ndews hotspot report - university of maryland · pdf filefor this ndews hotspot report, we...

AndreaMeier,MS,LADC,LCMHC,SarahK.Moore,PhD,ElizabethC.Saunders,MS,

StephenA.Metcalf,MPhil,BethanyMcLeman,BA,SamanthaAuty,BS,andLisaA.Marsch,PhD

NDEWSHOTSPOTREPORT

UNDERSTANDINGOPIOIDOVERDOSESINNEW

HAMPSHIREPhaseIIofaNationalDrugEarlyWarningSystem(NDEWS)HotSpotRapid

EpidemiologicalStudy

CenterforTechnologyandBehavioralHealthDartmouthCollege46CenterraParkway,Suite315Lebanon,NH03766Tel(603)646-7000Fax(603)646-7068www.c4tbh.org

TABLEOFCONTENTS

Contents

ExecutiveSummary______________________________________________________________________________________ 1

Introduction______________________________________________________________________________________________ 6

StudyParticipants:FullSample________________________________________________________________________11

StudyParticipants:Subsample_________________________________________________________________________13

SurveyResults:OpioidConsumers____________________________________________________________________15

SurveyResults:ResponderandEDpersonnel________________________________________________________23

InterviewFindingsbyCategory _______________________________________________________________________25

InterviewFindingsbyCategory:TrajectoryofOpioidUse__________________________________________26

InterviewFindingsbyCategory:FormulationofHeroinandFentanyl_____________________________29

InterviewFindingsbyCategory:Fentanyl-seekingBehavior________________________________________33

InterviewFindingsbyCategory:TraffickingandSupplyChain_____________________________________37

InterviewFindingsbyCategory:ExperienceswithOverdoses______________________________________41

InterviewFindingsbyCategory:ExperienceswithNarcan _________________________________________57

InterviewFindingsbyCategory:HarmReduction___________________________________________________63

InterviewFindingsbyCategory:ExperienceswithTreatment______________________________________66

InterviewFindingsbyCategory:Prevention__________________________________________________________76

InterviewFindingsbyCategory:LawsandPolicies__________________________________________________79

Discussion:UniquenessofNewHampshire __________________________________________________________83

NextSteps_______________________________________________________________________________________________89

ReferencesCited________________________________________________________________________________________90

APPENDIX_______________________________________________________________________________________________92

EXECUTIVESUMMARY

ExecutiveSummary

OVERVIEWRatesofsyntheticnon-methadoneopioidoverdoseinNewHampshirehaveincreasedbynearly1,600%from2010to2015.From2014-2015,thelatestdataavailableforthisreport,thestatesawanincreaseof94.4%,risingfrom12.4to24.1opioidoverdosesper100,000residentsinthatyearalone.Theescalationispredominatelydrivenbyincreasedratesoffentanyluseandoverdose.

InAugust2016,theNationalDrugEarlyWarningSystem(NDEWS)andtheCenterforTechnologyandBehavioralHealth(CTBH)atDartmouthCollege,withfundingfromtheNationalInstituteonDrugAbuse(NIDA),partneredtoconductaRapidHotSpotstudyonNewHampshire’ssyntheticnon-methadoneopioid(fentanyl)overdosecrisisintwophases.DuringPhaseI,researchersmetwithadiversearrayofNewHampshirestakeholderstoproduceareportaboutthefentanyloutbreak,highlightingavailabledataandinformationlearned.ResultsofthePhaseIstudyindicatedthatreal-timedatafromopioidconsumersandfirstresponderswasimperativetomoreaccuratelyinformpolicy(PhaseII).ThisreportpresentsresultsfromPhaseII.

METHODSPhaseIIoftheNDEWSRapidHotSpotstudywasconductedasanepidemiologicalinvestigationintotheexperiencesandperspectivesofopioidusers,firstrespondersandemergencydepartment(R/ED)personnelsurroundingtheopioidoverdosecrisisinNewHampshire.Seventy-sixopioidconsumers,18firstresponders,and18emergencydepartmentpersonnelwererecruitedfromsixcountiesacrossNewHampshire.RecruitmentwasheavilytargetedinHillsboroughCounty,whichhasseenparticularlyhighratesofopioidoverdoses.Eachparticipantcompletedasemi-structuredinterviewandabriefdemographicsurvey.InterviewsfocusedonquestionsthataroseduringthePhaseIHotSpotstudy,includingtrajectoryofopioiduse,experienceswithoverdose,traffickingandformulationoffentanyl,fentanyl-seekingversusaccidentalingestion,thevalueofharmreductionmodels,preventionstrategiesandtreatmentpreferences.

Interviewsweretranscribedandanalyzedusingcontentanalysistocondensethetranscriptsintocontent-relatedcategoriesandreviewtheseforthemes.

PARTICIPANTSForthisNDEWSHotSpotreport,weconductedinitialanalysesof20consumersand12R/EDpersonnel(3EmergencyDepartment,3EmergencyMedicalServices,3Fire,3Police).

UNDERSTANDINGOPIOIDOVERDOSESINNEWHAMPSHIRE

EXECUTIVESUMMARY

Consumerswere,onaverage,34.1(sd7.5)yearsofage,55%(11)weremale,90.%(18)werewhite,andall(20)wereneitherHispanicnorLatino.

Responderswere,onaverage,47.8(sd7.2)yearsofage,83.3%(10)weremale,91.7%(11)werewhite,andallwhoreportedethnicity(11)wereneitherHispanicnorLatino.

THEMESIDENTIFIEDAnalysisofconsumerandR/EDpersonnelinterviewsresultedin10identifiedcategories:

RESULTS

TrajectoryofopioiduseTheinitialresultssuggestthatconsumers’pathtoopioidusewastypicallyassociatedwith:

¾ Earlyrecreationalsubstanceuse,¾ Severeinjurieswarrantingaprescriptionopioid,sometimesfollowedbyanabrupttaper,¾ Intergenerationalsubstanceuseamongnuclearfamilymembers,and/or¾ Self-medicationofmentalhealthconditions.

Trajectoryofopioiduse

Formulationofheroin/fentanyl

Fentanyl-seekingbehavior

Traffickingandsupplychain

Experienceswithoverdoses

ExperienceswithNarcan Harmreduction Experiences

withtreatment

Prevention Lawsandpolicies

EXECUTIVESUMMARY

FormulationofHeroinandFentanylConsumersreportbeingabletodistinguishbetweenfentanylandheroinbythesubstance’scolor,taste,subjectiveeffect,andcost.Respondersreportlimitedknowledgeoftheformulationofheroin/fentanyl.

Fentanyl-seekingbehaviorMostconsumersreportseekingdrugsthatareknowntohavecausedanoverdose,buttypicallydonotspecificallyseekfentanylalone.Themajorityofconsumersreportbeingneutraloraversetousingfentanylbutiftheyhearthatitispresentinabatchthatcausedanoverdose,theyreportseekingthatbatch.R/EDpersonnelhavemixedreportsofthisbehavioramongconsumers.

TraffickingandsupplychainConsumersandR/EDpersonnelbothreportfentanylhitthesupplychaininNewHampshirein2014-2015.ConsumersandR/EDpersonnelreportfentanylislocallymanufacturedin,anddistributedfrom,Massachusetts,asthereisapotentialprofitfromsellinginNewHampshireversusMassachusetts.Demandinthestateisdrivenbylowercost,higherpotency,andeasieravailability.ManybelievefentanyloriginatesinChinaorMexico.

ExperienceswithoverdosesAlmosttwo-thirdsofconsumershadexperiencedanoverdose.BothconsumersandR/EDpersonnelagreedthatfentanylistheprimarycauseofoverdoseinNewHampshire,largelyduetoitspotencyandinconsistencyinfentanyl/heroinmixes.Bothgroupsunanimouslyreportedthatoverdosesinthestateoccuracrossalldemographics.

ExperienceswithNarcanNeitherconsumersnorR/EDpersonnelhadobservedanysideeffectsfromnaloxone(Narcan)administrations,asidefromitsintendedeffectofprecipitatedwithdrawalduringoverdosereversal.Despitethis,consumersreportedmanybarrierstoobtainingNarcanincludinghighcost,fearofpolice,fearofstigmatization,lackofknowledge,andfearofwithdrawalafteradministration.Nounanticipatedsideeffectswereobserved.

HarmreductionR/EDpersonnelandconsumersbothendorsedtheneedforneedleexchangeprogramsinNewHampshire,inadditiontoincreasingtheavailabilityofmedication-assistedtreatment,medicallyassisteddetoxification,andothertreatmentservices.

EXECUTIVESUMMARY

ExperienceswithtreatmentBothconsumersandR/EDpersonnelagreedthatconsumerscannotstopusingopioidswithouthelp.AvailableservicesarelackinginNewHampshireandincludelengthywaitlists,troublenavigatingthesystem,andfunding(bothforconsumerstoaffordcareandforprogramstoprovideit).Referralratesafteroverdosetreatmentarelowduetostaffingshortages.Recommendationsforimprovementinclude:

¾ Increasingaccesstomedicationassistedtreatment,especiallySuboxone,¾ Medically-assisteddetoxification,and¾ Morecounselingoptions.

PreventionParticipantsreportedthatadditionalpreventioneffortsarenecessaryandsuggestedearlyeducationaboutopioids(beforemiddleschool),dismantlingthestigmaaroundsubstanceuse,prudentprescribingofopioidanalgesics,andmoreeducationforpatientsregardingpainandopioids.R/EDpersonnelexpressedtheneedtomobilizecommunitiestofightthisepidemic.

LawsandpoliciesConsumersarenotwellinformedaboutstatelawsandpoliciesregardingopioiduse.Thereisfrustrationandmistrusttowardspoliceandthejusticesystemduetoencounterswiththecriminaljusticesystem,lackoftreatmentavailabilityinjailandmistrustoftheGoodSamaritanLaw(allowingconsumerstoreportanoverdoseandbeimmunefromprosecutionatthatevent).ConsumersandR/EDpersonnelreportedthatnewprescribingcrackdownsmayreduceopioidprescribingbutwouldlikelymeananincreaseinheroinuse.PrescriptionDrugMonitoringProgramswereviewedasusefulbutburdensomebyEDstaff.

UNIQUENESSOFNEWHAMPSHIRENewHampshirehassignificantlyhigherratesofprescribingoflong-acting/extendedreleaseopioidsaswellasconcurrentprescribingofhigh-doseopioidsandbenzodiazepinesthanthenationalaverage.Theshortageoftreatmentfundingandavailability,lowerratesofSuboxoneprescriberspercapita,anabsenceofaneedleexchangeprogram,barrierstoaccessingNarcan,andtheproximityofinterstateaccesstothesupplychainwereidentifiedasmakingNewHampshire’sopioidproblemuniquefromotherstates.SomeconsumersandR/EDpersonnelalsoidentifiedtheruralsettingofNewHampshireasacontributingfactor,i.e.,“LiveFreeorDie.”

EXECUTIVESUMMARY

NEXTSTEPS

Basedondatafromthisstudy,preliminaryconsiderationsforNewHampshire’sapproachtotacklingtheopioidoverdosecrisisinclude:

• Increasepublichealthfundstargetingsubstanceuse;• Expandpreventionprogramsinelementaryandmiddleschools;• Strengthentreatmenttoincludebroaderavailability,non-prohibitivecost,andinclusion

ofmedication-assistedoptionsandholisticapproaches;• Incentivizephysicianstobecomebuprenorphine-waiveredproviders;• Assistphysicianswithprudentprescribingofopioids,educatingpatients,andalternatives

topainmanagement;• Supportfirstresponderandemergencydepartmentpersonnelwithvicarioustrauma

associatedwithrespondingtooverdoses;• Initiateneedleexchangeprograms;• CollaboratewithMassachusettsonaddressingthemanufacturingandtraffickingof

fentanylandotheropioids;and• Launchprogrammingtodispelstigmaandfear:

o Educateconsumers(e.g.,NarcanandGoodSamaritanLaw)o Educatephysiciansandpharmacists(e.g.,chronicdiseasemanagementandvalue

ofNarcan)o Educatelawenforcement(e.g.,alternativeapproachestopunitivemeasures)o Educatethepublic(e.g.,opioidcrisisisnotisolatedtoonedemographic/areaand

breakingtheintergenerationalcycleofaddiction)

INTRODUCTION

Introduction

INTRODUCTIONPHASE1HOTSPOTSTUDYSince2014,thestateofNewHampshiresawadisproportionatelyhighrateofopioidoverdosescomparedtootherstates,especiallyinvolvingtheuseoffentanyl.From2013to2014alone,theCentersforDiseaseControlandPrevention(CDC)reporteda73.5%increaseinopioidoverdosesinthestate;estimationsofthatnumberhaveonlyincreasedintheyearssince.Inthe2013-2014reportingperiod,NewHampshireresidentsdiedofsyntheticopioid-relatedoverdosesatarateof12.4per100,000.Thesecond-closeststatetothatrateduringthatreportingperiod,RhodeIsland,sawsyntheticopioid-relatedoverdosedeathsatarateof7.9per100,000.InDecember2016,theCDCreleasedupdateddataforthe2014-2015reportingperiod.Alarmingly,NewHampshiresawadoubling(anincreaseof94.4%)ofsyntheticopioid-relatedoverdosedeathspercapitafrom2014-2015;24.1per100,000inNewHampshirediedfromsyntheticopioid-relatedoverdosesin2014-2015.Thesecond-closeststatereportingdeathsinthatperiodwasMassachusetts,whichsaw14.4per100,000(CentersforDiseaseControlandPrevention(CDC),2016).

In2014,theNationalInstituteonDrugAbuse(NIDA)initiatedaCooperativeAgreementwiththeCenterforSubstanceAbuseResearch(CESAR)attheUniversityofMarylandtocreatetheCoordinatingCenterfortheNationalDrugEarlyWarningSystem(NDEWS).NDEWSofferstheuniqueabilitytorapidlyidentifyemergingdrugs,includingsyntheticopioidssuchasfentanyl,andfacilitateamorerapidandinformedresponsetooutbreaksandchangesinsubstanceuseandmisuse.OneinnovativecomponentofNDEWSistheabilitytolaunchrapidHotSpotstudiesoflocaldrugoutbreaks.InpartnershipwiththeNDEWSandfundingbyNIDA,theCenterforTechnologyandBehavioralHealth(CTBH)atDartmouthCollegeconductedaPhaseIRapidHotSpotstudy(NationalDrugEarlyWarningSystem(NDEWS),2016),onNewHampshire’snon-methadonesyntheticopioid(fentanyl)overdosecrisisinAugust2016intwophases.DuringthePhaseIrapidstudy,theCTBHandNDEWSteamsmetwithmultiplestakeholdersthroughoutthestate,includingtreatmentproviders,medicalresponders,lawenforcement,andstateauthoritiesandpolicymakers,tolearnmoreabouttheirperspectivesonthefentanylcrisisinNew

INTRODUCTION

Hampshire.Stateauthoritiesexpressedseriousconcernregardingthestate’sapparenttrendtowardshigherratesofalcoholanddrugusecomparedtotherestofthecountryinnationalsurveys,andwereconcernedthatthecurrentdrugofchoiceisfentanyl.Furthermore,questionswereraisedabouthowmuchanecdotalorspeculativeinformationisdrivingpolicy;itwasclearfromstakeholdersthatpolicydecisionsneedtobebasedonvaliddataabouttheopioidoverdosecrisis.

ItwasapparentfromthePhaseIinterviewswithstakeholdersinNewHampshirethatmuchisunknownaboutthefentanyloverdosecrisisinthestate.Manystakeholdersexpressedthatuser-leveldatawasimperativetoanswerpointedquestionstomoreaccuratelyinformpolicy,suchasthetrajectoryoffentanyluse,thetraffickingoffentanyl,fentanyl-seekingbehaviorversusaccidentalingestion,thevalueofharmreductionmodels,andtreatmentpreferences.

WiththesupportofNIDAtoconductPhaseII,NDEWSawardedsub-contractstoresearchersatDartmouth’sCTBHandtheUniversityofMainetoconducttwoadditionalstudies.Thefirststudyinvolvedsystematicinterviewsoffirstresponders,emergencydepartmentpersonnel,activefentanylusers,andindividualsnewtotreatment(thefocusofthisreportfromDartmouth’sCTBH).Thesecondstudyexaminedmedicalrecordsandmedicalexaminerinvestigationsforpersonswhodiedfromfentanyl-relatedoverdosesinNewHampshire(MarcellaSorg,PhD,UniversityofMaine,PI;notincludedinthisreport).

Figure1.StudyRecruitmentArea

INTRODUCTION

PHASEIIRAPIDEPIDEMIOLOGICALSTUDYInthesecondphaseoftheNDEWSRapidHotSpotStudy,theresearchteamatCTBHconductedarapidepidemiologicalinvestigationofopioidusers’,firstresponders’,andemergencydepartment(ED)personnel’sperspectivesonopioidoverdoseinNewHampshire,toprovideupdateddatatoinformpolicyontacklingthefentanyloverdosecrisis.InadditiontothefundsprovidedbyNDEWS,CTBHalsoreceivesfundingfromtheNationalDrugAbuseTreatmentClinicalTrialsNetworkNortheastNode(basedoutofCTBHandfundedbyNIDA:UG1DA040309)andwasabletoutilizeadditionalfundstocoverinfrastructureforthisproject.

Thestudyteamconducted60-minutesemi-structuredsystematicinterviewswith76activeopioidconsumersorthosenewtotreatmentforopioidusedisorders,18firstresponders(police,fire,EMS),and18emergencydepartmentpersonnel.Interviewswerecompletedeitherviaphoneorin-persondependingonparticipantpreference.Participantintervieweescompletedbriefdemographicandsubstanceusehistorysurveys.ParticipantswererecruitedusingconnectionsprovidedbytheNortheastNodeoftheNationalDrugAbuseTreatmentClinicalTrialsNetwork,atGroups,Inc.,treatmentcentersthroughoutthestate,word-of-mouth,postershunginSafeStationlocations,treatmentfacilities,foodbanks,shelters,laboratories,andviaadsinlocalnewspapersandwww.CraigsList.com.Participantswereincentivizedtoparticipateinthisstudywith$50giftcardsforcompletingtheinterviewandsurvey.SamplingwaspurposelyheavilyconcentratedinHillsboroughCounty,giventhatitwastargetedasthe“hotspot”inNewHampshire(NewHampshireInformationandAnalysisCenter,2017),withadditionalsamplinginCheshire,Grafton,Rockingham,Strafford,andSullivancounties.

InterviewswithconsumersfocusedonquestionsthataroseduringPhaseI,includingthetrajectoryofopioiduse,thesupplychain,fentanyl-seekingbehaviorversusaccidentalingestion,thevalueofharmreductionmodels,opinionsaboutpreventionstrategies,andtreatmentpreferences.

Systematicinterviewswerealsoconductedwithfirstresponders(police,fire,andemergencymedicalservice[EMS]personnel)andemergencydepartment(ED)personnelincountieswhereopioidconsumerinterviewswereconducted.Interviewswiththesestakeholdersconcentratedontrendsinopioid-relatedoverdoses,includingusercharacteristicsandpatterns,assessmentandinvestigativeprotocols,Narcanadministration,andreferralpractices.Theseparticipantsalsocompletedbriefdemographicandemploymentsurveys.

Atotalof76consumersand36firstrespondersandEDpersonnelwereinterviewed.Twentyopioidconsumersand12firstrespondersandEDstaffinterviewswereanalyzedforthisNDEWSHotSpotreport.

INTRODUCTION

Fiveresearchteammembersconductedtheinterviewsandthemajorityoftheinterviewsweretranscribedbyanindependentcontractinggroup;afewweretranscribedbyresearchteammemberstofacilitateinitialfamiliaritywiththedata.GiventhedemandsofthecondensedtimelineforInstitutionalReviewBoard(IRB)review,recruitment,interviewconduct,analysesandreportproduction(6months),aswellasthereasonableexpectationofreaching‘saturation’—thepointatwhichinterviewanswersmaintainconsistency,usuallyafterreviewing12-15interviewspergroup(Guest,Bunce,&Johnson,2006)—weanalyzed20consumer(weightedacrossthetargetedNHcounties)and12responder(3ED,3EMS,3Fire,3Police)interviews.Alladditionalinterviewsarecurrentlybeinganalyzed,andthesedatawillbeincludedinfutureplannedpublications.

Theprimaryresearchteamanalystsusedcontentanalysistosystematicallyanalyzeanddescribethesedifferentperspectivesonopioidoverdosebycondensingvoluminouspagesofthetranscriptsintocontent-relatedcategoriesthatwerethenreviewedforpatterns(themes).Duetothehighlystructurednatureoftheinterviews,firstlevelcodeswerelargelypredeterminedbytheguidesthemselves(e.g.,trajectoriesofopioiduse,experienceswithoverdose).Theprimaryanalystsindependentlyreviewedasubsampleofbothconsumerandrespondertranscriptstoidentifypatternsanddevelopinitialcodelists.Oncetheinitialcodelistsweregenerated,theprimaryanalystscodedtheremainingtranscriptsinthesubsample.Thelargerresearchteammetweeklyoncedatacollectionwascompletesothattheprimaryanalystscouldshareemergentthemesfromtheanalysesandsothatremainingteammemberswhoconductedinterviewscouldprovidefeedbackonthetrustworthinessofthedataandtheanalyses.Throughtheseregularcheck-ins/consensussessions,codelistswerehonedanddiscrepancieswereresolved.DemographicdatawereanalyzedusingStata(StataCorp,2015)togeneratedescriptivestatistics.Onceboththequalitativeandquantitativedatawereanalyzed,weexaminedtheevidencefromthedifferentdatasourcestotriangulatethedata,checktheaccuracyofthefindings,andbuildacoherentunderstandingofopioidoverdoseinNewHampshirebasedonthedata.

Inlinewiththeaimsofthisproject,tencategorieswereidentifiedbytheresearchteamthatbestrepresentthedatacollected:(1)Trajectoryofopioiduse,(2)Formulationofheroinandfentanyl,(3)Fentanyl-seekingbehavior,(4)Traffickingandsupplychain,(5)Experienceswithoverdoses,(6)ExperienceswithNarcan,(7)Harmreduction,(8)Treatment,(9)Prevention,and(10)Lawsandpolicies.Thisreportisorganizedbythosecategories.

RESEARCHTEAMThePhaseIIrapidepidemiologicalHotSpotstudywasconductedforNDEWSbytheCenterforTechnologyandBehavioralHealth(CTBH;www.c4tbh.org)withthesupportoftheNortheastNodeoftheNationalDrugAbuseTreatmentClinicalTrialsNetwork(CTN;

INTRODUCTION

www.ctnnortheastnode.org),bothbasedatDartmouthCollege.TheNortheastNodemaintainsanextensivenetworkofpartnersthroughoutNewHampshire,whichallowedthestudytorapidlycoordinaterecruitmentsites.Additionally,theNortheastNodeAdministrativeTeam(AndreaMeier,DirectorofOperations;BethanyMcLeman,ResearchProjectManager;andSamanthaAuty,ResearchAssistant)providedinfrastructurefortheresearchteam.ParticipatingCTBHaffiliatesincludeSarahK.Moore,PhD(qualitativeresearchexpert),ElizabethSaunders,MS(PhDstudentmenteeofDr.LisaMarsch),andStephenA.Metcalf,MPhil(CTBHResearchProjectManager).UndertheleadershipofLisaMarsch,PhD(DirectorofCTBHandPrincipalInvestigatoroftheNortheastNode),theresearchteamsecuredDartmouthCommitteefortheProtectionofHumanSubjects(CPHS)approval,coordinatedprotocolsandrecruitmentprocedures,conducted112interviews,participatedinthetranscriptionprocess,analyzedthedatacollectedbythisstudy,andcontributedtothisNDEWSHotSpotreportfromOctober2016throughMarch2017.

ACKNOWLEDGEMENTSSupportforthisstudywasprovidedbytheNationalInstituteonDrugAbuse(NIDA)NationalDrugEarlyWarningSystem(NDEWS)attheUniversityofMaryland(U01DA038360-Z0717001,PI:EricD.Wish,PhD;Co-I:ErinArtigiani,MA;Sub-awardPI:LisaMarsch,PhD).InfrastructureandsupportforresearchteammembersfromtheNortheastNodeoftheNationalDrugAbuseTreatmentClinicalTrialsNetworkwasprovidedbytheClinicalTrialsNetwork(UG1DA040309,PI:LisaMarsch,PhD).

Thestudywasconductedinaccordancewithallhumansubjectprotectionsandgoodclinicalpractices(e.g.,HelsinkiDeclaration,BelmontPrinciples,andNurembergCode).TheTrusteesofDartmouthCollegeinstitutionalreviewboard(CommitteefortheProtectionofHumanSubjects(CPHS))approvedthecollection,analyses,andreportingofthesedata.

NDEWSisfundedunderNIDACooperativeAgreementDA038360,awardedtotheCenterforSubstanceAbuseResearch(CESAR)attheUniversityofMaryland,CollegePark.OpinionsexpressedbytheauthorsofthisreportmaynotrepresentthoseofNIDA.

STUDYPARTICIPANTS:FULLSAMPLE

StudyParticipants:FullSample

OPIOIDCONSUMERSInterviewswereconductedwithparticipantswhowereeitheractivelyusingopioidsorwerenewtotreatmentforopioidusedisorder.Inall,76interviewswereconductedwithopioidconsumersfromsixcountiesinNewHampshire.

FIRSTRESPONDERSInterviewswereconductedwithoneactivepoliceofficer,firefighter,andemergencymedicalservices(EMS)memberineachofthesixcounties,foratotalof18interviews.

EMERGENCYDEPARTMENTSTAFFInterviewswereconductedwiththreeclinicalstaffat

OpioidConsumers

Police6

FirstResponders

Figure2.StudyParticipants-FullSample

emergencydepartments(ED)fromeachofthesixcounties.Intervieweesincludednurses,physicians,andEDmedicaldirectors.Inall,18interviewswereconductedwithemergencydepartmentstaffacrossthesixcounties.

PARTICIPANTRECRUITMENTBYCOUNTYParticipantrecruitmentwasconductedinsixcountiesacrossNewHampshire(seeFigure3).HillsboroughCounty,inthesouthernregionofthestate,washeavilytargetedgivenithasbeenthefocusoftheepidemicinthestate.Cheshire,Grafton,Rockingham,StraffordandSullivancountieswerealsosampledtoproviderepresentationacrossthestateandtoassessregionalvariations.

Figure3.StudyParticipants-FullSample

STUDYPARTICIPANTS:SUBSAMPLE

StudyParticipants:Subsample

OPIOIDCONSUMERSInthisNDEWSHotSpotreport,datawereanalyzedfrom20opioidconsumerinterviews.Tomaintainconsistencywiththestudy’srecruitmentplanthroughoutthesixcounties,interviewswereselectedbasedonlocation.Forthisreport,10interviewswereselectedfromHillsboroughCountyandtwofromeachoftheremainingfivecounties(Cheshire,Grafton,Rockingham,Strafford,andSullivan).

Consumerinterviewsincludedinthesubsamplewereselectedpurposivelytomatchthegeographicdistributionofthefull

OpioidConsumers

20 ED3

Police3

FirstResponders

&EDPersonnel

Figure4.StudyParticipants-Subsample

consumersample.Therewerenosignificantdifferencesinthedemographic,lifetimesubstanceuse,previoustreatmenthistory,oropioidusecharacteristicsbetweenconsumersincludedinthesubsampleandthoseincludedonlyinthefullsample.

FIRSTRESPONDERSANDEMERGENCYDEPARTMENTSTAFFInthisNDEWSHotSpotreport,datawereanalyzedfrom12firstresponders/EDstaff.Togainanevenrepresentationfromeachdivisioninterviewed,threeinterviewseachwereselectedfrompolice,fire,EMS,andEDparticipants.

Thefirstresponderandemergencydepartmentsubsampledidnotdifferfromthefullrespondersamplebygender,race,ethnicity,oranyopioidoverdosetreatmentcharacteristics.Respondersselectedforthesubsampleweresignificantlyolderandemployedformoreyearsthanthoseonlyincludedinthefullsample.

SURVEYRESULTS:OPIOIDCONSUMERS

SurveyResults:OpioidConsumers

TABLE1.DEMOGRAPHICCHARACTERISTICSOFNEWHAMPSHIREOPIOIDUSERS

Demographics FullSample(n=76)

Subsample(n=20)

Male(n=37)

Female(n=39)

Agem(sd) 34.1(8.3) 34.1(7.5) 34.6(7.4) 33.7(9.2)Gendern(%)

MaleFemale

37(48.7%)39(51.3%)

11(55.0%)9(45.0%)

37(100%)0(0%)

0(0%)39(100%)

Racen(%)AsianBlack/AfricanAmericanWhiteOtherMultiracial

1(1.3%)1(1.3%)69(90.8%)1(1.3%)4(5.3%)

1(5.0%)0(0%)18(90.0%)1(5.0%)0(0%)

0(0%)0(0%)33(89.2%)1(2.7%)3(8.1%)

1(2.6%)1(2.6%)36(97.4%)0(0%)1(2.6%)

Ethnicityn(%)HispanicorLatinoNotHispanicorLatino

3(4.0%)72(96.0%)

0(0%)20(100%)

2(5.6%)34(94.4%)

1(2.6%)38(97.4%)

(Table1,Cont.)

DemographicsFullSample(n=76)

Subsample(n=20)

Male(n=37)

Female(n=39)

Educationn(%)LessthanHighSchoolHighSchool/GEDSomeCollegeAssociate’sBachelor’sMaster’s

5(6.6%)41(54.0%)16(21.1%)11(14.5%)1(1.3%)2(2.6%)

2(10.0%)9(45.0%)6(25.0%)3(15.0%)0(0%)1(5.0%)

2(5.4%)25(67.6%)4(10.8%)5(13.5%)1(2.7%)0(0%)

3(7.7%)16(41.0%)12(30.8%)6(15.4%)0(0%)2(5.1%)

EmploymentStatusn(%)WorkingFullTimeWorkingPartTimeUnemployedDisabledKeepingHouseStudentOtherTemporarilyLaidOff

20(26.3%)9(11.8%)22(29.0%)13(17.1%)3(4.0%)2(2.6%)3(4.0%)4(5.3%)

5(25.0%)3(15.0%)6(30.0%)2(10.0%)0(0%)1(5.0%)1(5.0%)2(10.0%)

14(37.8%)5(13.5%)11(29.7%)2(5.4%)0(0%)1(2.7%)2(5.4%)2(5.4%)

6(15.4%)4(10.3%)11(28.2%)11(28.2%)3(7.7%)1(2.6%)1(2.6%)2(5.1%)

MaritalStatusn(%)MarriedDivorcedSeparatedNeverMarriedLivingwithPartner

10(13.2%)9(11.8%)8(10.5%)31(40.8%)18(23.7%)

5(25.0%)3(15.0%)3(15.0%)8(40.0%)1(5.0%)

3(8.1%)5(13.5%)4(10.8%)19(51.4%)6(16.2%)

7(18.0%)4(10.3%)4(10.3%)12(30.8%)12(30.8%)

HousingStatusn(%)OwnHomeRentLivewithSomeoneResidentialShelterHomeless

3(4.0%)39(51.3%)20(26.3%)2(2.6%)6(7.9%)6(7.9%)

2(10.0%)10(45.0%)5(25.0%1(5.0%)1(5.0%)2(10.0%)

2(5.4%)16(43.2%)10(27.0%)1(2.7%)5(13.5%)3(8.1%)

1(2.6%)23(59.0%)10(25.6%)1(2.6%)1(2.6%)3(7.7%)

Countyn(%)CheshireGraftonHillsboroughRockinghamStraffordSullivan

7(9.2%)6(7.9%)41(54.0%)6(7.9%)8(10.5%)8(10.5%)

2(10.0%)2(10.0%)10(50.0%)2(10.0%)2(10.0%)2(10.0%)

5(13.5%)3(8.1%)19(51.4%)3(8.1%)4(10.8%)3(8.1%)

2(5.1%)3(7.7%)22(56.4%)3(7.7%)4(10.3%)5(12.8%)

Note:T-testconductedtocomparemeans;Pearson’schi-squaredtestconductedtocomparecounts;nosignificantdifferencesinparticipantcharacteristicsbetweenthefullandsubsample,orbetweenmalesandfemales,allp’s>0.05

SUMMARYThemajorityofparticipantswerenon-Hispanic,whiteyoungadults.ThisdemographicprofileisconsistentwiththedemographiccharacteristicsofheroinusersacrosstheUnitedStates(Cicero,Ellis,Surratt,&Kurtz,2014;Jones,Logan,Gladden,&Bohm,2015).Thissamplewasrelativelyeducated,with21%attendingsomecollegeand18%ofthesamplereceivingacollegedegree.Onethirdofparticipantsreportedcurrentunemployment,while38%hadfull-orpart-timeemployment.Thoughhalfofthesamplereportedrentingahome,otherparticipantswerehomeless,livinginashelter,orresidingwithsomeoneelse.Therewerenostatisticallysignificantdifferencesindemographiccharacteristicsbygender,oramongparticipantsincludedinthequalitativesubsampleascomparedwithothersfromthefullsample.

TABLE2.LIFETIMESUBSTANCEUSEANDAGEOFFIRSTUSE

Substance

LifetimeUsen(%) AgeatFirstUsem(sd)FullSample(n=76)

Subsample(n=20)

FullSample(n=76)

Subsample(n=20)

Alcohola 74(98.7%) 19(100%) 13.7(3.8) 14.5(5.6)Cannabis 75(98.7%) 19(95.0%) 13.9(2.8) 13.9(3.6)Inhalants 25(32.9%) 7(35.0%) 16.1(4.6) 16.3(3.2)Hallucinogens 52(68.4%) 13(65.0%) 16.6(2.9) 16.2(3.2)Cocaine 71(93.4%) 19(95.0%) 17.9(3.5) 18.5(4.4)Prescriptionopioids 75(98.7%) 20(100%) 21.1(7.1) 23.5(8.7)Stimulants 51(67.1%) 13(65.0%) 21.2(7.7) 20.5(8.9)Sedatives 24(31.6%) 6(30.0%) 21.4(7.3) 25.8(6.2)Benzodiazepines 53(69.7%) 12(60.0%) 22.1(7.1) 22.6(6.7)Heroin 70(92.1%) 18(90.0%) 24.1(7.0) 24.1(7.1)Fentanyl 64(84.2%) 19(95.0%) 28.1(7.3) 28.3(7.4)Other 4(5.3%) 1(5.0%) 28.5(14.4) 22.0(--)bNote:T-testconductedtocomparemeans;Pearson’schi-squaredtestconductedtocomparecounts;nosignificantdifferencesbetweenthefullandsubsamples,allp’s>0.05aFullsample:n=76Subsample:n=20bNostandarddeviationbecausemeanisforonlyoneparticipant

SUMMARYAlmostallstudyparticipantsreportedlifetimeuseofalcoholandcannabis,whichgenerallyprecededinitiationofanyothersubstances.Whilesomeparticipantsreportedtryingalcoholorcannabisasearlyastenyearsofage,theaverageageoffirstalcoholand/orcannabisusewasaround13-14yearsinthefullsample.Participants’averageageoffirstprescriptionopioiduse(21.1years)predatedtheirfirstuseofheroin(24.1years)orfentanyl(28.1years).Ofthoseparticipantswhousedprescriptionopioids,heroin,andfentanyl,55(86.0%)usedprescriptionopioidsbeforeheroinorfentanyl.Amongparticipantswhousedbothheroinandfentanyl,54(71.1%)ofparticipantsinitiatedheroinbeforefentanyland14(18.4%)initiatedbothheroinandfentanylatthesameage.Thistrendofmovingfromprescriptionsopioidstoheroinorfentanyl-lacedheroinisrepresentativeofnationaltrendsinopioiduseinitiation(Cicero2014,Botticelli2015).Therewerenosignificantdifferencesinlifetimeuseorageoffirstusebetweenparticipantsinthesubsampleandthosenotincludedinthesubsample.

AGEOFINITIATIONBYOPIOIDTYPE

SUMMARYFigure5showsthemeanage(21.1yearsforprescriptionopioids,24.1yearsforheroin,and28.1yearsforillicitfentanyl)atwhichconsumersinthefullsampleinitiateddifferenttypesofopioiduse.As55(86.0%)usedprescriptionopioidsatayoungeragethanheroinorfentanyl,and54(71.1%)usedheroinatayoungeragethanfentanyl,thisfigurehighlightsthepatternofopioidinitiationstartingwithprescriptionopioids,thenmovingtoheroinandfinallyfentanyl,onaverage.

21.1 years24.1 years

28.1 years

Prescription opioids Heroin FentanylType of opioid

=Individualstudyparticipant

=Meanageofinitiation

Figure5.TurnipPlotRepresentingAgeofInitiationbyOpioidType

TABLE3.RECENCYOFOPIOIDUSE

PrescriptionOpioids Heroin Fentanyl

FullSample(n=75)

Subsample(n=20)

FullSample(n=70)

Subsample(n=18)

FullSample(n=66)

Subsample(n=19)

LastreporteduseaPastWeekPastMonthPast6MonthsMorethan6Months

8(10.7%)12(16.0%)16(21.3%)39(52.0%)

3(15.0%)4(20.0%)4(20.0%)9(45.0%)

20(28.6%)13(18.6%)18(25.7%)19(27.1%)

6(33.3%)3(16.7%)5(27.8%)4(22.2%)

21(31.8%)12(18.2%)14(21.2%)19(28.8%)

7(36.8%)3(15.8%)3(15.8%)6(31.6%)

Note:Pearson’schi-squaredtestconductedtocomparefullsamplesandtheirrespectivesubsamples;nosignificantdifferencesbetweenthefullandsubsamples,allp’s>0.05aAmongconsumersreportinglifetimeuse

SUMMARYOver26.7%ofparticipantsinthefullsamplereportedusingprescriptionopioidsinthepastweekormonth.Forty-sevenpercentofconsumersreportinglifetimeheroinuseand50%ofthosereportinglifetimefentanylusehadusedduringthepastweekormonth.Therewerenosignificantdifferencesintherecencyofopioidusebetweenthesubsampleandthoseincludedinthefullsampleonly.

TABLE4.PREVIOUSOPIOIDUSEANDMENTALHEALTHTREATMENT

OpioidUseTreatment FullSample(n=76)

Subsample(n=20)

LifetimeTreatmentforOpioidUsen(%)NoYes

7(9.2%)69(90.8%)

1(5.0%)19(95.0%)

NumberofTreatmentEpisodesm(sd) 6.1(7.7) 7.7(10.3)CurrentlyonOUDTreatmentWaitlistn(%) 11(14.7%) 1(5.0%)NaltrexonePrescriptionan(%)

NeverPreviouslyCurrently

68(89.5%)6(7.9%)2(2.6%)

17(85.0%)2(10.0%)1(5.0%)

BuprenorphinePrescriptionan(%)NeverPreviouslyCurrently

26(34.7%)14(18.7%)35(46.7%)

4(20.0%)5(25.0%)11(55.0%)

MethadonePrescriptionan(%)NeverPreviouslyCurrently

47(61.8%)16(21.1%)13(17.1%)

13(65.0%)5(25.0%)2(10.0%)

MentalHealth(MH)Treatment LifetimeTreatmentforMHn(%)

31(40.8%)45(59.2%)

8(40.0%)12(60.0%)

NumberTreatmentEpisodesforMHonlym(sd)

2.4(3.8)

1.6(2.6)

MH,mentalhealth;OUD,opioidusedisorderNote:T-testconductedtocomparemeans;Pearson’schi-squaredtestconductedtocomparecounts;nosignificantdifferencesbetweenthefullandsubsample,allp’s>0.05aPrescribedanywhereintheUnitedStates,notnecessarilyinNewHampshire

SUMMARYParticipantshadhighratesofpastopioidandmentalhealthtreatment.Over90%(69)ofparticipantshadreceivedtreatmentfortheiropioiduseduringtheirlifetime.Moreparticipantshadreceivedprescriptionsforbuprenorphinethanmethadoneornaltrexone.Almost60%(45)ofparticipantshadreceivedmentalhealthtreatment.Again,therewerenosignificantdifferencesinprevioustreatmenthistoryvariablesbetweenthefullandsubsample.

TABLE5.OVERDOSEHISTORYANDNARCANUSE

OverdoseHistory FullSample(n=76)

Subsample(n=20)

LifetimeOverdosen(%)NoYes

23(30.3%)53(69.7%)

7(35.0%)13(65.0%)

Numberofoverdosesm(sd) 3.0(3.7)(Range:0-20)

2.9(2.9)(Range:0-8)

Percentofoverdosescausedbyn(%)***HeroinonlyFentanylonlyHeroinandFentanylcombinationOther

78(34.5%)32(14.2%)68(30.1%)48(21.2%)

31(54.4%)10(17.5%)14(24.6%)2(3.5%)

ReceivedNarcanan(%)NoYes

20(37.7%)33(62.3%)

4(30.8%)9(69.2%)

NumberofNarcanadministrationsperoverdosebm(sd)

3.0(1.6)(Range:1-7)

2.2(1.7)(Range:1-4)

Note:T-testconductedtocomparemeans;Pearson’schi-squaredtestconductedtocomparecountsaOfconsumerswhoreportedhavinganoverdose,FullSample(n=53),Subsample(n=13)bOfconsumerswhoreportedreceivingNarcan,FullSample(n=33),Subsample(n=9)***c2=21.4,p<0.001,allotherp’s>0.05

SUMMARYSeventypercentofparticipantsinthissamplehadoverdosed.Ofthoseparticipantswhohadoverdosed,62%receivednaloxone(Narcan)toreversetheiroverdose.Theseparticipantsreportedneedinganaverageof3dosesofNarcantoreversetheiroverdose,whichishigherthantheaveragenumberofNarcandosesestimatedbyresponders(Table6).Participantsinthesubsamplehadsignificantlyfeweroverdosescausedby“Other”drugs,incomparisontoparticipantsinthefullsample.

SURVEYRESULTS:RESPONDERANDEDPERSONNEL

SurveyResults:ResponderandEDpersonnel

SURVEYRESULTS:

RESPONDERANDED

PERSONNEL

SURVEYRESULTS:RESPONDERANDEDPERSONNEL

TABLE6.FIRSTRESPONDERANDEDPERSONNELCHARACTERISTICS

Note:T-testconductedtocomparemeans;Pearson’schi-squaredtestconductedtocomparecounts;statisticallysignificantdifferencebetweensubsampleandfullsample,*p<0.05,**p<0.001,allotherp’s>0.05aOnedoseofNarcanwasdefinedas0.4mgadministeredintravenouslyand2mgadministeredintranasally.

DemographicsOverall(n=36)

Subsample(n=12)

Police(n=6)

Fire(n=6)

EMS(n=6)

EmergencyDepartment

(n=18)Ageyearsm(sd) 42.5(9.6) 47.8(7.2)* 41.8(7.0) 42.2(11.2) 44.8(10.8) 42.0(10.1)Gender

MaleFemale

29(80.6%)7(19.4%)

10(83.3%)2(16.7%)

5(83.3%)1(16.7%)

6(100%)0(0%)

12(66.7%)6(33.3%)

Racen(%)Black/AfricanAmericanWhiteMultiracial

1(2.8%)34(94.4%)1(2.8%)

11(91.7%)1(8.3%)

0(0%)6(100%)0(0%)

1(5.6%)16(88.9%)1(5.6%)

Ethnicityn(%)HispanicandLatinoNotHispanicorLatino

2(5.7%)33(94.3%)

11(100%)

0(0%)5(100%)

0(0%)6(100%)

2(11.1%)16(88.9%)

Yearsemployedm(sd) 12.9(8.8) 18.5(8.5)** 17.2(7.3) 18.4(10.9) 18.3(9.1) 7.9(5.6)

Howmanyoverdoseshaveyourespondedto?Median(range)

78(4-1000)

219(30-1000)

62(24-1000)

58(40-100)

88(36-1000)

100(4-450)

HowmanytimeshaveyouadministeredNarcan?m(sd) 52(107) 89(175) 0(0) 33(17) 157(235) 30(37)

AverageNarcandoseperpatientam(sd) 1.6(0.8) 1.7(1.0) N/A 1.9(1.2) 1.6(0.5) 1.7(0.6)

SUMMARY

Overall,responderswerepredominatelynon-Hispanic,whitemales.Respondershadbeenemployedforoveradecadeonaverageandhadextensiveexperiencetreatingoverdoses.Allfire,EMS,andEDpersonnelhadadministeredNarcantopatientsonmultipleoccasions,thoughnopoliceofficershadeveradministeredNarcan.EMS,ED,andfirepersonnelestimatedthattheycurrentlyneededtoadministermorethanonedoseofNarcanperpatient.Therespondersselectedforthequalitativesubsamplewerecomparabletothefullsampleongender,race,ethnicity,andexperiencetreatingoverdoses.Thesubsamplewassignificantlyolderandhadmoreyearsofemploymentthanthoserespondersincludedonlyinthefullsample.

INTERVIEWFINDINGSBYCATEGORY

InterviewFindingsbyCategory

INTERVIEWFINDINGSBYCATEGORY

OVERVIEWThefollowingsectionsaredividedbythetencategoriestargetedduringtheinterviewswithconsumers,firstresponders,andEDpersonnelandthethemesthatemergedfromeach:(1)Trajectoryofopioiduse,(2)Formulationofheroinandfentanyl,(3)Fentanyl-seekingbehavior,(4)Traffickingandsupplychain,(5)Experienceswithoverdoses,(6)ExperienceswithNarcan,(7)Harmreduction,(8)Treatment,(9)Prevention,and(10)Lawsandpolicies.

Forthedurationofthereport,thefollowingacronymsshouldbenoted:

FLH–Fentanyl-lacedHeroin

R/ED–FirstResponderand/orEmergencyDepartmentPersonnel

INTERVIEWFINDINGSBYCATEGORY:TRAJECTORYOFOPIOIDUSE

InterviewFindingsbyCategory:TrajectoryofOpioidUse

OPIOIDCONSUMERSEarlyexperimentationwithsubstanceuse(e.g.,“Ismokedpotat8”;“IdrankalittlebitwhenIwas12”)wasendorsedbythevastmajorityofintervieweeswhenaskedtotalkabouttheirpathtoopioiduse.Severeinjuries(e.g.,brutaldogattackrequiring200stitchestotheface,2brokenlegsduetomotorcycleaccident,doublehipreplacementat13yearsofage)warrantingprescriptionopioidtherapy(chronicopioidtherapyinseveralcases)forassociatedpainwerecitedpervasivelyaswhat,“kindofstartedit,”“mighthavetriggeredthebeginningofit[opioidseekingbehavior]…itgotmybrainrunning.”Asubsetofthoseendorsingalegitimateprescriptionforopioidspointtotheabruptterminationand/orsteeptaperoftheirprescriptionbytheirdoctorsasthereasonforturningtothe“streetpharmacy”(seepullquote).

Manyconsumersprominentlyfeaturedsubstanceuseamongnuclearfamilymembers,includingintergenerationalsubstanceuse,intheirresponsestoquestionsabouthowitallstarted.Thatfamilysubstanceuseeliminatedbarrierstoaccessingdrugs,andsignaledapermissiveenvironmentinwhichtoinitiatedruguse,isevidentinthefollowingremarks:“thefirsttimeIusedcocainewaswithmymother”

“mybrotherintroducedmetoheroin”

“whenIwasborn,myfatherwasaheroinaddict”

“[atage8]mybrotherthoughtitwouldbefunnytogethislittlesisterhigh”

“Withourhugeopiatedilemma…withdoctorsafraidtoprescribepainmedicinetopeople,theywereveryshortwithmeandthepainmed.Theyweren’treallytakingcareofmeenough,andmyinsurancewouldn’tcovermetogetintoagoodpainclinic,soIwaskindofflyingononewing.Iwasstillinalotofpain,sowhattheyendedupmakingmedowaslookforotherpeoplethathadpainmedssoIcouldjustberight…nextthingIknew[heroin/fentanylmix]wasinfrontofme.”

Finally,severalconsumersunderscoredthesignificanceofunmanagedmentalhealthissues(e.g.,“italljustprogressedbecausemydepressiongotworseandworse”)ascontributingmeaningfullytoatrajectoryofopioiduse.

Significantly,theseriskfactorsintersect,overlap,andcompoundeachotherinallbutahandfulofcases(seeFigure6).Forexample,oneyoungwomancitesaPercocetprescriptionfollowingacesareansectionasthe“startofeverything,”yetshealsomentions“dabbling”withsubstances(i.e.,alcohol,marijuana,cocaine,andinhalants)startingatage15,aswellaspervasivefamilysubstanceusetotellherstoryofhowherdrugusestarted:“Bothofmyparentswereraisingheroinaddicts…Meandmytwin…Ihavecousinsthathavediedofheroinoverdoses;myauntsandunclesarealcoholicsanddrugaddicts.Itwasinmyfamily.”

Figure6.RiskContextforTrajectoriesofOpioidUse

FIRSTRESPONDERSANDEMERGENCYDEPARTMENTPERSONNELThoughmostfirstresponderandEDpersonnel(R/ED)lackedfirst-handknowledgeofopioidusetrajectories,severalspecificallyaskedconsumersabouttheir“on-ramptotheaddictionhighway”(ED).

R/EDpersonnelbelievedthatsomeconsumersinitiatedopioiduserecreationallywithfriendsduringadolescence,andacknowledgedanintergenerationalcycleofsubstanceusewhereby“parentswhoaredruguserstendtohavekidswhoaredrugusers”(Police).

R/EDpersonnelalsodiscussedthepathfromprescriptionopioidusetoillicitopioiduseafterabrupttapersoftheprescription.Asoneemergencydepartmentphysicianstated,“Ihavelatelybeensurveyingallmypatientsabouthowtheygotstartedinopiateaddiction….Manyofthemhadamedicalcondition,trauma,anoperation,andtheygothooked”(ED).

R/EDpersonnelreportedthatchangesinprescribingpracticesduringthe1990scontributedtoincreasedratesofopioidprescriptionsforinjuriesorchronicpain,whilerecentcrackdownsonprescribingmayhavepushedsomeconsumerstoseekheroin.

Althoughnotprominent,someR/EDpersonnelmentionedthatuntreatedmentalhealthproblemscontributedtoconsumers’initiationofopioiduse.“AlotoftimesI'mseeingittiedtomentalhealthreasonswithpeople,whetheritbedepressionorwhatever,peoplemaskingsomethingelsegoingon”(Police).

SUMMARYThemaintrajectoriestoopioidusereportedduringthestudywere:

(1) earlyrecreationaluseofsubstances,(2) injuriesorsurgeriesresultinginopioidprescriptionsforpainmanagement,and(3) intergenerationaluseofopioids.

Thesetrajectoriesoftenintersectedandoverlapped.

Lessprominentwasthetrajectoryofself-medicatingmentalhealthproblems(e.g.,depression,anxiety,oranger),asapproximately10%ofconsumersand8%ofR/EDpersonnelmentionedthisasacontextforopioiduseinitiation.

INTERVIEWFINDINGSBYCATEGORY:FORMULATIONOFHEROINANDFENTANYL

InterviewFindingsbyCategory:FormulationofHeroinandFentanyl

OPIOIDCONSUMERSThereisconsensusacrossinterviewsthatfentanylsurfaced“inthemix,”meaningmixedinorcutwithheroin,betweentwoandthreeyearsagoinNewHampshire(mid-orlate2014).Consumersoverwhelminglyreportbeingunawareornotapprisedbydealersthattheheroinproducthadbeenaltered.However,intervieweessuggestthatthedifferencesinformulationbetweenpureheroinandfentanyllacedheroin(FLH)aremanifold.Thefirstoffourprimarythemeshighlightinghowconsumersdiscriminatebetweenheroin,andFLHisbysight.Nearlyallconsumersreportnoticingthat“heroin”startedappearinglighterincolor.However,oneintervieweefeltstronglythat“youcannottellbylookingatit;”nevertheless,othercluespervasivelycitedbyconsumersenablediscriminatingthedifference.

Onelongtimeheroinuserrecalledasecondclueorthemeregardingadifferenceinformulationnotedbynearlyallconsumers.Hesaid,“whenthefentanylcamein,I[could]actuallytastethedifferencebetweenthetwo.”Thetasteisdescribedindifferentways,butthecommondenominatoramongthosespecifyingthetastedifferenceisthatfentanyl“isgonnahaveamuchsweetertaste.”Afewconsumersclarifythat“fentanyltendstobecutwithasugarybase,”or“there'snotaste,there'snosmelltoit,sometimesit'salittlesweet,butthat'sonlyifpeoplelikecutitwithlikesugarorsomethinglikethat.Butthepurefentanylhaslikeno...scent,theheroin,goodheroinsmellslikekindoflikevinegaralmost,itstinks.Butthefentanyl…Ifanything,there'snoscent.It'sodorless

“[Fentanyl]islikeawhitebeige…heroinisusually

brown.Theysayit’swhiteheroinbutIcanalmostguaranteeitsfentanyl.”

“[Heroin]wasalwaysbrown,reallydarkbrown.It’sjustreallylightnow,soI’msuremostofitisfentanylorfentanylcutwithheroin.”

“Fentanyltastessweetasopposedtobitter,ramen

noodlesmellingalmost…Ithasasweetalmostconfectioner

sugartaste.”

“Whenyouinjectit,youcankindoftasteadifferentchemicaltastebecausewhenyouinjectdrugs,youcanalwaystasteitinthebackofyourmouth.Withfentanyl,ithasmoreofa…chemicaltastethanheroin.”

andtasteless…”Triangulatingdatasources,oneconsumernoted,“whenyoubuyit,ifitlooksmoreonthewhitesideandithasasweetnesstoit,itusuallymeansthatthat'swhatitis.…that'swhenyouknowit'smixed.”

The“high”orsubjectiveeffectsassociatedwithingestingfentanylorFLHisalsoexperiencedasmarkedlydifferentfromaheroin“high”.Consumersreportthatitisstrongerthanheroin.

Beyondthebluntassessmentofpotency,consumersfrequentlycommentedondifferencesbetweenheroinandFLHintermsofthecourseoftheassociatedhigh.Onsetismarkedly

“quicker”withtheFLH:“IknowfrommyexperiencewhenIdidit[FLH]withinminutesIwasout…thelastthingIrememberIwasreachingformybeerandInevermadeit,Ihitthefloor.”Andsomeconsumersnotedthat“fentanyl[FLH]creepsuponyou”;“IguesshowitworksistheheroinwillhityoufirstandthenIguessittakesalittlelongerforthefentanyltohityoubutthenitcomesinrightbehindtheheroinandthat’swhenpeoplegoout.”

Thereisoverwhelmingagreementthat“thehighdoesnotlastaslongasheroin.”

“itdoesn’tlastaslongasheroin,soyouneedtouseitmoreandmore”

“Itjustseemslikeithitsyouhard,butthenitseemslikeyou'redopesickquick.Idon'tknowifthehalf-lifeisaslongasheroin,butforme,itseemslikeIwoulddobagoffentanyl.I'dprobablybesick,startfeelingfirstsignsofwithdrawalswithinlikesix,sevenhours,butifIdidheroin,Icouldprobably12to18hoursI'dbefinedependingonthedose”

“Itjustmakesyoureallysickafteryoushootit,andyoucatchthathabitalmostimmediatelyaftershootingit.”

Thisisnotsurprising,asfentanylisashort-actingopioid(Suzuki&El-Haddad,2017).

“Itisstrongerthanregularheroin…”

“There’salwaysthepotentialtooverdose,becausethefentanylis…justsomuch

stronger...”

“Icanalwaystellthedifferencebetweenregularheroinandheroinlacedwith[fentanyl].That’swhyIdon’tlikeregularfentanyl.Itgivesmetoomuchnausea,butmixedtogether,it’stolerablebecausetheheroin’sthere…takingthenauseaaway.It’salmostlikesomeonedroppedatonofbricksonyourchestandyoualmostloseyourbreathforaminute.”

Subjectiveevaluationsoftheeffectsaremixedandfallalongacontinuumfrom“Thehighiswaybetter…andyougetwayhigher…you’renoddedout,youlosecontrol,”to“Idon’tagreethatthehighisbetter…Idon’tthinkit’smuchofahighifyouarejustinstantlydead.Thereisn’tmuchtoenjoy.Youarejustazombie.Youaregone.”

However,onethingalmostallconsumersagreeonisthat“it’scheapertobuyfentanyl.”

FIRSTRESPONDERSANDEMERGENCYDEPARTMENTPERSONNELR/EDpersonnelwereconfidentthatconsumerswereoverdosingonopioidsbuthadlimitedknowledgeabouttheexactopioidtypesandformulations.Consumerswerenotconsistentlyforthcomingwithprovidinginformationtorespondersabouttheiropioiduse.“Thebulkofpatientswillkindof,iftheytellyouanything,willkindoftellyouthatwhattheypurchasedwasheroinorwhattheythinkwasheroin”(ED).

Despiteconsumerreportsofheroinuse,responderswerelargelycognizantthattheheroinmaybemixedwithfentanylbuthadlittleknowledgeoftheactualformulationoftheFLH.OneEMSresponderexplained,“Idon'treallyhaveanawfullotofexposuretotheillicitdrugsideoffentanyl,thatI'mawareof.Icouldbedealingwithit99%ofthetime,butI'mjustnotawareofit.I'mnotgettingthatfeedback”(EMS).

Multiplerespondershadwitnessedpillsorpowderatthescenewhenrespondingtooverdoses,andreportedthattobefentanyl.“Wealwaysgoontheassumptionthatit’s...fentanyl”(EMS).Accordingtoseveralpoliceofficers,thepowderformulationoffentanylwasmoreprevalentthanpillsorpatches:“It'salwaysinthepowderformuphere…Somepeopledogetfentanylpatchesandbuyfentanylpatchesillegally…Andthey'llflickthemdownorthey'lllickthegeloffofthemanddothat.That'sveryrare”(Police).Thesepillsandpowderdrugswereusually

“Ithinkyoucangetafingeroffentanyl,whichis10grams,for

aroundprobablytwohundredandsomething.Maybe200bucks.

Brownyoucangetfor300bucks.Ifyousellagram…peoplesella

gramfor60bucksandthentheybuyitfor200;theyjustmade400

bucks.”

“Ifyou’regoingtodoit,everybody’slookingforcanyougetthestuffwithfentanylinit…becausetheotherstuff,especiallyinNewHampshire,youspendusually,let’ssee,$150,$200tobuy10bagsofheroin.Ifit’snotgood,youcoulddoallofthatjusttogethigh.Peoplearespending$200justtobehighforafewhours.Ifit’sgoodandithasfentanylinit,youcangethighthreeorfourtimes.”

snortedorinjectedbyconsumers:“Ithinkwe'reseeingprobablya50/50splitonthosethatareinjectingandthosethataresnortingnow”(EMS).

DifferentiatingbetweenheroinandfentanylwasalsoathemeoftheR/EDpersonnelinterviews.Withtheexceptionofpolice,respondersandEDpersonnelusuallydidnothandleortestthedrugsfoundatoverdosescenessohadlittleexperiencedistinguishingbetweenheroinandfentanyl.R/EDpersonnellearnedthatconsumerscoulddistinguishbetweenheroinandfentanylbytheircolor,consistency,potency,andsubjectivefeeling.FentanylwasdescribedasbeingalightercolorthanheroinbyseveralR/EDpersonnel.“We'lltalktosomeoneonthestreetandthey'llsay,‘Well,Iknewhewasgoingtooverdosebecausewhenheinjecteditwaslight’"(EMS).ConsumersalsoreportedtoR/EDpersonnelthatthesubjectivehighwasdifferentforfentanyl.“Some[patients]willtellmethatitfeelsdifferentwhentheyuseit,sotheymaynotperceiveitwhenthey'relookingatitbutafterusingittheyfeelthatthetwodrugsaredifferent”(ED).

SUMMARYFromtheinterviewswithR/EDpersonnel,itisapparentthattheyreportlittleknowledgeoftheformulationofheroinandfentanyl.

Conversely,consumersbelievetherearemanywaystodeterminewhetherasubstanceisheroinorfentanyl,includingbysight,taste,effect(strength,speedofonset,anddurationofhigh),andcost.OverdosesarenotlimitedtothoseinjectingFLH,assomeconsumersarereportingoverdosingafterinhalationoftheproduct.

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