Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon.

INTRODUCTION: Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply. METHODS: We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone. CONCLUSION: People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

COVID-19 Vaccination Status and Concerns Among People Who Use Drugs in Oregon.

OBJECTIVES: The objective of this study was to examine COVID-19 vaccination acceptance and explore reasons for COVID-19 vaccine hesitancy among people who use drugs (PWUDs), a population with increased COVID-19 transmission and morbidity. METHODS: We conducted semi-structured in-depth interviews with PWUDs in 7 Oregon counties from May 11 to June 25, 2021. Participants (n = 34) were recruited in partnership with syringe service programs and local community organizations staff, participant-referrals, and flyer advertising. Research staff conducted interviews via telephone to assess participants' acceptance of the COVID-19 vaccine, find knowledge gaps where new educational information about vaccination would be helpful, and identify who would be perceived as a trustworthy source of information. Interviews were transcribed and coded using thematic analysis with a deductive approach. RESULTS: Most participants had not received the COVID-19 vaccine and were not planning on or were unsure about receiving it. Participants were mistrustful of the rapid COVID-19 vaccine development process, the agencies involved in the development, and vaccines in general. Participants shared varied and contrasting responses about who they would trust to provide information about the COVID-19 vaccine, including peer recovery support specialists, doctors, or other health care professionals, and specified federal agencies or media outlets. CONCLUSIONS: As addiction medicine and public health staff continue to respond to the evolving impacts of COVID-19, vaccination planning should be tailored to the unique needs of PWUD to increase COVID-19 vaccine acceptance in this high-risk population.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply.

BACKGROUND: Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl's dramatic increase in the recreational drug supply over the past decade. METHODS: We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers. CONCLUSION: PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Peer Recovery Support Services Across the Continuum: In Community, Hospital, Corrections, and Treatment and Recovery Agency Settings - A Narrative Review.

In this narrative review, we outline the literature describing the history, training, certification, and role of peer recovery support specialists working with people with substance use disorders at different stages of active use and recovery. We explore the impact of peer recovery support specialists serving people in various settings, including the community, hospitals and emergency departments, jails and prisons, and treatment and recovery agencies; and describes considerations for future expansion of peer recovery support services, including supervision needs, compassion fatigue and burnout, and scope of practice. Finally, we make recommendations to support the broad implementation of peer recovery support services as a sustainable, cohesive, and replicable component of harm reduction and addiction services. We also make recommendations for research to continue to evaluate peer recovery support specialist interventions across settings and outcomes.

Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality.

BACKGROUND: Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects. METHODS: We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply. RESULTS: In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73. CONCLUSIONS: Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.

Predictors of having naloxone in urban and rural Oregon findings from NHBS and the OR-HOPE study.

PURPOSE: Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon. BASIC PROCEDURES: We used data from participants in Portland's National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics. MAIN FINDINGS: Sixty one percent of NHBS and 30 % of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment. PRINCIPAL CONCLUSIONS: Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.

Harm Reduction and Adaptations Among PWUD in Rural Oregon During COVID-19.

Coronavirus Disease 2019 (COVID-19) may influence HIV/HCV transmission risk behaviors in rural communities. We conducted semi-structured qualitative interviews with people who use drugs (PWUD) in five rural Oregon counties and asked about COVID-19 impact on substance use and harm reduction practices and their advice for improving public health responses. Participants (n = 36) reported using only methamphetamine (52.8%), only heroin (16.7%), or both (30.6%); 75% of participants reported recent injection. Three thematic categories emerged: SSP adaptations and accessibility, PWUD harm reduction practices, and policy suggestions. Participants noted the importance of SSPs to COVID-19 prevention and wellbeing, though some experienced increased barriers, leading to increased risky injection practices. Participants suggested need-based rather than one-for-one exchange, increasing syringe delivery services, encouraging secondary exchange by PWUD, and peers as trusted voices for information exchange. Rapid implementation of policy and practice changes are urgently required to improve SSP access, reinforce safer use, and prevent HIV/HCV and COVID-19 transmission.

"Like Yin and Yang": Perceptions of Methamphetamine Benefits and Consequences Among People Who Use Opioids in Rural Communities.

OBJECTIVES: The objective of this study was to investigate methamphetamine use among people who use opioids in rural Oregon communities to explore reasons for use and perceptions of methamphetamine consequences. METHODS: We conducted interviews and surveys with participants who inject drugs or misuse prescription opioids in 2 rural Oregon counties with high opioid overdose rates. Survey participants were identified through participant-driven sampling initiated in syringe service programs and field outreach (n = 144). Semi-structured interviews with participants were recruited from the same locations (n = 52). RESULTS: Of 144 surveys completed, 112 reported using opioids in the past 30 days; 96% of the 112 also report methamphetamine use. Among the 124 reporting injection drug use, 50% indicated they injected both methamphetamine and heroin in the past 30 days. Interview participants reported early exposure to methamphetamine and indicated that methamphetamine was more widely available, less expensive, and less stigmatized compared to heroin. Participants reported using methamphetamine to improve work-life functioning and because they enjoy the high produced from simultaneous use. Several participants reported a conscious effort to shift to methamphetamine from heroin as a harm reduction strategy.Some participants reported being involuntarily discharged from treatment for opioid use disorder due to methamphetamine use. Several participants perceived methamphetamine as conveying overdose prevention or reversal benefits, while fentanyl contamination in methamphetamine was reported or suspected. CONCLUSION: As rural communities respond to evolving drug supply and demand, there is increasing need for public health efforts to address the emerging issue of concurrent methamphetamine and opioid use.

The Impacts of COVID-19 on Mental Health, Substance Use, and Overdose Concerns of People Who Use Drugs in Rural Communities.

OBJECTIVES: The objective of this study was to investigate the impact of COVID-19 on the mental health, substance use, and overdose concerns among people who use drugs (PWUDs) in rural communities to explore reasons for changes and ways to mitigate COVID-19 impact in the future. METHODS: We conducted semi-structured in-depth interviews with PWUDs in 5 rural Oregon counties with high overdose rates. Participants were identified through participant-driven sampling along with flyer and text advertising (n = 36). Research staff conducted audio-recorded in-depth interviews via telephone, assessing COVID-19 effects on substance use, mental health, and overdose risk. Transcribed interviewers were coded for themes using a semantic approach. RESULTS: Participants reported various mental health symptoms and experiences due to COVID-19, including increased feelings of boredom, loneliness, and depression; increased worry and stress; and increased suicidal ideation. Participants described varying impacts of COVID-19 on substance use. Overall, participants who used only methamphetamine reported decreased use and people who used only heroin or heroin with methamphetamine reported increased use. Most participants reported that they were not concerned about overdose and that COVID-19 did not impact their concerns about overdose, despite increases in risky use and suicidal ideations. CONCLUSIONS: As rural communities respond to the evolving impacts of COVID-19, there is increasing need to identify strategies to address PWUD's mental, physical, and social health needs during COVID-19.

Challenges with hepatitis B vaccination of high risk adults - A pilot program.

BACKGROUND: Acute hepatitis B virus (HBV) infections in the United States occur predominantly among persons aged 30-59 years. The Centers for Disease Control and Prevention (CDC) recommends vaccination of adults at increased risk for HBV infection. Completing the hepatitis B (HepB) vaccine dose-series is critical for optimal immune response. OBJECTIVES: CDC funded 14 health departments (awardees) from 2012 to 2015 to implement a pilot HepB vaccination program for high-risk adults. We evaluated the pilot program to assess vaccine utilization; vaccine dose-series completion, including by vaccination location type; and implementation challenges. METHODS: Awardees collaborated with sites providing health care to persons at increased risk for HBV infection. Awardees collected information on doses administered, vaccine dose-series completion, and challenges completing and tracking vaccinations, including use of immunization information systems (IIS). Data were reported by each awardee in aggregate to CDC. RESULTS: Six of 14 awardees administered 47,911 doses and were able to report patient-level dose-series completion. Among persons who received dose 1, 40.4% received dose 2, and 22.3% received dose 3. Local health department clinics had the highest 3-dose-series completion, 60.6% (531/876), followed by federally qualified health centers at 38.0% (923/2432). While sexually transmitted diseases (STD) clinics administered the most doses in total (17,173 [35.8% of 47,911 doses]), 3-dose-series completion was low (17.1%). The 14 awardees reported challenges regarding completing and tracking dose-series, including reaching high-risk adults for follow-up and inconsistencies in use of IIS or other tracking systems across sites. CONCLUSIONS: Dose-series completion was low in all settings, but lowest where patients may be less likely to return for follow-up (e.g., STD clinics). Routinely assessing HepB vaccination needs of high-risk adults, including through use of IIS where available, may facilitate HepB vaccine dose-series completion.