The Evolving Overdose Epidemic: Synthetic Opioids And Rising Stimulant-Related Harms

2020 ◽  
Author(s):  
Christopher M Jones ◽  
Faraah Bekheet ◽  
Ju Nyeong Park ◽  
G Caleb Alexander
Keyword(s):  
Illicit Drug ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Drug Supply ◽  
Synthetic Opioids ◽  
Key Stakeholders ◽  
Public Health Challenges ◽  
Concomitant Exposure ◽  
Over Time ◽  
Key Questions

Abstract The opioid overdose epidemic is typically described as having occurred in three waves, with morbidity and mortality accruing over time principally from prescription opioids (1999-2010), heroin (2011-2013) and illicit fentanyl and other synthetic opioids (2014-present). However, the increasing presence of synthetic opioids mixed into the illicit drug supply, including with stimulants such as cocaine and methamphetamine, as well as rising stimulant-related deaths, reflects the rapidly evolving nature of the overdose epidemic posing urgent and novel public health challenges. We synthesize the evidence underlying these trends, consider key questions such as where and how concomitant exposure to fentanyl and stimulants is occurring, and identify actions for key stakeholders regarding how these emerging threats, and continued evolution of the overdose epidemic, can best be addressed.

scholarly journals Opioid Agonist Treatment and Risk of Mortality During an Opioid Overdose Public Health Emergency: A Population-Based Retrospective Cohort Study

2020 ◽  
Vol 5 (5) ◽  
Author(s):  
Lindsay A Pearce ◽  
Jeong Eun Min ◽  
Micah Piske ◽  
Haoxuan Zhou ◽  
Fahmida Homayra ◽  
...  
Keyword(s):  
Relative Risk ◽  
Illicit Drug ◽  
Opioid Overdose ◽  
Drug Supply ◽  
Opioid Agonist ◽  
Opioid Agonist Treatment ◽  
Risk Of Death ◽  
Synthetic Opioids ◽  
Risk Of Mortality ◽  
Stopping Treatment

IntroductionOpioid agonist treatment (OAT) is a safe and effective treatment for opioid use disorder (OUD). However, people commonly stop and start OAT and their risk of death is high immediately after stopping. The prevalence of illicitly manufactured fentanyl and other highly potent synthetic opioids have increased in the illicit drug supply globally. Yet, there is limited evidence examining the relationship between OAT and mortality when these contaminants are widely available in the illicit drug supply. Objectives and ApproachWe aimed to compare the risk of mortality on and off OAT in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. We linked five health administrative datasets in British Columbia, Canada, creating a cohort of 55,347 people with OUD who received OAT during a 23-year period (1996 to 2018). We compared the risk of mortality on and off treatment over time, and according to time since starting or stopping treatment and by medication type. Results7,030 of 55,347 (12.7%) OAT recipients died during follow-up. All-cause SMR was substantially lower on OAT (4.6 [4.4 to 4.8]) compared to off OAT (9.7 [9.5 to 10.0]). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 [1.8 to 2.4] times higher than on OAT prior to the introduction of fentanyl, and increased to 3.4 [2.8 to 4.3] at the end of the study period (65% increase in relative risk). Conclusion / ImplicationsThe protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, while the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

scholarly journals Using Twitter to Surveil the Opioid Epidemic in North Carolina: An Exploratory Study (Preprint)

2019 ◽  
Author(s):  
Mohd Anwar ◽  
Dalia Khoury ◽  
Arnie P Aldridge ◽  
Stephanie J Parker ◽  
Kevin P Conway
Keyword(s):  
North Carolina ◽  
Language Processing ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Opioid Epidemic ◽  
Least Squares Regression ◽  
Online Data ◽  
Synthetic Opioids ◽  
Opioid Crisis ◽  
Twitter Data

BACKGROUND Over the last two decades, deaths associated with opioids have escalated in number and geographic spread, impacting more and more individuals, families, and communities. Reflecting on the shifting nature of the opioid overdose crisis, Dasgupta, Beletsky, and Ciccarone offer a triphasic framework to explain that opioid overdose deaths (OODs) shifted from prescription opioids for pain (beginning in 2000), to heroin (2010 to 2015), and then to synthetic opioids (beginning in 2013). Given the rapidly shifting nature of OODs, timelier surveillance data are critical to inform strategies that combat the opioid crisis. Using easily accessible and near real-time social media data to improve public health surveillance efforts related to the opioid crisis is a promising area of research. OBJECTIVE This study explored the potential of using Twitter data to monitor the opioid epidemic. Specifically, this study investigated the extent to which the content of opioid-related tweets corresponds with the triphasic nature of the opioid crisis and correlates with OODs in North Carolina between 2009 and 2017. METHODS Opioid-related Twitter posts were obtained using Crimson Hexagon, and were classified as relating to prescription opioids, heroin, and synthetic opioids using natural language processing. This process resulted in a corpus of 100,777 posts consisting of tweets, retweets, mentions, and replies. Using a random sample of 10,000 posts from the corpus, we identified opioid-related terms by analyzing word frequency for each year. OODs were obtained from the Multiple Cause of Death database from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Least squares regression and Granger tests compared patterns of opioid-related posts with OODs. RESULTS The pattern of tweets related to prescription opioids, heroin, and synthetic opioids resembled the triphasic nature of OODs. For prescription opioids, tweet counts and OODs were statistically unrelated. Tweets mentioning heroin and synthetic opioids were significantly associated with heroin OODs and synthetic OODs in the same year (<i>P</i>=.01 and <i>P</i>&lt;.001, respectively), as well as in the following year (<i>P</i>=.03 and <i>P</i>=.01, respectively). Moreover, heroin tweets in a given year predicted heroin deaths better than lagged heroin OODs alone (<i>P</i>=.03). CONCLUSIONS Findings support using Twitter data as a timely indicator of opioid overdose mortality, especially for heroin.

Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic

2018 ◽  
Vol 1 (21;1) ◽  
pp. 309-326 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
United States ◽  
The United States ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Opioid Epidemic ◽  
Synthetic Opioids ◽  
Opioid Crisis ◽  
Electronic Reporting ◽  
Number Of Patients ◽  
Overdose Deaths

The opioid epidemic has been called the “most consequential preventable public health problem in the United States.” Though there is wide recognition of the role of prescription opioids in the epidemic, evidence has shown that heroin and synthetic opioids contribute to the majority of opioid overdose deaths. It is essential to reframe the preventive strategies in place against the opioid crisis with attention to factors surrounding the illicit use of fentanyl and heroin. Data on opioid overdose deaths shows 42,000 deaths in 2016. Of these, synthetic opioids other than methadone were responsible for over 20,000, heroin for over 15,000, and natural and semisynthetic opioids other than methadone responsible for over 14,000. Fentanyl deaths increased 520% from 2009 to 2016 (increased by 87.7% annually between 2013 and 2016), and heroin deaths increased 533% from 2000 to 2016. Prescription opioid deaths increased by 18% overall between 2009 and 2016. The Drug Enforcement Administration (DEA) mandated reductions in opioid production by 25% in 2017 and 20% in 2018. The number of prescriptions for opioids declined significantly from 252 million in 2013 to 196 million in 2017 (9% annual decline over this period), falling below the number of prescriptions in 2006. In addition, data from 2017 shows significant reductions in the milligram equivalence of morphine by 12.2% and in the number of patients receiving high dose opioids by 16.1%. This manuscript describes the escalation of opioid use in the United States, discussing the roles played by drug manufacturers and distributors, liberalization by the DEA, the Food and Drug Administration (FDA), licensure boards and legislatures, poor science, and misuse of evidencebased medicine. Moreover, we describe how the influence of pharma, improper advocacy by physician groups, and the promotion of literature considered peer-reviewed led to the explosive use of illicit drugs arising from the issues surrounding prescription opioids. This manuscript describes a 3-tier approach presented to Congress. Tier 1 includes an aggressive education campaign geared toward the public, physicians, and patients. Tier 2 includes facilitation of easier access to non-opioid techniques and the establishment of a National All Schedules Prescription Electronic Reporting Act (NASPER). Finally, Tier 3 focuses on making buprenorphine more available for chronic pain management as well as for medication-assisted treatment. Key words: Opioid epidemic, fentanyl and heroin epidemic, prescription opioids, National All Schedules Prescription Electronic Reporting Act (NASPER), Prescription Drug Monitoring Programs (PDMPs)

scholarly journals Using Twitter to Surveil the Opioid Epidemic in North Carolina: An Exploratory Study

10.2196/17574 ◽  
2020 ◽  
Vol 6 (2) ◽  
pp. e17574
Author(s):  
Mohd Anwar ◽  
Dalia Khoury ◽  
Arnie P Aldridge ◽  
Stephanie J Parker ◽  
Kevin P Conway
Keyword(s):  
North Carolina ◽  
Language Processing ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Opioid Epidemic ◽  
Least Squares Regression ◽  
Online Data ◽  
Synthetic Opioids ◽  
Opioid Crisis ◽  
Twitter Data

Background Over the last two decades, deaths associated with opioids have escalated in number and geographic spread, impacting more and more individuals, families, and communities. Reflecting on the shifting nature of the opioid overdose crisis, Dasgupta, Beletsky, and Ciccarone offer a triphasic framework to explain that opioid overdose deaths (OODs) shifted from prescription opioids for pain (beginning in 2000), to heroin (2010 to 2015), and then to synthetic opioids (beginning in 2013). Given the rapidly shifting nature of OODs, timelier surveillance data are critical to inform strategies that combat the opioid crisis. Using easily accessible and near real-time social media data to improve public health surveillance efforts related to the opioid crisis is a promising area of research. Objective This study explored the potential of using Twitter data to monitor the opioid epidemic. Specifically, this study investigated the extent to which the content of opioid-related tweets corresponds with the triphasic nature of the opioid crisis and correlates with OODs in North Carolina between 2009 and 2017. Methods Opioid-related Twitter posts were obtained using Crimson Hexagon, and were classified as relating to prescription opioids, heroin, and synthetic opioids using natural language processing. This process resulted in a corpus of 100,777 posts consisting of tweets, retweets, mentions, and replies. Using a random sample of 10,000 posts from the corpus, we identified opioid-related terms by analyzing word frequency for each year. OODs were obtained from the Multiple Cause of Death database from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Least squares regression and Granger tests compared patterns of opioid-related posts with OODs. Results The pattern of tweets related to prescription opioids, heroin, and synthetic opioids resembled the triphasic nature of OODs. For prescription opioids, tweet counts and OODs were statistically unrelated. Tweets mentioning heroin and synthetic opioids were significantly associated with heroin OODs and synthetic OODs in the same year (P=.01 and P<.001, respectively), as well as in the following year (P=.03 and P=.01, respectively). Moreover, heroin tweets in a given year predicted heroin deaths better than lagged heroin OODs alone (P=.03). Conclusions Findings support using Twitter data as a timely indicator of opioid overdose mortality, especially for heroin.

Summary and conclusions

2018 ◽  
Author(s):  
Thomas F. Babor ◽  
Jonathan Caulkins ◽  
Benedikt Fischer ◽  
David Foxcroft ◽  
Keith Humphreys ◽  
...  
Keyword(s):  
International Organizations ◽  
Drug Policy ◽  
Drug Users ◽  
Illicit Drug ◽  
Supply And Demand ◽  
Unintended Consequences ◽  
Public Health Approach ◽  
Drug Supply ◽  
The Public ◽  
Balanced Approach

Among the 47 options reviewed in this book, most show some evidence of effectiveness in at least one country, but the evidence is less than definitive for many others, either because the interventions are ineffective, or the research is inadequate. Unfortunately, policies that have shown little or no evidence of effectiveness continue to be the preferred options of many countries and international organizations. The evidence reviewed in this book supports two overarching conclusions. First, an integrated and balanced approach to evidence-informed drug policy is more likely to benefit the public good than uncoordinated efforts to reduce drug supply and demand. Second, by shifting the emphasis toward a public health approach, it may be possible to reduce the extent of illicit drug use, prevent the escalation of new epidemics, and avoid the unintended consequences arising from the marginalization of drug users through severe criminal penalties.

Confirmed reports of bupropion sold as crack cocaine in the illicit drug supply

2021 ◽  
pp. 1-2
Author(s):  
Rachel S. Wightman ◽  
Earth Erowid ◽  
Fire Erowid ◽  
Sylvia Thyssen ◽  
Mary Wheeler ◽  
...  
Keyword(s):  
Crack Cocaine ◽  
Illicit Drug ◽  
Drug Supply

Auras of Detection: Power and Knowledge in Drug Prohibition

2021 ◽  
pp. 009145092110354
Author(s):  
Jennifer J. Carroll
Keyword(s):  
Law Enforcement ◽  
Knowledge Production ◽  
Illicit Drug ◽  
Drug Market ◽  
Epistemic Authority ◽  
People Who Use Drugs ◽  
Drug Supply ◽  
Political Implications ◽  
Starting Point ◽  
Drug Checking

Drug checking is an evidence-based strategy for overdose prevention that continues to operate (where it operates) in a legal “gray zone” due to the legal classification of some drug checking tools as drug paraphernalia—the purview of law enforcement, not public health. This article takes the emergence of fentanyl in the U.S. drug supply as a starting point for examining two closely related questions about drug checking and drug market expertise. First, how is the epistemic authority of law enforcement over the material realities of the drug market produced? Second, in the context of that authority, what are the socio-political implications of technologically advanced drug checking instruments in the hands of people who use drugs? The expertise that people who use drugs maintain about the nature of illicit drug market and how to navigate the illicit drug supply has long been discounted as untrustworthy, irrational, or otherwise invalid. Yet, increased access to drug checking tools has the potential to afford the knowledge produced by people who use drugs a technological validity it has never before enjoyed. In this article, I engage with theories of knowledge production and ontological standpoint from the field of science, technology, and society studies to examine how law enforcement produces and maintains epistemic authority over the illicit drug market and to explore how drug checking technologies enable new forms of knowledge production. I argue that drug checking be viewed as a form of social resistance against law enforcement’s epistemological authority and as a refuge against the harms produced by drug criminalization.

354 Trends in the Drug-Sparing Effects for Benzodiazepines and Prescription Opioids among Insomnia Patients on Suvorexant in the US

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A141-A141
Author(s):  
Hrishikesh Kale ◽  
Rezaul Khandker ◽  
Ruchit Shah ◽  
Marc Botteman ◽  
Weilin Meng ◽  
...  
Keyword(s):  
Interrupted Time Series ◽  
Charlson Comorbidity Index Score ◽  
Prescription Opioid ◽  
Prescription Opioids ◽  
Opioid Use ◽  
Before And After ◽  
Prescription Opioid Use ◽  
Incident Cohort ◽  
Over Time ◽  
Post Period

Abstract Introduction Use of benzodiazepines to treat insomnia has been associated with serious side effects and abuse potential. Insomnia patients are at high risk of opioid abuse and better sleep patterns may help to reduce opioid use. This study examined the trend in the use of benzodiazepines and prescription opioids before and after initiation of suvorexant in insomnia patients. Methods The study analyzed 2015–2019, Optum Clinformatics Data Mart. Insomnia patients, identified using ICD-9/10 codes and prescribed suvorexant were included. The study included incident (newly diagnosed) and prevalent cohorts of insomnia patients. The proportion of patients on benzodiazepines or prescription opioids were calculated for 12 monthly intervals before (pre-period) and after initiation of suvorexant (post-period). Interrupted time series (ITS) analysis was conducted to assess trends for use of benzodiazepine or prescription opioids over time. Results A total of 5,939 patients from the incident insomnia cohort and 18,920 from the prevalent cohort were included. For the incident cohort, mean age was 64.47 (SD: 15.48), 63% were females, 71% had Medicare Advantage coverage, 59% had Charlson comorbidity index score (CCI) ≥ 1, 27% had an anxiety disorder and 16% had substance abuse disorder. Prevalent insomnia cohort was similar but had higher CCI. Results from ITS suggested that at the beginning of the pre-period, 28% of incident insomnia patients used either opioids or benzodiazepines with the rate of use in the pre-period increasing by 0.11% per month. In the post-period, the rate of use decreased by 0.33% per month. About 26% patients used benzodiazepines or opioids at 12-month after suvorexant initiation. In the absence of suvorexant, this proportion would have been 31%. Similar findings were observed for the prevalent insomnia cohort. A larger decrease was observed for opioid use than benzodiazepines. Conclusion The rate of benzodiazepines or prescription opioid use decreased over time after the initiation of suvorexant. Suvorexant has the potential to reduce the use of opioids and benzodiazepines among insomnia patients. Further research is needed to confirm these findings. Support (if any) This study was sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

scholarly journals Increasing presence of xylazine in heroin and/or fentanyl deaths, Philadelphia, Pennsylvania, 2010–2019

2021 ◽  
pp. injuryprev-2020-043968
Author(s):  
Jewell Johnson ◽  
Lia Pizzicato ◽  
Caroline Johnson ◽  
Kendra Viner
Keyword(s):  
Public Health ◽  
United States ◽  
Drug Users ◽  
Active Drug ◽  
Illicit Drug ◽  
Adverse Outcomes ◽  
Drug Supply ◽  
Health Consequences ◽  
Potential Health ◽  
The Usa

Reports from active drug users state that xylazine, the veterinary tranquilliser, has been increasing in the illicit drug supply in Philadelphia. To describe trends and characteristics of unintentional deaths from heroin and/or fentanyl overdose with xylazine detections occurring in Philadelphia, Pennsylvania, the Philadelphia Department of Public Health analysed data on deaths from unintentional heroin and/or fentanyl overdose from the Philadelphia Medical Examiner’s Office over a 10-year period (2010–2019). Xylazine went from being detected in less than 2% cases of fatal heroin and/or fentanyl overdose between 2010 and 2015 to 262 (31%) of the 858 fatal heroin and/or fentanyl overdose cases in 2019. Currently, information is limited on the presence of xylazine in continental United States. Xylazine’s association with adverse outcomes in other locations indicates that potential health consequences should also be monitored in the USA. Whenever possible, jurisdictions should consistently test for xylazine.

scholarly journals America’s Failing Trade War With China: A Focus on Fentanyl

2021 ◽  
Vol 8 (2) ◽  
pp. 171-182
Author(s):  
Corinna K. Hamilton
Keyword(s):  
Economic Interdependence ◽  
Prescription Opioids ◽  
State Governments ◽  
People's Republic Of China ◽  
Republic Of China ◽  
Trade Relations ◽  
Synthetic Opioids ◽  
History Of ◽  
Trade War ◽  
The U.S

As this article will explain in detail, much of the fentanyl reaching the hands of Americans comes from The People’s Republic of China (“China”). However, as seen by the rise in overdoses, most efforts to control the invasion of fentanyl have been unsuccessful. Although the federal and state governments have attempted to curtail this crisis by imposing sanctions and urging China to regulate production and shipping of the substance, fentanyl continues to flood the streets of the U.S. Moreover, the economic interdependence between the two nations complicates the matter. Because of this interdependence, the U.S. must take control of the situation. The U.S. fentanyl problem will persist if Americans are not dissuaded from using the drug. We must focus on the demand, rather than the supply. This comment focuses on the rise of opioids and synthetic pain relievers, and the variety of attempts at decreasing the number of addicts and overdoses. Initially, the comment will discuss the history of the popular drug opium, opiates, and prescription opioids, discussing state and federal attempts at curbing the crisis that the U.S. faces. It will address the rise of synthetic opioids, such as fentanyl, and how and why it was created. Section two will discuss how fentanyl and its precursors are imported into the U.S. from China. Section three will discuss U.S. federal and state attempts at legislation to control the flow of fentanyl into the U.S. Section four will address the implications, or perhaps fuel to the fire, that the influx in the supply of fentanyl from China has had on trade relations, and how the trade linkage between the two nations obfuscates the situation. The comment will conclude by hypothesizing how the U.S. and China will recalibrate their relationship and recommend that to combat the fentanyl emergency, the U.S. needs to take steps to offer Americans with drug addictions the assistance they need.

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