By Sarah S. Shin, Kate LaForge, Erin Stack, Justine Pope, Gillian Leichtling, Jessica E. Larsen, Judith M. Leahy, Andrew Seaman, Daniel Hoover, Laura Chisholm, Christopher Blazes, Robin Baker, Mikaela Byers, Katie Branson & P. Todd Korthuis

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.

Harm Reduction Journal volume 19, Article number: 76 (2022)

By Lauren J. Tanz, R. Matt Gladden, Amanda T. Dinwiddie, Kimberly D. Miller, Dita Broz, Eliot Spector, Julie O’Donnell

Summary

What is already known about this topic?

More than 109,000 drug overdose deaths occurred in the United States in 2022; nearly 70% involved illegally manufactured fentanyls (IMFs). Data from the western United States suggested a transition from injecting heroin to smoking IMFs.

What is added by this report?

From January–June 2020 to July–December 2022, the percentage of overdose deaths with evidence of smoking increased 73.7%, and the percentage with evidence of injection decreased 29.1%; similar changes were observed in all U.S. regions. Changes were most pronounced in deaths with IMFs detected, with or without stimulant detection.

What are the implications for public health practice?

Strengthening and expanding public health and harm reduction services to address overdose risk with smoking and other noninjection routes might reduce deaths.

Preliminary reports indicate that more than 109,000 drug overdose deaths occurred in the United States in 2022; nearly 70% of these involved synthetic opioids other than methadone, primarily illegally manufactured fentanyl and fentanyl analogs (IMFs). Data from the western United States suggested a transition from injecting heroin to smoking IMFs. CDC analyzed data from the State Unintentional Drug Overdose Reporting System to describe trends in routes of drug use in 27 states and the District of Columbia among overdose deaths that occurred during January 2020–December 2022, overall and by region and drugs detected. From January–June 2020 to July–December 2022, the percentage of overdose deaths with evidence of injection decreased 29.1%, from 22.7% to 16.1%, whereas the percentage with evidence of smoking increased 73.7%, from 13.3% to 23.1%. The number of deaths with evidence of smoking increased 109.1%, from 2,794 to 5,843, and by 2022, smoking was the most commonly documented route of use in overdose deaths. Trends were similar in all U.S. regions. Among deaths with only IMFs detected, the percentage with evidence of injection decreased 41.6%, from 20.9% during January–June 2020 to 12.2% during July–December 2022, whereas the percentage with evidence of smoking increased 78.9%, from 10.9% to 19.5%. Similar trends were observed among deaths with both IMFs and stimulants detected. Strengthening public health and harm reduction services to address overdose risk related to diverse routes of drug use, including smoking and other non-injection routes, might reduce drug overdose deaths.

Morbidity and Mortality Weekly Report; February 15, 2024

By Jason ElighBy Jason Eligh

Despite the extensive population containment and control measures put into place across the globe in the wake of the COVID-19 pandemic, the flow of cocaine powder from Latin America to global markets appears to have been largely uninterrupted. This is despite the fact that measures to significantly reduce supply have been put in place by the governments of Colombia – a country that is still the primary cultivator of coca – and the United States, the primary progenitor of and ally in the war on drugs.

The markets and supply chains for cocaine, as well as other illicit drugs, have proven to be remarkably resilient in the face of the growing patchwork of restrictions on movement and transport since March 2020 in the wake of the COVID-19 pandemic. The many predictions by experts of supply chain disruption to drug flows and the potentially disruptive impact of this on consumer markets have not come to pass. Cocaine distribution networks and related agents quickly found ways to bypass challenges raised by lockdowns and restrictions. Coca cultivation and potential cocaine production even expanded during the first year of the pandemic, reaching record or near-record levels in the three primary cultivation countries of the Andean production region. 

Geneva: Global Organization Against Transnational Organized Crime, 2022. 64p.

By United States and Rand Corporation

The Commission on Combating Synthetic Opioid Trafficking, established under Section 7221 of the National Defense Authorization Act for Fiscal Year 2020, was charged with examining aspects of the synthetic opioid threat to the United States—specifically, with developing a consensus on a strategic approach to combating the illegal flow of synthetic opioids into the United States. This final report describes items involving the illegal manufacturing and trafficking of synthetic opioids, as well as the deficiencies in countering their production and distribution, and includes action items directed to appropriate executive branch agencies and congressional committees and leadership. Get appendices to the report.

Rand, 2022. 148p.

By Bryce Pardo, Lois M. Davis, Melinda Moore

The opioid overdose crisis has continued to accelerate in recent years because of the arrival of potent synthetic opioids, such as fentanyl and related substances. Although several synthetic opioids have legitimate medical applications, the majority of overdoses are due to illicitly manufactured imports. Researchers from the Homeland Security Operational Analysis Center evaluated publicly available data to better understand the dimensions of the consumption and supply of these substances. They performed four tasks designed to gain insight into this new and quickly evolving phenomenon: (1) They evaluated trends in overdoses across regions and over time. Understanding where overdoses due to synthetic opioids occur provides a rough proxy for where law enforcement should prioritize screening efforts for packages that enter the country destined for such markets. (2) They evaluated the supply of fentanyl and related substances using public data from state and local forensic laboratories that report to national systems. The authors note a relationship between lab exhibits and fatal overdoses across regions and over time. (3) They examined the online markets for synthetic opioids. The team collected quantitative and qualitative data from online marketplaces and vendors to better understand what supply and concealment mechanisms vendors use when shipping product to the United States. (4) They evaluated the adulterants and other bulking agents used in retail distribution. There are limitations to each of these approaches, and the authors provide caveats to interpreting their findings.

Santa Monica, CA: Rand, 2019. 91p.

By Julie O’Donnell, Lauren J. Tanz, R. Matt Gladden, Nicole L. Davis, Jessica Bitting

During May 2020–April 2021, the estimated number of drug overdose deaths in the United States exceeded 100,000 over a 12-month period for the first time, with 64.0% of deaths involving synthetic opioids other than methadone (mainly illicitly manufactured fentanyls [IMFs], which include both fentanyl and illicit fentanyl analogs).* Introduced primarily as adulterants in or replacements for white powder heroin east of the Mississippi River (1), IMFs are now widespread in white powder heroin markets, increasingly pressed into counterfeit pills resembling oxycodone, alprazolam, or other prescription drugs, and are expanding into new markets, including in the western United States† (2). This report describes trends in overdose deaths involving IMFs (IMF-involved deaths) during July 2019–December 2020 (29 states and the District of Columbia [DC]), and characteristics of IMF-involved deaths during 2020 (39 states and DC) using data from CDC’s State Unintentional Drug Overdose Reporting System (SUDORS).

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  During July 2019–December 2020, IMF-involved deaths increased sharply in midwestern (33.1%), southern (64.7%), and western (93.9%) jurisdictions participating in SUDORS. Approximately four in 10 IMF-involved deaths also involved a stimulant. Highlighting the need for timely overdose response, 56.1% of decedents had no pulse when first responders arrived. Injection drug use was the most frequently reported individual route of drug use (24.5%), but evidence of snorting, smoking, or ingestion, but not injection drug use was found among 27.1% of decedents. Adapting and expanding overdose prevention, harm reduction, and response efforts is urgently needed to address the high potency (3), and various routes of use for IMFs. Enhanced treatment for substance use disorders is also needed to address the increased risk for overdose (4) and treatment complications (5) associated with using IMFs with stimulants.

MMWR Morb Mortal Wkly Rep 2021;70:1740-1746.

By The Scottish Drug Deaths Taskforce

This, the final report of the Scottish Drug Deaths Taskforce, sets out a suite of evidence-based recommendations and actions that will reduce drug-related deaths and harms and improve and save the lives of people who use drugs. Our final report has four substantive chapters. 1. Context: explores where we are now, gives an overview of the work of the Taskforce to date and discusses the legal context in which Scotland operates. 2. Culture: sets out what the ethos of the system should be and the changes that are needed to achieve this. It calls for broad culture change from stigma, discrimination, politicisation and punishment towards care, compassion and human rights. 3. Care: investigates what is needed to deliver an effective, consistent, personcentred, whole-systems approach that delivers high-quality care. It builds on the principle that drug dependency should receive parity with any other health conditions, with people getting the care they need when they need it. 4. Co-ordination: sets out the foundations of the changes that are required, including targeted resource and decisive leadership. Twenty overarching recommendations are provided at the beginning of the report. Each chapter then includes evidence-based actions that are summarised in a table at the end of the report.

Edinburgh: The Scottish Drug Deaths Taskforce, 2022. 135p.

By Gianmarco Daniele, Marco Le Moglie, Federico Masera

The opioid epidemic and migration along the US–Mexico border are two of the most-debated policy issues in recent US politics. We show how these two topics are interlinked: the US opioid epidemic generated large Mexican migration flows. We exploit the fact that in 2010, a series of reforms to the US health care system resulted in a shift in demand from legal opiates to heroin. This demand shock had considerable effects on Mexico, the main supplier of heroin consumed in the US. Violence and conflicts increased in Mexican municipalities suitable for opium production, as they became highly valuable to drug cartels. People migrated out of these municipalities to escape this violence, mostly to areas close to the US border and into the US. The rise in US demand for heroin increased internal migration by an estimated 90,000 individuals and migration across the border at least by 12,000

BAFFI CAREFIN Centre Research Paper No. 2020-141, 2020. 60p.

By Lucas Marín Llanes and Hernando Zuleta

There is scarce empirical evidence on the impacts of drug consumption decriminalization, especially, on problematic drug use and violence. In 2001, Portugal decriminalized the consumption of all illicit drugs. In this paper, we focus on determining the short, medium, and long-term impact of Portuguese decriminalization on mortality due to drug use and homicides, from both theoretical and empirical perspectives. We model drug consumption using an intertemporal consumption model and the decisions of trafficking firms to gain market share employing an optimization model. Our results suggest a non-linear effect of decriminalization on drug consumption risk and increasing incentives for firms to expand their market share employing violence after decriminalization. Empirically, we estimate a negative short-run effect on drug-related deaths and null long-run impacts of this legal reform. In terms of homicides, we find a positive effect in a range of 28.7%-34.2% in the medium- and long-term.

Colombia: Universidad de los Andes, 2022. 38p.

Edited by Bruce M. Bagley and Jonathan D. Rosen

In 1971, Richard Nixon declared a war on drugs. Despite foreign policy efforts and attempts to combat supply lines, the United States has been for decades, and remains today, the largest single consumer market for illicit drugs on the planet.

This volume argues that the war on drugs has been ineffective at best and, at worst, has been highly detrimental to many countries. Leading experts in the fields of public health, political science, and national security analyze how U.S. policies have affected the internal dynamics of Mexico, Colombia, Bolivia, Peru, Brazil, Argentina, Central America, and the Caribbean islands. Together, they present a comprehensive overview of the major trends in drug trafficking and organized crime in the early twenty-first century.

In addition, the editors and contributors identify emerging issues and propose several policy options to address them. This accessible and expansive volume provides a framework for understanding the limits and liabilities in the U.S.-championed war on drugs throughout the Americas.

Gainesville: University Press of Florida, 2015. 464p.

By June S. Beittel

Mexican transnational criminal organizations (TCOs) significantly influence drug trafficking in the United States and pose the greatest drug trafficking threat, according to the U.S. Drug Enforcement Administration’s (DEA’s) annual National Drug Threat Assessment. These organizations control the market and movement of a wide range of illicit drugs destined for the United States; for this reason, they are commonly referred to as drug cartels and drug trafficking organizations (DTOs). These poly-criminal organizations also participate in extortion, human smuggling, arms trafficking, and oil theft, among other crimes. Homicide rate increases in Mexico are widely attributed to heightened DTO-related violence, often tied to territorial control over drug routes and criminal influence. Congress has tracked how Mexican TCOs affect security on the U.S.-Mexico border, perpetrate violence, and contribute to the U.S. opioid crisis. A major concern is the organizations’ trafficking of cocaine, heroin, methamphetamine, marijuana, and synthetic opioids, such as fentanyl. Many analysts assess that Mexican TCOs’ role in the production and trafficking of synthetic opioids into the United States has significantly expanded since 2018. According to the Centers for Disease Control and Prevention, more than 106,000 overdose deaths occurred in the United States in 2021, more than 70% of which involved opioids, including fentanyl.

Washington, DC: Congressional Research Service, 2022. 43p.