Analysis of Wastewater Samples to Explore Community Substance Use in the United States: Pilot Correlative and Machine Learning Study.

BACKGROUND: Substance use disorder and associated deaths have increased in the United States, but methods for detecting and monitoring substance use using rapid and unbiased techniques are lacking. Wastewater-based surveillance is a cost-effective method for monitoring community drug use. However, the examination of the results often focuses on descriptive analysis. OBJECTIVE: The objective of this study was to explore community substance use in the United States by analyzing wastewater samples. Geographic differences and commonalities of substance use were explored. METHODS: Wastewater was sampled across the United States (n=12). Selected drugs with misuse potential, prescriptions, and over-the-counter drugs and their metabolites were tested across geographic locations for 7 days. Methods used included wastewater assessment of substances and metabolites paired with machine learning, specifically discriminant analysis and cluster analysis, to explore similarities and differences in wastewater measures. RESULTS: Geographic variations in the wastewater drug or metabolite levels were found. Results revealed a higher use of methamphetamine (z=-2.27, P=.02) and opioids-to-methadone ratios (oxycodone-to-methadone: z=-1.95, P=.05; hydrocodone-to-methadone: z=-1.95, P=.05) in states west of the Mississippi River compared to the east. Discriminant analysis suggested temazepam and methadone were significant predictors of geographical locations. Precision, sensitivity, specificity, and F1-scores were 0.88, 1, 0.80, and 0.93, respectively. Finally, cluster analysis revealed similarities in substance use among communities. CONCLUSIONS: These findings suggest that wastewater-based surveillance has the potential to become an effective form of surveillance for substance use. Further, advanced analytical techniques may help uncover geographical patterns and detect communities with similar needs for resources to address substance use disorders. Using automated analytics, these advanced surveillance techniques may help communities develop timely, tailored treatment and prevention efforts.

Using wastewater to overcome health disparities among rural residents.

The SARS-CoV-2 pandemic highlighted the need for novel tools to promote health equity. There has been a historical legacy around the location and allocation of public facilities (such as health care) focused on efficiency, which is not attainable in rural, low-density, United States areas. Differences in the spread of the disease and outcomes of infections have been observed between urban and rural populations throughout the COVID-19 pandemic. The purpose of this article was to review rural health disparities related to the SARS-CoV-2 pandemic while using evidence to support wastewater surveillance as a potentially innovative tool to address these disparities more widely. The successful implementation of wastewater surveillance in resource-limited settings in South Africa demonstrates the ability to monitor disease in underserved areas. A better surveillance model of disease detection among rural residents will overcome issues around the interactions of a disease and social determinants of health. Wastewater surveillance can be used to promote health equity, particularly in rural and resource-limited areas, and has the potential to identify future global outbreaks of endemic and pandemic viruses.

Analysis of Substance Use and Suicidal Ideation in Midwestern Frontier and Non-Frontier Locations.

BACKGROUND: Emergency departments represent a unique opportunity to intervene in mental health and substance use crises. For people residing in frontier and remote locations (greater than 60 min from cities of 50,000 people), emergency departments may be a critical source of mental healthcare, given limited local access to mental health professionals. The purpose of the current study was to investigate emergency department usage for substance use disorders and suicidal ideation in patients residing in frontier and non-frontier locations. METHODS: South Dakotan syndromic surveillance data from 2017-2018 were obtained for this cross-sectional study. ICD-10 codes were queried to identify substance use disorder and suicidal ideation during emergency department visits. Differences in substance use visits were investigated in frontier and non-frontier patients. Additionally, logistic regression was used to predict suicidal ideation in cases and age- and sex-matched controls. RESULTS: Frontier patients had a higher percentage of emergency department visits with a diagnosed nicotine use disorder. Conversely, non-frontier patients were more likely to use cocaine. Substance use for other categories of substances was similar between the frontier and non-frontier patients. Alcohol, cannabis, nicotine, opioid, stimulant, and psychoactive substance diagnoses all increased the patient's odds of receiving a suicidal ideation diagnosis. Further, residing in a frontier location also increased the odds of suicidal ideation. CONCLUSION: Patients residing in frontier locations differed in some forms of substance use disorders and in suicidal ideation. Increasing access to mental health and substance use treatment may be critical for those residing in these remote locations.

Population Health Metrics During the Early Stages of the COVID-19 Pandemic: Correlative Pilot Study.

BACKGROUND: COVID-19 has caused nearly 1 million deaths in the United States, not to mention job losses, business and school closures, stay-at-home orders, and mask mandates. Many people have suffered increased anxiety and depression since the pandemic began. Not only have mental health symptoms become more prevalent, but alcohol consumption has also increased during this time. Helplines offer important insight into both physical and mental wellness of a population by offering immediate, anonymous, cheap, and accessible resources for health and substance use disorders (SUD) that was unobstructed by many of the mandates of the pandemic. Further, the pandemic also launched the use of wastewater surveillance, which has the potential for tracking not only population infections but also consumption of substances such as alcohol. OBJECTIVE: This study assessed the feasibility of using multiple public surveillance metrics, such as helpline calls, COVID-19 cases, and alcohol metabolites in wastewater, to better understand the need for interventions or public health programs in the time of a public health emergency. METHODS: Ethanol metabolites were analyzed from wastewater collected twice weekly from September 29 to December 4, 2020, in a Midwestern state. Calls made to the helpline regarding housing, health care, and mental health/SUD were correlated with ethanol metabolites analyzed from wastewater samples, as well as the number of COVID-19 cases during the sampling period. RESULTS: Correlations were observed between COVID-19 cases and helpline calls regarding housing and health care needs. No correlation was observed between the number of COVID-19 cases and mental health/SUD calls. COVID-19 cases on Tuesdays were correlated with the alcohol metabolite ethyl glucuronide (EtG). Finally, EtG levels were negatively associated with mental health/SUD helpline calls. CONCLUSIONS: Although helpline calls provided critical services for health care and housing-related concerns early in the pandemic, evidence suggests helpline calls for mental health/SUD-related concerns were unrelated to COVID-19 metrics. Instead, COVID metrics were associated with alcohol metabolites in wastewater. Although this research was formative, with continued and expanded monitoring of population metrics, such as helpline usage, COVID-19 metrics, and wastewater, strategies can be implemented to create precision programs to address the needs of the population.