Q&A: Illicit fentanyl use raises risk for infection in injection drug users
In a study conducted in Los Angeles and San Francisco among 395 people who inject drugs, researchers found that participants who reported perceived illicit fentanyl use were at an increased risk for injection-related infectious diseases.
Compared with participants who used street drugs not including fentanyl, those who reported perceived illicit fentanyl use in the past 6 months had a greater odds of high-frequency opioid use (adjusted OR = 2.36; 95% CI, 1.43-3.91), high-frequency injection (aOR = 1.84; 95% CI, 1.08-3.13) and receptive syringe sharing (aOR = 2.16; 95% CI, 1.06-4.36), according to Barrot Lambdin, PhD, MPH, senior epidemiologist and implementation scientist at RTI International, and colleagues.
Infectious Disease News spoke with Lambdin about the study findings, what clinicians need to know and what actions can be taken to reduce risk. – by Marley Ghizzone
Q: What prompted the study?
A: In terms of what led us to undertake this study, a number of different sources — some qualitative research that has come from Canada and the United States as well as an ongoing ethnography of fentanyl use in the U.S. — have documented that fentanyl intoxication has a short duration of effect, typically 5 to 15 minutes, compared with heroin. It is not difficult to imagine that this shorter duration of effect could lead to more frequent use and more frequent drug injection events, and this is what we wanted to look at with this study. Other research coming from Vancouver some time ago (not specific to fentanyl but more specific to cocaine injection) documented that a higher injection frequency has been shown to lead to a higher likelihood of sharing syringes between people, which, in turn, can lead to an increased number of viral exposure events, such as HIV or hepatitis C virus. As we know, fentanyl has really overtaken the illicit opioid market across many regions in the U.S. Therefore, we thought this would be extremely important to begin building our understanding of whether the introduction of fentanyl into the illicit drug supply could be driving more frequent use, more frequent drug injection and perhaps more syringe sharing.
Q: What did you find?
A: Our main finding fell in line with our hypotheses and aligned with some of the anecdotal reports we were hearing. Really, our findings suggested that people who are reporting illicit fentanyl use had a greater odds of high-frequency opioid use — they are using opioids more frequently — which could, in turn, be contributing to some of the increases in overdose rates that the U.S. is experiencing. They also had higher odds of high-frequency injection, as well as receptive syringe sharing, as compared with people who are using heroin and other street drugs, not necessarily fentanyl. So, we observed in our findings some of these concerns we were beginning to have. Our study was conducted in community-based settings in San Francisco and Los Angeles, and we saw that about half of people who inject drugs reported illicit fentanyl use in the last 6 months. In some parts of the country, this would be a very hard study to conduct because fentanyl has completely replaced the heroin market. For our study, the perception of illicit fentanyl use was a pretty strong measure because fentanyl is sold here as a white powder, which is visually distinct from the traditional black tar heroin common on the West Coast. On the East Coast, heroin has historically been sold in a white power form, so there can be more difficulty in distinguishing between the two.
Q: Were the findings surprising?
A: I would characterize the findings as alarming, though not necessarily surprising. The findings also align with what we know about fentanyl’s pharmacokinetic profile and how it metabolizes in the body. It is a synthetic opioid, it is lipophilic and it has a rapid onset of action and a very short duration of effect. So, when it is injected, the combination of that rapid onset and short duration translates to — what a lot people describe as — a strong rush followed by a very brief period of euphoria. We understand a good amount of how fentanyl is metabolized in the body, because it is used and monitored in medical settings. But there has not been that much research related to understanding how illicit fentanyl use is playing out in the community in terms of affecting different risk behaviors, which have big implications for HIV or hepatitis C transmission. As I said, these findings are alarming and something that we really need to be paying attention to so that we do the necessary work to most importantly mitigate those risks and also figure out how we can better understand this.
Q: Do the findings have implications for infection prevention efforts in PWID?
A: Absolutely. I think the immediate actions that must be taken to reduce these risks include improving access to syringe service programs. There is a huge body of research showing the effectiveness of syringe service programs in preventing HIV. A recent systematic review showed a nearly 60% reduction in HIV could be attributed to syringe service programs. We have to really scale-up these programs around the country. Last I checked, there were around 350 active syringe service programs in the U.S. as a rough estimate, compared to over 3,500 in Australia. We really need more of these programs and we need to make sure they are available throughout the country, especially in regions that have had more recent increases in opioid use. These programs also need to be implementing best practices so that we really have the most prevention potential reaching the community and preventing another infectious disease outbreak. We have to scale up opioid treatment as well, and we also have to consider other innovative approaches, such as drug checking so that more people have information about the types of drugs they are getting. In some places, it is not necessarily clear to the individual that fentanyl is in their drug, while in other places it is more clear, but having access to drug checking can improve some of that clarity. Other types of delivery models should also be considered, such as supervised consumption services, which have been shown to reduce infectious disease transmission in other countries and have a lot of other benefits as well.
Q: What should clinicians know?
A: For clinicians, I think making sure they are a part of and/or supporting efforts to make sure people have access to clean supplies and other medical care will be absolutely critical. These services are not accessible in an equitable way for people who use drugs, and advocating for these services if your community does not have them is essential. I think clinicians have to make sure that people who use drugs have access to the full suite of options, meeting people where they are and helping them to reduce risks and access care in a non-coercive way.
Disclosure: Lambdin reports no relevant financial disclosures.