Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study

Abstract

Background Illicit fentanyl use has become wide spread in the US, causing high rates of overdose deaths among people who use drugs. This study describes patterns and perceptions of fentanyl exposure among opioid users in Rhode Island. Methods A mixed methods study was conducted via questionnaire with a convenience sample of 149 individuals using illicit opioids or misusing prescription opioids in Rhode Island between January and November 2016. Of these, 121 knew of fentanyl and reported known or suspected exposure to fentanyl in the past year. Semi-structured interviews were conducted with the first 47 participants. Results Study participants were predominantly male (64%) and white (61%). Demographic variables were similar across sample strata. Heroin was the most frequently reported drug of choice (72%). Self-reported exposure to illicit fentanyl in the past year was common (50.4%, n=61). In multivariate models, regular (at least weekly) heroin use was independently associated with known or suspected fentanyl exposure in the past year (adjusted prevalence ratio (APR)=4.07, 95% CI: 1.24-13.3, p=0.020). In interviews, users described fentanyl as unpleasant, potentially deadly, and to be avoided. Participants reporting fentanyl exposure routinely experienced or encountered non-fatal overdose. Heroin users reported limited ability to identify fentanyl in their drugs. Harm reduction strategies used to protect themselves from fentanyl exposure and overdose, included test hits, seeking prescription opioids in lieu of heroin, and seeking treatment with combination buprenorphine/naloxone. Participants were often unsuccessful in accessing structured treatment programs. Conclusion Among illicit opioid users in Rhode Island, known or suspected fentanyl exposure is common, yet demand for fentanyl is low. Fentanyl-contaminated drugs are generating user interest in effective risk mitigation strategies, including treatment. Responses to the fentanyl epidemic should be informed by the perceptions and experiences of local users. The rapid scale-up of buprenorphine/naloxone provision may slow the rate of fentanyl-involved overdose deaths.

Fentanyl in the US heroin supply: A rapidly changing risk environment

“…Ciccarone and colleagues report on qualitative findings from Massachusetts, a CDC “high-burden” state for synthetic overdose deaths, and point out their respondents’ discernment and mixed opinions regarding the desirability of fentanyl. This contrasts somewhat with Carroll et al’s report on their respondents’ limited ability to discern fentanyl and low desirability for it (Carroll et al 2017). Clearly use patterns and perceptions are moving targets with local and evolving cultural norms and degrees of adaptation.…”

“…An understanding of the heroin supply, and how it is changing, supports the geographic correlation between rising heroin overdose and availability of fentanyls. A ready explanation is that illicit fentanyls come in powder form and thus more easily adulterate powder heroin than solid, i.e., ‘black tar’, heroin (Carroll et al 2017); the former predominates in the eastern US while the latter is more common in the West (Ciccarone 2009). A new source-form of heroin from Mexico is an unknown entity requiring further inquiry.…”

“…Carroll and colleagues report on data from an interdisciplinary study of persons using illicit opioids in Rhode Island (Carroll et al 2017). In their survey study, participants reported that exposure to fentanyl was common and that the biggest independent risk for suspected fentanyl exposure was regular use of heroin.…”

“…Carroll et al and Ciccarone et al discuss the effect that controlled consumption of drug, aka a “tester shot”, “taste” or insufflation (aka snorting) prior to or in lieu of injection might have in reducing overdose risk (Carroll et al 2017, Ciccarone, Ondocsin, and Mars 2017). Point-of-use testing or “drug checking” has been used especially in Europe, to inform and engage persons who consume drugs as well as provide a potential surveillance platform (Hondebrink et al 2015, Caudevilla et al 2016, Brunt et al 2017).…”

Being “hooked up” during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York City

“…Department of Justice Drug Enforcement Admnistration, 2017), fentanyl and its analogs are visually indiscernible from one another, making it difficult to detect differences between them without thorough laboratory testing (Suzuki & El-Haddad, 2017). Persons who use drugs (PWUD) are often unaware when drugs are “cut”, or mixed with fentanyl (Carroll, Marshall, Rich, & Green, 2017; Macmadu, Carroll, Hadland, Green, & Marshall, 2017; Mars, Ondocsin, & Ciccarone, 2017; Spies et al, 2016; Stogner, 2014). Consequently, use of drugs containing fentanyl have been linked to sharp increases in rates of opioid morbidity and mortality (Centers for Disease Control & Prevention, 2017; Daniulaityte et al, 2017; Katz, 2017; Marshall et al, 2017; O’Donnell, Halpin, Mattson, Goldberger, & Gladden, 2017; Rudd, Aleshire, Zibbell, & Gladden, 2016; Rudd, Seth, David, & Scholl, 2016; Slavova et al, 2017).…”