Literature Collection

The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19-June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms.

BACKGROUND: The United States continues to experience an opioid overdose epidemic with mortality patterns that reflect existing social and environmental inequities. Although research has examined various factors associated with opioid-related mortality, the relationships between social-environmental vulnerability (SEV), health care presence, and geography remain poorly characterized. PURPOSE: To explore whether SEV accelerates opioid overdose rates and to assess how the presence of health care services-specifically opioid treatment programs (OTPs) and primary care providers (PCPs)-modifies these patterns across rural and urban contexts. METHODS: A retrospective ecological analysis using hierarchical linear modeling was conducted from January 2020 to December 2022, analyzing 172,359 observations across 57,453 census tracts within 1219 US counties. The primary exposure was census-tract-level SEV, operationalized using the CDC Environmental Justice Index. Health care indicators included county-level presence of OTPs and PCPs. RESULTS: Areas in the highest quartile of SEV demonstrated elevated acceleration coefficients (β=3.224; SE=0.803; P<.001), with pronounced patterns observed in rural areas, though ecological design limitations preclude individual-level causal inference. Interaction analyses suggested that high-SEV counties containing both OTP and primary care resources demonstrate lower acceleration coefficients (β= -11.478, SE=5.429, P=0.035). Areas without health care presence showed higher baseline rates in overdose acceleration, particularly in urban high-vulnerability settings. CONCLUSIONS: High SEV was associated with accelerated opioid overdose rates during 2020-2022, particularly in rural areas. The presence of OTPs and primary care services within counties was associated with attenuated acceleration in high-vulnerability areas. This may indicate that policies prioritizing comprehensive health care services in high-SEV communities could address opioid overdose disparities.

INTRODUCTION: Recent studies from urban academic centers have shown the promise of emergency physician-initiated buprenorphine for improving outcomes in opioid use disorder (OUD) patients. We investigated whether emergency physician-initiated buprenorphine in a rural, community setting decreases subsequent healthcare utilization for OUD patients. METHODS: We performed a retrospective chart review of patients presenting to a community hospital emergency department (ED) who received a prescription for buprenorphine from June 15, 2018-June 15, 2019. Demographic and opioid-related International Classification of Diseases, 10th Revision, (ICD-10) codes were documented and used to create a case-matched control cohort of demographically matched patients who presented in a similar time frame with similar ICD-10 codes but did not receive buprenorphine. We recorded 12-month rates of ED visits, all-cause hospitalizations, and opioid overdoses. Differences in event occurrences between groups were assessed with Poisson regression. RESULTS: Overall 117 patients were included in the study: 59 who received buprenorphine vs 58 controls. The groups were well matched, both roughly 90% White and 60% male, with an average age of 33.4 years for both groups. Controls had a median two ED visits (range 0-33), median 0.5 hospitalizations (range 0-8), and 0 overdoses (range 0-3), vs median one ED visit (range 0-8), median 0 hospitalizations (range 0-4), and median 0 overdoses (range 0-3) in the treatment group. The incidence rate ratio (IRR) for counts of ED visits was 0.61, 95% confidence interval (CI), 0.49, 0.75, favoring medication-assisted treatment (MAT). For hospitalizations, IRR was 0.34, 95% CI, 0.22, 0.52 favoring MAT, and for overdoses was 1.04, 95% CI, 0.53, 2.07. CONCLUSION: Initiation of buprenorphine by ED providers was associated with lower 12-month ED visit and all-cause hospitalization rates with comparable overdose rates compared to controls. These findings show the ED's potential as an initiation point for medication-assisted treatment in OUD patients.

Background: The use of the natural product, kratom, has increased significantly in recent years. The active compounds in kratom have been shown to produce both opioid and stimulant-like effects. While kratom is marketed as a safe, non-addictive method to treat pain and opioid withdrawal, there have been reports demonstrating that kratom is physiologically addictive and linked to overdose deaths. A limited number of case-reports are available describing treatment of kratom use disorder in middle-aged adults, generally in the context of chronic pain and in inpatient settings. Our case is unique in that we describe outpatient treatment of kratom use disorder in a young adult with comorbid attention deficit hyperactivity disorder (ADHD) and in the absence of chronic pain. Case: A 20-year-old college student with ADHD presented to an office-based opioid agonist treatment clinic (OBOT) for treatment of kratom use disorder. He was unable to attend inpatient or residential substance use treatment due to work and school obligations. Additionally, he had stopped taking his prescribed stimulant due to cardiac side effects. The OBOT team successfully initiated buprenorphine-naloxone (BUP/NAL) sublingual films via home induction to treat his kratom use disorder. The patient is being monitored monthly with plans to slowly taper his BUP/NAL dose as tolerated. Discussion: We present a case of a young adult male with kratom use disorder, complicated by a diagnosis of ADHD, successfully treated with BUP/NAL via home induction. The patient is currently kratom-free, reports improved mood and sleep patterns since initiating BUP/NAL, and is able to once again tolerate his ADHD stimulant medication. Healthcare providers should be aware of the use of kratom and consider utilizing BUP/NAL to treat dependence to this botanical drug.

Patients with co-occurring medical and psychiatric conditions often face fragmented care and prolonged hospitalizations in traditional medical units (MUs). Integrated medical-psychiatry units (MPUs) offer a model of concurrent care that may better meet the needs of these patients, but limited data exist on which patient populations benefit most. This study retrospectively compared outcomes for patients with psychiatric conditions discharged from an MPU versus traditional MUs within a single academic medical center between 2019 and 2023. Subgroups included patients presenting with suicidal ideation (SI) or toxic overdose (OD). Primary outcomes were length of stay (LOS) and discharge to the community. MPU patients were younger, more likely to be on Medicaid, and had significantly higher rates of psychotic, mood, substance use, and cognitive disorders (all P < 0.001). Despite this higher psychiatric complexity, MPU patients had shorter LOS and higher rates of discharge to home than their counterparts on general MUs, even after adjusting for demographic and clinical differences. Among patients with SI, those on the MPU had an average LOS of 5.5 days compared to 6.7 days in traditional units (P = 0.006). These findings highlight the effectiveness of MPUs in managing complex, high-need patients and support the broader implementation of integrated, interdisciplinary care models to improve hospital outcomes and care transitions for vulnerable populations.

Opioid-involved drug overdose deaths have been a growing concern in the United States for several decades. The Centers for Disease Control and Prevention identified several strategies to address the opioid overdose epidemic, including increased availability of and access to medication-assisted treatment and guidance on safer opioid prescribing practices. Telehealth offers the potential for increasing access and availability to these strategies, and laws governing telehealth have implications for their utilization. To understand how state telehealth laws intersect with the opioid overdose epidemic, we conducted a legal mapping study, a type of legal epidemiological assessment, of statutes and regulations that intersect at telehealth and opioids. This search yielded 28 laws from 17 states. These laws intersect both telehealth and the opioid overdose epidemic in different ways including prescribing limitations, opioid treatment through medication and counseling, patient plan review, and professional collaboration. Continued legal and policy surveillance is needed to be able to evaluate the impact of law in addressing opioid overdose outcomes.

The United States is experiencing an unprecedented opioid crisis, with a record of about 93,000 opioid-involved overdose deaths in 2020, which requires rapid and substantial scaling up of access to effective treatment for opioid use disorder. Only 18% of individuals with opioid use disorder receive evidence-based treatment, and strategies to increase access are hindered by a lack of treatment providers. Using a case study from the largest municipal hospital system in the United States, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. This national problem demands a multipronged approach, including federal programs to grow and diversify the pipeline of addiction providers, medical education initiatives, and enhanced training and mentorship to increase the capacity of allied clinicians to treat patients who have an opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care and with new treatment models, including telehealth, which can lower patient barriers to accessing treatment.

BACKGROUND: Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. METHODS: Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods. RESULTS: Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal. CONCLUSIONS: People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.