Background
Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation.
Methods
From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use.
Results
Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose.
Conclusions
Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.
Background: The increase of illicitly manufactured fentanyl in the drug supply and the lack of a reliable fentanyl detection method have led to a public health innovation: the community distribution and use of fentanyl test strips (FTS) to detect presence of fentanyl in drugs. The One2One project, based on a 2020 six-site pilot project, was a police-driven project spearheaded in Massachusetts and Maine in 2021 that consisted of police and community collaborators using FTS distribution as a low barrier tool to engage with people who use drugs and connect them to harm reduction supplies, services and referrals. Methods: Implementation and evaluation of the program occurred over 8-months. Policeofficers and program staff were trained on community use of FTS and were provided technical and logistical supports to encourage broad-scale local distribution of FTS kits to people who use drugs. The structure of the program encouraged departments to be innovative around FTS distribution and to use test strips as tools to support PWUDs with referrals, direct services and other harm reduction resources. The evaluation included site observations, interviews of staff and recipients, a community stakeholder survey, and analysis of administrative and demographic data to measure uptake and reach (engagement ratio and kit distribution impact rate) of the project as well as catalog implementation successes and challenges across participating police departments.Results: Twenty-one police departments and their collaborators distributed 2,556 FTS kits and reported a combined 3,703 referrals or direct services, yielding an engagement ratio of 1.44 (one referral or service per FTS kit distributed) and a kit distribution impact rate (kits distributed per overdose mortality rate) of 4.37 conveying substantial public health reach of FTS in high overdose burden communities. Qualitative data analysis captured the nuances across police departments of FTS kit distribution approaches, engagement methodologies, and the shift in willingness to embrace harm reduction principles through police-led efforts. Conclusion: FTS distribution through the One2One program exemplifies new and evolving shifts in public health and harm reduction policing roles and strategies. Further research should investigate how FTS distribution can be integrated across more geographies and implemented by other institutions.
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