Faculty Bibliography

BACKGROUND:Pentobarbital is a Schedule II/III short-acting barbiturate with limited medical use in humans. Veterinary professionals use pentobarbital to euthanize dogs, cats, and other companion animals. Pentobarbital is also utilized in capital punishment and small amounts are illegally shipped or diverted to assist in suicides. However, five kilograms of pentobarbital smuggled in from Mexico was recently seized by an organized crime drug enforcement task force (along with fentanyl, heroin, and cocaine), which may suggest a shift in illicit supply. We investigated potential indicators of illicit pentobarbital use or availability in the US to help determine whether this drug is becoming an emerging public health concern. METHODS:The National Drug Early Warning System requested information on pentobarbital from its sentinel surveillance sites and collaborators and conducted a search of current literature. RESULTS:In early 2024, multiple batches of counterfeit pills (e.g., pressed as "M30s" to represent oxycodone) confiscated near the Southwest border tested positive for pentobarbital plus combinations of fentanyl, fentanyl analogs, and xylazine. Other indicators suggest pentobarbital is being smuggled in powder form and possibly sold as another drug such as heroin. One national drug analysis program detected pentobarbital in 217 drug submissions from 2020 to 2023, and there were at least 12 fatal exposures linked to use from 2020 to 2022. CONCLUSION/CONCLUSIONS:Continued monitoring of illicit use and availability is needed as pentobarbital may continue to appear on the illicit market. Unknown exposure can occur if the drug is mixed into counterfeit pills or sold in powder form represented to be another drug.

Research suggests that hair color, hair dyeing, and perspiration can bias hair test results regarding drug exposure, but research is needed to examine such associations in a multivariable manner. In this epidemiology study, adults were surveyed entering nightclubs and dance festivals in New York City, and 328 provided hair samples, which were analyzed using ultra-high-performance liquid chromatography-tandem mass spectrometry to determine the level of detection of cocaine and 3,4-methylenedioxymethamphetamine (MDMA). Reporting use was not an inclusion criterion for analysis. We used two-part multivariable models to delineate associations of hair color, past-year hair dyeing, and frequency of past-month hat wearing (which may increase perspiration) in relation to any vs. no detection of cocaine and MDMA as well as level of detection, controlling for hair length, self-reported past-year cocaine/ecstasy/MDMA use, and age, sex, and race/ethnicity. Those reporting having dyed their hair were at increased odds of having any level of cocaine detected (adjusted odds ratio [aOR] = 3.75, 95% CI confidence interval [CI]: 1.85-6.70), and compared to those with brown hair, those with blond(e) hair on average had lower levels of cocaine (ng/mg) detected (beta = -7.97, p = 0.025). Those reporting having dyed their hair were at increased odds of having any level of MDMA detected (aOR = 3.05, 95% CI: 1.44-6.48), and compared to those who reported never wearing a hat, those who reported wearing a hat daily or almost daily on average had lower levels of MDMA (ng/mg) detected (beta = -6.61, p = 0.025). This study demonstrates the importance of using multivariable models to delineate predictors of drug detection.

INTRODUCTION/BACKGROUND:While morbidity and mortality related to synthetic opioids such as illicitly manufactured fentanyl (IMF) are monitored in the U.S., there has been a lack of national survey data focusing on use. Survey data are important as self-report can help estimate prevalence of use among living persons. METHODS:Data were examined from the 2022 National Survey on Drug Use and Health, a nationally representative probability sample of noninstitutionalized individuals age ≥12 in the U.S. (N=59,069). Prevalence and correlates of past-year use of IMF were estimated. Data were analyzed in 2024. RESULTS:The estimated prevalence of past-year IMF use was 0.23% (95% confidence interval [CI]: 0.17-0.31). Compared to no past-year use, individuals were at increased odds for IMF use if proxy-diagnosed with use disorder involving use of cannabis (aOR=3.72, 95% CI: 1.34-10.32), cocaine (aOR=11.96, 95% CI: 4.78-29.93), methamphetamine (aOR=5.60, 95% CI: 1.65-19.02), heroin (aOR=20.56, 95% CI: 8.90-47.52), and/or prescription opioids (aOR=10.65, 95% CI: 3.54-32.03). (Mis)use without use disorder was only significant for prescription opioids (aOR=5.77, 95% CI: 2.55-13.06). Those receiving treatment for substance use in the past year were also at increased odds for use (aOR=5.79, 95% CI: 2.58-13.00). CONCLUSIONS:Prevalence of IMF use is rare in the general U.S. POPULATION/METHODS:While past-year (mis)use of other drugs (without use disorder) was not consistently associated with IMF use, cannabis, cocaine, methamphetamine, heroin, and prescription opioid use disorder was associated with higher odds of IMF use, suggesting that more "severe" use of various drugs is more of a risk factor than use.

PURPOSE OF REVIEW/OBJECTIVE:New psychoactive substances (NPS) continue to emerge globally and present a threat to public health. This article summarizes the most recent literature on approaches for monitoring NPS use and adverse events related to use. RECENT FINDINGS/RESULTS:A variety of approaches have recently been employed for surveillance of NPS use and associated harms, including the use of toxicology testing of patients in emergency departments, surveys of sentinel populations, drug checking and syringe services programs, wastewater-based epidemiology, and retrospective analyses of clinical samples and toxicology reports. These studies cover a range of time periods and NPS examined across numerous countries. SUMMARY/CONCLUSIONS:Areas of particular interest for future research include the use of data from drug checking services to inform surveillance efforts of the illicit drug supply and the development of methods for wastewater-based monitoring of NPS. Studies that combine self-report data with toxicology testing in particular are important for capturing unintentional or unknown exposure to NPS including fentanyls and drugs like xylazine. Given the limitations associated with individual indicators of drug use and associated harms, the harmonization of multiple data sources can help present a more complete picture of both trends involving NPS to better inform public health responses.

BACKGROUND:Rates of synthetic opioid-related deaths over time and across regions have been compared within the US, but other indicator data could help inform prevention and harm reduction as well. We compared regional trends in fentanyl seizures to examine potential shifts in illicit fentanyl availability. METHODS:Annual trends in fentanyl seizures were examined using data from High Intensity Drug Trafficking Areas for the US overall and by region from 2017 through 2023. Multiple measures included the number of seizures, the number of powder seizures, the number of pill seizures, the total weight of seizures, the number of pills seized, and the percentage of the number of pill seizures relative to the number of total seizures. RESULTS:The percentage of seizures in pill form in the US increased from 10.3 % in 2017 to 49.0 % in 2023 (adjusted annual percentage change [AAPC]=25.2, 95 % CI: 17.6, 33.2), with 115.6 million individual pills seized in 2023. Pill weight related to total seizure weight also increased from 0.4 % to 54.5 % (AAPC=112.6, 95 % CI: 78.6, 153.2). In 2023, the plurality of seizures was in the West, in seven out of eight of our measures, with 77.8 % of seizures in the West being in pill form. Although the Midwest had lower prevalence of seizures than the West, there were notable increases in the Midwest in the number of pill seizures (AAPC=142.2, 95 % CI: 91.9, 205.8) and number of pills seized (AAPC=421.0, 95 % CI: 272.7, 628.4). Total weight of fentanyl seized increased the most in the West (AAPC=84.6, 95 % CI: 72.3, 97.8). CONCLUSIONS:The number and size of fentanyl seizures is increasing in the US, with the majority of seizures, especially in pill form, in the West. Continued monitoring of regional shifts in the fentanyl supply can help inform targeted prevention and public health response.

INTRODUCTION/BACKGROUND:Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) is a drug commonly used by people who attend electronic dance music (EDM) events at nightclubs and dance festivals. Drug checking has gained popularity in recent years to test for adulterants, but epidemiology studies are needed to estimate potential shifts in prevalence of drug checking to further inform harm reduction efforts. METHODS:Adults entering randomly selected EDM events in New York City were surveyed in 2017 and 2022. Those reporting past-year ecstasy use were asked if they tested their ecstasy in the past year using a drug testing kit and whether they found out or suspected their ecstasy contained other drugs. We compared estimates between 2017 and 2022. RESULTS:In 2017, an estimated 23.1% had tested their ecstasy, and this estimate increased to 43.1% in 2022 (86.6% increase, p = 0.006). Among those who tested their ecstasy, in 2017, 31.2% always tested their drug, and this increased to 60.6% in 2022 (94.2% increase, p = 0.026). In 2017, 59.6% of those who tested their ecstasy reported finding out or suspecting their drug was adulterated, which decreased to 18.4% in 2022 (69.1% decrease, p < 0.001). Suspected methamphetamine adulteration in particular decreased, from 21.9% in 2017 to 3.6% in 2022 (83.6% decrease, p = 0.007). DISCUSSION AND CONCLUSIONS/CONCLUSIONS:The use of drug testing kits has increased among EDM event attendees who use ecstasy and, at the same time, among those who had tested their ecstasy, suspected adulteration has decreased. Continued interest in understanding ecstasy contents among this population suggests the need for formal drug checking services.

A new class of synthetic cannabinoids called OXIZIDs has emerged in recent years. This class consists of compounds with oxindole cores and hydrazide/hydrazone linker moieties and has often been described as being designed to circumvent a Chinese class-wide ban that was effective as of July 1, 2021. However, through hair testing of nightclub attendees in New York City-a high-risk population for recreational drug use-we have evidence suggesting exposures to an OXIZID called BZO-4en-POXIZID (4en-pentyl MDA-19) prior to the effective ban. Through analysis of 6 cm segmented hair samples from attendees collected in 2021, we detected five cases of exposure. Specifically, we detected a cluster of three cases based on hair samples collected on June 20, 2021, and then two additional cases from samples collected on July 16, 2021. Four of these hair samples were long enough to analyze two 6 cm hair segments (representing approximately two six-month timeframes) and three of four of these cases tested positive for repeated exposure (for an estimated exposure over six months prior to hair collection). All cases included young adult females reporting past-year cannabis use but all tested negative for THC exposure. Three cases also reported past-year use of cocaine, ecstasy, and/or ketamine, and four cases tested positive for exposure to cocaine, MDMA, MDA, methamphetamine, and/or eutylone. These subjects were exposed to BZO-4en-POXIZID-likely as an adulterant in other drugs, and these cases are among the first documented cases which occurred approximately half a year before the Chinese legislative ban.