International Journal of Drug Policy

Opioid-related deaths are a national problem that have increased over the past two decades. Multiple policy interventions have been enacted to decrease opioid misuse and expand treatment. The Comprehensive Addiction and Recovery Act (CARA) was passed in July 2016, just before declaring the opioid epidemic a National Emergency in 2017. CARA was enacted to combat the opioid epidemic by providing more funding yearly for items including but not limited to prevention, treatment, and opioid overdose reversal. To evaluate the impact of these policy changes, we carried out secondary data analysis for the period 2011-2019 using the CDCs Wide-ranging Online Data for Epidemiologic Research and National Survey of Substance Abuse Treatment Services databases. Research variables included: a comparison of the 50 states across the 2011-2019 timeframe, the number of opioid treatment centers, the percentage of government funding for facilities per state, percentage of opioid treatment facilities which offer free/low-income services and the opioid death rate. We also assessed differences in low-income access to opioid treatment services by comparing Medicaid expansion states versus non-Medicaid expansion states. While both the number of treatment facilities per state and opioid death rates nearly doubled during this time, there was little to no association between them (R2 ranging from: 0.094-0.188 for years 2013-2019). Our research suggests that while state-level differences in opioid use disorder treatment facility characteristics related to access to care, they were only weakly associated with opioid-related deaths. This analysis may be used in the planning of subsequent actions against the national opioid epidemic and invites further inquiry into the impact of state Medicaid expansion on drug-specific opioid usage and mortality.

BackgroundXylazine is a veterinary tranquilizer found in the unregulated drug supply in the United States. It appears alone or as an adulterant in fentanyl ("tranq dope"). Xylazines symptomatology is well described and includes skin and soft tissue damage, bradycardia, and loss of consciousness. However, little is known about whether and how substance use behaviors have changed as xylazines presence in street drugs has grown. MethodsWe conducted semi-structured in-depth interviews with people with recent overdose reversal experiences in two mid-sized midwestern cities (n=52). Interviews were part of a larger study on naloxone administration behaviors. Participants were asked about their knowledge and perceptions of local drug supply trends. Transcript data were analyzed using the rigorous and accelerated data reduction technique. ResultsParticipants preferred fentanyl and heroin without xylazine. Most participants discussed adjusting opioid use toward safer practices: using less in amount or frequency, abstaining or seeking treatment, alternating use (e.g., ingesting xylazine only at night), or changing route of administration from injecting to smoking, snorting, or boofing (ingesting anally). Motivations for changes in use included not experiencing intended opioid agonist effects, fear of physical health risks, loss of functionality and productivity, and overdose concerns. ConclusionFindings suggest that xylazine is encouraging reduced fentanyl and heroin use. Our results corroborate laboratory, clinical, and behavioral studies showing that xylazine, which causes severe health harms, may also, paradoxically, be protective against fatal overdose. More research is needed on this phenomenon in light of recent downward trends in overdose mortality.

BackgroundThe large increase in opioid use, subsequent addiction and related death has come to be known as a national epidemic in the United States, particularly affecting rural areas. The crisis has been met with an increase in attempts to address the large overdose rates. In many of these strategies, first responders such as police and emergency services personnel are placed on the front lines. The input and opinions of these individuals, and the communication with them from agency leadership during program implementation can dramatically affect the success of drug related policies. However, there is a paucity of research focused on the attitudes of primary responders, particularly in rural settings. This study conducts a geographically-focused investigation into the attitudes of rural EMS and law enforcement personnel in regards to opioid treatment in a location that was currently implementing a major substance use policy. MethodsQualitative semi-structured interviews were conducted with 24 members of law enforcement and 22 emergency medical providers within a single rural county in North Carolina. Interviews spanned three sections: demographics, barriers to opioid treatment and county-specific programs. ResultsThe largest barriers to care cited were lack of local treatment resources, the stigma against drug use and a perception that people who use opioids did not want to change. A multi-agency approach to the crisis was supported by EMS personnel and law enforcement. However, first responders awareness of an active multiagency county-wide initiative was very limited. This was very surprising, as first responders were expected to implement the program, and this phenomena resulted in very low program efficacy to that point. This result underscored the importance of communication between and within agencies, particularly in environments that are resource-constrained. ConclusionsThis study is unique in comparing attitudes of rural EMS and law enforcement regarding substance use treatment. This paper provides insight into the viewpoints of rural first responders, with clear implications for rural drug policy. This paper further underscores opportunities for maximizing effective opioid policy in rural settings, particularly emphasizing clear communication between agencies.

BackgroundThe opioid overdose crisis is especially pronounced in Maine. The Diversion Alert Program (DAP) was developed to combat illicit drug use and prescription drug diversion by facilitating communication between law enforcement and healthcare providers with the goal of limiting drug-related harms and criminal behaviors. Our objectives in this report were to analyze 2014-2017 DAP for: 1) trends in drug arrests and, 2) differences in arrests by offense, demographics (sex and age) and by region. MethodsDrug charges (N = 8,193, 31.3% female, age = 33.1 {+/-} 9.9) reported to the DAP were examined by year, demographics, and location. ResultsThe most common substances of the 10,064 unique arrests reported were heroin (N = 2,203, 21.9%), crack/cocaine (N = 945, 16.8%), buprenorphine (N = 812, 8.1%), and oxycodone (N = 747, 7.4%). While the overall number of arrests reported to the DAP declined in 2017, the proportion of arrests involving opioids (heroin, buprenorphine, or fentanyl) and stimulants (cocaine/crack cocaine, or methamphetamine), increased (p < .05). Women had significantly increased involvement in arrests involving sedatives and miscellaneous pharmaceuticals (e.g. gabapentin) while men had an elevation in stimulant arrests. Heroin accounted for a lower percentage of arrests among individuals age > 60 (6.6%) relative to young-adults (18-29, 22.3%, p < .0001). Older-adults had significantly more arrests than younger-adults for oxycodone, hydrocodone, and marijuana. ConclusionHeroin had the most arrests from 2014-2017. Buprenorphine, fentanyl and crack/cocaine arrests increased appreciably suggesting that improved treatment is needed to prevent further nonmedical use and overdoses. The Diversion Alert Program provided a unique data source for research, a harm-reduction tool for health care providers, and an informational resource for law enforcement.

IntroductionThe purity, accessibility, and affordability of illicit methamphetamine has increased in recent decades, which has been linked to rising rates of methamphetamine-involved overdoses, psychosis, cardiovascular events, and other health consequences. Nevertheless, information about the quantity of methamphetamine used by regular consumers has been limited, despite the potential clinical utility of exposure quantification. MethodsFrom August 2024-April 2025, self-reported daily methamphetamine consumption was assessed among n=68 individuals. Methamphetamine samples (n=112) were analyzed for purity using liquid chromatography-mass spectrometry. Percent bioavailability by route of administration and stimulant equivalency were obtained from literature. A simulation model leveraging bootstrapping was used to estimate MOAE. ResultsThe average reported daily methamphetamine consumption was 0.96g (median 0.36g; range 0.1g-4.0g). Average purity was 71.6% (median 75.5%; range 0.1%-95.0%). Given estimated average bioavailability of 52.0% when smoked, 79.3% when insufflated, 67.2% orally or inserted rectally, and a 2:1 amphetamine-methamphetamine equivalency, the average consumer used 1,549.0 MOAE daily (median 516.6; range 1.3-10,112.0). DiscussionWe estimate that consumers of methamphetamine in Los Angeles use an average daily stimulant dose (>1,500 MOAE) that is 25-fold higher than the maximum typical recommended clinical dose of mixed amphetamine salts (60mg). This may help explain the limited efficacy of prescription stimulant treatment for methamphetamine use disorder, which typically employs considerably lower quantities. Given this high dose, these findings shed light on the rising incidence of methamphetamine-related sequalae, such as psychosis, cardiovascular complications, and sudden death. Although exposure quantification is commonplace for alcohol and tobacco use disorders, uncertainties in illicit drug markets has complicated this practice for most illicit drugs. This study supports leveraging emerging information from drug checking programs so that clinicians can approximate exposure quantification.

The opioid epidemic began more than two decades ago and continues to increase in severity with the rate of overdose death increasing steadily. The epidemic was born in problematic claims about opioids and aggressive prescribing. After initial analysis of the first decade of the epidemic it became clear that actions would need to be taken to curtail overprescribing and many states passed legislation tracking and limiting opioid prescribing. Since then opioid prescribing has declined, but overdose has continued to increase at an alarming rate. This analysis is focused on evaluating more recent trends in opioid prescribing and overdose to see if the close positive correlation that existed between these values prior to 2010 holds true for the following decade. My findings indicate that between 2013 and 2019 that there is no relationship, or possibly a negative relationship, between opioid prescribing and overdose. Between 2013 and 2019 there was a 25% decrease in opioid prescribing rate yet a 96% increase in opioid overdose deaths. The close relationship that existed between prescribing and overdose appears to have diverged to the point where overdose increases as prescribing decreases. Linear regression on both national and state data revealed a significant negative relationship between overdose and prescribing for national data between 2013 and 2019 (R2 value of 0.84 and a p-value of 0.003) and no relationship between overdose and prescribing for state data between 2014 and 2019 (R2 value of 0.04 and a p-value of < 0.001). This questions the value of further efforts to reduce prescribing in preventing overdose and supports the hypothesis that restriction of prescription opioids can contribute to increased use of dangerous illicit opioids.

BackgroundPeople who inject drugs (PWID) have high overdose risk. To assess the burden of drug overdose among PWID in light of opioid epidemic-associated increases in injection drug use (IDU), we estimated rates of non-fatal and fatal overdose among PWID living in Organization for Economic Cooperation and Development (OECD) countries using data from 2010 or later. MethodsPubMed, Psych Info, and Embase databases were systematically searched to identify peer-reviewed studies reporting prevalence or rates of recent (past 12 months) fatal or non-fatal overdose events among PWID in OECD countries. Data were extracted and meta-analyzed using random effects models to produce pooled non-fatal and fatal overdose rates. Results57 of 13,307 identified reports were included in the review, with 33/57 studies contributing unique data and included in the meta-analysis. Other (24/57) studies presented overlapping data to those included in meta-analysis. The rates of non-fatal and fatal overdose among PWID in OECD countries were 24.74 per 100 person years (PY) (95% CI: 19.86 - 30.83; n=28; I2=98.5%) and 0.61 per 100 PY (95% CI: 0.32 - 1.16; n=8; I2=93.4%), respectively. The rate of non-fatal overdose was 27.79 in North American countries, 25.71 in Canada, 28.59 in the U.S., and 21.44 in Australia. ConclusionThese findings suggest there is a fatal overdose for every 40 non-fatal overdose events among PWID in OECD countries. The magnitude of overdose burden estimated here underscores the need for expansion of overdose prevention and treatment programs and serves as a baseline estimate for monitoring success of such programs.

ObjectivesPeople experiencing homelessness are at increased risk for addiction, with substance use both a cause and response to homelessness. Street Medicine (SM) programs provide decentralized, low-barrier care to people experiencing homelessness and have begun to offer medication for opioid use disorder (MOUD). Literature on MOUD initiation via SM is nascent. This study investigated the impact of SM-initiated MOUD on ED utilization among people experiencing homelessness in a mid-sized US city. MethodsWe completed a retrospective medical record review of patients initiated on buprenorphine in 2023 by the SM program. Age, gender, prescription refill status, and emergency department (ED) utilization were recorded. Outcome measures were the number of overdose-related, opioid use disorder (OUD)-related, and all-cause ED visits in the 12 months before versus 12 months after buprenorphine initiation. ResultsIn the year prior to buprenorphine initiation, 115 patients had 221 cumulative ED visits, 79 of which were OUD-related. In the year following initiation, cumulative ED visits declined to 191, of which 44 were related to OUD (p<0.05). Overdose-related ED visits decreased from 26 to 13. In terms of prescription renewal, 44% of subjects renewed, 13% via SM and 31% via another provider. ConclusionsBuprenorphine initiation by a SM program was associated with a significant decline in OUD-related ED visits and insignificant reductions in overdose-related and total ED visits. These conclusions support SM-initiated buprenorphine as a strategy for reducing opioid-related ED utilization while encouraging sustained engagement in care. SM programs represent promising avenues to initiate buprenorphine and reduce OUD-related morbidity in the unhoused population.

Opioid use disorder (OUD) is a major public health concern in the United States (US), resulting in high rates of overdose and other negative outcomes. Methadone, a treatment for OUD, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analyzed the distribution of methadone for the treatment of OUD across the US using data from the Drug Enforcement Administrations Automated Reports and Consolidated Ordering System, Medicaids State Drug Utilization Data, and the US Census Bureau. Analysis revealed that methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020, and there was a significant increase in overall distribution of methadone to opioid treatment programs (OTP) in the US from 2010 to 2020 (+61.00%) and from 2015 to 2020 (+26.22%). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%). Furthermore, pronounced variation in methadone distribution among states were observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment and address the opioid overdose crisis in the US.

BackgroundIn a profound reversal of prior trends, U.S. drug overdose deaths declined by 26.9% in 2024. Two proposed explanations are: (1) expansion of prevention, treatment, and harm-reduction infrastructure and (2) changes in the illicit fentanyl supply. This study evaluated which hypothesis best aligns with observed changes in drug involvement in overdose mortality. MethodsCDC WONDER multiple-cause-of-death data for 2023 and 2024 were analyzed using complementary approaches. In a preliminary analysis, overdose deaths involving cocaine, methamphetamine, prescription opioids, heroin, and methadone were stratified by fentanyl involvement, and 2024/2023 mortality rate ratios were calculated. The primary analysis used a parsimonious 2x2 design (year x fentanyl involvement) to estimate differential mortality changes. A secondary analysis classified deaths into mutually exclusive strata defined by fentanyl, non-fentanyl opioid, and stimulant involvement, and estimated year-by-drug interaction effects using log-linear Poisson regression. ResultsBetween 2023 and 2024, fentanyl-involved deaths declined by 36.5%; non-fentanyl-involved deaths declined by only 5.3% (p < 0.001). Regression models identified a large year x fentanyl interaction (RR = 0.65), consistent with a fentanyl-specific decline. In contrast, non-fentanyl opioid-involved (RR = 1.04) and stimulant-involved deaths (RR = 1.03) exhibited small relative increases. ConclusionsThe 2023-2024 decline in overdose mortality was confined to fentanyl-involved deaths. These findings are most consistent with supply-side changes affecting fentanyl toxicity rather than more uniform effects of infrastructure expansion. Continued investment in prevention and surveillance, with attention to potential market adaptation toward highly potent synthetic opioids, remains essential.

BackgroundBetween 2017 and 2020, Ontario implemented overdose prevention sites (OPS) and consumption and treatment services (CTS) in nine of its 34 public health units (PHU). We tested for the effect of booth-hours (spaces within OPS/CTSs for supervised consumption) on opioid-related health service use and mortality rates at the provincial-(aggregate) and PHU-level. MethodsWe used monthly rates of all opioid-related emergency department (ED) visits, hospitalizations, and deaths between January 2015 and March 2021 as our three outcomes. For each PHU that implemented OPS/CTSs, we created a synthetic control as a weighted combination of unexposed PHUs. Our exposure was the time-varying rate of booth-hours provided. We estimated the population-level effects of the intervention on each outcome per treated/synthetic-control pair using controlled interrupted time series with segmented regression; and tested for the aggregate effect using a multiple baseline approach. We adjusted for time-varying provision of prescription opioids for pain management, opioid agonist treatment (OAT), and naloxone kits; and corrected for seasonality and autocorrelation. All rates were per 100,000 population. For sensitivity analysis, we restricted the post-implementation period to before COVID-19 public health measures were implemented (March 2020). ResultsOur aggregate analyses found no effect per booth-hour on ED visit (0.00, 95% CI: -0.01, 0.01; p-value=0.6684), hospitalization (0.00, 95% CI: 0.00, 0.00; p-value=0.9710) or deaths (0.00, 95% CI: 0.00, 0.00; p-value=0.2466). However, OAT reduced ED visits (-0.20, 95% CI: -0.35, -0.05; p-value=0.0103) and deaths (-0.04, 95% CI: -0.05, -0.03; p-value=<0.0001). Conversely, prescription opioids for pain management modestly increased deaths (0.0008, 95% CI: 0.0002, 0.0015; p-value=0.0157) per 100,000 population, respectively. Except for a few treated PHU/synthetic control pairs, disaggregate results were congruent with overall findings. ConclusionBooth-hours had no population-level effect on opioid-related overdose ED visit, hospitalization, or death rates.

AimsTo characterize decreases in overdose mortality in the United States between 2023 and 2024 by substance involvement, geography, race/ethnicity, demographic, and other key dimensions. DesignPopulation-based study of national death records. SettingUnited States. Participants/casesAll individuals who died from drug overdose between January 1999 and December 2024. MeasurementsAnnual or monthly (annualized) overdose deaths per 100,000 population. Year and month of occurrence of overdose death; substance involvement; census region and division; state; county; race/ethnicity, age, and sex. FindingsAfter over two decades of mostly exponential increases, monthly data show consistent decreases in overdose deaths between June 2023 and December 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulants); however, increasing trends through 2024 were still seen in deaths involving stimulants without fentanyl, and those involving xylazine. Death rates in the Northeast, South and Midwest fell to 19.5, 19.4 and 17.3 per 100,000, respectively, in December 2024, but remained elevated in the West, compared with other regions, at 27.2 per 100,000. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024 falling 29.3%, but remained elevated at 36.0 per 100,000, compared to the national average of 23.7 per 100,000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose mortality rate in 2024, at 50.8 per 100,000. ConclusionsRecent decreases in overdose deaths are encouraging and unprecedented. Racial gaps remained large but shrunk by a modest margin. The geography of the overdose crisis has shifted, with the West now the most affected region, which may have implications for the targeting of funding. The nature of the crisis is also shifting, as stimulants and xylazine continue to represent increasingly important public health challenges, and renewed attention to nonfatal aspects of addiction in the US is needed.

BackgroundThe opioid epidemic remains an emergent health issue in the United States, as opioid-related deaths continue to rise in the second year of COVID-19. The introduction of synthetic opioids into the illicit supply began causing deaths in 2015, however, data describing the illicit opioid supply is scarce. MethodsWe used a newly available national dataset of drug seizure reports, aggregated from law enforcement agencies across the United States, to describe changes in fentanyl, heroin, and other opioid presence in the national illicit supply from 2011-2017, by state and geographic region. We assessed the relationship between drug seizures and opioid-related deaths at the state level using linear regression. ResultsNational and state increases in opioid seizure rates from 2011-2017 were entirely due to increased fentanyl and heroin seizures, as other opioid seizure rates remained constant. Most increases in seizures occurred in the Northeast, Midwest, and Appalachia, where fentanyl seizures and heroin seizures were highest and increased most sharply along with opioid deaths. The composition of drugs seized was similar within geographic regions, but did vary across regions. State opioid seizures of all types were strongly associated with state opioid deaths. The strongest relationship was between fentanyl seizures and fentanyl deaths. ConclusionsThe association between opioid seizures and deaths means seizure data has potential as an early-warning system to predict overdose, although national level data requires quality improvement. Regional variation in seizure rates supports existing evidence that illicit fentanyl and heroin supplies differ between regions, producing distinct regional risk environments, causing varying mortality rates.

In 2017, the Acting U. S. Secretary of Health and Human Services declared the "opioid crisis" a nation-wide health emergency. However, the crisiss geography was not nation-wide. Many counties and towns had no overdose deaths, whereas others were home to hundreds. According to many influential research reports and news stories, geographic variation in overdose deaths was due to geographic variation in opioid prescription rates and/or geographic variation in socioeconomic factors, such as unemployment. Our goal was to test the degree to which prescription rates and socioeconomic correlates of income inequality predicted overdose deaths in the 1055 U.S. Midwest ("Heartland") counties over the years 2006 to 2020. We used multilevel regression models to gauge the predictive strength of overdose rates and six socioeconomic measures that are correlated with income inequality. There were significant state-level and county-level differences. Intergenerational income mobility was the strongest predictor of overdose deaths, with regression coefficients that averaged about twice as large as the coefficients for opioid prescription rates. Every year, counties with greater upward intergenerational income mobility had lower overdose death rates. Social capital had the second largest regression coefficients, albeit by a small margin. Counties are the smallest demographic unit for which drug overdose rates are available; the results of this study link growing income inequality and drug overdose deaths at the county level.

Background and objectiveCannabis use during adolescence is common. Cannabis use and identity are thought to influence one another. This study aimed to examine what London-based adolescents (aged 16-17 years) think about cannabis use, its relationships with identity, and its benefits and harms. MethodThree semi-structured focus groups interviews were conducted, two with adolescents who use cannabis (n=3 and n=5) and one with adolescents who do not use cannabis (n=6). Participants also completed a drug-use questionnaire. ResultsThematic analysis (TA) revealed four identities. Two identities emerged from both groups: The person who uses cannabis is chilled and The person who uses cannabis is sometimes ostracised. Two identities emerged from the group of adolescents who used cannabis: The person who uses cannabis is an expert in risky things and The person who uses cannabis is not addicted. Skunk was identified as potentially more harmful than hash, but more powerful and pleasurable. ConclusionThe findings provide insight into how cannabis use shape personal and social identity amongst teenagers in London in the late 2010s. Those who use cannabis described the benefits of cannabis, including socialising and for relaxation, and emphasised they are not addicted. Stigmatising and devaluing attitudes were held by some non-users about adolescents who use cannabis. Stereotypes seem to still exist, despite cannabis normalisation. Implications for research and policy are outlined.

Recent years have shown increases in overdose (OD) mortality caused by polydrug exposure to synthetic opioids such as fentanyl and stimulants such as methamphetamine or cocaine. The goal of this study is to understand the recent trajectory in this polydrug OD mortality, especially associated with decedents sex and age. We carried out a cross-sectional analysis of national data for persons aged 15-74, from CDC WONDER for 2018-2024 (data for 2024 are considered provisional at the time of analysis). The outcome measure was OD mortality/100,000 population; annual data for 2018-2024 were analyzed with joinpoint regression, and the most recent years (2023-2024) were analyzed with ANOVA and multiple linear regression. Males had greater polydrug OD mortality compared to females, across 2018-2024. Sex-specific joinpoint regressions detected increases in polydrug OD after 2018, then decreases from 2023 in males, and from 2022 in females. For these polydrug OD, the mean annual percent change (APC) in 2024 versus 2023 was -36% and -31% in males and females, respectively. For synthetic opioids without stimulants, OD trends in 2024 versus 2023 were similar to those for polydrug OD (-42% and -39% APC in males and females, respectively). However, OD for stimulants without synthetic opioids showed relatively smaller changes (-3% and -2% APC in males and females, respectively). Stratification into 10-year age groups for polydrug OD revealed that mortality peaked at age 35-44 and then declined at older ages. Recent decreases in polydrug OD mortality were observed across age groups, with joinpoints detected in 2022 or 2023. These findings indicate that after increases from 2018 onward, polydrug OD mortality caused by synthetic opioids and stimulants exhibited substantial decreases in both males and females in the most recent data for 2024, across a broad age range. Because relatively small changes were observed in OD mortality caused by stimulants without synthetic opioids in this time period, the decreases in polydrug OD mortality are more likely to be caused by changes in exposure, prevention or intervention strategies focused on opioids rather than on stimulants. While this polydrug OD mortality has decreased in 2024, it remains at concerning levels.

IntroductionThe market shift from heroin to illicitly-manufactured-fentanyl in North America led to surging rates of opioid overdose and mortality. However, limited detailed information exists about the dose of fentanyl regularly consumed by individuals with opioid use disorder. We examined purity of fentanyl samples and estimate the typical daily oral milligrams of morphine equivalent (MME) consumed. MethodsLeveraging community-based drug checking data from Los Angeles, we ascertained the purity of 384 samples of fentanyl collected between September 2023 and July 2025 using liquid chromatography mass spectrometry. We assessed typical consumption quantity and routes of administration among 31 respondents who reported regularly using fentanyl. We drew bioavailability estimates and approximate MME conversion factors from literature. To estimate daily MME consumed, and incorporate uncertainty from all parameters, we used a bootstrapping model with 10,000 draws. ResultsAmong participants, the median daily consumption of fentanyl was 1.0 grams (1000 milligrams). Illicit fentanyl products had a median fentanyl purity of 9.4%., and the median estimated bioavailability based on routes of administration was 72.3%. Using a median IV fentanyl to PO morphine conversion factor of 1:182, the median estimated daily consumption in our sample was 10,933 MME (IQR 25,272 MME). ConclusionsWe estimate that individuals consuming illicit fentanyl in Los Angeles use quantities of opioids that are several orders of magnitude higher than clinical guidelines or typical methadone doses. This undoubtedly contributes to high overdose mortality rates and reflects a high tolerance among individuals with OUD. It also likely undermines the success of medications for OUD at conventional doses.

BackgroundThe COVID-19 pandemic strained healthcare facilities and the isolation and uncertainty associated with the pandemic compromised mental health around the world. The pandemic has also been associated with an exacerbation of the opioid crisis in the United States (US), and previous studies have reported changing trends in opioid misuse during the pandemic. Our study investigated naltrexone, a prescription drug used to treat alcohol and opioid use disorders by blocking opioid receptors to reduce cravings. We sought to investigate the changes in naltrexone prescriptions issued to Medicaid enrollees in light of the COVID-19 pandemic. MethodsThe total number of naltrexone, generic and brand name, prescriptions across the US were obtained from the Medicaid.gov database, expressed as prescriptions per state corrected for the number of enrollees, and organized into two time periods - the pre-pandemic period from January 2019 to December 2019 and the pandemic period from January 2020 to March 2021. Statistical analyses included a paired t-test, a heat map to depict state level variation, and waterfall figures. Procedures were approved by the IRB of Geisinger. ResultsThere were increases in total naltrexone prescriptions throughout the time frame studied, but a decrease in prescriptions per 100,000 Medicaid enrollees. A paired t-test revealed a significant decrease in naltrexone prescriptions during the pandemic period. There was a 398-fold difference between the highest and lowest states in 2019 Quarter 1 and 424-fold in 2021 Quarter 1. Percent change calculations indicated South Dakota (+141%) and Oregon (+172%) showed a significant increase in total naltrexone prescriptions from pre-pandemic to post-pandemic from the national mean (-23.57%+5.60%). ConclusionsThe results of this study were significant and indicated a relationship between the COVID-19 pandemic and declining naltrexone prescription rates. Naltrexone prescriptions per 100,000 enrollees decreased in most states during the pandemic and fell by over 32% nationally from 2019 to 2021 despite a slight increase in total prescription numbers and an increase in Medicaid enrollees. These data suggest wide variation in access to substance use disorder treatment during the pandemic. Further research with privately insured patients may be beneficial.

BackgroundThe variation in purity of illicitly manufactured fentanyl has been theorized to be a key driver of overdose. However, data on the purity of illicitly manufactured fentanyl in the United States typically comes from law enforcement seizures and is rarely available at the consumer-level, which is most relevant to overdose risk. MethodsSamples were analyzed from a community-based drug checking program operating at four geographic sites in Los Angeles County, California 2023 Q1 to 2025 Q2. Participants answered an anonymous survey about sample characteristics. Qualitative and quantitative analyses were conducted leveraging directly-observed mass spectrometry (DART-MS) and Liquid chromatography mass spectrometry (LC/MS) respectively. LC/MS quantified a panel of compounds including fentanyl and fluorofentanyl. Composite fentanyl purity was estimated by adding the percent mass of fentanyl and fluorofentanyl. ResultsA total of 353 samples had either fentanyl, fluorofentanyl, or both, quantified. Average purity was 10.0%, SD 11.1%, range 0.1%-64.9%. Samples expected to be fentanyl (n=308) had higher average purity (10.9%) compared to those expected to be heroin (n=24, average purity=2.7%) or other drugs. Powder samples (n=318) had higher average concentration (10.8%) compared to pills (n=11, 1.4%) or tar (n=22, 3.2%). Of expected-fentanyl samples, 42.5% (n=117) had a fentanyl purity of less than 5%, while 17.5% (n=51) had purity over 20%. ConclusionsWe found high variation in fentanyl purity among consumer-level samples sold as fentanyl, which may explain overdose among people with opioid tolerance. Fentanyl concentration was lower among samples sold as heroin, other drugs, or in pill form, and was particularly low among expected non-opioid drugs.

In Wisconsin, opioid use disorder (OUD) is highly prevalent among individuals impacted by the criminal justice system. Medications for opioid use disorder (MOUD), including injectable naltrexone, are crucial for treating OUD and especially important for individuals transitioning out of correctional facilities and back into the community. Unfortunately, few formerly incarcerated individuals are able to access MOUD upon community reentry, remaining at high risk of overdose and rearrest. Community pharmacists are a promising resource for providing injectable naltrexone to formerly incarcerated individuals using this treatment option, but are underutilized during reentry planning and by formerly incarcerated individuals upon release. This is due, in large part, to several barriers that exist across the socioecological scale. Accordingly, this study utilized a participatory design process to inform an intervention that address these barriers and improves access to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals upon community reentry. Three iterative focus groups were conducted with five community pharmacists who have experience providing injectable naltrexone and treating formerly incarcerated patients. The goals of each focus group were to: 1) discuss perceptions of existing barriers and prioritize barriers to be addressed, 2) discuss and rank potential interventions to address the prioritized barriers, and 3) discuss components and anticipated challenges related to the prioritized intervention. Focus groups were analyzed via deductive content analysis using a priori categories. Based on discussions of perceived impact and feasibility, the participants prioritized two barriers to be addressed: lack of awareness of community pharmacist-provided injectable naltrexone services and lack of interagency collaboration among primary care clinics, community pharmacies, and correctional facilities. The final intervention included pharmacist-led educational meetings with correctional providers and reentry staff. Several intervention components and anticipated challenges were also identified. Next steps include developing, implementing, and evaluating the efficacy of the intervention on improving access to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals.