Understanding Opioid Overdose Risk and Response Preparedness among People who use Cocaine and other Drugs: Mixed-Methods Findings from a Large, Multi-City Study

Abstract

Background: Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. Methods: From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences (p < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews (n = 172) contextualized survey findings. Results: The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. Conclusions: Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities

“…3 The age-adjusted rate of drug overdose deaths involving psychostimulants, including methamphetamine, increased 10-fold from 0.5 per 100 000 people in 2009 to 5.0 per 100 000 people in 2019. 4 Although both cocaine and methamphetamine combined with opioids increase the risk of overdose, 5 methamphetamine is associated with an increased risk of overdose, regardless of opioid use. 4 Methamphetamine use has been endemic in the western US for decades, particularly in rural communities where use is more prevalent than in metropolitan areas.…”

Changes to opioid overdose deaths and community naloxone access among Black, Hispanic and White people from 2016 to 2021 with the onset of the COVID‐19 pandemic: An interrupted time‐series analysis in Massachusetts, USA

“…These strategies may include raising awareness about the worsening disparities, improving access to OUD treatment, harm reduction services and integrating them into routine clinical care, using innovative service delivery models and implementing a holistic community-based response to overdose prevention [12]. Providing naloxone kits and training to people who use stimulants without intending to use opioids, who often lack awareness of fentanyl and access to naloxone, has also became increasingly important [39].…”

Suspected Nonfatal Cocaine-Involved Overdoses Overall and With Co-involvement of Opioids

“…8 It also is essential to account for overdoses coinvolving cocaine and opioids, given public health and law enforcement warnings in recent years regarding the increased mixing of fentanyl with cocaine, including some adulteration of cocaine with fentanyl, resulting in unintended exposure to fentanyl. [9][10][11] Most fatal cocaine-involved overdoses involve opioids, 6 and approximately a quarter of nonfatal cocaineinvolved overdose ED visits involve an opioid. 2,4 Notably, ED visits for overdoses involving both cocaine and opioids increased 14.7% annually from 2006 to 2016.…”

“…9,16 Persons who use cocaine may be unaware of opioid (primarily illicitly manufactured fentanyl) contamination in the drug supply, 9 opioidnaive, 16 and unprepared to respond to an opioid overdose (ie, not having access to naloxone and using alone). 9 One previous analysis of syndromic surveillance data examined cocaine-involved overdoses using diagnosis codes but did not analyze the unstandardized chief complaint text (ie, the purpose of the ED visit). 4 Examining solely diagnosis codes may underestimate cocaine-involved overdoses, as discharge diagnoses may be preliminary or incomplete in syndromic surveillance data.…”

“…Prompt detection of cocaine-involved overdoses, overall and with opioid co-involvement, will help inform prevention and response efforts in local communities. The rising numbers of nonfatal overdoses co-involving cocaine and opioids are particularly important because the co-use or mixing of these 2 drug classes can increase risk of fatal overdose 9,16. Persons who use cocaine may be unaware of opioid (primarily illicitly manufactured fentanyl) contamination in the drug supply,9 opioid-naive,16 and unprepared to respond to an opioid overdose (ie, not having access to naloxone and using alone) 9…”