Background Stimulant use has increased across the US, with concomitant opioid and methamphetamine use doubling between 2011 and 2017. Shifting patterns of polysubstance use have led to rising psychostimulant-involved deaths. While it is known that individuals who use methamphetamine require greater access to treatment, there is still little known about methamphetamine use and treatment among individuals who are already engaged in outpatient substance use treatment. Objectives To characterize care-engaged individuals who use methamphetamine to guide harm reduction and treatment strategies. Methods Retrospective cohort study of individuals at a large academic medical center in Massachusetts with ≥ 2 positive methamphetamine oral fluid toxicology tests between August 2019 and January 2020. We performed descriptive analysis of sociodemographic, medical, and drug use characteristics and a comparative analysis of injection methamphetamine use versus other routes of use. Results Included were 71 individuals [56 male (80%), 66 non-Hispanic white (94%), median age 36 (IQR 30–42)]. Nearly all had opioid (94%) and stimulant use disorder (92%). Most had (93%) or were (83%) being treated with medications for opioid use disorder, but few received pharmacologic treatment for methamphetamine use disorder (24%). None received contingency management treatment. People who inject methamphetamine (68%) were more likely to have a history of overdose (91% vs. 70%; p = 0.02), have HCV (94% vs. 52%; p < 0.01), use fentanyl (93% vs. 65%; p = 0.02), and engage in sex work (19% vs. 0%; p = 0.03) compared to those who used via other routes. Both groups had prevalent homelessness (88% vs. 73%; p = 0.15), incarceration (81% vs. 64%; p = 0.11), depression (94% vs. 87%; p = 0.34), and bacteremia (27% vs. 22%; p = 0.63). Conclusions Individuals in our study had high prevalence of polysubstance use, particularly concomitant methamphetamine and opioid use. Individuals who were well connected to substance use treatment for their opioid use were still likely to be undertreated for their methamphetamine use disorder and would benefit from greater access to contingency management treatment, harm reduction resources, and resources to address adverse social determinants of health.

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Objective: To estimate coronavirus disease 2019 (COVID-19) mortality rates among individuals incarcerated in U.S. state prisons by race and ethnicity (RE). Design: Retrospective population-based analysis Setting: Data from state-level Departments of Corrections (DOCs) from March 1 through October 1, 2020. Participants: Publicly available data collected by Freedom of Information Act requests representing adults in the custody of US state DOCs. Main Outcomes: Cumulative COVID-19 death and custody population data. Crude RE-specific cumulative death rates per 1,000 persons, by state and in aggregate, using RE-specific custody population on March 1, 2020, as the denominator. Rate ratios (RR) and 95% confidence intervals (95%CI) compared state-level and aggregate cumulative age-adjusted mortality rates as of 10/01/2020 by RE, with White individuals as reference group. Results: Of all COVID-related deaths in U.S. prisons through October 2020, 23.35% (272 of 1165) were captured in our analyses. The average age at COVID-19 mortality was 63 years (SD=10 years) and was significantly lower among Black (60 years, SD=11 years) compared to White adults (66 years, SD=10 years; p<0.001). In age-standardized analysis, COVID-19 mortality rates were significantly higher among Black (RR=1.93, 95% CI: 1.25-2.99), Hispanic (RR=1.81, 95% CI: 1.10-2.96) and those of Other racial and ethnic groups (RR=2.60, 95% CI: 1.01-6.67) when compared to White individuals. Conclusions: Age-standardized mortality rates were higher among incarcerated Black, Hispanic and those of Other RE groups compared to their White counterparts. Greater data transparency from all carceral systems is needed to better understand populations at disproportionate risk of COVID-19 morbidity and mortality.

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Author Contribution MYL, JAM, and BIB conceived of this idea. MYL wrote the first draft. JAM and BIB edited the manuscript.Funding Dr. Bearnot is supported by NIDA under award K12DA043490.