Faculty Bibliography

BACKGROUND:Biological testing can be used to validate or detect underreported drug use. Since hair testing is increasingly used in survey research, we examined how the utility of hair testing compares to a more common method-urine testing. METHODS:532 adults (ages 18-29) reporting past-month heroin use and/or nonmedical prescription opioid use were surveyed about past-month use of various drugs. Participants were urine-tested and the majority (79.3%) provided a hair sample for analysis. We examined the utility of urine vs. hair-testing in detecting past-month use of various drugs. RESULTS:Compared to hair testing, urine testing was able to confirm higher proportions of self-reported use of heroin/opioids (85.5% vs. 80.9%), marijuana (73.9% vs. 22.9%), benzodiazepines (51.3% vs. 15.1%), and methadone (77.0% vs. 48.7%), while hair testing was more likely to detect reported cocaine use (66.3% vs. 48.0%) (Ps<.01). Compared to hair testing, urine testing was more likely to detect unreported use of marijuana (11.3% vs. 0.9%), and benzodiazepines (14.4% vs. 5.4%), and hair testing was more likely to detect unreported use of cocaine (27.0% vs. 5.8%) and oxycodone (19.7% vs. 1.4%) (Ps<.001). When added to urine testing, hair testing increased detection of reported and non-reported use of cocaine and oxycodone ranging from 14 to 22%. CONCLUSIONS:While hair testing is efficacious in detecting drug use in wide window periods (e.g., past-year use), it is less efficacious than urine testing when testing for past-month use of select drugs among opiate/opioid users. However, hair testing is particularly efficacious in detecting unreported use of cocaine and/or oxycodone.

Novel synthetic opioids include various analogs of fentanyl and emerging non-fentanyl compounds with different chemical structures, such as AH-7921, MT-45 and U-47700. In recent years, these drugs have rapidly emerged on the drug market, and their abuse has been increasing worldwide. The motivations for use of these new compounds include their legal status, ready availability, low cost, users' curiosity or preference for their particular pharmacological properties and the intention to avoid detection. Furthermore, more common drugs like heroin are now increasingly being replaced or cut with fentanyl or new designer opioids; thus, many drug users are unintentionally or unknowingly using synthetic fentanyl analogs. In this scenario, the detection of new psychoactive substances in hair can provide insight into their current diffusion among the population and social characteristics of these synthetic drug users. In this manuscript, we describe a simple, fast, specific and sensitive UHPLC-MS-MS method able to detect 13 synthetic opioids (including fentanyl analogs) and metabolites in hair samples. Furthermore, the method includes the detection of 4-anilino-N-phenethyl-piperidine (4-ANPP), which is considered both a precursor and a metabolite of several fentanyl analogs. The method was applied to 34 real hair samples collected in New York City from subjects who had reported past-year non-medical opioid and/or heroin use. In total, 17 samples tested positive for at least one target analyte, with oxycodone (nine samples) and tramadol (eight samples) being the most common. Among these, the method was able to quantify furanyl-fentanyl and fentanyl in the pg/mg range in two samples. Simultaneously, also 4-ANPP was detected, giving evidence for the first time that this compound can be selected as a marker of fentanyl analogs use via hair testing. In conclusion, this study confirmed the increasing diffusion of new synthetic opioids and "fentalogs" with high potency among non-medical opioid users.

OBJECTIVES/OBJECTIVE:This study aims to examine patterns and first mentions of reported use of new or uncommon drugs across 13 years, among nationally representative samples in the United States. METHODS:Participants (ages ≥12) in the National Surveys on Drug Use and Health (2005-2017, N = 730,418) were provided opportunities to type in names of new or uncommon drugs they had ever used that were not specifically queried. We examined self-reported use across survey years and determined years of first mentions. RESULTS:From 2005 to 2017, there were 2,343 type-in responses for use of 79 new or uncommon synthetic drugs, and 54 were first-ever mentions of these drugs. The majority (65.8%) of mentions were phenethylamines (e.g., 2C-x, NBOMe), which were also the plurality of new drug mentions (n = 22; 40.7%). Mentions of 2C-x drugs in particular increased from 30 mentions in 2005 to 147 mentions in 2013. We estimate an upward trend in use of new or uncommon drugs between 2005 and 2017 (p < 0.001). CONCLUSION/CONCLUSIONS:Although type-in responses on surveys are limited and underestimate prevalence of use, such responses can help inform researchers when new compounds are used. Continued surveillance of use of new and uncommon drugs is needed to inform adequate public health response.

BACKGROUND:Use of synthetic cathinones, commonly referred to as "bath salts", has been associated with tens of thousands of emergency department visits in the US; however, few national studies have estimated prevalence of use and we know very little about use among adolescents. In this study we estimate prevalence and correlates of use of "Flakka" (alpha-PVP), a highly-potent "bath salt" associated with at least 80 deaths in the US. METHODS:We analyzed data from the 2016/2017 Monitoring the Future study, which surveyed a nationally representative sample of high school seniors in the US (n = 3786). Bivariable and multivariable models were used to determine demographic and drug-related correlates of use. RESULTS:Overall, 0.8% (95% CI: 0.5-1.2) of high school seniors in 2016/2017 is estimated to have used Flakka in the past year. Students whose parents have less than a high school education were at higher odds for use (aOR = 4.12, 95% CI: 1.00-16.94). Flakka users reported high prevalence of use of other drugs, particularly synthetic cannabinoids (85.6%), ketamine (72.3%), marijuana (59.1%), and GHB (47.5%). Flakka use was also associated with use of a higher number of other drugs and higher frequency of use of other drugs, with 51.7% using 4-12 other drugs and 22.4% using 4-12 other drugs >6 times. CONCLUSIONS:Students who use multiple drugs are elevated risk for Flakka use, suggesting synthetic cathinone use alone is rare and the use of multiple substances may compound adverse effects of these drugs. Socio-economic disparities are concerning given reduced access to prevention and intervention.

BACKGROUND:Electronic dance music (EDM) parties at nightclubs and festivals are high-risk scenes for drug use. Although intention to use drugs (such as ecstasy) has been shown to be the most proximal determinant of use, little is known regarding the extent to which drug use is unplanned in this high-risk scene. METHODS:We surveyed 954 adults entering EDM parties in New York City in 2017 and asked about planned drug use that night. A quarter (n = 236) completed the optional online follow-up survey which asked about drug use during their outing. We examined prevalence and correlates of planned and unplanned use. RESULTS:A fifth (21.0%) of attendees reported planning to use a specific drug the night of the party and over a third (35.4%) reported using a drug later that night. A quarter (26.6%) used in an unplanned manner. Unplanned marijuana use was most common (10.7%), followed by unplanned use of ecstasy (7.3%), cocaine (4.7%), amphetamine (1.4%), LSD (1.3%), and MDA (1.1%). Unplanned initiation of ecstasy and PMA also occurred. Unplanned drug use was more likely to occur among those recruited outside of nightclubs compared to festivals. Non-heterosexual participants and those with a college degree or higher were also more likely to engage in unplanned marijuana use compared to heterosexual and less educated participants, respectively. CONCLUSIONS:Unplanned drug use is common at EDM parties. Results can inform prevention and harm reduction in these scenes as unplanned use may exacerbate potential adverse outcomes related to drug use and often extreme party environments.

RATIONALE/BACKGROUND:Current prevalence estimates of synthetic cathinone ("bath salt") use may be underestimates given that traditional metrics (e.g., surveys, urinalysis) often fail to capture the emergent issue of synthetic cathinone adulteration of more common illegal drugs, such as ecstasy (3,4-methylenedioxymethamphetamine). OBJECTIVES/OBJECTIVE:This review examines the evolution of synthetic cathinones and prevalence of use over the past decade in the United States. We also review methods of self-report and biological testing of these compounds as well as adverse outcomes associated with adulterated drug use. RESULTS:Synthetic cathinone use emerged in the United States by 2009 with use associated with tens of thousands of poisonings. Reported poisonings and self-reported use have substantially decreased over the past five years. However, our review suggests that current estimates of use are underestimates due to underreporting stemming primarily from unknown or unintentional use of adulterated formulations of relatively popular illegal drugs, such as ecstasy. CONCLUSIONS:While intentional synthetic cathinone use has decreased in recent years, evidence suggests that prevalence of use is underestimated. Testing of drugs and/or biological specimens can improve the accuracy of synthetic cathinone use estimates. Furthermore, we advocate that researchers and clinicians should become better aware that exposure to these potent compounds (e.g., as adulterants) often occurs unknowingly or unintentionally. To improve our understanding of synthetic cathinone adulteration, research utilizing a combinatorial approach (survey and biological testing) will help more accurately estimate the prevalence and impact of this public health issue.

Adults ≥50 years of age have high rates of prescription opioid use. The purpose of this study is to estimate the prevalence and correlates of prescription opioid misuse among middle-aged and older adults in the United States who use prescription opioids. Data from adults age ≥ 50 from the two most recent cohorts (2015 and 2016) of the National Survey of Drug Use and Health were examined (N = 17,608). Characteristics of past-year prescription opioid misusers, including demographics, substance use, depression, chronic disease, and emergency department (ED) use, were compared to adults who used prescription opioids as prescribed in the past year and non-users. We used multivariable logistic regression to determine correlates of prescription opioid misuse among adults who used prescription opioids. Among the entire sample, 61.4% reported no past-year prescription opioid use, 36.0% reported past-year prescription opioid use without misuse, and 2.5% reported past-year prescription opioid misuse. Among past-year prescription opioid users, 6.6% reported misuse. Past-year misuse was higher among males, adults age 50-64, misusers of prescription sedatives, stimulants, and tranquilizers, users of other substances (i.e., tobacco, marijuana, cocaine), and those with alcohol use disorder. Past-year misuse was lower among adults with 2 or more chronic diseases. Past-year prescription misuse of sedatives (AOR 4.08 [95% CI 2.05-8.12]), stimulants (AOR 3.88 [95% CI 2.00-7.53]), and tranquilizers (AOR 10.02 [95% CI 6.48-15.50]) were all associated with past-year opioid misuse. Characteristics of opioid misusers determined in this study-particularly misuse of other substances-may help determine middle-aged and older adults at risk for prescription opioid misuse.

BACKGROUND:Benzodiazepine overdose rates have increased in the US, largely from concomitant use of other drugs such as opioids. Studies are needed to examine trends in prescription tranquilizer (e.g., benzodiazepine) use-with a particular focus on use of other drugs such as opioids-to continue to inform prevention efforts. METHODS:We conducted a secondary analysis of the 2005-2014 National Survey on Drug Use and Health, a repeated cross-sectional, nationally representative probability sample. Trends in past-year nonmedical tranquilizer use and trends in demographic and other past-year substance use characteristics among nonmedical users were examined (N = 560,099). RESULTS:Prevalence of nonmedical tranquilizer use remained stable from 2005/06 through 2013/14 at 2%. Prevalence of past-year heroin use and heroin use disorder both more than doubled among nonmedical tranquilizer users between 2005/06 and 2013/14 (Ps<.001). Nonmedical opioid use decreased between 2005/06 and 2013/14 (P < .001); however, opioid use disorder increased from 13.4% to 16.7% (P = .019). Prevalence doubled among those age >50 between 2005/06 and 2013/14 from 7.9% to 16.5% (P < .001), and nonmedical tranquilizer use among racial minorities also increased (Ps<.01). Prevalence of nonmedical use also increased among those with health insurance (P = .031), and this increase appeared to be driven by a 190.6% increase in nonmedical use among those with Medicare (from 2.6% to 7.4%; P = .002). CONCLUSIONS:Characteristics of nonmedical tranquilizer users are shifting, and many shifts are related to past-year nonmedical prescription opioid use and heroin use. Prevention needs to be geared in particular towards older individuals and to those who use opioids nonmedically.

BACKGROUND:Deaths from fentanyl exposure continue to increase in the US. Fentanyl test strips are now available to test urine for presence of fentanyl, but additional testing methods are needed to determine past exposure and to determine exposure to specific analogs. OBJECTIVES/OBJECTIVE:To investigate exposure to such analogs through hair testing. METHODS:Forty individuals in inpatient detoxification (7.5% female) reporting past-month heroin use were surveyed and provided a hair sample to be tested at a later date. While results could not be provided to patients, they were asked how they would respond if informed that their hair tested positive for fentanyl. UHPLC-MS/MS was used to test for past exposure to fentanyl, six other novel synthetic opioids, and fentanyl biomarkers/metabolites. RESULTS:27.5% reported known fentanyl use in the past year and 67.5% reported suspected exposure. 97.5% (39 of 40) tested positive for fentanyl, 90.0% tested positive for 4-ANPP (a biomarker) and norfentanyl (a metabolite); 82.5% tested positive for acetyl-fentanyl, 47.5% tested positive for furanyl-fentanyl, and 7.5% tested positive for U-47700. Most participants (82.5%) reported they would warn others about fentanyl if they learned their hair tested positive; 75.0% reported they would try to stop using heroin, and 65.0% reported they would ensure that someone nearby has naloxone to reverse a potential overdose. CONCLUSIONS:Hair testing is useful in detecting past exposure to fentanyl, its analogs, and other novel synthetic opioids. Further research is needed to determine whether individuals who use heroin learning about exposure affects drug-taking and treatment-seeking behavior.

INTRODUCTION AND AIMS/OBJECTIVE:Polysubstance users are a high-risk population for negative health-related consequences. Although some studies have described harm reduction strategies adopted by polysubstance users, studies have not examined their effectiveness in minimising health-related consequences. We aimed to identify dosing-related harm reduction strategies in a sample of polysubstance-using dance festival attendees, and explore the relationship between harm reduction strategies and self-reported adverse health consequences. DESIGN AND METHODS/METHODS:Data were examined for 1226 past-year dance festival attendees who self-identified as past-year multiple drug users. We conducted bivariable and multivariable analyses to explore relationships between six dosing-related harm reduction strategies and 13 self-reported adverse consequences. RESULTS:Self-reported use of dosing-related harm reduction strategies was prevalent, mainly avoidance of mixing depressants (69.2%) and setting limits on quantity (62.2%). Frequent users of harm reduction strategies reported experiencing fewer adverse health consequences (P values < 0.05). Those who reportedly set limits on quantity were at decreased odds of experiencing a bad mood after drug use, sexual difficulties while under drug influence, injuries or fractures while under drug influence, and involvement in fights or being attacked while under drug influence (P values < 0.05). Moreover, those who report frequently avoid mixing depressants were at decreased odds of experiencing headache, loss of consciousness, drop in blood pressure, injuries of fractures, and fights or attacks (P values < 0.05). DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Adoption of dosing-related harm reduction strategies appears to be associated with less drug-related harm among polysubstance-using festival attendees. Findings may inform organisations and policymakers in the designing of harm reduction interventions with this population.