Infections and mortality among people who use drugs

Bacterial and fungal infections associated with injection drug use are increasing substantially alongside trends in drug overdose deaths. Methadone and buprenorphine are two medications (MOUD) known to reduce opioid use disorder symptoms and modify underlying behaviors such as injection drug use, which are a driver of bacterial infections including skin and soft tissue infections (SSTI).The overall objective of this proposal is to expand the knowledge base concerning infection-related mortality and the potential effects of medications for opioid use disorder (MOUD) on infection-related outcomes. The project utilized an extensive dataset of public and private healthcare insurance claims linked with death certificate data for North Carolina residents during 2007 through 2018. The specific aims were to 1) examine the incidence and risk factors of bacterial and fungal infection-related mortality and drug overdose among people who use drugs, and 2) estimate the association between MOUD mortality among people with opioid use-associated skin and soft tissue infections. Bacterial and fungal infections and overdose were contributors to mortality among people with drug use diagnoses. Specifically, within the first year of follow up, overdose mortality incidence was 36 per 10,000 people (95% confidence interval: 33-40). Bacterial and fungal infection-associated mortality incidence was 16 per 10,000 people (95% confidence interval: 14-18). Bacterial and fungal infection-associated mortality was higher as age increased. In contrast, overdose mortality was higher among younger adults. People with opioid use-related skin or infections had a high risk of mortality, with 12 per every 100 people dying within the first 3 years after their initial SSI diagnosis. However, MOUD was associated with reductions in both mortality and hospitalization: for every 100 people on MOUD, there were 4 fewer deaths (95% confidence interval: 2 to 6) compared to what it would have been, had they not been on MOUD. However, few people were on MOUD (16% among the total population) following their infection diagnosis. While bacterial and fungal infections are contributors to mortality among people who use drugs, MOUD are one approach to improve the wellbeing among people who develop these infections.Doctor of Philosoph

Take-Home Dosing Experiences among Persons Receiving Methadone Maintenance Treatment During COVID-19

Purpose: Methadone maintenance treatment is a life-saving treatment for people with opioid use disorders (OUD). The coronavirus pandemic (COVID-19) introduces many concerns surrounding access to opioid treatment. In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance allowing the expansion of take-home methadone doses. We sought to describe changes to treatment experiences from the perspective of persons receiving methadone at outpatient treatment facilities for OUD. Methods: We conducted an in-person survey among 104 persons receiving methadone from three clinics in central North Carolina. Surveys collected information on demographic characteristics, methadone treatment history, and experiences with take-home methadone doses in the context of COVID-19 (i.e., before and since March 2020). Results: Before COVID-19, the clinic-level percent of participants receiving any amount of days’ supply of take-home doses at each clinic ranged from 56% to 82%, while it ranged from 78% to 100% since COVID-19. The clinic-level percent of participants receiving a take-homes days’ supply of a week or longer (i.e., ≥6 days) since COVID-19 ranged from 11% to 56%. Of the 87 participants who received take-homes since COVID-19 began, only four reported selling their take-home doses. Conclusions: Our study found variation in experiences of take-home dosing by clinic and little diversion of take-home doses. While SAMSHA guidance should allow expanded access to take-home doses, adoption of these guidelines may vary at the clinic level. The adoption of these policies should be explored further, particularly in the context of benefits to patients seeking treatment for OUD

Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply

Tobias et al. (Am J Epidemiol. 2022;191 (2):241-247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone

Xylazine informational flyer for people who use drugs

In February 2021, the North Carolina Survivors Union and the Opioid Data Lab detected a substance called xylazine alongside heroin, fentanyl, and some sugars (a common filler). Xylazine is a veterinary tranquilizer that causes central nervous system depression. While it was assessed for human use by the FDA several decades ago, it was ultimately not approved for human use. People who inject xylazine may experience unexpected symptoms, including a slowed pulse, slowed breathing, low blood pressure, and excessive fatigue. Xylazine has also been linked to skin ulceration among people who inject xylazine. In order to inform people who use drugs about xylazine, we developed a flyer containing background information and tips

Take-home dosing experiences among persons receiving methadone maintenance treatment during COVID-19

Purpose: Methadone maintenance treatment is a life-saving treatment for people with opioid use disorders (OUD). The coronavirus pandemic (COVID-19) has introduced many concerns surrounding access to opioid treatment. In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance allowing for the expansion of take-home methadone doses. We sought to describe changes to treatment experiences from the perspective of persons receiving methadone at outpatient treatment facilities for OUD. Methods: We conducted an in-person survey among 104 persons receiving methadone from three clinics in central North Carolina in June and July 2020. Surveys collected information on demographic characteristics, methadone treatment history, and experiences with take-home methadone doses in the context of COVID-19 (i.e., before and since March 2020). Results: Before COVID-19, the clinic-level percent of participants receiving any amount of days' supply of take-home doses at each clinic ranged from 56% to 82%, while it ranged from 78% to 100% since COVID-19. The clinic-level percent of participants receiving a take-homes days' supply of a week or longer (i.e., ≥6 days) since COVID-19 ranged from 11% to 56%. Among 87 participants who received take-homes since COVID-19, only four reported selling their take-home doses. Conclusions: Our study found variation in experiences of take-home dosing by clinic and little diversion of take-home doses. While SAMSHA guidance should allow expanded access to take-home doses, adoption of these guidelines may vary at the clinic level. The adoption of these policies should be explored further, particularly in the context of benefits to patients seeking OUD treatment

Research led by people who use drugs: centering the expertise of lived experience

Background: Research collaborations between people who use drugs (PWUD) and researchers are largely underutilized, despite the long history of successful, community-led harm reduction interventions and growing health disparities experienced by PWUD. PWUD play a critical role in identifying emerging issues in the drug market, as well as associated health behaviors and outcomes. As such, PWUD are well positioned to meaningfully participate in all aspects of the research process, including population of research questions, conceptualization of study design, and contextualization of findings. Main body: We argue PWUD embody unparalleled and current insight to drug use behaviors, including understanding of novel synthetic drug bodies and the dynamics at play in the drug market; they also hold intimate and trusting relationships with other PWUD. This perfectly situates PWUD to collaborate with researchers in investigation of drug use behaviors and development of harm reduction interventions. While PWUD have a history of mistrust with the medical community, community-led harm reduction organizations have earned their trust and are uniquely poised to facilitate research projects. We offer the North Carolina Survivors Union as one such example, having successfully conducted a number of projects with reputable research institutions. We also detail the fallacy of meaningful engagement posed by traditional mechanisms of capturing community voice. As a counter, we detail the framework developed and implemented by the union in hopes it may serve as guidance for other community-led organizations. We also situate research as a mechanism to diversify the job opportunities available to PWUD and offer a real-time example of the integration of these principles into public policy and direct service provision. Conclusion: In order to effectively mitigate the risks posed by the fluid and volatile drug market, research collaborations must empower PWUD to play meaningful roles in the entirety of the research process. Historically, the most effective harm reduction interventions have been born of the innovation and heart possessed by PWUD; during the current overdose crisis, there is no reason to believe they will not continue to be

Treatment experiences for skin and soft tissue infections among participants of syringe service programs in North Carolina

Introduction: Bacterial and fungal infections, such as skin and soft tissue infections (SSTIs) and infective endocarditis (IE), are increasing among people who use drugs in the United States. Traditional healthcare settings can be inaccessible and unwelcoming to people who use drugs, leading to delays in getting necessary care. The objective of this study was to examine SSTI treatment experiences among people utilizing services from syringe services programs. This study was initiated by people with lived experience of drug use to improve quality of care. Methods: We conducted a cross-sectional survey among participants of five syringe services programs in North Carolina from July through September 2020. Surveys collected information on each participant’s history of SSTIs and IE, drug use and healthcare access characteristics, and SSTI treatment experiences. We examined participant characteristics using counts and percentages. We also examined associations between participant characteristics and SSTI history using binomial linear regression models. Results: Overall, 46% of participants reported an SSTI in the previous 12 months and 10% reported having IE in the previous 12 months. Those with a doctor they trusted with drug use-related concerns had 27 fewer (95% confidence interval = − 51.8, − 2.1) SSTIs per every 100 participants compared to those without a trusted doctor. Most participants with a SSTI history reported delaying (98%) or not seeking treatment (72%) for their infections. Concerns surrounding judgment or mistreatment by medical staff and self-treating the infection were common reasons for delaying or not seeking care. 13% of participants used antibiotics obtained from sources other than a medical provider to treat their most recent SSTI. Many participants suggested increased access to free antibiotics and on-site clinical care based at syringe service programs to improve treatment for SSTIs. Conclusions: Many participants had delayed or not received care for SSTIs due to poor healthcare experiences. However, having a trusted doctor was associated with fewer people with SSTIs. Improved access to non-judgmental healthcare for people who use drugs with SSTIs is needed. Expansion of syringe services program-based SSTI prevention and treatment programs is likely a necessary approach to improve outcomes among those with SSTI and IE

Measuring the Loschmidt amplitude for finite-energy properties of the Fermi-Hubbard model on an ion-trap quantum computer

Calculating the equilibrium properties of condensed matter systems is one of the promising applications of near-term quantum computing. Recently, hybrid quantum-classical time-series algorithms have been proposed to efficiently extract these properties from a measurement of the Loschmidt amplitude $\langle \psi| e^{-i \hat H t}|\psi \rangle$ from initial states $|\psi\rangle$ and a time evolution under the Hamiltonian $\hat H$ up to short times $t$. In this work, we study the operation of this algorithm on a present-day quantum computer. Specifically, we measure the Loschmidt amplitude for the Fermi-Hubbard model on a $16$-site ladder geometry (32 orbitals) on the Quantinuum H2-1 trapped-ion device. We assess the effect of noise on the Loschmidt amplitude and implement algorithm-specific error mitigation techniques. By using a thus-motivated error model, we numerically analyze the influence of noise on the full operation of the quantum-classical algorithm by measuring expectation values of local observables at finite energies. Finally, we estimate the resources needed for scaling up the algorithm.Comment: 18 pages, 12 figure

What is Heroin Anymore?

Presentation at University of Texas Austin on drug checking

Invited commentary: Drug checking for novel insights into the unregulated drug supply.

Tobias et al. (Am J Epidemiol. 2022;191 (2):241-247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone