1. Overdose prevention and treatment implications of fentanyl use in the United States

During the COVID-19 pandemic in the United States, annual overdoses continued to increase to greater than 100,000 deaths driven by fentanyl-contamination of the illicit drug supply. Cocaine or methamphetamine were increasingly present with fentanyl. Racially and ethnically minoritized people experienced disproportionate increases in overdose deaths.

I review the United States Center for Disease Control and Prevention overdose death time trend, toxicology, and demographic data and the emerging literature on overdose prevention and substance use treatment innovations deployed in response to increasing fentanyl overdose deaths.

Overdose prevention strategies emerging in response to worsening overdose death rates due to fentanyl included: a) broader naloxone distribution to people using opioids, cocaine, methamphetamine, and counterfeit prescription benzodiazepines and stimulants, b) fentanyl test strip distribution, c) drug checking of street drugs and equipment at harm reduction sites, and d) post-overdose outreach to survivors. Substance use treatment innovations included: a) liberalized methadone treatment regulations b) tele-buprenorphine treatment c) methadone, buprenorphine micro- and macro-dosing approaches to reduce fentanyl-related withdrawal and d) funding and facilitation of contingency management treatment.

As overdoses continue to surge, new and adapted approaches to overdose prevention and substance use treatment that build on naloxone rescue and medication for opioid use disorder are emerging in the United States. Together, these approaches have not yet been enough to reverse the trends in increasing overdose. Nor is it clear whether they will counteract or exacerbate the race and ethnically-based inequities in overdose or prevention and treatment access.