Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:The U.S. drug landscape is rapidly shifting necessitating early warning surveillance of emerging drug threats. We describe one such surveillance effort from the United States: the National Drug Early Warning System (NDEWS). RECENT FINDINGS/RESULTS:NDEWS monitors drug indicators with a particular focus on trends in new psychoactive substances (NPS) and emerging adulterants. NDEWS has five major goals: develop a collaboration network, including people with lived experience, initiate methods that deliver the freshest data on drug trends, integrate data from sources to better understand signals, disseminate findings widely, and train the next generation of surveillance scientists. NDEWS collects primary data using venue-based methods (Rapid Street Reporting), Web Monitoring, and 911 (Emergency Medical Service) data, and utilizes secondary data on drug seizures and poisonings. Information is shared bidirectionally with our 16 Sentinel Sites, our Community-Based Health Expert network, and our informal networks which include medical examiners, toxicologists, funeral directors, reporters, and community overdose response workers. SUMMARY/CONCLUSIONS:Surveillance of emerging drug trends is increasingly important around the world as patterns of drug use continue to shift. With a focus on NPS and nonlagged data strategies, NDEWS warns communities at risk to prevent serious consequences and death.

OBJECTIVES/OBJECTIVE:Self-report and biospecimen testing to assess drug exposure have limitations. Surface testing of personal objects (e.g., mobile phones) may provide complementary information about drug exposure, particularly when there is discordance between biospecimen results and self-report. We examined whether mobile phone swab testing, alongside self-report and oral fluid data, could provide information regarding drug exposure among nightlife attendees-a population with high prevalence of party drug use. We also examined whether detection could inform situations in which a drug is detected in oral fluid but not reportedly used. METHODS:In 2025, we assessed self-reported drug use and analyzed oral fluid and swabs of mobile phones from 127 adults attending nightclubs in New York City. We compared the prevalence of detection of cocaine, ketamine, 3,4-methylenedioxymethamphetamine (MDMA), and 4-methylmethcathinone (4-MMC) across the three modes of collection. RESULTS:Cocaine was detected on 26.8% of phones, followed by ketamine (22.0%), 4-MMC (3.1%), and MDMA (2.4%). When classifying phone detection, reported past-48-hour use and oral fluid detection of cocaine and ketamine demonstrated high specificity (0.85-0.91), but lower sensitivity (0.37-0.73). Among participants with oral fluid positivity after not reporting use, 33.3% and 17.1% of these discordant cases had ketamine and cocaine detected on their phones, respectively. CONCLUSIONS:Phone swab results often align with self-reported use and, less consistently with biologically confirmed exposure. However, drugs detected on phones may reflect less recent use or unintentional environmental sources contributing to oral fluid detection, supporting the role of phone swabbing as a complementary tool for detecting possible drug exposure.

BACKGROUND:In the US, 40 states and the District of Columbia (DC) have implemented medical cannabis legalization (MCL), while 24 states and DC have enacted some form of recreational cannabis legalization (RCL). We examined the association between cannabis legalization and law enforcement cannabis seizures to understand illegal drug market responses to increasing state cannabis legalization. METHODS:Data on law enforcement cannabis seizures came from the High Intensity Drug Trafficking Areas (HIDTA) program. We tested the association between state-level RCL and MCL adoption and annual changes in cannabis seizures aggregated by state-year from 2010 to 2023 using a series of Poisson regression models that controlled for time-varying state demographic and law enforcement variables in addition to state and year fixed effects. To account for potential lag time between MCL/RCL effective dates and policy impacts on seizures, we conducted additional analyses with 1-year MCL/RCL lags. RESULTS:Over the study period, there were 286,844 cannabis seizures by HIDTA-affiliated agencies, with 686 state-years of observation. In primary adjusted models, RCL adoption was associated with a significant decrease in cannabis seizures in MCL & RCL states versus MCL-only states, both immediately following RCL adoption (exp(β)=0.55, 95% CI: 0.54, 0.56) and one year after RCL went into effect (exp(β) for 1-year lag=0.62, 95% CI: 0.61, 0.64). CONCLUSIONS:The adoption of RCLs in US states, beyond only MCLs, may help to reduce the size of illegal cannabis markets, or there may be shifting law enforcement seizure priorities in those states.

BACKGROUND AND AIMS/OBJECTIVE:Nitazenes are a novel subclass of synthetic opioids that have been increasingly implicated in the United States (US) overdose crisis. Despite their growing presence in the illicit drug supply, national trends have not been systematically evaluated. This study aimed to describe temporal and geographic patterns in nitazene detections and assess substances co-involved in nitazene-positive biospecimens. DESIGN/METHODS:Cross-sectional study using forensic data from two national sources: the US Drug Enforcement Administration's National Forensic Laboratory Information System (NFLIS) and the Center for Forensic Science Research & Education's (CFSRE) NPS Discovery Program. SETTING AND CASES/METHODS:Nitazene detections in all 50 US states and the District of Columbia between 2019 and 2024. MEASUREMENTS/METHODS:We quantified annual nitazene detections overall and by individual nitazene analog, US Census region and state. Temporal trends were modeled using piecewise linear regression with a Poisson distribution and log link, nationally and by region. NPS Discovery data were used to characterize substances co-involved with nitazene-positive biospecimens. FINDINGS/RESULTS:Between 2019 and 2024, 7117 nitazene analog reports were submitted to NFLIS, increasing from 43 in 2019 to 1905 in 2024. Counts rose sharply from 2019 to 2021 [count ratio = 7.32; 95% confidence interval (CI) = 2.22-24.20] but did not increase statistically significantly from 2021 to 2024 (count ratio = 1.08; 95% CI = 1.00-1.17). Early detections were predominated by isotonitazene (97.7% of NFLIS nitazene reports in 2019) but later shifted toward metonitazene and protonitazene (29.5% and 30.1%, respectively, in 2024). NPS Discovery identified 361 nitazene-positive biospecimens, increasing from 11 in 2019 to 113 in 2024, with counts increasing by approximately 45% per year (count ratio = 1.45; 95% CI = 1.23-1.71). Nearly all nitazene-positive biospecimens (98.3%) had at least one co-detected substance, most commonly fentanyl (54.6%). CONCLUSIONS:Nitazene detections increased sharply across the United States between 2019 and 2024, with shifting patterns in the prevalence of individual nitazenes and extensive polysubstance involvement. These findings highlight the need to strengthen drug testing capacity, expand epidemiological surveillance and implement targeted public health interventions to mitigate harms associated with this emerging class of synthetic opioids.

OBJECTIVE/UNASSIGNED:The authors sought to examine substance use patterns across the sexual identity spectrum, particularly among individuals who describe their sexual identity using different terms or express uncertainty about their orientation-groups that remain poorly understood beyond lesbian, gay, or bisexual (LGB) categories. METHODS/UNASSIGNED:Using data from the 2023 National Survey on Drug Use and Health among individuals ≥12 years of age (N=52,525), the authors examined past-year substance use across five sexual identity groups: heterosexual, gay/lesbian, bisexual, those using a different term to describe their sexual identity, and those unsure of their identity. Associations were examined between sexual identity (overall and disaggregated by sex using sex-specific heterosexual reference groups) and past-year use of cannabis, hallucinogens, cocaine, inhalants, methamphetamine, and misuse of prescription opioids, tranquilizers/sedatives, and stimulants. RESULTS/UNASSIGNED:Substance use was higher across all other sexual identity groups compared with heterosexual individuals. Bisexual and gay/lesbian individuals showed elevated odds across most substances examined, particularly inhalants, hallucinogens, and cannabis. Both individuals using different terms and those unsure of their sexual identity showed elevated odds for inhalants, hallucinogens, cannabis, and prescription tranquilizer/sedative misuse, with those using different terms additionally showing elevated odds for prescription stimulant misuse. In sex-disaggregated analyses, both males and females showed elevated odds across multiple substances, with females generally showing elevations across a greater number of substances, although some estimates for males were suppressed due to small sample sizes. CONCLUSIONS/UNASSIGNED:These findings extend our understanding of substance use beyond LGB categories, revealing nuanced patterns among emerging identity groups, underscoring the importance of targeted screening and prevention strategies.

INTRODUCTION/BACKGROUND:As new psychoactive substances (NPS) continue to emerge both in the US and globally, research is needed to determine the extent of adverse effects associated with NPS use beyond poisonings or mortality to inform prevention and harm reduction efforts in this population. METHODS:Data were from the National Drug Early Warning System Rapid Street Reporting study, which uses a venue-intercept design to survey adults (≥ 18 years) in US cities over weekend periods. Between January 2022 and November 2023, 6039 individuals were surveyed in 20 cities regarding their use of a range of NPS and other common drugs. Those reporting past 12-month use of a drug were asked if they experienced a harmful or very unpleasant effect after use. RESULTS:Overall, among those reporting any past 12-month NPS use (n = 259), over a quarter (27.03%) reported experiencing an adverse effect related to the use of at least one NPS in the past 12 months. Among those reporting NPS use, those who also reported past 12-month opioid use had over two times the prevalence of reporting an adverse effect related to NPS use (adjusted prevalence ratio 2.66, 95% confidence interval 1.41, 5.01). Symptom profiles were broadly similar between NPS and common drug classes. DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Adverse effects from NPS appear to be common among those self-reporting NPS use, particularly among those reporting polysubstance use. More data are needed to determine event-specific adverse outcomes involving the use of NPS and other drugs.

PURPOSE OF REVIEW/UNASSIGNED:As the overdose crisis evolves, it is important to monitor fentanyl consumption patterns. This review provides an overview of recent findings regarding illegally manufactured fentanyl (IMF) availability, use, and associated harms in the US. RECENT FINDINGS/UNASSIGNED:Availability of IMF has increased, especially in pill form, and the increasing adulteration of IMF with veterinary tranquilizers such as xylazine complicates overdose response. Prevalence in the general population based on self-reported IMF use is rare, and likely underestimated. Transitions from injection to smoking have been documented in recent years, particularly in the western US. Fentanyl-stimulant polysubstance use has also been observed increasingly among IMF-related overdose deaths. SUMMARY/UNASSIGNED:Shifts in routes of administration, availability of counterfeit pills containing fentanyl, and common adulterants add complexity to the landscape of IMF use and related harms. Additional data is needed for monitoring changes in consumption patterns to inform prevention and harm reduction efforts.

BACKGROUND/UNASSIGNED:The ketamine landscape in the USA is rapidly shifting, especially given recent increases in off-label prescribing of ketamine as a psychiatric treatment. Research is needed to determine the extent to which illicit ketamine is available, nonmedically used, and associated with morbidity and mortality in the USA. METHODS/UNASSIGNED:This observational study used eight unique annual repeated cross-sectional datasets to examine illicit ketamine availability (using seizure data as a proxy), use, and consequences of use, including self-reported nonmedical use among noninstitutionalized individuals aged ≥12 years (2006-2014, 2015-2019, and 2021-2023) and among 12th grade students (2000-2023). Further, it assessed reported ketamine-related poisonings (1991-2023) and mortalities (2020-2023), diversion of undispensed pharmaceutical ketamine (2008-2024), drug seizures testing positive for ketamine (2001-2024), and the number and total weight of ketamine seizures from two additional law enforcement agencies (2017-2024 and 2019-2024). Piecewise linear regression models were used to estimate annual trends. FINDINGS/UNASSIGNED:Nonmedical ketamine use among individuals aged ≥12 years increased between 2021 (0.19%) and 2023 (0.34%) (b [slope] = 0.08 [SE = 0.001], p = 0.0072). Regarding reported poisonings, there was initial increase from 1994 to 2000 (from 0.17 to 1.40 per 1,000,000 population; b = 0.20 [SE = 0.02], p < 0.0001), a decrease through 2003 (0.58 per 1,000,000 population; b = -0.34 [SE = 0.08, p = 0.0002) and an increase from 2017 through 2023 (from 0.76 to 1.54 per 1,000,000 population; b = 0.12 [SE = 0.03], p = 0.0002). The number of reported diversions increased from 2008 (n = 23) to 2017 (n = 202) (b = 18.72 [SE = 2.20], p < 0.0001) and again from 2021 (n = 183) to 2024 (n = 286) (b = 39.00 [SE = 12.04], p < 0.0001). Regarding seizures, there was an increase in ketamine reports to one agency from 2015 (n = 1448) through 2024 (n = 4008) (b = 201.41 [SE = 57.83], p = 0.0023). In another source, there was an increase in seizures from 2022 (n = 247) through 2024 (n = 502) (b = 127.50 [SE = 10.40], p = 0.0003). Rates of ketamine-involved deaths did not significantly shift between 2020 and 2023. Nonmedical use declined among 12th grade students, first from 2000 (2.49%) through 2005 (1.61%) (b = -0.19 [SE = 0.06], p = 0.0039] and then again from 2005 through 2023 (0.9%) (b = -0.04 [SE = 0.01], p = 0.0019). INTERPRETATION/UNASSIGNED:Ketamine poisonings, pharmaceutical diversion, and seizures have increased; trends in nonmedical ketamine use vary. Prevention and harm reduction are needed as use and morbidity are expected to continue to increase. FUNDING/UNASSIGNED:National Institute on Drug Abuse at the National Institutes of Health.