International Journal of Drug Policy

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.

ObjectiveThis study investigated associations between social determinants of health (SDoH) and time to MOUD initiation across care settings, providing insights for targeted interventions to promote equitable care for OUD patients. Material and MethodsWe linked patient-level electronic health records (EHRs) from a regional integrated health system with census-tract-level SDoH from the Population Level Analysis and Community Estimates (PLACES) database. The study cohort included patients newly diagnosed with OUD (including overdose) between 2000 and 2024. We assessed temporal trends in newly diagnosed OUD cases and MOUD prescriptions, mapped the spatial correlation between OUD cases and the Area Deprivation Index, and used multivariable regression models to quantify associations between SDoH and MOUD initiation, adjusting for demographics, insurance type, and comorbidities. Analyses were stratified by care setting (emergency department, inpatient, and outpatient) to examine setting-specific associations. ResultsDuring 2000-2024, 51,521 patients with OUD or opioid overdose, among whom 14,858 (28.8%) received MOUD. OUD diagnoses peaked at 3,787 cases in 2017, then declined by 42.1% to 2,191 cases in 2024. MOUD initiation, especially buprenorphine, steadily increased throughout the study period. Geospatial analyses revealed more OUD cases in high-ADI neighborhoods. In multivariate analyses, older age and Black or African American race were associated with slower MOUD initiation. In the stratified analyses by care setting, significant associations between SDoH and MOUD initiation were primarily observed in the outpatient setting, though effect sizes were modest. ConclusionsIntegrating neighborhood-level SDoH with EHRs can uncover care-setting-specific disparities in treatment initiation and identify neighborhoods with unmet treatment needs.

Background: Drug checking services (DCS) promote drug supply awareness among people who use drugs (PWUD) by detecting adulterants such as fentanyl and xylazine that are associated with overdose morbidity and mortality. However, there is limited research on DCS implementation in Latin America (LA). Methods: We conducted a survey of 38 DCS across LA (n=10) and the US (n=28) and compared program characteristics and barriers between these two regions. We also conducted a focus group discussion (FGD) with staff representing six organizations implementing DCS in LA. FGD themes were mapped to constructs quantitatively assessed in the survey. Results: Compared to US DCS, LA DCS more frequently reported funding gaps as a major implementation barrier (80% vs. 54%), law enforcement confiscating DCS supplies (38% vs. 11%), as well as offering supervised drug consumption (30% vs. 4%) and mental health/counseling (40% vs. 18%), but less frequently reported that DCS equipment was legal (44% vs. 75%). DCS on the Mexico-US border focused on people who inject drugs and offered syringe services, supervised consumption, and rapid sexually transmitted infection testing. DCS in central Mexico, Colombia, Peru, and Chile primarily provided DCS for the nightlife community (e.g., attendees of concerts/raves). Barriers to DCS implementation cited by FGD discussants included inadequate funding, DCS legal ambiguities, lack of government support, and cartel violence. Conclusion: DCS in LA would benefit from increased funding, government support, and a more permissive legal environment, thereby strengthening harm reduction efforts and improving safety for PWUD. Keywords: drug checking services; harm reduction; overdose; people who use drugs; Latin America; fentanyl; tusi

BackgroundRecreational cannabis legalization has expanded rapidly across US states. The regulatory approaches states adopt vary widely, with varying implications for public health. This study aimed to characterize heterogeneity in recreational cannabis laws (RCLs) across US states and to identify state-level characteristics associated with these regulatory models. MethodsWe conducted Latent Class Analysis (LCA) of state-year RCL provisions from 2013 to 2024 (n=612) to identify distinct RCL approaches. Descriptive analyses and exploratory multinomial regression analyses were used to examine correlations between state characteristics and RCL approaches from 2020 to 2024, when sufficient cross-state variation in RCL adoption was available. Eleven recreational cannabis policy provisions spanning governance, potency limits, consumption restrictions, access controls, taxation, marketing regulations, and driving prohibitions are primarily from the Alcohol Policy Information System. State-level characteristics included cannabis use prevalence, market conditions, medical cannabis history, political factors, demographic, and socioeconomic covariates obtained from multiple secondary data sources. ResultsWe identified four latent classes of state-year RCL provisions representing different regulatory approaches: No RCL, Pre-commercial, Full Access, and Dispensary Access. The No RCL corresponded to state-years without RCL. The Pre-commercial class represented state-years in early-stage legalization with a minimal regulated approach in terms of commercial infrastructure. The Full Access class was characterized by permitting on-site retail consumption and home delivery and restricting (but not prohibiting) public use. In contrast, the Dispensary Access class limited retail sales to off-site consumption only, prohibited public use, and imposed stricter market controls. Higher past-month cannabis use prevalence was associated with a greater likelihood of membership in the Full Access class (RRR = 1.78; 95% CI: 1.21-2.62), relative to No RCL. A longer duration since medical cannabis legalization was associated with a higher likelihood of membership in the Dispensary access class (RRR = 1.47; 95% CI: 1.02-2.12). Higher beer excise taxes were associated with a lower likelihood of membership in any RCL class relative to No RCL. ConclusionsFrom 2013 to 2024, US recreational cannabis regulations clustered into four distinct regulatory approaches, with two distinct commercial models: one permitting on-site retail consumption and home delivery, the other restricting sales to off-premises only and prohibiting public use. Higher cannabis use prevalence and longer medical cannabis history were associated with more access-oriented and more restrictive commercial approaches, respectively.

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.

BackgroundThe COVID-19 pandemic amplified the risk environment for people who inject drugs (PWID), making continued access to harm reduction services imperative. Research has shown that some harm reduction service providers were able to continue to provide services throughout the pandemic. Most of these studies, however, focused on staff perspectives, not those of PWID. Our study examines changes in perceptions of access to harm reduction services among PWID participating in a longitudinal study conducted through the University of Illinois-Chicagos Community Outreach Intervention Project field sites during the COVID-19 pandemic. MethodsResponses to a COVID-19 module added to the parent study survey that assessed the impact of COVID-19 on PWID participating in an ongoing longitudinal study were analyzed to understand how study participants self-reported access to harm reduction services changed throughout the pandemic. Mixed effects logistic regression was used to examine difficulty in syringe access as an outcome of COVID-19 phase. ResultsMost participants reported that access to syringes and naloxone remained the same as prior to the pandemic. Participants had significantly higher odds of reporting difficulty in accessing syringes earlier in the pandemic. ConclusionsThe lack of perceived changes in harm reduction access by PWID and the decrease in those reporting difficulty accessing syringes as the pandemic progressed suggests the efficacy of adaptations to harm reduction service provision (e.g., window and mobile service) during the pandemic. Further research is needed to understand how the COVID-19 pandemic may have impacted PWIDs engagement with harm reduction services.

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.

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.

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.

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.

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.

The Centers for Disease Control and Prevention reported 70 630 drug overdose deaths for 2019 in the United States, 70.5% of which were opioid-related. Preliminary estimates now warn that drug overdose deaths likely surpassed 86 000 during 2020. Despite a 57.4% decrease in opioid prescribing since a peak in 2012, the opioid death rate has increased 105.8% through 2019, as the share of those deaths involving fentanyl increased from 16.4% to 72.9%. This letter seeks to determine whether the opioid prescribing and mortality paradox is robust to accepted methods of causal policy analysis and if prescribing rates mediate the effects of policy interventions on overdose deaths. Using loge-loge ordinary least squares with three different specifications as sensitivity analyses for all 50 states and Washington, DC for the period 2001-2019, the elasticities from the regressions with all control variables report operational prescription drug monitoring programs (PDMPs) reduce prescribing rates 8.7%, while mandatory PDMPs increase death rates from opioids 16.6%, heroin and fentanyl 19.0%, cocaine 17.3% and all drugs 10.5%. There is also weak evidence that recreational marijuana laws reduce prescribing, increases in prescribing increase pain reliever deaths, pill mill laws increase cocaine deaths, and medical marijuana laws increase total overdose deaths, with demographic variables suggesting states with more male, less non-Hispanic white, and older citizens experience more overdoses. Weak mediation effects were observed for pain reliever, cocaine, and illicit opioid deaths, while broad reductions in prescribing have failed to reduce opioid overdoses.

ImportanceManual inpatient screening for substance misuse is labor-intensive and inconsistently applied. Evaluation of artificial intelligence (AI)-assisted screening during clinical implementation is needed to determine clinical and economic performance. ObjectiveTo assess whether an AI-based screening program with the Substance Misuse Algorithm for Referral to Treatment Using Artificial Intelligence (SMART-AI) maintained delivery of addiction-related services compared with manual screening and to evaluate readmissions and costs. Design, Setting, and ParticipantsProspective, quasi-experimental pre-post study at a large academic medical center in Chicago, Illinois between 2022 and 2025. The pre-implementation period (manual screening) included 31,432 hospitalizations, and the post-implementation period with AI augmentation (SMART-AI) included 33,564. Interventions/ExposuresDuring the post-implementation period, SMART-AI screened clinical documentation within 24 hours of admission to identify patients at-risk for a substance use disorder and notified the Substance Use Intervention Team. In the pre-implementation period, screening relied on manual processes, with nurses and social workers screening with standardized questionnaires. Main Outcomes and MeasuresThe primary outcome was receipt of [&ge;]1 addiction-related service (initiation or adjustment of medication for alcohol or opioid use disorder; brief intervention/motivational interviewing; naloxone dispensing; or a completed addiction medicine consultation). The prespecified noninferiority margin was -0.5 percentage points (1-sided = 0.025). Secondary outcomes included 6-month readmission, discharge against medical advice, and program costs. ResultsAddiction-related services were received in 1,189 of 31,432 hospitalizations (3.8%) during manual screening and 1,144 of 33,564 (3.4%) during SMART-AI (difference, -0.4 percentage points; 95% CI, -0.7 to -0.1; P = 0.20). The lower limit of the confidence interval was below the noninferiority margin, so noninferiority was not achieved. Six-month readmissions across all hospitalizations occurred in 9,586 patients (30.5%) in the manual period and 10,244 patients (30.5%) in the SMART-AI period (P = 0.95), and discharge against medical advice did not differ (1.3% v. 1.1%). Among patients who received a SUIT intervention (n = 2,296), 6-month readmission occurred in 41.3% (485/1,175) during usual care versus 37.0% (415/1,121) during SMART-AI (odds ratio: 0.86, 95% CI: 0.73-1.03, p=0.10). Program costs over a 1-year period were $6,166.71 lower after SMART-AI automation. Conclusions and RelevanceAI-assisted screening did not meet the prespecified non-inferiority criterion for maintaining service delivery, but it was associated with maintaining secondary outcomes among patients screened for substance use disorder with lower program costs. Findings support the feasibility and potential value of automated screening at scale. Trial RegistrationClinicalTrials.gov Identifier NCT03833804

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.

The public health impact of vaping in the United States reflects a complex balance of potential benefits and emerging risks. While e-cigarettes can substantially reduce exposure to toxic combustion byproducts and may aid in smoking cessation for adult tobacco users, evidence links e-cigarette use to respiratory and cardiovascular injury, raising concerns about long-term health outcomes in vapers. Unfortunately, vaping has become deeply entrenched among youth. In 2024, 38.4% of adolescent e-cigarette users reported habitual vaping patterns, underscoring persistent nicotine dependence within this vulnerable population. This escalating youth uptake underscores the urgent need for comprehensive, evidence-based policies that simultaneously advance cessation support for adults and enable robust prevention strategies for adolescents. Thus, to inform the optimal use of predictive technologies in vaping cessation efforts, we conducted a social-media-based survey targeting young adult vapers. Our aims were to (1) characterize cessation-related behaviors and attitudes and (2) evaluate machine learning and XAI methods for predicting quit attempts and successes within this population In our study, we employed both forward selection and backward elimination techniques to identify key predictors of successful vaping cessation. The dataset was partitioned into training (70%) and testing (30%) subsets to facilitate model development and evaluation. We applied a range of machine learning algorithms to the training data and subsequently validated their performance on the test set. For linear modeling, we utilized least absolute shrinkage and selection operator (LASSO), ridge regression, and elastic net. In addition, we incorporated non-linear approaches including random forest (RF) and support vector machine (SVM) to capture more complex relationships within the data. We assessed the model performance through C-Statistics/ area under the curve (AUC). Further we validated the performance through Brier Scores. Among the models evaluated, linear approaches demonstrated superior overall performance, with non-linear models such as random forest (RF) and support vector machine (SVM) exhibiting strong predictive accuracy on the training data. LASSO regression yielded robust results, with area under the curve (AUC) values of 0.89 for the training set and 0.91 for the test set. Ridge regression followed closely, achieving AUCs of 0.88 and 0.93, respectively. Elastic net regression performed consistently across both datasets, with an AUC of 0.91 in training and testing. Key predictors of successful vaping cessation included age, environmental triggers, vaping frequency, sex, and long-term behavioral outlook. Age emerged as a particularly influential factor, with individuals under 25 exhibiting increased vulnerability--likely due to neurodevelopmental sensitivity and elevated usage rates. Environmental cues, especially social exposure, were strongly associated with relapse risk, highlighting the importance of trigger management in cessation strategies. Interestingly, vaping frequency served as a counterintuitive indicator: erratic usage patterns correlated with lower cessation success, suggesting that consistent use may reflect a greater readiness for behavioral change. Sex-based differences were also notable, with males demonstrating more intense withdrawal symptoms and higher consumption levels, underscoring the need for gender-responsive interventions. These findings underscore the utility of machine learning in uncovering nuanced behavioral and contextual determinants of addiction and cessation outcomes, offering valuable insights for the design of targeted public health interventions.

IntroductionMedical cannabis use is increasing worldwide, and information about its use could aid clinicians in decision making. A Prescription Drug Monitoring Program (PDMP) is an electronic database designed to track controlled substance (CII-CV) prescriptions; the use evolved to support patient care. We analyzed the perceived impact of cannabis information in the PDMP within an integrated health system in Pennsylvania and state PDMP policies around cannabis. MethodsWe conducted a sub-analysis of 50 semi-structured interview transcripts. Interviews were conducted March-July 2023 with a multidisciplinary group of clinicians and administrators to understand cannabis use documentation. Twenty-four participants were asked if cannabis in the PDMP would impact their work. Additionally, we asked PDMP administrators of 50 US states and the District of Columbia (D.C.) if cannabis is in their PDMP. If yes, we inquired about software, timeframe, and data sharing. ResultsAlmost two-thirds of 26 participants (N = 17, 65.4%) believed cannabis in the PDMP would positively impact patient care. Fifty states and D.C. replied to our survey. Six states (i.e., CT, LA, NY, OH, MS, and VA) have medical cannabis dispensations. Four states (i.e., AZ, IL, ND, and UT) have a medical cannabis card indicator in the PDMP. Conclusions: Participants perceive medical cannabis in the PDMP could enhance clinical decisions, but inclusion requires policy changes in 40 states and D.C. Rescheduling of cannabis could accelerate adoption of medical cannabis into the PDMP. The PDMP is an underutilized tool that could provide crucial information to clinicians, but substantial policy changes are necessary. HighlightsO_LIUnrecognized drug interactions with cannabis can be harmful C_LIO_LIMinimal research exists on the impact on patient care with cannabis in the PDMP C_LIO_LIThis research offers an examination of state legislation to patient care C_LIO_LIClinicians suggest medical cannabis in the PDMP could benefit patient care C_LI O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=85 SRC="FIGDIR/small/25332003v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): org.highwire.dtl.DTLVardef@44ebdorg.highwire.dtl.DTLVardef@cd6dcaorg.highwire.dtl.DTLVardef@e31c79org.highwire.dtl.DTLVardef@6282c1_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOGraphical AbstractC_FLOATNO Themes from clinician interviews and heat map showing the ten states that have medical cannabis in their Prescription Drug Monitoring Program (PDMP) along with the characteristics of other states. Cannabidiol: CBD; Kansas: KS: Idaho: ID; Tetrahydrocannabinol: THC. C_FIG

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.

IntroductionScreening, Brief Interventions and Referral to Treatment (SBIRT) programs reduce unhealthy alcohol use among adolescents. However, self-report screening alone may lead to false negatives and low service use, especially in HIV care settings. This study explored the contextual implementation factors and strategies of an alcohol biomarker-augmented SBIRT program for HIV-affected adolescents in Zambia, where alcohol use and HIV prevalence are high. MethodsWe conducted key informant interviews (n=7) with mental health providers and policymakers and focus groups (n=16 groups; 10-11 participants each) with healthcare providers, adolescents, and caregivers, guided by a case vignette of the biomarker-augmented SBIRT program. Thematic analysis followed the implementation frameworks Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Practical, Robust Implementation and Sustainability Model (PRISM). ResultsParticipants perceived the SBIRT program as appropriate for adolescent alcohol use. Key contextual factors included: lack of alcohol treatment programs, community stigma against HIV and alcohol use, and robust implementation infrastructure through HIV healthcare. Strategies to enhance acceptability included making alcohol screening universal to avoid labeling adolescents, privacy and confidentiality during biomarker sampling, and peer-led age-matched counseling at screening. To enhance reach, participants suggested designing the program with attention to gender-specific needs and integrating it into HIV healthcare and alcohol use hotspots (e.g. schools). ConclusionsImplementation strategies should be designed to reduce stigma, build trust, engage adolescents across genders, and reach youth through clinical and community channels. Future research should define how to select, train, and evaluate peer counselors and assess the effectiveness of alcohol biomarkers within SBIRT programs in motivating behavior change.

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.

BACKGROUNDThis study evaluates the reach, scalability, and implementation of a large-scale, multi-site tele-buprenorphine program designed to treat opioid use disorder (OUD) within rural carceral settings. Given that individuals transition frequently between jails and the community, these facilities represent a critical window for OUD intervention, yet they often face significant provider shortages and logistical barriers. We conducted a retrospective chart review of 842 unique patients (1,321 treatment episodes) enrolled in the University of Marylands tele-buprenorphine program across six rural county jails between June 2020 and May 2025. Data extracted from jail records and electronic health records were used to analyze patient demographics, prescribing patterns, and program retention. RESULTSThe patient population was primarily male (71.1%) and White (75.7%), with a mean age of 35.4 years. Participants reported high-severity OUD, with an average of 12.6 years of opioid use. Reflecting broad admission criteria, 55.2% of participants were new treatment initiates not receiving MOUD prior to booking. Patients spent a mean of 35.6 days incarcerated before initiation and were retained in the program for an average of 66 days. Buprenorphine doses were titrated from a mean initiation dose of 8.8 mg to 16.2 mg at discharge. The program demonstrated a 99.5% adherence rate among retained patients. Only 3% of the total sample were discharged for medication diversion or hoarding. CONCLUSIONSTelemedicine is a highly feasible and scalable model for delivering evidence-based MOUD in rural jails. By utilizing a "liberal admission policy" that prioritizes both treatment initiation and maintenance, programs can successfully reach high-risk individuals who lack access to community-based care. These findings suggest that tele-buprenorphine can effectively bridge the treatment gap in underserved jurisdictions, potentially reducing the risk of overdose during the high-risk post-release period.