact of these interventions, eco-
nomic policies to reduce community-level poverty targeting educa-
tion barriers, wage stagnation, and unemployment, could be imple-
mented by raising the minimum wage, investing in public education
(particularly for low-income communities), and strengthening labor
rights.194 Finally, access to affordable health care is needed to support
recovery.
Continuum of Overdose Risk in the Social Determinants of Health 
Reversing the Criminalization of PWUD
Activists, academics, and policymakers are increasingly recognizing the
harms to individuals and societies that results from drug prohibition
and the aggressive enforcement of punitive legislation, including the
criminalization of addiction.11,12 These laws and policies have resulted
in high incarceration rates among PWUD and low-level drug dealers
but have done little to stem the flow of illicit opioids (including fen-
tanyl) into the United States and have systematically targeted and ex-
ploited Black communities for many decades.11,195 The many psychoso-
cial and economic consequences of heavy-handed law enforcement and
repeated incarceration have been shown to amplify the risks associated
with drug use—including overdose—and to raise barriers to providing
public health resources to prevent overdoses.
The criminal legal system—from initial police encounters to incar-
ceration, parole, and reentry—plays an outsized role in this crisis. An
estimated 65% of the 2.3 million people in US prisons and jails have
a diagnosable SUD, more than seven times the rate in the general
population.196 Nearly 15% of incarcerated men and 30% of women also
have diagnosable mental health disorders.197 There is broad recognition
that in the context of mass incarceration, correctional institutions act as
the de facto national substance use and mental health safety net.198 Even
so, correctional health efforts to address these health conditions often fall
below medically accepted standards of care.
Each phase of involvement in the criminal legal system—from the
point of crisis before arrest, through detention, and after release—is an
opportunity to better address SUD and mental health challenges. This
means that criminal legal institutions must (1) screen and diagnose, (2)
treat, (3) monitor and support, and (4) triage individuals to appropriate
health care and prevention services. Other researchers have developed a
model for using key inflection points to help provide necessary health
care along a five-phase continuum.199 Rhode Island is a model state for
providing the continuum of OUD care among individuals who enter the
criminal legal system.199,200
Even where there is access to treatment, the conditions of commu-
nity supervision frequently bar returning individuals from obtaining
buprenorphine or methadone and then punish them for experiencing
relapse.201 This may be done through parole boards’ policies, judges’
or community supervision staff practices, or conditions imposed by
 J.N. Park et al.
transitional housing and other programs.202 Reforming community su-
pervision systems to play a supportive rather than a punitive and coercive
role can help facilitate recovery and prevent negative outcomes, includ-
ing death.
Cyclical involvement in the criminal legal system is likely if the social
determinants of health are not addressed. Untreated substance use and
mental health challenges, poverty, barriers to employment and educa-
tion, isolation, intrusive government surveillance, and racism are among
the factors driving the cycle of vulnerability. To stop this cycle, “off
ramps” must be built to divert individuals to supportive structures and
services. This begins in the community—at Intercept 0—where mea-
sures like Law Enforcement Assisted Diversion (LEAD) programs and
opioid agonist treatment can help avoid system involvement now and
prevent it in the future.203 Given the multiple cascades of harm, the
ultimate goal must be to minimize system contact whenever possible.
Off ramps should never lead into a ditch, however. In most juris-
dictions, policing and criminal legal budgets have long outpaced in-
vestment in community-based services. As a result, many communities
lack adequate quality substance use and mental health treatment, af-
fordable housing, meaningful employment, and other supportive mech-
anisms that can help avert contact with the criminal legal system. This
has ensured that the criminal legal sector is not just the safety net of
last resort but is the only governmental system that many vulnerable
people can reliably access. In the short term, improvements to health
and other services in correctional and other criminal legal system com-
ponents are urgently needed to reduce their harm. This includes the
provision of sanitary supplies, testing, screening, and treatment to help
prevent the spread of COVID-19. In the long term, investing in legit-
imate public health approaches and measures of social support through
the decriminalization of low-level drug possession (as realized in Por-
tugal and several other countries12,204,205), early-release efforts, and the
reversal of decades of policies that have systematically disenfranchised
PWUD from education, employment, and housing will help reduce our
reliance on coercive and punitive systems to address the substance use
and mental health crisis in our society.13 There is a precedent in the
United States for reversing the criminalization of PWUD, from mari-
juana decriminalization to the release of nonviolent PWUD from jails
because of COVID-19.
Continuum of Overdose Risk in the Social Determinants of Health 
Research Gaps
Too often, the social determinants of health are neglected when examin-
ing the COR and developing methods to address the escalation of risk.
Public health initiatives would benefit from a more detailed understand-
ing of the social drivers of illicit opioid use initiation (NMPO, heroin,
synthetics), decision making that sustains use, transitions between dif-
ferent types of opioids, and how use propels individuals along the COR.
Despite the scope of fentanyl-involved polysubstance use, we have yet
to determine whether PWUD have a greater need for stimulants ow-
ing to the strength of fentanyl and whether their frequency of use has
increased, which may confer greater risks. In addition, despite efforts
to research the actual and perceived benefits of substance use (eg, mar-
ijuana, alcohol use), as well as ways to minimize harm, research in this
area is limited for opioids, particularly fentanyl. Related to this is the
need to employ a more diverse set of outcome measures in substance use
research, including measures of frequency of use, quality of life, inter-
personal relationships, job stability, and de-escalation of risk through
transitioning to other substances (ie, marijuana).
Biomedical research could spur the development of crucial tools for
prevention (eg, the link between OUD and mental health) harm reduc-
tion (eg, drug checking tools, a naloxone-equivalent for all drugs in-
volved in overdoses), and treatment (eg, medication-assisted treatment
for cocaine). We also need US-based proof-of-concept research for suc-
cessful biomedical interventions that are available in other countries (eg,
diacetylmorphine “heroin-assisted” treatment).206,207
The stigma toward PWUD, harm reduction programs, and medica-
tions for OUD persists in many parts of the country, including among
law enforcement, first responders, providers, researchers, and policymak-
ers, and it threatens public health responses to the opioid epidemic. We
urgently need to develop and evaluate effective interventions that re-
duce stigma and the resultant harms among different populations.208 In
addition to stigma, we need to better understand why evidence-based
public health-oriented approaches, such as the role of power and inter-
est groups, are widely available in some countries but not others (see the
Limitations section).
Finally, new and existing laws, policies, programs, and practices that
address drug use should be based on data and rigorously evaluated.
We should do more to support real-world implementation research that
 J.N. Park et al.
evaluates prevention, harm reduction, treatment, and criminal justice
approaches to the epidemic, with priorities set in consultation with
PWUD. Removing barriers to accessing health data at the county and
state levels and increasing funding for community- and policy-based re-
search on the social determinants of health framework would boost this
line of work. Future studies could also examine how frequently PWUD
are given key roles in drug-related research (eg, funding decisions, re-
search design, and authorship). Given the scope of the current drug over-
dose epidemic, it is important that these large gaps in knowledge be
addressed to end overdoses.
Limitations
Structures of authority are configured to benefit certain groups.209 As
articulated by historian Elizabeth Hinton,195 who built on the work
of Michelle Alexander and others,11 the drug control policies in the
United States since at least the 1960s cannot be separated from larger
efforts to contain perceived threats in American society and win political
support from white voters following the civil rights movement, includ-
ing the changes taking place in American cities and deliberate social
and political linkages made between urban Black youth and crime. The
work and opinions of scholars contributed to racist beliefs about African
Americans, thus perpetuating these harmful policies. Mainstream po-
litical coalitions have been built on “tough on crime” policies, which
have penalized and disenfranchised urban communities of color, includ-
ing PWUD. These policies have led to the expansion of the criminal
justice system at all levels of government, including law enforcement,
courts, prosecutors, and private for-profit prisons, as well the US De-
partment of Justice (including the Drug Enforcement Agency and the
Office of Justice Programs). The conflation between urban policy and
drug control policy led to the diversion of federal funding, so that the
criminal justice system became, and remains, the de facto public health
and social service agencies in many low-income communities across the
country. Scholars have also shown that various industries are reliant on
prison labor to be financially viable. Without recognizing and address-
ing racism and the beneficiaries of the status quo, our efforts regard-
ing prevention, treatment, recovery, and criminal justice reform will fall
short.
Continuum of Overdose Risk in the Social Determinants of Health 
Conclusions
The tragic toll of the opioid epidemic underscores a pressing and over-
due obligation to fundamentally shift public policy from punishment to
public health and to adopt more innovative and comprehensive strate-
gies to curb the harms associated with opioid use. First and foremost,
PWUD should be represented in leadership and decision making to
shape programs, laws, policies, and research pertaining to drug use. For
example, a national advisory council could be formed to consult on these
activities. Adopting comprehensive harm reduction approaches in part-
nership with PWUD would help engage the most at-risk communities
and bolster ongoing public health efforts that have centered on the pre-
vention of drug use and treatment. The outcomes that are monitored
should be expanded to include the full COR. Without comprehensive
legal reform, our successes will be short-lived. This article has explained
several common-sense policies, such as decriminalizing drug possession,
which could de-escalate risk and improve health for many generations to
come, as well as such factors as the underlying racism and vested interests
that hinder progress. Without treating all members of society as equal
citizens with equal access to resources and opportunities, and addressing
the social determinants of health, the United States will continue to see
preventable overdoses for the foreseeable future.
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Funding/Support: JN Park and SG Sherman were supported by the
Johns Hopkins University Center for AIDS Research (1P30AI094189).
S Rouhani was supported by the National Institute on Drug Abuse
(T32DA007292). L Beletsky was supported in part by the National In-
stitute on Drug Abuse (R01DA039073). B Saloner was supported by
the National Institute on Drug Abuse (K01-DA042139).
Conflict of Interest Disclosures: All authors have completed the ICMJE
Form for Disclosure of Potential Conflicts of Interest. No conflicts were
reported.
Address correspondence to: Ju Nyeong Park, Department of Health Behavior
and Society, Johns Hopkins Bloomberg School of Public Health, 624 N
Broadway St., Hampton House Suite 186, Baltimore, MD 21205 (email:
ju.park@jhu.edu).
... Increasingly, public health professionals argue that a more comprehensive approach to address root causes is necessary, calling for the social determinants of health framework to be adopted and applied to overdose prevention efforts [17,8]. Although there is widespread acknowledgment that social and economic determinants of health continue to contribute to health disparities and inequities [21], many response efforts remain "too narrow for the scale and scope of the crisis. ...
... Although there is widespread acknowledgment that social and economic determinants of health continue to contribute to health disparities and inequities [21], many response efforts remain "too narrow for the scale and scope of the crisis. " [17]. ...
... Conditions that may contribute to SEM such as homelessness, stigma within healthcare systems, a recent release from prison, and Medicaid eligibility have been linked to overdose [10,22]. Social factors including experiencing early childhood trauma may be amplified by structural racism and income inequality and are critical in shaping risks associated with drug initiation and future use [17]. The criminalization of people who use drugs leads them to encounter law enforcement at high frequencies. ...
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Individuals who have survived an overdose often have myriad needs that extend far beyond their drug use. The social determinants of health (SDOH) framework has been underutilized throughout the opioid overdose crisis, despite widespread acknowledgment that SDOH are contributors to the majority of health outcomes. Post Overdose Response Teams (PORTs) engage with individuals who have experienced 1 or more nonfatal overdoses and bear witness to the many ways in which overdose survivors experience instability with healthcare, housing, employment, and family structure. Employing a harm reduction model, PORTs are well-positioned to reach people who use drugs (PWUD) and to address gaps in basic needs on an individualized basis, including providing social support and a sense of personal connection during a period of heightened vulnerability. The New York State Department of Health (NYSDOH) PORT program is a harm reduction initiative that utilizes law enforcement data and several public databases to obtain accurate referral information and has been active since 2019 in NYC. This PORT program offers various services from overdose prevention education and resources, referrals to health and treatment services, and support services to overdose survivors and individuals within their social network. This perspective paper provides an in-depth overview of the program and shares quantitative and qualitative findings from the pilot phase and Year 1 of the program collected via client referral data, interviews, and case note reviews. It also examines the barriers and successes the program encountered during the pilot phase and Year 1. The team’s approach to addressing complex needs is centered around human connection and working toward addressing SDOH one individualized solution at a time. Application of the NYSDOH PORT model as outlined has the potential to create significant positive impacts on the lives of PWUD, while potentially becoming a new avenue to reduce SDOH-related issues among PWUD.
... Why does the US continue to experience significantly high numbers of overdose deaths, and why has drug overdose been disproportionately impacting minoritized communities? Converging data points to the widespread availability of highly potent synthetic opioids (HPSO) such as fentanyl, rapidly rising rates of polysubstance use [2][3][4], persistent structural and social vulnerabilities [2,[5][6][7][8] stemming from structural racism, and inequities in access to medication for opioid use disorder (MOUD) and harm reduction services [4,[9][10][11][12][13] as among the main contributing factors. This article summarizes key findings from recent literature aimed at enhancing the understanding of racial and ethnic inequities in opioid overdose mortality and emphasizes the necessity for tailored interventions to prevent exacerbating these inequities as well as other policy-level and structural strategies to stem this trend. ...
... Although changes in drug supply over time is an important driver of disparities in overdose mortality, it is not the only cause. Increasing research shows that the accumulation and persistence of experiences of marginalization in different systems that govern our lives due to structural racism are a root cause of racial and ethnic health disparities [8,14,22], including drug overdose disparities [2,3,[5][6][7]23]. For example, Black, AI/AN, and Latine are unfairly incarcerated at disproportionately higher rates than Whites [24]. ...
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Purpose of Review This review synthetizes findings reflecting the increasing racial and ethnic inequities in opioid overdose mortality and emphasizes the necessity for tailored interventions as well as other policy-level and structural strategies to stem this trend. Recent Findings Factors contributing to inequities in overdose mortality include changes in drug supply, persistent social-structural vulnerabilities stemming from structural racism, and inequities in access to medication for opioid use disorder and harm reduction services. Key strategies to address these inequities include the cultural adaptation of evidence-based interventions within an equity-based framework, integrating social determinants of health into addiction treatment, centering anti-racism praxis in addiction research, diversifying the addiction workforce, and integrating structural competency as a tool to restructure education and inform practice. Summary Structural racism must be recognized as a key driver of inequities in substance use outcomes, and this understanding must be integrated into existing models of substance use disorder prevention, treatment, and research.
... SDOH factors such as socioeconomic deprivation, the neighbourhood and built environment, and structural racism 10 11 affect a range of health outcomes, 12 including overdose risk. 13 However, research on SDOH and overdose often fails to examine the role of criminal-legal systems in driving and exacerbating social adversities. 14 15 Recent research suggests overdose events increase in the days after an opioid-related drug seizure. ...
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Full-text available
Background The opioid overdose mortality crisis in the USA is an ongoing public health epidemic. Ongoing law enforcement strategies to disrupt local unregulated drug markets can have an iatrogenic effect of increasing overdose by driving consumers towards new suppliers with unpredictable drug products of unknown potency. Methods Cross-sectional study using point-level information on law enforcement opioid-related drug seizures from property room data, opioid-related non-fatal overdose events from emergency medical services and block group-level social determinants of health data from multiple sources. Using an endemic-epidemic spatiotemporal regression model, we estimated the degree to which exposure to drug supply disruptions triggers future overdose events within small space-time distances in Indianapolis, Indiana. Results Neighbourhoods with more structural racism, economic deprivation or urban blight were associated with higher rates of non-fatal overdose. Exposure to an opioid-related drug seizure event had a significant and positive effect on the epidemic probability of non-fatal overdose. An opioid seizure that occurred within 250 m and 3 days, 250 m and 7 days, and 250 m and 14 days of an overdose event increased the risk of a new non-fatal overdose by 2.62 (rate ratio (RR)=2.62, 95% CI 1.87 to 3.67), 2.17 (RR=2.17, 95% CI 1.87 to 2.59) and 1.83 (RR=1.83, 95% CI 1.66 to 2.02), respectively. Similar spatiotemporal patterns were observed in a smaller spatial bandwidth. Conclusions Results demonstrated that overdoses exhibit a community spread process, which is exacerbated following law enforcement strategies to disrupt the unregulated drug market. We discuss decriminalisation and increasing resources that promote safer drug use to combat this public health crisis.
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This analysis sets out to inquire why the comprehensive public health response to the alarming surge in illicit opioid and stimulant-related fatalities in the Canadian province of British Columbia has not yielded the intended results, despite its forward-thinking policies grounded in a concern for health over criminalization (Govt of BC, 2016; Burton et al., 2021). I will claim that this purportedly progressive approach to public health has been ineffective because it fails to address the socio-political drivers of the overdose crisis. Relating the work of cultural anthropologist Philippe Bourgois on drug use as a coping mechanism and Carol Bacchi's ontopolitical approach to the issue, I will trace the discursive dynamics through which the opioid crisis has been constructed in a manner that obviates its structural roots in the political economy of capitalist democracies.
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Social risks (individual social and economic conditions) have been implicated as playing a major role in the opioid epidemic and may be more prevalent in the most medically vulnerable patients. However, the extent to which specific social risks and other patient factors are associated with opioid use among high-risk patients has not been comprehensively assessed. To identify patient-reported and electronic health record (EHR)-derived demographic, social, behavioral/psychological, and clinical characteristics associated with opioid use in Veterans Affairs (VA) patients at high risk for hospitalization or death. We used generalized estimating equations to calculate the probability of long-term opioid therapy (LTOT) and the probability of filling any opioid prescription (regardless of duration) over five intervals during a 4-year period (12/2016–12/2020). Prospective cohort of 4121 medically high-risk VA patients not receiving palliative or end-of-life care, and who responded to a survey mailed to a nationally representative sample of 10,000 high-risk VA patients. Patient-reported demographic, social risk, behavioral/psychological, and clinical measures, and linked EHR-derived data. The average age was 69.8 years, 6.7% were female, and 17.5% were Non-Hispanic Black race/ethnicity. The majority had diagnosed chronic pain (76.1%). LTOT and any opioid prescription were positively associated with the following: younger age, non-Hispanic White race/ethnicity (compared to non-Hispanic Black race/ethnicity), male sex assigned at birth (LTOT only), not being currently employed, current tobacco use, no alcohol use, higher grit (any opioid prescription only), functional limitations, diagnosed chronic pain, lower comorbidity burden (LTOT only), obesity class I or class II/III (any opioid prescription only), undergoing surgery (any opioid prescription only), and diagnosed cancer (any opioid prescription only). Multifactor screening could help identify individuals at elevated risk for adverse opioid-related outcomes and augment current multifaceted initiatives, as several social risks and patient characteristics were predictors of LTOT and any opioid prescription.
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To fully understand the opioid epidemic, it is necessary to elucidate the role of depression in mutually reinforcing relationships with pain and prescription opioid use. By bringing together contributions from neuroscience, pain psychiatry, clinical epidemiology, pharmacoepidemiology, clinical trials, and research on social determinants of health, this volume integrates currently siloed areas of investigation and clinical knowledge. Readers will come to understand the central role of depression, other psychiatric disorders, and social determinants that contribute to pain management outcomes, the opioid epidemic, and our response to opioid dependence and opioid use disorder. By taking a multidisciplinary approach to compiling what is known about the relationships between pain, depression, other psychiatric disorders, and opioids, this work serves as a valuable resource for trainees and clinicians working in a range of healthcare settings while also spawning new directions for researchers.
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Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions. Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.
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Background In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. Methods We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. Results We predict that for an annual cost of 1.8million,asingleSIFwouldgenerate1.8 million, a single SIF would generate 7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. Conclusions We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.
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Of the 70,237 drug overdose deaths in the United States in 2017, approximately two thirds (47,600) involved an opioid (1). In recent years, increases in opioid-involved overdose deaths have been driven primarily by deaths involving synthetic opioids other than methadone (hereafter referred to as synthetic opioids) (1). CDC analyzed changes in age-adjusted death rates from 2017 to 2018 involving all opioids and opioid subcategories* by demographic characteristics, county urbanization levels, U.S. Census region, and state. During 2018, a total of 67,367 drug overdose deaths occurred in the United States, a 4.1% decline from 2017; 46,802 (69.5%) involved an opioid (2). From 2017 to 2018, deaths involving all opioids, prescription opioids, and heroin decreased 2%, 13.5%, and 4.1%, respectively. However, deaths involving synthetic opioids increased 10%, likely driven by illicitly manufactured fentanyl (IMF), including fentanyl analogs (1,3). Efforts related to all opioids, particularly deaths involving synthetic opioids, should be strengthened to sustain and accelerate declines in opioid-involved deaths. Comprehensive surveillance and prevention measures are critical to reducing opioid-involved deaths, including continued surveillance of evolving drug use and overdose, polysubstance use, and the changing illicit drug market; naloxone distribution and outreach to groups at risk for IMF exposure; linkage to evidence-based treatment for persons with substance use disorders; and continued partnerships with public safety.
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Purpose of review Drug checking services invite drug consumers to anonymously submit drug samples for chemical analysis and provide feedback of results. Drugs are tested for strength/dose and/or presence of adulterants. Drug checking appears to be more common in recent years in response to increases in fentanyl-related deaths and the proliferation of new psychoactive substances (NPS). We aim to provide information regarding the current state of drug checking in relation to analysis methods, adulteration rates, and behavioral responses to results. Recent findings Various technologies are being used to detect the presence of fentanyl, its analogs, and other NPS in drug samples. Proxy drug checking, which we define as biospecimen testing for drug exposure postconsumption, is also becoming common. However, there appears to a dichotomy between research focusing on populations at high risk for fentanyl exposure and to exposure to NPS such as synthetic cathinones. Summary Drug checking research and services largely focus on opioid consumers and nightclub and dance festival attendees, but more focus may be needed on the general population. Drug checking results can inform surveillance efforts, and more research is needed to overcome barriers to drug checking and to focus on whether test results indeed affect behavior change.
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Background: Fentanyl has caused rapid increases in US and Canadian overdose deaths, yet its presence in illicit drugs is often unknown to consumers. This study examined the validity in identifying the presence of fentanyl of three portable devices that could be used in providing drug checking services and drug supply surveillance: fentanyl test strips, a hand-held Raman Spectrometer, and a desktop Fourier-Transform Infrared Spectrometer. Methods: In Fall 2017, we first undertook an assessment of the limits of detection for fentanyl, then tested the three devices' sensitivity and specificity in distinguishing fentanyl in street-acquired drug samples. Utilizing test replicates of standard fentanyl reference material over a range of increasingly lower concentrations, we determined the lowest concentration reliably detected. To establish the sensitivity and specificity for fentanyl, 210 samples (106 fentanyl-positive, 104 fentanyl-negative) previously submitted by law enforcement entities to forensic laboratories in Baltimore, Maryland, and Providence, Rhode Island, were tested using the devices. All sample testing followed parallel and standardized protocols in the two labs. Results: The lowest limit of detection (0.100 mcg/mL), false negative (3.7%), and false positive rate (9.6%) was found for fentanyl test strips, which also correctly detected two fentanyl analogs (acetyl fentanyl and furanyl fentanyl) alone or in the presence of another drug, in both powder and pill forms. While less sensitive and specific for fentanyl, the other devices conveyed additional relevant information including the percentage of fentanyl and presence of cutting agents and other drugs. Conclusion: Devices for fentanyl drug checking are available and valid. Drug checking services and drug supply surveillance should be considered and researched as part of public health responses to the opioid overdose crisis.
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Background People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada. Methods and findings Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33–46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24–123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7–27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27–42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26–0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings. Conclusions We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.
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Introduction and Aims The increased availability of prescription opioids (PO) and non‐medical prescription opioids (NMPO) has fundamentally altered drug markets and typical trajectories from initiation to high‐risk use among people who use opioids (PWUO). This multi‐site study explores trends in opioid initiation in three US cities and associations with sociodemographic factors, current drug use and overdose risk. Design and Methods We analysed survey data from a cross‐sectional study of PWUO in Baltimore, Maryland (n = 173), Boston, Massachusetts (n = 80) and Providence, Rhode Island (n = 75). Age of first exposure to PO, NMPO and heroin was used to calculate opioid of initiation, and multinomial regression was employed to explore correlates of initiating with each. Results Thirty‐three percent of PWUO initiated with heroin, 24% with PO, 18% with NMPO and 24% with multiple opioids in their first year of use. We observed a reduction in heroin initiation and gradual replacement with PO/NMPO over time. Women were more likely to initiate with NMPO [relative risk ratio (RRR) 2.4; 95% confidence interval (CI) 1.1, 5.0], PO (RRR 2.2, 95% CI 1.1, 4.4) or multiple opioids (RRR 2.1, 95% CI 1.1, 4.2), than heroin. PWUO initiating with NMPO had significantly higher current benzodiazepine use, relative to those initiating with heroin (RRR 3.2, 95% CI 1.4, 7.4), and a high prevalence of current fentanyl use (30%). Discussion and Conclusions Our study highlights women and PWUO initiating with NMPO as key risk groups amid the changing landscape of opioid use and overdose, and discusses implications for targeted prevention and treatment.
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Background and aims: Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings. Design: Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework. Setting: Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. Participants: A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder. Measurements: Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. Findings: The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments. Conclusions: Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.