The mortality in drug related deaths has increased in many countries, calling it an epidemic. Overdose caused by opioids have contributed to the increasing drug related deaths. This study aims to examine and compile which methods and strategies have shown to reduce the mortality in drug related deaths. Using a systematic review and no limitation to countries a mix of methods and strategies was found. Some Ministries of Health department list them as important in reducing damages and risk behavior related to addiction. The repressive approach that was historically dominated has shown less successful. Individuals own strengths and access to treatments and strategies are momentous. It is also of great importance that governments and health care applies the listed methods and strategies. Blood diseases have decreased with needle exchange programs as a result of having implemented the method. Medications for addiction treatment are improving living conditions for people with opioid addiction. Still there are problems and difficulties with access to addiction treatment and harm reduction strategies. Stigma and the historical perception of drug use and addiction are some of the reasons for the inaccessibility and lack of harm reduction strategies.

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Background: Opioid overdoses have killed almost 20,000 Canadians since 2016. To address this, Canada has established supervised consumption sites where people can use drugs in the presence of trained staff and get access to pharmacological treatments such as methadone. However, there is very little research on whether supervised consumption clients use methadone, or whether their use of methadone prevents opioid overdose. Methods: A secondary data analysis of information collected from one supervised consumption site was undertaken in order to explore relationships between client self-reported methadone dosage and subsequent observed same-day opioid overdose. Results: Statistical analysis showed no correlation between methadone usage and reduced chance of opioid overdose. However, the most common dosage of methadone reported (30mg/day) was far below the minimum therapeutic dose of methadone. Conclusion: Clients of supervised consumption sites often report being prescribed methadone, but not at a dose high enough to reduce opioid overdose.

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Opioid overdose deaths in the United States have been steadily increasing for decades. Initially, these deaths were driven by overdoses from prescription opioids. Strict limits were placed on opioid prescriptions to decrease the supply of available opioids. Instead, this prompted a shift toward the illicit opioid market, causing an increase in heroin-related overdoses. Fentanyl, a synthetic opioid that is more potent than heroin, has become commonplace in the illicit supply of opioids. The illicit opioid market is unregulated and unpredictable, and there is no way to know exactly what is in a bag sold as heroin or “dope”. Illicit drug use has been historically dealt with as a crime rather than a public health issue in the United States. Recently, harm reduction has been offered as an alternative to this punitive approach. Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Naloxone distribution and syringe service programs are examples of currently utilized harm reduction strategies in the United States. While these programs are necessary to improve the quality of life of people who use illicit drugs, the rates of death from overdose are continuing to increase. These strategies do not protect people from the toxic and unpredictable drug supply. Safe supply is a relatively new concept, but there have been some small-scale implementations of this practice in Canada. Safe supply refers to a legal and regulated supply of drugs with mind and body-altering properties that traditionally have been accessible only through the illicit drug market. This is a necessary strategy to combat the alarming rise in overdose mortality. In this paper, I will analyze the ethics of this strategy using a principalism approach. This analysis concludes that safe supply is ethically sound, and it should be a part of our approach to the overdose epidemic. Safe supply promotes autonomy, prevents harms, advances well-being, and upholds justice for people who use drugs. / Urban Bioethics

Introduction: The entire United States has felt the effects of the overdose epidemic, but rural Appalachia has experienced disproportionate overdose deaths. This variation in overdose mortality can be attributed to the risk environment for overdose in rural Appalachia. Overdose prevention behaviors are individual level behaviors that people who inject drugs can implement that may have the potential to reduce their risk of overdose, however limited research exists regarding the utilization of those behaviors. It is important to consider how the risk environment can influence the utilization of overdose prevention behaviors among people who inject drugs. Therefore, the purpose of this research was to identify overdose prevention behaviors among people who inject drugs in rural Appalachia and better understand the relationship between those behaviors and the rural risk environment for overdose. Methods: This research was conducted using a mixed methods approach, including a scoping review, qualitative, and quantitative study. A scoping review was used to identify overdose prevention strategies and behaviors in rural America. Semi-structured interviews were used to identify overdose prevention behaviors among people who inject drugs in rural Appalachia. A quantitative survey was used to examine the relationship between risk environment determinants and overdose prevention behaviors utilization among people who inject drugs in rural Appalachia. Results: Results of primary data collection showed that people who inject drugs in rural Appalachia do utilize overdose prevention behaviors, including several drug checking methods and safe use behaviors. However, environmental barriers and disparities among people who inject drugs in rural Appalachia were highlighted in this research. Potential relationships exist between environmental determinants and the utilization of some overdose prevention behaviors. Conclusion: This research found the need for several policy and community program implications which all stem from the War on Drugs. Results highlighted the need for systems level change regarding the care for people who inject drugs, which includes the necessity for policy makers to consider harm reduction methods to reduce overdose mortality among people who live in rural Appalachia.

Micellar electrokinetic capillary chromatography (MECC) is a form of capillary zone electrophoresis. Addition of a surfactant produces micelles in an aqueous/organic buffer. Separation of drugs is obtained via differences in the electrophoretic mobilities of the analytes within the capillary, resulting from their electrophoretic velocity and the electroosmotic flow of the buffer in a given electric field. The migration order is determined by the differential partitioning of the drugs between the micelles and the aqueous/organic phase. Barbiturates were extracted from various biological fluids at pH 4.5 with TOXI-TUBES B. MECC analyses were performed using a Waters Quanta 4000 Capillary Electrophoretic System with a 745 Data Module with a 75 μ x 60 cm capillary and an aqueous/organic buffer of 85% 10 mM borate, 10 mM phosphate, 100 mM sodium dodecyl sulfate and 15% acetonitrile at a pH of 8.5 with a voltage of 20 kV using ultraviolet absorption detection at 214 nm. Migration times were: phenobarbital, 7.78 min.; butalbital, 8.01 min.; butabarbital, 8.23 min.; mephobarbital (internal standard), 8.88 min.; amobarbital, 9.41 min.; pentobarbital, 10.03 min. and secobarbital, 10.79 min. Correlation coefficients (r) between peak areas and concentration ranges of 3 to 60 μg/mL were from 0.964 to 0.999. Coefficients of variation (CV) raged from 2.6 to 8.6% between days and 2.3 to 9.8% within day. Application of this methodology to four forensic cases of butalbital intoxication detected concentrations of 0.7 to 12.7 μg/mL in blood; 0.8 to 1.9 μg/mL in vitreous humor and 1.5 to 7.6 μg/mL in urine. MECC is applicable to forensic analysis of barbiturates extracted from biological fluids.

With the rise of accidental fentanyl overdoses and recreational opioid use in college-aged populations, the need for campus-based overdose prevention and harm reduction measures is at an all-time high. Naloxone, an opioid antagonist, is an FDA-approved, lifesaving, medication which can be intranasally delivered by laypersons. Naloxone reverses opioid overdose, essentially buying time until an overdosing individual receives emergency medical attention. While some previous studies have examined access to naloxone on college campuses, to my knowledge no study has explored distribution of naloxone in residential college areas, such as dormitories and within Greek housing. Therefore, the purpose of this thesis was to identify themes in student perception surrounding naloxone, as well as potential processes and barriers/facilitators to naloxone distribution within residential areas (e.g., dormitories, sorority housing, and fraternity housing.) This study addresses these issues through qualitative, semi-structured, interviews with a convenience sample of students at the University of Central Florida, with questions informed by the Consolidated Framework for Implementation Research and Proctor et al. implementation outcomes. Seven students (n = 7) participated in the interview, all of whom either had personal experience with substance use disorder (SUD) or were close to someone with SUD. I analyzed data for themes using a mixed deductive-inductive template analysis approach in Dedoose software. Resulting themes relating to barriers to distribution within residential areas were as follows: lack of knowledge; fear of negative consequences from external parties; desire of administrators to maintain image of a “drug free campus”; lack of funding for distribution; student desire to avoid stigmatization. Resulting themes relating to facilitators to distribution in residential areas included the following: active involvement of peers; providing free naloxone; educating students about where to get and how to use naloxone; physical accessibility; and anonymous ways to access naloxone. Targeting residential areas for naloxone distribution was also discussed as a theme. Types of people who could/should be involved in naloxone distribution included the following: residential assistants; secondary distributors; pharmacists; UCF leadership; sorority and fraternity leaders; and student liaisons. Study results could be used to inform efforts at UCF and other colleges to expand naloxone access.

The dissertation is intended to guide the selection and implementation of health department-led interventions with a long-term goal of reducing opioid overdose deaths. This dissertation is comprised of three aims. First, a narrative review describes models of buprenorphine treatment, summarizes retention in buprenorphine treatment, and includes descriptions of how each study defined and measured retention in treatment to aid cross-study comparisons. Trends in buprenorphine retention, as well as heterogeneity in trends, are described, and sub-analyses examine the role clinician experience in inducting patients on buprenorphine treatment may play in promoting retention. Lastly, the effect of a specific intervention—academic detailing—aimed at reducing the prescribing of opioid analgesics is measured using methods aimed at isolating the impact of a policy intervention that occurred at the same time as the detailing campaign. Overall, this dissertation finds a lack of consistency in how retention in buprenorphine treatment is measured, which precludes easy identification of the most effective models and interventions for retention in buprenorphine treatment. Additionally, significant variation in buprenorphine treatment retention and trends in buprenorphine treatment was observed, suggesting opportunities for improvement. From 2015 to 2019, retention in buprenorphine increased among New York City residents; however, in 2019, the predicted prevalence of retention for three months was 52.7% and 34.6% for six months, below rates observed in other studies. Lastly, this dissertation should prompt public health officials to reconsider using academic detailing campaigns to decrease opioid analgesic prescribing, given that decreases in prescribing practices were only observed following one detailing campaign, which coincided with a policy change, and did not occur following another campaign, which took place two years after the policy change.