Shifting Pathways of Stimulant Use Among Individuals With Opioid Use Disorder: A Retrospective Analysis of the Last Thirty Years

Background: Stimulant use among individuals with opioid use disorder has recently increased, driven by changes in drug distribution channels. However, our understanding of polysubstance use is often limited by a need to provide targeted treatment to a primary drug of addiction. Yet there is a crucial need to better understand pathways to addiction, and how the use of multiple substances may differ between populations, as well as time periods.Methods: Using a national opioid surveillance system, we analyzed survey data from new entrants to 124 opioid use disorder treatment centers from 2017 to 2020. Age of first use was collected for prescription opioids, illicit opioids, prescription stimulants, crack/cocaine, and methamphetamines. Year of initial use of an opioid or stimulant was calculated and grouped by 5 year blocs, inclusive of initial use starting from 1991 and ending in 2020 (n = 6,048).Results: Lifetime exposure to stimulants was 82.5% among individuals with opioid use disorder. Mean age of initiation increased for all drugs in 2016–2020, in particular prescription opioids (22.3 to 31.8). Stimulants were initiating drugs for a substantial proportion of individuals with opioid use throughout the analyzed time period. Those initiating opioid/stimulant use from 1991 to 1995 had a mean average of 6.8 years between first and second drug exposure, which steadily decreased to 1.5 years between exposures in 2016–2020. Sankey plots depict significantly more drug transitions in those initiating use from 1991 to 2000 (65.1% had at least two drug transitions) compared to 2010–2020 (16.0%). Opioid-stimulant use increased over time among racial/ethnic minorities, sexual minorities, and those with an educational attainment of high school or less.Conclusion: These data highlight not only the substantial prevalence of stimulant use among individuals who develop opioid use disorder, but also the variability through which pathways of use occur. Prevention and intervention efforts need to take into account increasing ages of initial drug exposures, demographic shifts in stimulant-using populations, and more rapid drug transitions between opioid and stimulants. But at a broader level, prevention, harm reduction ideology, and addiction medicine needs to take into account the ubiquity of polysubstance use among individuals with substance use disorders.

Prevalence of crack cocaine use and its associated factors in patients treated in a specialized outpatient service

Background Despite the advance in studies addressing the use of crack cocaine, knowledge about the characteristics of users that seek treatment in the different modalities of care for substance use disorders is important to plan the operationalization of these services. Objective To analyze the prevalence and factors associated with the use of crack cocaine in outpatients. Method Cross-sectional study consisting in the analysis of the medical records of outpatients of a chemical dependency clinic located in the south of Brazil from 1999 to 2015. The Fisher’s exact test and the Poisson regression model were used to analyze the data. Results Medical records from 1,253 patients were analyzed, and 1,196 (95.5%) of them contained information on the use of crack cocaine. Use of this substance was reported by 47% (95% CI [44, 50]) of the outpatients. The risk group was composed of adults aged 20-39 years, with no income, who had three or more children, did not consume alcohol or marijuana, had continuous family assistance, spontaneously looked for the service, and had already been hospitalized or assisted at a therapeutic community or psychosocial center. Conclusion There is great demand for the outpatient care of crack cocaine users. It is crucial that the risk factors guide treatment planning.

Using Surveillance With Near–Real-Time Alerts During a Cluster of Overdoses From Fentanyl-Contaminated Crack Cocaine, Connecticut, June 2019

In 2019, Connecticut launched an opioid overdose–monitoring program to provide rapid intervention and limit opioid overdose–related harms. The Connecticut Statewide Opioid Response Directive (SWORD)—a collaboration among the Connecticut State Department of Public Health, Connecticut Poison Control Center (CPCC), emergency medical services (EMS), New England High Intensity Drug Trafficking Area (HIDTA), and local harm reduction groups—required EMS providers to call in all suspected opioid overdoses to the CPCC. A centralized data collection system and the HIDTA overdose mapping tool were used to identify outbreaks and direct interventions. We describe the successful identification of a cluster of fentanyl-contaminated crack cocaine overdoses leading to a rapid public health response. On June 1, 2019, paramedics called in to the CPCC 2 people with suspected opioid overdose who reported exclusive use of crack cocaine after being resuscitated with naloxone. When CPCC specialists in poison information followed up on the patients’ status with the emergency department, they learned of 2 similar cases, raising suspicion that a batch of crack cocaine was mixed with an opioid, possibly fentanyl. The overdose mapping tool pinpointed the overdose nexus to a neighborhood in Hartford, Connecticut; the CPCC supervisor alerted the Connecticut State Department of Public Health, which in turn notified local health departments, public safety officials, and harm reduction groups. Harm reduction groups distributed fentanyl test strips and naloxone to crack cocaine users and warned them of the dangers of using alone. The outbreak lasted 5 days and tallied at least 22 overdoses, including 6 deaths. SWORD’s near–real-time EMS reporting combined with the overdose mapping tool enabled rapid recognition of this overdose cluster, and the public health response likely prevented additional overdoses and loss of life.

The association between non-injection drug use and hepatitis C infection among HIV-negative men who have sex with men

Background: This study investigated the association between drug use and Hepatitis C Virus (HCV) infection in HIV-negative men who have sex with men (MSM) who reported drug use but not injection drug use. Methods: This cross-sectional study analyzed the data of 118 HIV-negative MSM who reported drug use but not injection drug use recruited from two inner-city communities between 2004 and 2007. Latent class analysis (LCA) was used to identify drug use latent classes. Multinomial logistic regression analysis was used to evaluate the association between drug use latent class and HCV infection. Results: Four distinct latent classes of drug use were identified: (1) persons >=42 years old who used only crack cocaine, (2) persons about 42 years old who used >2 drugs, (3) persons <42 years old who used >5 drugs, and (4) persons >=42 years old who used >6 drugs. Class 4, persons >= 42 years old who used >6 drugs were significantly associated with HCV infection. Compared with persons about 42 years old who used >2 drugs, persons >=42 years old who used >6 drugs had more than 16 times the odds of having HCV infection (adjusted OR = 16.9, 95%CI: 1.4-205.4), and compared with persons <42 years old who used >5 drugs, persons >=42 years old who used >6 drugs were about 22 times as likely to have HCV infection (adjusted OR=21.8, 95%CI: 1.5-322.8). Conclusions: The subgroup of MSM >=42 years old with non-injection but multiple use of heroin, speedball, and methamphetamine, in addition to crack cocaine and marijuana, had high probability of HCV infection. Public health and education programs, as well as drug treatment and rehabilitation programs, should be developed for this high-risk subgroup to prevent HCV acquisition and transmission.

Stimulant Use Interventions May Strengthen ‘Getting to Zero’ Initiatives in Illinois: Insights from a Modeling Study

Objective(s)Young Black men who have sex with men (YBMSM) are a key population identified in the Illinois Getting to Zero (GTZ) initiative who have experienced disproportionate HIV incidence. Rising stimulant use has been determined to impede the effectiveness of ART and pre-exposure prophylaxis for suppressing HIV transmission in populations. This modeling study explores the impact of stimulant use on HIV incidence among YBMSM – given the limited development of dedicated or culturally appropriate interventions for this population – and assesses the impact of these interventions on downstream HIV transmission in the context of achieving GTZ goals.MethodsA previously developed agent-based network model (ABNM), calibrated using data for YBMSM in Illinois, was extended to incorporate the impact of stimulant use (methamphetamines, crack/cocaine, and ecstasy) on sexual networks and engagement in HIV treatment and prevention continua. The model simulated the impact of a residential behavioral intervention (BI) for reducing stimulant dependency and an outpatient biomedical intervention (mirtazapine) for treating methamphetamine dependence on improved engagement in the HIV treatment and prevention continua. The downstream impact of these interventions on population-level HIV incidence was the primary intervention outcome.ResultsBaseline simulated annual HIV incidence in the ABNM was 6.9(95% CI: 6.83,7.04) per 100 person years (py) and 453 (95% CI: 445.9,461.2) new infections annually. A residential targeted to 25% of stimulant users yielded a 27.1% decline in the annual number of new infections. Initiating about 50% of methamphetamine users on mirtazapine reduced the overall HIV incidence by about 11%. A 25% increase in antiretroviral treatment (ART) and preexposure prophylaxis (PrEP) uptake in the non-stimulant using YBMSM population combined with a 25% uptake of BI for stimulant users produces an HIV incidence consistent with HIV elimination targets (about 200 infections/year) identified in the GTZ initiative.ConclusionsTargeted behavioral and biomedical interventions to treat stimulant dependency are likely to provide additive benefits to expanding ART and PrEP uptake for everyone in accomplishing GTZ initiatives for HIV elimination.

Association between alcohol and crack: Prevalence, effects, associated factors and experiences of combined use

Objective To estimate the prevalence and factors associated with the effect of alcohol on crack cocaine use and to analyze experiences related to combined use. Materials and methods: sequential mixed methods (qualitative and quantitative) research, carried out between August 2014 and August 2015 with people who use crack. In the quantitative approach, a cross-sectional study was conducted with 1,062 participants. Factors associated with “alcohol use with the effect of increasing the effect of crack/crack craving” were estimated by multiple regression. In the qualitative approach, 39 interviews were conducted using Bardin’s content analysis technique. Results 871 (82.0%) participants reported consuming alcohol, among them, 668 (76.7%) used alcohol combined with crack: 219 (32.8%) reported feeling an effect of reduction in paranoia and/or crack craving and 384 (57.5%) reported feeling an increase in the effect of crack and in the craving to consume the drug. This relationship was also observed in the narratives of the people who use crack, with the possibility of a cyclic effect of consumption of the two substances. Those who related alcohol use to the effect of increasing crack craving (384) were more likely to use alcohol before crack (OR: 1.81; 95%CI: 1.13–2.89); to consume more than 20 stones daily (OR: 1.48; 95%CI: 1.01–2.16); to remain in abstinence from crack for less than one month (OR: 3.20; 95%CI: 1.91–5.35); to use dependence treatment services (OR: 1.85; 95%CI: 1.26–2.71); and to commit physical violence (OR:1.67; 95%CI:1.08–2.56). Conclusion The findings of this study indicate that the modulation of the effect of alcohol use on crack cocaine depends on the moment when the drugs are consumed, and the use of alcohol before crack consumption is associated with characteristics that suggest a greater vulnerability to patterns of harmful crack use. Even though combined use is referred to as a way of reducing the negative effects of crack, the damage of this association may be greater than its possible benefits.