Fentanyl Polysubstance Use Patterns and Their Associations With Hepatitis C Virus, Skin and Soft Tissue Infections, and Non-Fatal Overdose Among People Who Inject Drugs in New York City
Mehrdad Khezri
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
Search for more papers by this authorSarah Kimball
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Search for more papers by this authorChenziheng Allen Weng
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Search for more papers by this authorCorresponding Author
Courtney McKnight
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Center for Drug Use and HIV/HCV Research, New York, New York, USA
Correspondence:
Courtney McKnight ([email protected])
Search for more papers by this authorDon Des Jarlais
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Center for Drug Use and HIV/HCV Research, New York, New York, USA
Search for more papers by this authorMehrdad Khezri
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
Search for more papers by this authorSarah Kimball
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Search for more papers by this authorChenziheng Allen Weng
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Search for more papers by this authorCorresponding Author
Courtney McKnight
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Center for Drug Use and HIV/HCV Research, New York, New York, USA
Correspondence:
Courtney McKnight ([email protected])
Search for more papers by this authorDon Des Jarlais
Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
Center for Drug Use and HIV/HCV Research, New York, New York, USA
Search for more papers by this authorFunding: This work was supported by US National Institute on Drug Abuse (5R01DA003574).
ABSTRACT
Introduction
Fentanyl's euphoric effects and short half-life may increase infectious disease transmission risks through frequent injecting and syringe sharing. We examined fentanyl polysubstance use (PSU) patterns and associations with hepatitis C virus (HCV), skin and soft tissue infections (SSTI), and non-fatal overdose among people who inject drugs (PWID) in New York City.
Methods
We recruited 495 PWID between October 2021 and July 2024. Participants were tested for HCV antibody and underwent urine toxicology screenings using the Premier Biotech 13-panel BioCup.
Results
Fentanyl was identified in 83.6% of the sample; however, only 23.0% self-reported recent intentional fentanyl use. The most common fentanyl PSU combinations were fentanyl with methadone (67.9%), opiates (66.9%), cocaine (65.9%), cannabis (45.4%), xylazine (36.7%), heroin (35.5%), benzodiazepines (32.5%) and alcohol (29.3%). Compared to no fentanyl use, intentional fentanyl use was associated with HCV antibody seropositivity (aOR 3.44, 95% CI 1.75, 6.93), SSTIs (aOR 4.75, 1.66, 17.20) and non-fatal overdose (aOR 2.35, 1.15, 5.00). Co-use of fentanyl with opiates (aOR 2.08, 1.16, 3.82), cocaine (aOR 2.71, 1.52, 4.97), heroin (aOR 2.06, 1.11, 3.91), benzodiazepines (aOR 2.91, 1.55, 5.63) and alcohol (aOR 3.27, 1.72, 6.37) were associated with HCV. Co-use of fentanyl with benzodiazepines (aOR 2.08, 1.04, 4.34) and alcohol (aOR 2.57, 1.29, 5.37) were associated with non-fatal overdose.
Discussion and Conclusions
In addition to overdose, when combined with other psychoactive substances, fentanyl PSU is associated with a higher prevalence of infectious diseases. This underscores the need for tailored medication dosing for opioid use disorder and expanding access to syringe service programs and medical care for PWID in the fentanyl era.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1 D. Ciccarone, “Fentanyl in the US Heroin Supply: A Rapidly Changing Risk Environment,” International Journal of Drug Policy 46 (2017): 107–117.
- 2 D. Ciccarone, “Editorial for US Heroin in Transition: Supply Changes, Fentanyl Adulteration and Consequences IJDP Special Section,” International Journal on Drug Policy 46 (2017): 107.
- 3 J. Friedman and C. L. Shover, “Charting the Fourth Wave: Geographic, Temporal, Race/Ethnicity and Demographic Trends in Polysubstance Fentanyl Overdose Deaths in the United States, 2010–2021,” Addiction 118, no. 12 (2023): 2477–2485.
- 4 M. R. Spencer, M. Garnett, and A. M. Miniño, “Drug Overdose Deaths in the United States, 2002–2022,” US Department of Health and Human Services, Centers for Disease Control, (2024).
- 5 E. B. M. Tuazon, T. Sun, A. Weitz, J. DeWalt, S. Mantha, and A. Harocopos, “Unintentional Drug Poisoning (Overdose) Deaths in New York City in 2022: New York City Department of Health and Mental Hygiene: Epi Data Brief (137),” (2023), https://home.nyc.gov/assets/doh/downloads/pdf/epi/databrief137.pdf.
- 6 M. Nolan, E. Tuazon, J. Blachman-Forshay, and D. Paone, “Unintentional Drug Poisoning (Overdose) Deaths in New York City, 2000 to 2017,” New York City Department of Health and Mental Hygiene: Epi Data Brief (104), (2018).
- 7 C. McKnight, C. A. Weng, M. Reynoso, S. Kimball, L. M. Thompson, and D. Des Jarlais, “Understanding Intentionality of Fentanyl Use and Drug Overdose Risk: Findings From a Mixed Methods Study of People Who Inject Drugs in New York City,” International Journal of Drug Policy 118 (2023): 104063.
- 8 Centers for Disease Control and Prevention, Increases in Fentanyl Drug Confiscations and Fentanyl-Related Overdose Fatalities (Health Alert Network, 2015).
- 9 M. L. Nolan, S. Shamasunder, C. Colon-Berezin, H. V. Kunins, and D. Paone, “Increased Presence of Fentanyl in Cocaine-Involved Fatal Overdoses: Implications for Prevention,” Journal of Urban Health 96 (2019): 49–54.
- 10 M. E. Sutter, R. R. Gerona, M. T. Davis, et al., “Fatal Fentanyl: One Pill Can Kill,” Academic Emergency Medicine 24, no. 1 (2017): 106–113.
- 11 R. M. Gladden, “Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine—25 States, July–December 2017 to January–June 2018,” MMWR. Morbidity and Mortality Weekly Report 68 (2019): 737–744.
- 12 A. M. Bunting, R. Shearer, A. N. Linden-Carmichael, et al., “Are You Thinking What I'm Thinking? Defining What We Mean by Polysubstance Use,” American Journal of Drug and Alcohol Abuse 50, no. 1 (2024): 1–7.
- 13 D. Ciccarone, “The Rise of Illicit Fentanyls, Stimulants and the Fourth Wave of the Opioid Overdose Crisis,” Current Opinion in Psychiatry 34, no. 4 (2021): 344–350.
- 14 M. Kariisa, “Drug Overdose Deaths Involving Cocaine and Psychostimulants With Abuse Potential—United States, 2003–2017,” MMWR. Morbidity and Mortality Weekly Report 68 (2019): 388–395.
- 15 S. Liu, “Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines—38 States and the District of Columbia, 2019–2020,” MMWR. Morbidity and Mortality Weekly Report 70 (2021): 1136–1141.
- 16 S. Liu, “Nonfatal Drug and Polydrug Overdoses Treated in Emergency Departments—29 States, 2018–2019,” MMWR. Morbidity and Mortality Weekly Report 69 (2020): 1149–1155.
- 17 H. Palis, C. Xavier, S. Dobrer, et al., “Concurrent Use of Opioids and Stimulants and Risk of Fatal Overdose: A Cohort Study,” BMC Public Health 22, no. 1 (2022): 2084.
- 18 A. H. Hébert and A. L. Hill, “Impact of Opioid Overdoses on US Life Expectancy and Years of Life Lost, by Demographic Group and Stimulant Co-Involvement: A Mortality Data Analysis From 2019 to 2022,” Lancet Regional Health—Americas 36 (2024): 100813.
- 19 J. H. Silverstein, M. F. Rieders, M. McMullin, S. Schulman, and K. Zahl, “An Analysis of the Duration of Fentanyl and Its Metabolites in Urine and Saliva,” Anesthesia and Analgesia 76, no. 3 (1993): 618–621.
- 20 J. R. Friedman, D. Abramovitz, B. Skaathun, et al., “Illicit Fentanyl Use Independently Predicts HCV Seroconversion Among a Cohort of People Who Inject Drugs in Tijuana and San Diego,” medRxiv. 2024:2024.03.22.24304609.
- 21 F. Montero, P. Bourgois, and J. Friedman, “Potency-Enhancing Synthetics in the Drug Overdose Epidemic: Xylazine (Tranq), Fentanyl, Methamphetamine, and the Displacement of Heroin in Philadelphia and Tijuana,” Journal of Illicit Economies and Development 4, no. 2 (2022): 204–222.
- 22 K. S. Kenny, G. Kolla, S. Greig, et al., “Association of Illicit Fentanyl Use With Injection Risk Practices Among People Who Inject Drugs,” AIDS and Behavior 27, no. 6 (2023): 1757–1765.
- 23 B. H. Lambdin, R. N. Bluthenthal, J. E. Zibbell, L. Wenger, K. Simpson, and A. H. Kral, “Associations Between Perceived Illicit Fentanyl Use and Infectious Disease Risks Among People Who Inject Drugs,” International Journal of Drug Policy 74 (2019): 299–304.
- 24 A. Talu, K. Rajaleid, K. Abel-Ollo, et al., “HIV Infection and Risk Behaviour of Primary Fentanyl and Amphetamine Injectors in Tallinn, Estonia: Implications for Intervention,” International Journal of Drug Policy 21, no. 1 (2010): 56–63.
- 25
K. E. Moeller, K. C. Lee, and J. C. Kissack, eds., “ Urine drug screening: practical guide for clinicians,” in Mayo Clinic Proceedings (Elsevier, 2008).
10.4065/83.1.66 Google Scholar
- 26 M. N. Tzatzarakis, E. Vakonaki, L. Kovatsi, et al., “Determination of Buprenorphine, Norbuprenorphine and Naloxone in Fingernail Clippings and Urine of Patients Under Opioid Substitution Therapy,” Journal of Analytical Toxicology 39, no. 4 (2015): 313–320.
- 27 A. S. Huhn, J. G. Hobelmann, G. A. Oyler, and E. C. Strain, “Protracted Renal Clearance of Fentanyl in Persons With Opioid Use Disorder,” Drug and Alcohol Dependence 214 (2020): 108147.
- 28 A. P. Z. S. Thakrar, M. H. Davis, R. Bhatia, et al., “ Manifestations of Xylazine Exposure Among Hospitalized Patients in Philadelphia: A Retrospective Cohort Study,” in Oral Presentation at the Society of General Internal Medicine (SGIM) National Conference (Society of General Internal Medicine (SGIM), 2023).
- 29 E. J. Cone, P. Welch, J. M. Mitchell, and B. D. Paul, “Forensic Drug Testing for Opiates: I. Detection of 6-Acetylmorphine in Urine as an Indicator of Recent Heroin Exposure; Drug and Assay Considerations and Detection Times,” Journal of Analytical Toxicology 15, no. 1 (1991): 1–7.
- 30 D. A. Regier, W. E. Narrow, E. A. Kuhl, and D. J. Kupfer, “The Conceptual Development of DSM-V,” American Journal of Psychiatry 166, no. 6 (2009): 645–650.
- 31 S. D. Easton, N. S. Safadi, Y. Wang, and R. G. Hasson, “The Kessler Psychological Distress Scale: Translation and Validation of an Arabic Version,” Health and Quality of Life Outcomes 15 (2017): 1–7.
- 32 R Core Team, R: A Language and Environment for Statistical Computing (R Foundation for Statistical Computing, 2021).
- 33 V. W. Tsang, J. S. Wong, J. N. Westenberg, et al., “Systematic Review on Intentional Non-Medical Fentanyl Use Among People Who Use Drugs,” Frontiers in Psychiatry 15 (2024): 1347678.
- 34 R. Foglia, III, N. Cooperman, D. Mattern, S. Borys, and A. Kline, “Predictors of Intentional Fentanyl Use: Market Availability vs Consumer Demand,” International Journal of Drug Policy 95 (2021): 103403.
- 35 K. Hayashi, M.-J. Milloy, M. Lysyshyn, et al., “Substance Use Patterns Associated With Recent Exposure to Fentanyl Among People Who Inject Drugs in Vancouver, Canada: A Cross-Sectional Urine Toxicology Screening Study,” Drug and Alcohol Dependence 183 (2018): 1–6.
- 36 J. N. Park, K. E. Schneider, D. Fowler, S. G. Sherman, R. Mojtabai, and P. S. Nestadt, “Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis,” Journal of Addiction Medicine 16, no. 1 (2022): 49–55.
- 37 S. A. Klar, E. Brodkin, E. Gibson, et al., “Furanyl-Fentanyl Overdose Events Caused by Smoking Contaminated Crack Cocaine—British Columbia, Canada,” MMWR. Morbidity and Mortality Weekly Report 65, no. 37 (2016): 1015–1016.
- 38 M. Amin-Esmaeili, M. Farokhnia, R. Susukida, et al., “Reduced Drug Use as an Alternative Valid Outcome in Individuals With Stimulant Use Disorders: Findings From 13 Multisite Randomized Clinical Trials,” Addiction 119, no. 5 (2024): 833–843.
- 39 A. Board, C. Alpren, B. Hernandez, et al., “A Qualitative Study of Injection and Sexual Risk Behavior Among Unstably Housed People Who Inject Drugs in the Context of an HIV Outbreak in Northeast Massachusetts, 2018,” International Journal of Drug Policy 95 (2021): 103368.
- 40 K. Cranston, “Notes From the Field: HIV Diagnoses Among Persons Who Inject Drugs—Northeastern Massachusetts, 2015–2018,” MMWR. Morbidity and Mortality Weekly Report 68 (2019): 253–254.
- 41 M. R. Patel, C. Foote, J. Duwve, et al., “Reduction of Injection-Related Risk Behaviors After Emergency Implementation of a Syringe Services Program During an HIV Outbreak,” JAIDS Journal of Acquired Immune Deficiency Syndromes 77, no. 4 (2018): 373–382.
- 42 J. N. Park, J. Owczarzak, G. Urquhart, et al., “HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland,” AIDS and Behavior 26, no. 1 (2022): 1–7.
- 43 N. Y. Hall, L. Le, I. Majmudar, and C. Mihalopoulos, “Barriers to Accessing Opioid Substitution Treatment for Opioid Use Disorder: A Systematic Review From the Client Perspective,” Drug and Alcohol Dependence 221 (2021): 108651.
- 44 J. Perrone, R. Haroz, J. D'Orazio, et al., “National Institute on Drug Abuse Clinical Trials Network Meeting Report: Managing Patients Exposed to Xylazine-Adulterated Opioids in Emergency, Hospital and Addiction Care Settings,” Annals of Emergency Medicine 84 (2024): 20–28.
- 45 T. Quijano, J. Crowell, K. Eggert, et al., “Xylazine in the Drug Supply: Emerging Threats and Lessons Learned in Areas With High Levels of Adulteration,” International Journal of Drug Policy 120 (2023): 104154.
- 46 D. L. Biancarelli, K. B. Biello, E. Childs, et al., “Strategies Used by People Who Inject Drugs to Avoid Stigma in Healthcare Settings,” Drug and Alcohol Dependence 198 (2019): 80–86.
- 47 S. Ayub, S. Parnia, K. Poddar, et al., “Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications,” Cureus 15, no. 3 (2023): e36864.
- 48 R. Gupta, D. R. Holtgrave, and M. A. Ashburn, “Xylazine—Medical and Public Health Imperatives,” New England Journal of Medicine 388, no. 24 (2023): 2209–2212.
- 49 S. Serinelli, S. White, P. Arunkumar, D. Wang, and L. Gitto, “The Outbreak of Fentanyl-Related Deaths in Cook County, Illinois, Between October 2015 and December 2017: A Retrospective Study and a Comparison With Previous Data,” Journal of Forensic Sciences 64, no. 6 (2019): 1735–1742.
- 50 P. O. Coffin, S. Galea, J. Ahern, A. C. Leon, D. Vlahov, and K. Tardiff, “Opiates, Cocaine and Alcohol Combinations in Accidental Drug Overdose Deaths in New York City, 1990–98,” Addiction 98, no. 6 (2003): 739–747.
- 51 K. Witkiewitz and K. E. Vowles, “Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review,” Alcoholism: Clinical and Experimental Research 42, no. 3 (2018): 478–488.
- 52 J. P. De Aquino, S. Parida, and M. Sofuoglu, “The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder,” Clinical Drug Investigation 41, no. 5 (2021): 425–436.
- 53 R. León-Barriera, S. J. Zwiebel, and V. Modesto-Lowe, “A Practical Guide for Buprenorphine Initiation in the Primary Care Setting,” Cleveland Clinic Journal of Medicine 90, no. 9 (2023): 557–564.
- 54 C. Ronsley, S. Nolan, R. Knight, et al., “Treatment of Stimulant Use Disorder: A Systematic Review of Reviews,” PLoS One 15, no. 6 (2020): e0234809.
- 55 M. G. McDonell, E. Leickly, S. McPherson, et al., “A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness,” American Journal of Psychiatry 174, no. 4 (2017): 370–377.
- 56 M. Karamouzian, C. Dohoo, S. Forsting, R. McNeil, T. Kerr, and M. Lysyshyn, “Evaluation of a Fentanyl Drug Checking Service for Clients of a Supervised Injection Facility, Vancouver, Canada,” Harm Reduction Journal 15 (2018): 1–8.
- 57 S. Klaire, R. M. Janssen, K. Olson, et al., “Take-Home Drug Checking as a Novel Harm Reduction Strategy in British Columbia, Canada,” International Journal of Drug Policy 106 (2022): 103741.
- 58 T. S. Bartholomew, H. E. Tookes, T. A. Chueng, et al., “Availability of Telehealth-Based Services at Syringe Services Programs Under the COVID-19 Public Health Emergency,” Harm Reduction Journal 20, no. 1 (2023): 122.
- 59 K. McLean, J. Murphy, and N. Kruis, “I Think We're Getting Better but We're Still Not There: Provider-Based Stigma and Perceived Barriers to Care for People Who Use Opioids (PWUO),” Journal of Substance Use and Addiction Treatment 159 (2024): 209270.
