International Journal of Drug Policy

BackgroundOpioid overdose mortality in the United States remains a severe public health crisis, with the burden distributed unequally across communities that differ in epidemic trajectory, baseline resources, and local context. While harm reduction through naloxone distribution and treatment through buprenorphine are both evidence-based strategies, how their effectiveness varies across county-level contexts has received limited quantitative study, limiting the ability of local policymakers to prioritize resources across counties. MethodsWe developed a simulation model of opioid use disorder (OUD) progression, calibrated separately to three Pennsylvania counties spanning large urban (Allegheny), mid-sized (Erie), and rural (Clearfield) settings using Bayesian calibration. We projected county-specific overdose mortality trajectories under three levels of proportional increase in dispensing rates of buprenorphine and naloxone (10%, 20%, and 30% above each countys observed baseline dispensing levels), over a 2025-2029 projection horizon. ResultsA 30% increase in naloxone dispensing above observed county baseline levels was projected to reduce cumulative overdose deaths over 2025-2029 by approximately 50% in Allegheny County (large urban), modestly in Erie County (mid-sized), and only slightly in Clearfield County (rural). Projected reductions were consistently smaller for buprenorphine across all three counties, except in Erie, where buprenorphine produced larger projected reductions than the other counties. Heterogeneity in naloxone responsiveness was strongly associated with each countys historical naloxone dispensing variability. ConclusionsThe same proportional increase in naloxone dispensing yields substantially different projected mortality reductions across counties depending on each countys baseline distribution history, a pattern invisible from mortality statistics alone. County-level context must inform harm reduction and treatment prioritization rather than uniform, population-proportional approaches.

BackgroundDrug 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). MethodsWe 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. ResultsCompared 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. ConclusionDCS 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.

BackgroundOpioid-related mortality in Texas has escalated dramatically, increasingly driven by illicitly manufactured fentanyl. To address local surges in mortality, the Galveston County Health District deployed the Galveston County Opioid Defense Effort (GCODE) in July 2023, leveraging digitally integrated surveillance data from emergency medical services (EMS) and the Medical Examiner to provide targeted naloxone distribution in identified overdose hot spots. MethodsUsing a segmented interrupted time series (ITS) design and Poisson regression with robust standard errors, we evaluated the population-level impact of GCODE on opioid-involved mortality through the end of 2025. Data were sourced from the Galveston Area Ambulance Authority (GAAA) and vital statistics (ICD-10 codes). We assessed mortality trajectory changes, the observed fatality ratio among EMS-detected opioid events (the "Survival Gap"), and demographic and geographic covariates. ResultsThe Poisson ITS model included 519 weekly observations (N = 14,827 tract-weeks across 101 census tracts). Pre-intervention, opioid mortality increased by 0.16% weekly (IRR = 1.0016; 95% CI: 1.000-1.003; p = 0.011). Following GCODE deployment, the mortality trajectory reversed to a sustained 0.55% weekly decrease (IRR = 0.9945; 95% CI: 0.990-0.999; p = 0.021). The observed fatality ratio among EMS-detected events declined from 7.59% (pre-intervention mean; SD = 0.111) to 1.71% (post-intervention; SD = 0.042; {chi}{superscript 2} = 19.824; p = 0.0001). Opioid decedents were significantly younger than the general mortality population (OR = 0.945 per year of age; p < 0.001), and were descriptively more likely to lack documented race/ethnicity data (41.23% vs. 8.27% "Unknown"; p < 0.001), limiting equity analysis. ConclusionsThe findings are consistent with GCODE having meaningfully reduced opioid mortality by substantially lowering event-level lethality. These results suggest that targeted, digitally coordinated harm reduction can decouple overdose incidence from fatal outcomes, with implications for harm reduction program design in structurally constrained environments.

Background and Aims: The North American overdose crisis is increasingly characterized by complex polysubstance use alongside a transition from injecting to smoking unregulated opioids. However, transitions involving multiple substances remain understudied. We characterized longitudinal transitions in the route of administration and frequency of heroin, fentanyl, and methamphetamine use and examined whether these transitions differed by multilevel factors hypothesized to influence patterns of polysubstance use and routes of administration over time. Design: People who inject drugs (PWID) enrolled in a cohort study completed baseline surveys (October 2020-2021) and three biannual follow-up visits (through April 2023). Setting: San Diego, California, and Tijuana, Baja California. Participants: Among 612 PWID, median age was 43 years; most were male (74%), Hispanic, Latino, or Mexican (72%), and San Diego residents (67%). Measurements: Based on past six-month substance use behaviors reported at each visit, we categorized participants according to six indicators over time: low- (< weekly) and high-frequency ([&ge;] weekly) smoking and injecting of heroin, fentanyl, and methamphetamine. We then used latent transition analysis (LTA) to identify distinct subgroups of participants with respect to these indicators at baseline and examine transitions between them over 18 months. We fit models with 2-5 subgroups, selecting the final model based on fit and interpretability and used multiple-groups LTA to examine differences in subgroup transitions by multilevel factors. Findings: We identified four subgroups: Subgroup 1 (Heroin-Methamphetamine Polyroute), characterized by high-frequency heroin and methamphetamine smoking and injection, included 22% of participants at baseline but 0% at 18 months. Subgroup 2 (Methamphetamine-dominant Smoking), characterized by high-frequency methamphetamine smoking, accounted for 14% of participants at baseline and 18 months. Subgroup 3 (Fentanyl-Methamphetamine Smoking), characterized by high-frequency fentanyl and methamphetamine smoking, included 4% of participants at baseline and 21% at 18 months. Subgroup 4 (Heroin-dominant Injecting), characterized by high-frequency heroin injection, included 61% of participants at baseline and 65% at 18 months. Participants in Subgroup 1 primarily transitioned to Subgroups 3 and 4 over time. Larger increases in Subgroup 3 prevalence occurred for participants who, at baseline, experienced homelessness, resided in San Diego (vs. Tijuana), received syringes from a syringe services program, and overdosed in the past six months. Conclusions: PWID in this region increasingly transitioned from high-frequency heroin and methamphetamine injection toward fentanyl and methamphetamine smoking, likely reflecting shifts in drug availability. Results highlight the need for multilevel interventions that address health harms resulting from polysubstance smoking alongside continued injection.

Pregnant and postpartum people who use drugs in the United States are trying to survive at the intersection of two of the gravest public health crises of the 21st century US: epidemics of (1) maternal mortality and (2) the overdose epidemic. Although extensive evidence documents racial/ethnic disparities in each of these epidemics separately, comparatively little research has characterized racial/ethnic patterns in their collision, that is, in maternal overdose mortality. We analyzed individual-level mortality records from the National Vital Statistics System (NVSS) for 2016-2022 to describe racial/ethnic disparities in pregnancy-associated overdose deaths (PA-OD) and pregnancy-associated substance use disorder-related deaths (PA-SUD). Racial/ethnic-specific mortality rates were calculated per 100,000 live births with exact Poisson confidence intervals. Temporal trends were summarized using annual percent change (APC), and disparities were quantified using rate ratios and differences relative to non-Hispanic White individuals. Overdose-related maternal mortality increased substantially during the study period across multiple racial and ethnic groups. Rates increased nearly threefold among non-Hispanic White individuals and rose more steeply among non-Hispanic Black individuals, producing a Black-White disparity that emerged over time. Rates among Hispanic individuals remained lower but increased rapidly, while estimates among American Indian and Alaska Native individuals were often high but unstable because of small counts. Substance use disorder-related maternal mortality exhibited a pronounced surge during 2019-2021 across several racial and ethnic groups. These findings highlight rapidly evolving racial/ethnic patterns in maternal overdose mortality and underscore the need for targeted prevention and harm-reduction strategies to reduce overdose-related deaths during pregnancy and the postpartum period. FundingWe are grateful to the following NIH grants for supporting this research: U54HD113292 and R01DA059182.

ObjectivesTo examine the extent to which heat-related causes of death are recorded in fatal drug overdoses, how these patterns vary across states and over time, and how overdose characteristics differ between deaths with, versus without, heat involvement recorded. MethodsDeath certificate data for all drug overdose deaths in US residents from 2001 to 2024 (from the National Center for Health Statistics) were analyzed to identify whether a heat-related cause of death was also listed on the death certificate. Joinpoint regression, descriptive statistics, and nonparametric tests were used to examine temporal trends and compare overdose deaths with versus without recorded heat involvement. ResultsIn 2001, fewer than 10 drug overdose deaths with recorded heat involvement were identified, but this number increased to 558 in 2024. From 2013 to 2024, mortality rates increased significantly, with an estimated annual percent change of 30.1 (95% Confidence Interval, 26.5-47.1). The highest mortality rates and numbers of deaths were observed in residents of Arizona and Nevada. American Indian/Alaska Native, Mexican-heritage, and foreign-born populations accounted for larger shares of overdose deaths with, compared to without, heat involvement recorded. A street or highway was more frequently identified as the place of injury in overdose deaths with (18.9%), versus without (2.2%) heat involvement reported. Psychostimulants such as methamphetamine were involved in 85.9% of overdose deaths with, compared to 28.9% without, recorded heat involvement. ConclusionsAlthough representing only a fraction of all overdose deaths, fatal overdoses involving heat exposure have increased markedly over time and disproportionately impact certain states and demographic groups.

PurposeOpioid overdose deaths disproportionately affect racial and ethnic minority populations in the United States, yet claims-based evidence characterizing the multi-dimensional structure of these disparities across incidence, treatment access, costs, and insurance coverage remains limited. MethodsWe conducted a retrospective cross-sectional and longitudinal cohort analysis using the HealthVerity Launch Sample, a large administrative claims database. The study population comprised 3,675,823 patients across 5 racial groups enrolled between 2020 and 2024. Eight primary analyses were conducted, including age-sex standardized overdose rates, temporal disparity trends, medication-assisted treatment (MAT) receipt, naloxone access, pharmacy costs, insurance payer type, care setting, and multivariable logistic regression for overdose risk. ResultsBlack patients had the highest age-sex standardized overdose rate (363.4 per 100,000; rate ratio [RR] = 1.27 vs. White), and those with opioid use disorder (OUD) received MAT at a rate 35% lower than White patients (19.8% vs. 30.7%; RR = 0.645), driven primarily by a buprenorphine access deficit. AIAN patients demonstrated consistent multi-dimensional disadvantage across naloxone access, MAT engagement, and pharmacy costs. After adjustment for payer type, age, and sex, all non-White groups showed lower adjusted odds of overdose than White patients (Black OR = 0.87; AIAN OR = 0.25), with Medicaid enrollment carrying 7.06 times the overdose odds of commercial insurance. ConclusionInsurance type is the dominant predictor of overdose risk, and the disproportionate Medicaid enrollment of Black patients is both a consequence of structural disadvantage and access disparities. Targeted interventions such as buprenorphine expansion in Medicaid and enhanced naloxone distribution are recommended.

ImportanceThe rapid rise of online sports gambling in the U.S. has been associated with financial harms, raising concern that it may adversely affect population mental health. ObjectiveTo estimate the causal effect of state legalization of online sports gambling on population mental health, including a range of self-reported and registry-based outcomes. Design, Setting, and ParticipantsRepeated cross-sectional study using nationally representative Behavioral Risk Factor Surveillance System (BRFSS) data from 2014-2025 and registry-based mortality records from 2012-2024. We leveraged state-level variation in the legalization of online sports gambling and applied a stacked difference-in-differences with event study design. The analytic sample included 4,660,948 BRFSS respondents and mortality records for virtually all state-years. We estimated effects on all adults and several higher-risk subgroups, including men, young men, and men with lower educational attainment. ExposureState legalization of online sports gambling. Main Outcomes and MeasuresSelf-reported outcomes included poor mental health days, depressive disorder diagnoses, ever binge drinking, number of binge drinking episodes, and marijuana use. Registry-based outcomes included suicide mortality and alcohol-induced mortality per 100,000. ResultsAmong 4,660,948 BRFSS respondents, 48.7% were men, 40.2% had no more than a high school education, and the mean age was 47.6 years. Legalization of online sports gambling had no discernible effect on poor mental health days of all U.S. adults (-0.01 days; 95% CI, -0.16 to 0.14; P=0.88), depressive disorder diagnoses (0.1 percentage points; 95% CI, -0.7 to 0.9; P=0.84), binge drinking, binge drinking episodes, or marijuana use. Meanwhile, mean suicide mortality was 14.1 per 100,000 and mean alcohol-induced mortality was 12.2 per 100,000. Legalization did not affect adult suicides (0.13 deaths per 100,000; 95% CI, -0.71 to 0.97; P=0.76) or alcohol-induced mortality (1.08 deaths per 100,000; 95% CI, -0.58 to 2.73; P=0.21). Results were null among men and higher-risk subgroups of men. Conclusions and RelevanceThe legalization of online sports gambling has not produce detectable population-level changes in a range of mental health outcomes, including reported symptoms, diagnoses, substance use, and registry-based mortality due to suicide or alcohol, in up to 3 years of follow-up. These findings suggest that although online sports gambling may cause financial harm and severe distress for some individuals, legalization has not produced measurable average changes in population mental health over the observed follow-up period. Key pointsO_ST_ABSQuestionC_ST_ABSHas the legalization of online sports gambling affected population-level mental health, including symptoms, diagnoses, substance use, suicides, and alcohol-induced mortality? FindingsIn this repeated cross-sectional study that applied a difference-in-differences design to more than 4.6 million individual-level survey responses and mortality records, the legalization of online sports gambling from 2018-2024 did not affect reported poor mental health days, depressive disorders, binge drinking, marijuana use, suicide mortality, or alcohol-induced mortality. Results were similar among men and higher-risk subgroups of men. MeaningThe legalization of online sports gambling has not produced detectable population-level changes in a broad range of mental health outcomes in up to 3 years of follow-up.

Background and Aims: Synthetic opioids cause tens of thousands of deaths each year in North America, and there are indications that synthetic opioids are also becoming increasingly prevalent in the European drug market. This study aimed to examine high-risk substance use in the German drug-using community with a particular focus on the synthetic opioids fentanyl and nitazenes and related awareness, concerns, overdose experiences, and harm-reduction behavior. Design: Cross-sectional, observational online survey. Setting: Open drug-use scenes, addiction clinics, and substitution practices at numerous geographic locations throughout Germany, August to September 2025. Participants: 235 individuals aged 14+ from the drug using community (mean age 43.4 years; 57.9% male), 79.6% recruited by peers in open drug-use scenes. Measurements: The primary outcome was substances used within the past 12 months. In addition, sources, forms, routes of administration, and perceived changes in availability and price of (synthetic) opioids were assessed as well as risk perceptions, fears, harm-reduction behavior, and overdose-related experiences. Findings: 227 respondents reported substance use with an average of 6.2 substances, and 73.1% (95% confidence interval [CI] = 67.0-78.5%) had used at least one opioid in the past year. Synthetic opioids were consumed in many parts of Germany and across all age and gender groups. Among participants who experienced a shortage of their primary opioid in the past year, 25% (95% CI = 15.8-37.2%) reported having used fentanyl instead. 56.5% (95% CI = 36.8-74.3%) of individuals using synthetic opioids reported having experienced an overdose in the past twelve months. Most of the respondents perceived synthetic opioids as posing a high risk, and a substantial proportion expressed fear that they could be mixed into their own substances. However, only 9.9% (95% CI = 6.6-14.7%) use drug checking, although the vast majority stated they would use it if it were available to them. Conclusions: Synthetic opioids, including fentanyl and nitazenes, have entered the German drug scene, with users reporting high rates of overdose and limited access to harm reduction measures. Germany may be in an early phase of a synthetic opioid transition, warranting urgent expansion of surveillance, naloxone distribution, and drug checking services.

Aims and SettingIn the U.S., the emergence of new adulterants and novel psychoactive substances continues to complicate approaches to overdose, treatment, and public safety. Information about this changing drug supply is often gleaned from police drug seizures, but community drug checking services, which test the contents of a persons drug supply and share that data, provide another means to understand local drug supplies. However, it is unclear how seized drugs differ from those collected in the community, whether one approach is potentially more instructive, and what can be learned about local drug supplies from each source. We therefore compared drug samples tested from police departments (PDs) and community partner (CP) drug checking programs to examine what, if any, differences existed in sample content, form, submitter characteristics, and emerging substance presence. DesignWe conducted a retrospective cohort analysis of drug samples collected and tested between April 2018 and December 2025 by the Massachusetts Drug Supply DataStream derived from CPs and PDs operating in the same geographic area across eight locations. Bivariate analyses (Chi-square, Fishers exact) tested for differences in sample and submitter characteristics by source. FindingsThere were 2,430 unique samples submitted by CPs (68.1%) and PDs (31.9%) from the same location. Compared to CP samples, proportionally more PD samples showed fentanyl as primary substance (74.2% PD vs. 64% CP, p<.001) and less often contained additives (xylazine 15.0% PD vs. 27.4% CP; medetomidine 0.6% PD vs. 2.2% CP, both p<.001). PD samples were typically powders (73.2% vs. 37.9%) and pills (13.6% vs. 3.6%) while CP samples were more often residue (51.9% vs. 2.1%, p<.001). Submitter characteristics, when reported, differed by source: gender (n=528, male: 78.6% PD vs. 50.1% CP, p<.001), race/ethnicity (n=468, Black: 15.8% PD vs. 7.8% CP; Hispanic: 6.7% PD vs. 13.2% CP, p<.05), and associated overdose (n=242, fatal: 62.9% vs. 10.9%, p<.001). Emergent substances were detected a median of 249 days sooner in CP than co-located PD samples, though drugs exhibiting concerning patterns (e.g., unexpected fentanyl in stimulants) had similar, swift detection times. ConclusionDrug samples differ based on PD vs. CP source in significant ways that may introduce bias when drawing conclusions about drug supply trends but also offer unique insights for public health and responses to emerging drugs. Modern drug monitoring should include a broad range of sources to best prepare for changes the illicit supply may bring to overdose prevention, public safety, and health systems.

Objectives: To examine COVID19 vaccine uptake among people diagnosed with sexually transmitted and bloodborne infections (STBBI) and reported methamphetamine users in Manitoba, Canada, during the acute phase of the COVID19 pandemic. Methods: We conducted a retrospective matched cohort study using linked population based administrative healthcare, laboratory, and vaccination databases in Manitoba. Individuals aged 16+ years with laboratory confirmed chlamydia/gonorrhea (CT/NG), syphilis, HIV, and/or documented methamphetamine use during the four years prior to March 1, 2020 were included in eight exposed cohorts. Each cohort was matched to unexposed comparators on age, sex, geographic region, and income quintile. The primary outcome was receipt of 2+ COVID19 vaccine doses between December 1, 2020 and March 31, 2022. Poisson regression models estimated adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs) for vaccine uptake. Results: Compared with matched comparators, most exposed cohorts were less likely to complete the COVID19 primary vaccine series. Individuals in the Syphilis Only (aRR: 0.87, 95% CI: 0.85 0.90), Syphilis Plus (aRR: 0.84, 95% CI: 0.81 0.86), CT/NG Only (aRR: 0.95, 95% CI: 0.94 0.96), CT/NG Plus (aRR: 0.82, 95% CI: 0.80 0.85), Methamphetamine Only (aRR: 0.78, 95% CI: 0.76 0.80), and Methamphetamine + STBBI cohorts (aRR: 0.74, 95% CI: 0.72 0.77) had significantly lower vaccine uptake. The HIV Only cohort did not differ significantly from matched comparators (aRR: 0.98, 95% CI: 0.95 1.01). Lower uptake was concentrated among individuals living in lower-income areas. Conclusions: People diagnosed with STBBI and methamphetamine users in Manitoba experienced significant inequities in COVID19 vaccine uptake, particularly those with STBBI coinfections and concurrent substance use. Integrated vaccination approaches linked with HIV, harm reduction, and addiction services may improve vaccine equity during future public health emergencies.

IntroductionCurrent best practice is for primary care physicians (PCPs) to screen patients for problematic substance use at checkups. However, this practice is not routine, is done in an unstandardized manner, and contributes to the overburdening of PCPs. Screening practices also target current, potentially problematic use behaviors, thus limiting their capacity to help patients prevent problems before they start. Recent scientific advances in identifying people at high risk for substance use problems as a means of facilitating prevention efforts have not yet been integrated into medical practice. To address these issues, our research team developed a freestanding platform called the Comprehensive Addiction Risk Evaluation System (CARES). CARES provides personalized information about genetic and behavioral/environmental risk for substance use disorder (SUD) and connects individuals to resources based on their risk profile. The present study evaluated the potential for adoption and implementation of CARES within a health care system through qualitative interviews with key stakeholders. MethodsSemi-structured interviews were developed using the Consolidated Framework for Implementation Research (CFIR) and conducted with N=15 interviewees. Transcripts were analyzed using rapid qualitative analysis. ResultsKey themes included perceived need for new SUD screening tools, current SUD screening procedures and their pros/cons, openness to new ideas and clinical tools, fit of CARES with organizational goals and priorities, considerations for use of CARES with adolescent populations, anticipated patient response to CARES, barriers to implementation and uptake of CARES, changes required for implementation, and possibility for medical record integration. Interviewees generally expressed need for new screening tools and openness to using new tools, but expressed concern that existing provider burden, lack of SUD knowledge, and discomfort/stigma could stymie efforts to implement CARES. Conclusions.There is a clear need for a low-burden, easy-to-use tool for substance use screening. CARES appears to be an acceptable and feasible approach to fill this gap. These findings will be used to inform pilot implementation of CARES in a clinical care setting.

IntroductionAlthough prior studies suggest e-cigarette use is associated with worse mental health, it remains unclear whether these associations persist independent of diagnosed depression and how tobacco use and depression jointly affect health-related quality of life. Although the long-term health risks of vaping are still unknown, self-reported health is a reliable measure of quality of life. This study provides the first health utility estimates of the independent and combined effects of cigarette use, e-cigarette use, and depression on health-related quality of life. MethodsWe analyzed 2022-2023 Behavioral Risk Factor Surveillance System data on health-related quality of life as measured by self-reported physically or mentally unhealthy days in the past 30 days. The average number of unhealthy days was estimated by age, gender, smoking status (current versus non-smoking), depression status (received a prior diagnosis), and current e-cigarette use status (every day or some day use). We converted the number of overall healthy days into EQ-5D utility scores by age-specific percentile matching of BRFSS and MEPS distributions, a method developed by Jia and Lubetkin. ResultsCigarette use, e-cigarette use, and depression were each associated with worse health-related quality of life. Mentally unhealthy days increased with the accumulation of these conditions. Associations with physically unhealthy days followed a similar pattern, particularly among younger adults, although the magnitude of association was smaller. E-cigarette use alone was associated with 2.0-4.2 (95% CI: 2.0-4.6) additional mentally unhealthy days per month across all age groups. Notably, e-cigarette use was independently associated with poorer mental health among adults aged 18-64 with or without diagnosed depression. After accounting for smoking and depression status, e-cigarette use was associated with disutility scores of 0.011 in men and 0.015 in women among young adults, with the largest losses observed when multiple conditions co-occurred. ConclusionE-cigarette use is associated with poorer health-related quality of life, particularly among younger adults, and these effects are amplified when combined with cigarette use and depression. Quantifying these joint impacts as health utility losses highlights the importance of addressing e-cigarette use within integrated tobacco control and mental health policies, especially for young populations.

Background Evidence on factors associated with cannabis for medical purposes (CMP) authorizations among Veterans Affairs Canada (VAC) clients remains limited and inconsistent, particularly concerning mental health and posttraumatic stress disorder (PTSD), a leading indication for use. We investigated demographic, clinical and service characteristics associated with VAC authorizations for CMP reimbursement. Method We linked VAC administrative CMP program data with responses from the 2019 Life After Services Studies cross-sectional survey of Regular Force veterans released between 1998 and 2018. Multivariable logistic regressions examined associations between CMP reimbursement (yes/no) and demographic, clinical and well-being factors, with analyses stratified by PTSD status. Results Among 1,289 respondents (weighted n=33,131), 18.4% were authorized for CMP reimbursement. Younger age (<40 vs. [&ge;]60 years: OR 4.78, 95% CI: 2.24-10.21), unemployment with inability to work vs. employed (OR 3.10, 95% CI: 1.78-5.40), land service vs. air (OR 2.07, 95% CI: 1.22-3.50), PTSD (OR 2.81, 95% CI: 1.69-4.66), anxiety (OR 2.32, 95% CI: 1.45-3.70), and severe pain vs. no pain (OR 3.61, 95% CI: 1.97-6.60) were independently associated with authorization. Unemployment and severe pain were consistent correlates across PTSD strata. Among those without PTSD, younger age, multiple physical conditions, and frequent mental health visits were significant; among those with PTSD, shorter service, witnessing destruction, and suicidal ideation were additional factors. Conclusions CMP authorization patterns among Canadian veterans reflect the intersection of mental health, pain, and functional impairment, with variation by PTSD status. These findings underscore the need for longitudinal research on CMP mechanisms, effectiveness and safety.

Background: Correctional facilities are vital venues for expanding testing and treatment for hepatitis C virus (HCV) infections, essential components of national hepatitis C elimination plans. Objective: This study characterizes HCV testing and treatment outcomes among individuals entering incarceration into California state prisons, overall, by year, and by key individual-level characteristics. Methods: We analyzed individual-level electronic health record data from all adults entering California prisons ('entrants') between July 1, 2016 and June 30, 2023. We quantified the percentages of entrants receiving an HCV antibody test within four weeks of entry, the percentage antibody positive among tested, the percentage RNA positive among antibody positive, and the percentage initiating direct acting antiviral (DAA) treatment within one year among RNA positive. Results: Of entrants, 133,639 (76%) were tested for HCV antibody, 25,455 (19% of tested) were ever HCV-infected, and 16,738 (66% of ever infected) were currently infected. Among individuals currently infected, 7,479 (45%) initiated DAA treatment within one year. Individuals with identified SUD had 3.2 times higher antibody positivity and 1.3 times higher proportions initiating DAA, compared to individuals not having an identified SUD. Discussion: We show that HCV testing and treatment in California prisons, a central component of national hepatitis C elimination efforts, supported effective and equitable increases in access to hepatitis C treatment, particularly for those with SUD.

ObjectivesTo evaluate the effectiveness and cultural feasibility of family-supervised disulfiram as a first-line treatment for alcohol use disorder (AUD) in Sri Lanka, and to compare its clinical outcomes with standard therapy delivered at a tertiary psychiatric unit. DesignSingle-blind Randomized Controlled Trial known as ETAT-RCT (Efficacy of Two Alcohol Treatments) was conducted under routine clinical setup with three parallel groups: family-supervised disulfiram, locally developed psychosocial intervention, and routine treatment. Allocation was independently concealed; assessors were blinded. Analyses followed an intention-to-treat approach using repeated-measures ANOVA (group x time). This paper reports the disulfiram (test) versus routine treatment (control) comparison; the psychosocial intervention will be reported separately. SettingUniversity Psychiatry Unit, National Hospital of Sri Lanka, Colombo (UPU, NHSLC). ParticipantsPatients aged [&ge;]14 years with AUD presenting to the unit were recruited consecutively without inducements. Planned allocation ratio was 1:1:1 with 31 participants per arm; key exclusions were lifetime psychotic disorder and current contraindication to disulfiram. RandomisationParticipants were randomised into each treatment arm using an independent concealed paper-based allocation system. Intervention(1) family-supervised disulfiram, with psychoeducation/support only - DT arm, (2) a locally developed denormalization focused psychosocial programme - PT arm, and (3) standard therapy (motivational/cognitive/behavioural input; naltrexone permitted; no disulfiram/denormalisation) - ST arm. Outcome measuresPrimary outcome was Alcohol Use Disorders Identification Test (AUDIT) score at 12 months. Key secondary outcomes were past 30 day alcohol use via Timeline Follow-Back (TLFB); alcohol biomarkers [ALT (alanine aminotransferase), {gamma}-GT (gamma-glutamyl transferase), MCV (mean corpuscular volume)]; locally developed measures of addiction-relevant cognitive, affective, behavioural factors [AARSU (Attitude Assessment Related to Substance Use), BARSU (Behaviour Assessment Related to Substance Use)]; and Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Outcomes were assessed at baseline, 6, and 12 months. ResultsParticipants in DT (n=33) and ST (n=38) were comparable at baseline. Both groups showed clinically and statistically significant improvement in AUDIT scores over 12 months (DT: F=39.90, p<0.001; ST: F=49.90, p<0.001), with no groupxtime interaction (F<0.001, p=0.98). Biomarkers and AARSU, and BARSU and Q-LES-Q-SF to a lesser degree, mirrored the AUDIT pattern. TLFB did not change significantly over time in either arm (p>0.05). In moderator analyses, improvement in AUDIT was not moderated by baseline motivation (F=0.20, p=0.89) but was moderated by baseline AUD severity (F=7.70, p=0.007). No serious adverse events were attributed to disulfiram. Adherence to supervised dosing was generally high during periods of supervision but intermittent overall. ConclusionsIn this pilot RCT, family-supervised disulfiram achieved 12-month outcomes comparable to standard therapy in a tertiary Sri Lankan setting. Improvements were independent of baseline motivation and varied by baseline AUD severity. These findings may support family-supervised disulfiram as a culturally feasible first-line option in Sri Lanka; larger, adequately powered multicentre trials are warranted to confirm effectiveness and scalability. Trial registrationSLCTR/2014/021 Strengths and limitations of this studyO_LIThis pragmatic randomised controlled trial demonstrates an improved real world applicability and validity as it was conducted in an unmodified public-sector psychiatric setting. C_LIO_LIStrong generalisability of the study with similar health systems due to broad eligibility criteria of patients warranted the inclusion of regular and general patient cohort with alcohol use disorders, strengthening generalisability within similar health systems. C_LIO_LIInterventions were carried out without additional staff or patient monitoring reflecting routine clinical practice. C_LIO_LIComprehensive assessment beyond abstinence alone with multidimensional outcomes such as alcohol related harm, biomarkers, cognitive behavioural change and quality of life. C_LIO_LIMinor potential in performance bias due to the nature of intervention where blinding study subjects and clinicians is not feasible. C_LIO_LISampling bias towards males and variability within the ST arm can affect the generalisability. C_LI

Drug overdose deaths in the United States reached record levels during the fentanyl era before recently declining. A plausible hypothesis is that a sudden drop in fentanyl purity beginning in 2023 caused the downturn in overdose mortality. We evaluated this hypothesis by replicating a published analysis with regional overdose data, using models that account for time trends and autocorrelation, and negative control indicators to test for spurious correlation. When fentanyl purity was rising, the national purity series did not track overdose increases in most regions and showed only a modest association in the West. When both purity and mortality later declined, the observed associations were also seen with unrelated macroeconomic indicators that shared the same time pattern. National fentanyl purity alone does not provide a sufficient explanation for recent overdose declines.

Background: Long-acting pre-exposure prophylaxis (PrEP) expands HIV prevention options for women. However, PrEP impact depends on addressing persistent gaps in awareness, access, and use. Artificial intelligence (AI) tools, including conversational agents, are being explored to advance PrEP uptake, but comfort with AI may influence their impact. Thus, we examined women's comfort with AI and its association with PrEP awareness. Methods: We analyzed self-reported data from women aged [&ge;]18 years in a cross-sectional survey conducted in New York City from August 2023 to August 2024. We performed descriptive analyses, applied latent class analysis to identify AI knowledge/comfort profiles, and estimated unadjusted and adjusted odds ratios to assess associations between profile membership and PrEP awareness. Results: Among 306 respondents without a diagnosis of HIV who completed AI-related survey items, the median age was 36. Most women identified as Hispanic/Latina (60%) or Non-Hispanic Black (18%), had not completed college (53%), and spoke only English or were bilingual (81%). Latent class analysis identified four AI knowledge/comfort profiles that differed by PrEP awareness, race/ethnicity, borough, prior drug use, and technology utilization. Women with varied AI knowledge, broad AI discomfort, and comfort with clinicians maintaining privacy had lower odds of PrEP awareness (OR: 0.35, 95% CI: 0.16-0.75), but this association did not persist after statistical adjustment. Conclusions: PrEP awareness and AI knowledge were limited, yet many women expressed openness to AI-enabled tools when privacy was assured. AI-enabled HIV prevention tools should prioritize trust, transparency, confidentiality, and the lived contexts of the women they intend to serve.

Decarceration, the process of reducing incarceration rates, is increasingly viewed as a strategy to improve population health and reduce health inequities. Yet, evidence on its health effects remains limited and may depend on how decarceration occurs. We developed a national decarceration "atlas" to characterize the mechanisms and dynamics of decarceration across more than 2,800 U.S. counties between 1999-2019. Using longitudinal county-level jail and prison data, we identified four operational types of decarceration: reduced pretrial detention, reduced jail time, reduced prison admissions, and reduced prison time. Nearly two-thirds of counties, including most rural counties, experienced at least one decarceration type during the study period. Declines typically followed periods of recent growth and were relatively modest in magnitude, with median reductions of 19% to 38% ten years after onset. The frequency and timing of decarceration types varied by urbanicity, state, and region, with many counties experiencing multiple mechanisms concurrently. Validation against documented case studies of state and local decarceration demonstrated alignment with known legislative and de facto drivers, while revealing substantial sub-state heterogeneity. This atlas provides a scalable framework and hypothesis-generating resource to support comparative studies of decarceration's heterogeneous health effects.

IntroductionEmpirical evidence linking specific national structural policies to the provision of key HIV services in low- and middle-income settings remains scarce. This study addresses the research gap by quantifying the within-country relationships between six national structural policy indicators and the presence of the HIV prevention service component targeted at sex workers in Southeast Asia. MethodsWe constructed a balanced panel dataset covering eight Southeast Asian countries from 2018 to 2025 from the UNAIDS Global AIDS Monitoring (GAM) framework. We used Fixed-Effects (FE) and Random-Effects (RE) models to analyse the relationships, with the FE model selected as the more statistically appropriate estimator. We enhanced robustness by using clustered standard errors and one-period lagged explanatory variables. ResultsThe primary finding from the FE model indicated a statistically significant and positive contemporaneous association between the existence of legal or administrative barriers to social protection (barriers_spi,t) and the presence of HIV prevention services for sex workers ({beta} = 0.8531; p< 0.001). However, the robustness check revealed a statistically significant negative association between the two when using the lagged barrier variable (barriers_spi,t-1), suggesting a decline in HIV prevention service availability over time ({beta} = -0.3540; p < 0.05). We did not find any other policy variables coefficient to be statistically significant in the FE models. ConclusionsWhile the immediate recognition (contemporaneous effect) of structural barriers to access social protection may occur alongside prioritised HIV prevention service provision, the sustained presence of these impediments acts as a long-term constraint that undermines the effectiveness and sustainability of targeted HIV programmes. National HIV programmes must urgently prioritise the removal of structural barriers to ensure long-term service stability for key populations. Key MessagesO_LIWhat is already known on this topic: The global HIV response requires addressing structural determinants, such as legal barriers to social protection, to achieve epidemic control. However, there is a lack of robust empirical evidence linking the adoption of specific national structural policies to the actual availability of essential HIV services for key populations in low- and middle-income settings. C_LIO_LIWhat this study adds: This study provides the first evidence using FE panel data that the existence of national policy barriers to social protection is initially associated with a higher likelihood of having an HIV prevention service component for sex workers. The study also demonstrates that this positive association is short-lived, with the sustained presence of the barrier negatively impacting HIV prevention service availability for sex workers in the subsequent year. C_LIO_LIHow this study might affect research, practice or policy: Policymakers should recognise that simply identifying and reporting structural barriers, while perhaps coinciding with initial HIV prevention service investment, is insufficient for sustained policy intervention effectiveness. Policy should focus not just on the adoption of targeted programmes but on the urgent removal of structural barriers to ensure the long-term sustainability and success of prevention services for key populations. C_LI