By Stacey Mckenna

Overdose deaths have skyrocketed across the United States in recent years, increasing by 622 percent between 2000 and 2020, with more than 112,000 lives lost in 2023. This crisis has been largely driven by the proliferation of potent synthetic opioids such as illicitly manufactured fentanyl, which is up to 50 times stronger than heroin.

The opioid antagonist, naloxone, is an especially important harm reduction tool in this landscape. Naloxone binds to opioid receptors in the brain, preventing other opioids, such as fentanyl or heroin, from binding to and activating them. The U.S. Food and Drug Administration (FDA) first approved the medication for the reversal of opioid overdoses in 1971. When administered in a timely manner, naloxone can restore breathing within minutes and successfully reverse 75 to 100 percent of overdoses.

Consequently, lawmakers and government agencies across the country have taken steps to improve access to naloxone. State legislatures have passed laws providing immunity to laypeople who administer the medication, authorized statewide standing orders to facilitate prescription-free pharmacy access, and purchased naloxone in bulk for direct distribution and to pass along to community-based organizations and first responders. Last year, the FDA approved intranasal naloxone products for over-the-counter sale for the first time.

However, with novel, increasingly potent synthetic opioids dominating the illicit supply, some medical experts worry that naloxone as we know it is simply not good enough anymore. In fact, in 2021, the FDA approved both higher-dose naloxone products and new, longer-lasting opioid antidotes, and some government agencies have begun purchasing these products for distribution in their communities.

This policy study aims to inform legislators and public health decision-makers about how high-dose naloxone fits into federal, state, and local efforts to combat the opioid overdose crisis. We examine the research on naloxone efficacy—in laboratory and medical settings and in the real world—and assess potential drawbacks associated with alternatives to standard-dose naloxone.

R Street Shorts No. 135 Washington, DC: R Street, 2024. 10p.

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 C.J. Valaseka , Samantha A. Streuli a, Heather A. Pines , Steffanie A. Strathdeec , Annick Borquez , Philippe Bourgois , Tara Stamos-Buesige , Carlos F. Verac , Alicia Harvey-Verac , Angela R. Bazzi

Background: People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods: From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results: Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants’ most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion: Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

Volume 7, June 2023, 100154, Drug and Alcohol Dependence Reports

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 Raminta Daniulaityte, Kaylin Sweeney , Seol Ki, Bradley N. Doebbeling and Natasha Mendoza

Background: Worsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona. Methods: Between October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo. Results: Out of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills (“blues,” “dirty oxys”) that were most commonly used by smoking. The majority indicated frst trying NPF pills in the past year, and the frst use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF efects. They were also infuenced by conficting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difculty of quitting, and perceived benefts of switching to the non-injection route of opioid administration (e.g., from injecting heroin to smoking NPF pills). Conclusion: Our fndings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specifc risks, attitudes, and behaviors.

Harm Reduction Journal (2022) 19:52

Edited by Bradley D. Stein, Beau Kilmer, Jirka Taylor, Mary E. Vaiana

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. In this 600-page report, researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include chapters on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education.

Santa Monica, CA: RAND, 2023. 618p.

By Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (UK)

  Serious violence and drug abuse are major problems in England and Wales. In its Serious Violence Strategy, published in April 2018, the Government identified strong links between increases in violence and the exploitation of children and vulnerable adults by criminal drug dealers operating ‘county lines’. The strategy included a commitment that Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services would carry out an inspection. Policing county lines drug offending involves three main components as follows: • The 43 territorial police forces in England and Wales. Each is responsible for policing a local area (usually a county, several counties or a metropolitan area). • A network of police-led regional organised crime units. These provide specialist policing capabilities to help the forces in their region tackle organised crime. • The National Crime Agency. This operates on a national (and international) basis, providing further specialist capabilities to support regional organised crime units and individual forces. Also, the National Crime Agency hosts the national county lines co-ordination centre (also referred to in this report as ‘the centre’), which it operates jointly with the police. For this inspection, we analysed documents and data. We visited the national county lines co-ordination centre, three regional organised crime units and ten police forces. We visited British Transport Police (which polices the rail network across Great Britain) because rail travel is a common feature of county lines offending. We interviewed relevant staff in each location. We also consulted representatives from other bodies. 

London: HMICFRS, 2020. 38p.

By Marie Gottschalk

A closer examination of media coverage, the response of law enforcement and policy makers, the legislative record, and the availability of proven, highquality treatments for substance abuse casts doubt on claims that the country pivoted toward public health and harm-reduction strategies to address the opioid crisis because its victims were disproportionately white people. Law enforcement solutions directed at people who use and sell street drugs continue to far outpace public health and harm-reduction strategies. Government support for expanding access to proven treatments for opioid use disorder that save and rebuild lives remains paltry given the scale of this public health catastrophe. And although the rhetoric has been somewhat more sympathetic, at times it rivals the excesses of the crack era. The article examines the various phases of the opioid crisis as they have unfolded over the past 25 years; related geographic and racial shifts in overdose fatalities with each new phase; media coverage of the crisis; the federal government’s response, including by the US Congress and presidents from George H.W. Bush to Joe Biden; punitive developments at the state and local levels; and the country’s poor record on prevention and making effective treatment widely available for people with substance use disorder.

Annual Review of Criminology, 2023. 6:363–98 . 39p.

By Jeffrey A. Singer and Trevor Burrus

Fifty‐one years after President Richard M. Nixon declared a “war on drugs,” overdose deaths from illicit drug use have climbed to record levels. Last November, the Centers for Disease Control and Prevention reported 100,000 overdose deaths for the 12‐month period ending in April 2021, a 28.5 percent increase over the year before. Nearly 76,000 of those deaths were opioid related, and 83 percent of opioid‐related deaths involved illicit fentanyl.

Fentanyl is a highly potent opioid—about 50 times stronger than heroin—that can easily cause overdoses, particularly if users don’t know if it is in their drug supply or how much. Over the past decade, drug traffickers have increasingly preferred fentanyl because of its compact size. The smuggler’s preference for higher potency drugs is a manifestation of the “iron law of prohibition,” and it is almost the entire reason fentanyl has poisoned the American drug supply. The iron law of prohibition states that, all things being equal, as enforcement ramps up, smugglers prefer higher potency forms of a drug for the same reason those who sneak alcohol into a football game prefer hard alcohol in flasks to 12‐packs of beer. The lethal logic of the iron law of prohibition means that we cannot enforce our way out of the opioid crisis. And if fentanyl smugglers bexcome somehow easy to catch, there’s always carfentanil, which is about 100 times more potent than fentanyl and has already been showing up in America’s drug supply.

Washington, DC: Cato Institute, 2022. 10p.

By Jeffrey A. Singer

Dr. Rahul Gupta, the White House director of the Office of National Drug Control Policy, stated the Biden administration would be “prioritizing harm-reduction practices because these are proven, cost-effective and evidence-based methods that work to save lives.”1 Overdose prevention centers (OPCs) are a successful harm-reduction strategy that has been saving lives in 16 developed countries—including the United States, where such facilities operate in defiance of the law. OPCs, also known as safe consumption sites or drug consumption rooms, began in Europe in the mid-1980s.2 Governments and harm-reduction organizations now operate OPCs in much of Europe, Canada, Mexico, and Australia. Unfortunately, a federal law that prosecutors and harm reduction opponents call the “crack house” statute (21 U.S.C. Section 856) makes them illegal in the United States.3 Some OPCs in the United States operate in the shadows. Underground OPCs have been providing services since at least 2014. More recently, state and local officials have been approving OPCs in defiance of federal law. This policy brief reviews how OPCs are an effective, mainstream harm-reduction strategy. Congress should stop standing in the way of local harm-reduction organizations that seek to reduce overdose deaths by establishing OPCs.

Washington, DC: Cato Institute, 2023. 12p.

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).

• More.....

  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 Vanda Felbab-Brown

Synthetic opioids remain the source of the deadliest U.S. drug epidemic ever. Since 1999, drug overdoses have killed approximately 1 million Americans,[1] an overdose lethality that has increased significantly since 2012 when synthetic opioids from China began supplying the U.S. demand for illicit opioids. Even though China placed the entire class of fentanyl-type drugs and two key fentanyl precursors under a controlled regulatory regime in May 2019, it remains the principal (if indirect) source of U.S. fentanyl. Fentanyl scheduling and China’s adoption of stricter mail monitoring has created some deterrence effects. Instead of finished fentanyl being shipped directly to the United States, most smuggling now takes place via Mexico. Mexican criminal groups source fentanyl precursors — and increasingly pre-precursors — from China, and then traffic finished fentanyl from Mexico to the United States. Scheduling of fentanyl and its precursors in China is not sufficient to stem flows to the United States.

• More.....

  There is little visibility into China’s enforcement of its fentanyl regulations, but it clearly remains limited. U.S.-China counternarcotics cooperation remains fraught, and from the U.S. perspective inadequate. Rejecting U.S. blame of China for the opioid epidemic and emphasizing U.S. responsibilities for that calamity, Beijing points to its benevolence in anti-drug cooperation. But China’s cooperation with the U.S. in the global counternarcotics campaign has been subordinated to the overall deteriorated geostrategic relationship between the two superpowers. There is little prospect that in the absence of significant warming of the overall U.S.-China bilateral relationship, China would significantly intensify its anti-drug cooperation with the United States. U.S. punitive measures, such as sanctions and drug indictments, are unlikely to change that. Structural characteristics of synthetic drugs, including the ease of developing similar, but not scheduled synthetic drugs and their new precursors — increasingly a wide array of dual-use chemicals — pose immense structural obstacles to controlling supply, irrespective of political will to prohibit and regulate their use and enforce the regulations.

New York: Brennan Center for Justice, 2022. 84p.

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.