However, a recent study published in Harm Reduction Journal warns that change is coming. Reviewing data across three key countries, the authors chart a potentially dangerous turn in South American drug markets. Synthetic opioids, ketamine and Tusi (known as “pink cocaine,” but typically including a mix of synthetic substances) have all rapidly increased in popularity—on a continent where harm reduction services, especially for opioids, are sorely lacking.

According to the study’s lead author, Ignacio Bórquez of New York University’s Grossman School of Medicine, these new trends are a stark departure from the traditional local drug supply.

“What we’ve been seeing since, I would say, 2010 onwards in Latin America is the emergence of synthetic drugs.”

“Latin America and the Caribbean really have a history using cannabis and cocaine,” he told Filter. “[T]hey’re locally produced, so they’re very cheap. A gram of cocaine is around $10 in Latin America—here in the US, it’s $100.”

Bórquez and his team compared multiple data sources, including forensic analyses, law enforcement seizures and surveys of people who use drugs, to get a pulse on substance use in Brazil, Chile and Colombia. Clear trends quickly emerged.

“What we’ve been seeing since, I would say, 2010 onwards in Latin America is the emergence of synthetic drugs. Particularly in the party scene, things like MDMA, ketamine,” Bórquez said. “And then we’ve also been seeing seizures of synthetic opioids and some evidence of diverted opioids from pharmaceuticals.”

In Chile, the volume of ketamine seized annually by law enforcement rose by over 5,000 percent from 2017 to 2023, and that trajectory was corroborated in Chilean wastewater analysis. Oral samples from Brazilian nightclub attendees also showed ketamine use rising—often along with cocaine, in the combination known as Tusi.

The data tell a similar story for opioids. According to a nationally representative Chilean survey, opioid use has nearly quadrupled since 2002. While fentanyl is not a major factor in Chile or Colombia, law enforcement seizure data do show a rise. In addition, other synthetic opioids, including nitazenes, are being manufactured in Brazil.

“We are a continent torn by violence … because with crops like cocaine or cannabis, you really need territorial land.”

Globalization and online connectivity have propelled these new substances’ popularity, with rapid distribution available on social media platforms like the gay dating app Grindr. And relative to the region’s traditional plant-based drugs, these new options require far fewer resources to produce.

“We are a continent torn by violence … that has been very linked to drug trafficking and drug production, because with crops like cocaine or cannabis, you really need territorial land,” study co-author Francisco I. Bastos, of Brazil’s Fundação Oswaldo Cruz, told Filter. “And with these new substances we’re looking at, they don’t need that.”

In part because South America has not faced a major overdose crisis, the continent’s harm reduction infrastructure is vastly underdeveloped. Citing the Global State of Harm Reduction 2024, the authors note that of the 34 countries in this region, only three have syringe service programs, and only four offer opioid agonist therapy. Naloxone is also largely inaccessible.

The solution, however, is not simply to import North American and European harm reduction models, because South American patterns of drug use remain very different. While these new substances are on the rise, they still represent a minority of drug use, which continues to be dominated by stimulant smoking and concurrent alcohol use. Injecting remains largely taboo.

Bórquez loses sleep at night thinking about how to adapt harm reduction models like supervised consumption sites to communities in South America.

“It would need to be a place where stimulant use, which is very different from opioid use, could be contained in a non-harmful way,” he said. “[Y]ou’re not gonna have 30 people using stimulants together in a room … it’s hard to think of a [harm reduction] service for people who use stimulants and alcohol.”

“It is a very different balance from the US. The US is the largest producer and importer of opioids in the world … Brazil is on the other side of the balance.”

Meanwhile, attempting to combat synthetic opioid diversion by restricting importation of medical opioids would threaten the availability of these substances for their clinical uses, such as pain relief for cancer patients and palliative care.

“If we just put pressure on the supply, we cannot have medicines for the people who need the medicine,” Bastos explained. “It is a very different balance from the US. The US is the largest producer and importer of opioids in the world, so there are opioids for everything—opioids for cancer patients, opioids for the streets. Brazil is on the other side of the balance.”

Yet there are still many promising paths forward. The authors highlight drug checking, overdose prevention training and naloxone accessibility as relevant harm reduction services. They also suggest increasing investment in nonintrusive surveillance, such as local wastewater monitoring programs, to stay abreast of this rapidly shifting market and target harm reduction efforts accordingly.

“[These efforts] will be essential to mitigate future harm and prevent another synthetic drug epidemic from taking hold in the Americas,” the study concludes.

Photograph of Rio de Janeiro by Rafael Rabello de Barros via Wikimedia Commons/Creative Commons 3.0

The post South America’s Drug Supply Is Rapidly Becoming More Synthetic appeared first on Filter.

A new study published in Harm Reduction Journal highlights the health risks of this policy. Surveys with over 700 English people who smoke crack cocaine reveal that one-third have been hospitalized for respiratory illness, and the majority have recently experienced respiratory issues. Follow-up interviews indicate that people having to resort to homemade smoking devices contributes greatly to these startling figures.

“It was a bit of a risky study. How do you generate evidence about something that’s not within the law?”

The data come from the Safe Inhalation Pipe Project (SIPP), led by Dr. Magdalena Harris of the London School of Hygiene & Tropical Medicine. SIPP provided safer smoking kits in six locations across England to evaluate their impact on drug-user health.

“It was a bit of a risky study,” Harris told Filter. “How do you generate evidence about something that’s not within the law?”

Harris and her team overcame this “catch-22,” as she described it, by obtaining temporary police approval. They also received a generous donation of pipes from Exchange Supplies, since government research funding could not be used to fund the intervention.

While analysis of SIPP’s impact is still in progress, data from the baseline phase of the study document clear respiratory health issues among people who smoke crack in the UK.

“Looking at the baseline survey data from 733 people, 60 percent of them … had respiratory symptoms within the last 28 days,” Harris said. “In terms of hospitalization, 31 percent had been hospitalized for a respiratory condition ever. And diagnoses are really high—31 percent have been diagnosed with asthma, and 12 percent have been diagnosed with COPD.”

She also warned that even these high figures are likely underestimates, due to this population’s relatively limited access to medical care.

“We know that COPD is really underdiagnosed in this population,” Harris noted. “So if 12 percent have been diagnosed, I’m sure there’s a lot more undiagnosed, particularly given the high [prevalence of] symptoms.”

“People would often start out with tin cans.”

In addition to the survey questions about respiratory harms, Harris and her team also conducted 33 in-depth interviews with participants, asking them to share their strategies for making their own pipes in the absence of safer supplies.

“People would often start out with tin cans,” Harris said. Other common materials included miniature liquor bottles, asthma inhalers, umbrella handles, naloxone syringes and disposable vapes.

A tin can pipe, which Harris noted can be made “in less than a minute”

While these approaches were innovative, they also tended to be dangerous. Plastic containers, for instance, release toxic chemicals when heated or scraped for valuable residue, while certain glass containers cause severe burns and cuts.

“One of the biggest issues in terms of respiratory harm with homemade pipe use is unsafe suspension devices,” Harris said. When smoking out of tin cans, for example, people tend to place their crack on top of ash. “The issue there is that you’re inhaling a lot of ash, which is really bad for your lungs.”

“[People] talk about burns to their lips or their tongue. But … there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

Other popular suspension materials included stainless steel scrubber (also called “steel wool”), which quickly breaks apart into inhalable metal fragments, and small metal bolts, which reach scalding temperatures. Since stimulants like cocaine have numbing effects, the damage caused by these high temperatures is often greater than people are able to perceive.

“[People] talk about burns to their lips or their tongue,” Harris said. “But then what they’re probably not realizing is that there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

A repurposed metal cannabis pipe, which may cause severe burns

To mitigate use of these homemade alternatives, SIPP provided study participants with pipes made of heat-resistant glass and a more robust suspension material. However, not all participants preferred these safer, purpose-built pipes.

“We collated all of that participant information and took it back to Exchange Supplies and … developed a better pipe.”

“[T]he filter was too dense—it was a good, steel filter made specifically for using crack, but it was just too dense for people,” Harris said. “So what we were seeing is that often people might throw it away and go back to using stainless steel scrubber or whatnot.”

Many people were also unhappy with the size of the pipe and its carrying case, preferring a thinner, more discreet option.

“We collated all of that participant information about the pipes and took it back to Exchange Supplies and … developed a better pipe,” Harris said. “That was a really nice output of the study—something practical that reflects the participants [and] their preferences.”

The new pipe kit, redesigned based on SIPP participants’ feedback

While SIPP is based in the UK, the challenges it’s addressing are global. Many countries continue to crack down on pipe distribution, including the United States, where modest efforts to provide safer smoking supplies under the Biden Administration were met with political outcry.

Harris hopes that SIPP will provide an evidence-based perspective on how pipe distribution can impact the health of people who smoke stimulants. The final results—which will compare this baseline data to new surveys collected six months after the intervention—are still in progress, but preliminary evidence suggests positive effects.

“Our impact evaluation has shown reductions in crack pipe sharing, injecting of any drug, use of homemade pipes and use of ash as a suspension device,” Harris said. “This is a very positive outcome, with longer-term implications for reducing respiratory and injecting-related health harms.”

All photographs courtesy of Magdalena Harris

The post UK Stimulant Pipe Program Tracks the Risks of Homemade Options appeared first on Filter.

Mobile services are particularly important in Appalachia, where overdose rates remain far higher than the national average and structural disadvantage amplifies barriers to care.

A new study in Harm Reduction Journal surveyed over 250 people living in rural Kentucky counties who inject drugs, asking about their preferences for service delivery.

“Given the geographic barriers and transportation barriers in rural Appalachia, we wanted to look at the willingness among rural Appalachian people who use drugs to engage with mobile syringe service programs,” lead author Dr. Alexander Elswick, of the University of Kentucky, told Filter.

Nearly 60 percent were willing to use a mobile SSP, with interest concentrated among the most disadvantaged populations. Participants preferred clinical, discreet vehicles with evening hours of operation.

The survey is part of the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic project (CARE2HOPE), founded in 2019 by Elswick’s colleague Dr. April Young. The research team recruited 259 adults across five counties who had used opioids or injected drugs to get high in the previous 30 days.

All participants completed a baseline survey that assessed their willingness to use a mobile SSP, and 135 returned six months later for a follow-up survey which gathered their feedback on how best to design mobile programs.

Overall, 59.9 percent of participants said they would be likely to use an SSP “that operated out of a mobile van that made visits throughout the community.” Importantly, mobile SSP were especially popular among many of the people they are designed to reach.

“It’s the more vulnerable population—those who experienced geographic and transportation barriers—who would be more likely to use the SSP,” Elswick said.

“Everybody knows everybody, and anonymity is so much more of a concern.”

People unable to access transportation were significantly more willing to use a mobile SSP, as were people earning less than $500 per month. Acceptance was also higher among people who tended to reuse their own syringes or share with others.

While a 60 percent acceptance rate might seem low, Elswick found these results encouraging.

“I took it generally as a positive,” he said. “Particularly in communities where there’s so much stigma … even moderate willingness is probably a good thing.”

However, one subset of participants was unenthusiastic about mobile services: people who reported feeling shame about their substance use. Elswick suspects that the tight-knit nature of some rural communities, which makes privacy difficult, might exacerbate fear of receiving services.

“There’s something unique about some of these rural Appalachian communities that are very small,” he said. “Everybody knows everybody, and anonymity is so much more of a concern.”

A desire for anonymity seems to have influenced participants’ stated preferences for mobile SSP deployment and design. Most participants endorsed parking mobile units at hospitals or clinics, but more general public locations—like large retail parking lots, gas stations and churches—were substantially less popular.

Participants also preferred vehicles to be smaller, and with more discreet markings—such as a research study logo, rather than health department branding.

“Appalachia has experienced a disproportionate burden … yet it’s underrepresented in research.”

“Another thing that surprised me was that there was low desire to engage with a peer who uses drugs,” Elswick said. “What participants preferred in terms of setting and provider were both more clinical in nature.”

That preference differs from those expressed by service users in other places—which underscores the importance of designing harm reduction services in conversation with their intended users, to reflect specific local circumstances and needs.

Syringe service programs have been legal in Kentucky since 2015, and their coverage has dramatically increased in recent years. But they’re only effective if people feel comfortable using them.

“Acceptability of the services really matters,” Elswick emphasized. “Design preferences have to be taken into consideration in order to increase engagement.”

While their findings suggest that rural Kentuckians prefer discreet, clinical mobile outreach services, the researchers are cautious about extrapolating these conclusions to other rural communities. Instead, they hope to shed light on Appalachians’ unique harm reduction needs and desires.

“Appalachia has experienced a disproportionate burden and consequences from the opioid epidemic and drug-related harms in general,” Elswick said. “Yet it’s underrepresented in research.”

Elswick’s stake in the work is not only academic. He is a Kentuckian in recovery himself, and a co-founder of Voices of Hope, which operates its own mobile outreach program. His research has left him feeling cautiously optimistic about the future of harm reduction efforts in his home state.

“This is a positive sign, but there’s still the need to reduce stigma and shame so that more people can get on board,” he concluded.

Image via County of Los Angeles Public Health

The post Appalachians Want to Use Mobile Syringe Programs, If They’re Discreet  appeared first on Filter.

A March study published in The Lancet Regional Health — Americas highlights one particular strategy that could dramatically improve hep C treatment access for people who use opioids. The randomized controlled trial found that when people enrolled in opioid treatment programs (OTP) were offered hep C treatment on-site at those same programs, they were nearly four times more likely to initiate it compared to people who were given off-site referrals. 

Though the likelihood of patients completing the regimen and confirming they’d been cured was similar, the higher uptake in the OTP route would mean more people getting cured. The study is the first randomized controlled trial in North America to compare the two methods.

“[W]e’re able to show that integrating hepatitis C testing and treatments into OTPs transforms the hepatitis C care cascade,” lead author Dr. Oluwaseun Falade-Nwulia, an associate professor at the Johns Hopkins School of Medicine, told Filter.

Falade-Nwulia said this involved first training OTP providers to deliver hep C care to their patients. Next, finding people with lived experience to offer peer support through the treatment process.

Among patients offered on-site hep C treatment at OTP—commonly known as methadone clinics—nearly nine out of 10 initiated it. Only two out of 10 initiated care treatment through an offsite referral. After nine months, 61 percent of participants in the on-site treatment group had been cured of hepatitis C, compared to just 14 percent in the referral group.

Hepatitis C treatment does not require abstinence from substance use.

A decade ago, hep C treatment was revolutionized with the arrival of direct-acting antiviral (DAA) medications, which replaced interferon-based therapy. Interferon injections had to be administered every few days for the better part of a year, came with severe side effects and ultimately had a low success rate. DAA are oral medications, often taken for just eight weeks, that almost never cause any side effects and have a 95-percent success rate. And, critically, DAA do not require abstinence from substance use, which was a barrier with interferon.

Falade-Nwulia lamented that hep C is “still such a major public health issue,” when strategies like on-site treatment at OTP could have such a big impact. But what may seem like a straightforward intervention becomes complicated by the health care industry.

Hep C treatment is extraordinarily expensive, and so patients must first be enrolled in insurance that will cover it. In many states, patients must obtain prior authorization from Medicaid before they can receive DAA—a process that can delay care or discourage providers from offering it altogether. Seventeen states currently impose some form of prior authorization requirement. So hep C continues to spread among those least able to access treatment.

“The way OTP reimbursement is structured currently in the US limits the ability of the OTP to get additional compensation for providing this additional service,” Falade-Nwulia said. “I think we really do need policy change to provide additional support to OTPs to be able to integrate this care in their settings.”

“This is just such a low-barrier, low-threshold approach.”

One clear advantage of the OTP strategy is that it leverages existing infrastructure, upskilling staff and peers to support patients more effectively. It is not a complex or high-tech intervention, and it may be one of the most effective.

“This is just such a low-barrier, low-threshold approach,” Falade-Nwulia said. “I think the additional cost at the system level is significantly outweighed by the potential benefit, both to the people accessing services at these OTPs and the larger society that will be protected from ongoing transmission of hepatitis C.”

Still, Falade-Nwulia said that scaling this model will require addressing significant policy and financial barriers. The study demonstrated what is possible under ideal conditions; such a high level of support isn’t typically available in OTP programs. AbbVie Inc., which funded the study, also provided the DAA—sidestepping the insurance hurdles that bar so many low-income people from treatment. Abbvie manufactures Mavyret, one of the most widely used DAA.

“In states that still have prior authorization requirements for Medicaid approval of hepatitis C treatment, it will be critical to have [them] removed for OTPs to even begin to consider integrating hepatitis C treatment into their routine care,” Falade-Nwulia said.

Image (cropped) via New York State Department of Health

The post Partnering With Methadone Clinics “Transforms” Hep C Care, Study Finds appeared first on Filter.

The score, which uses a machine learning approach called cognitive computing, is one of many innovative artificial intelligence tools that strive to reduce drug-related risks. But the first external evaluation of the model, recently published in the Journal of General Internal Medicine, found discouraging—if not dangerous—results.

Comparing Epic’s risk score to reality for over 700,000 patients, the evaluation reports that the model did accurately rule out low-risk patients. But it only caught around 8 percent of the patients who did go on to experience an overdose or receive an OUD diagnosis.

The Opioid Risk Score aims to facilitate overdose prevention and enhance primary care physicians’ efforts to detect and treat OUD as early as possible. Since it uses information already available in a patient’s electronic health record (EHR), the Opioid Risk Score could be a lightweight yet powerful addition to physicians’ toolkits.

“Basically, they’re trying to predict if a patient comes into a primary care appointment, what level of risk they are for developing opioid use disorder or having an overdose in the next year,” study co-author Dr. Stephanie Hooker, of HealthPartners Institute, told Filter. “If you know who might be at higher risk, you can appropriately direct the resources to try to prevent overdoses or to treat people who have opioid use disorder.”

Over 2,000 patients experienced an overdose or OUD diagnosis, but Epic’s system only flagged 185 of them as high-risk.

To test the model’s accuracy, the researchers pulled patient data from three health care systems—two rural sites in Pennsylvania and along the Minnesota-North Dakota border, plus an urban hospital system in Minneapolis. They compared Epic’s prediction to the actual outcome for 704,764 patients across 92 primary care clinics.

The model struggled to correctly identify high-risk patients, producing a concerning amount of false positives and false negatives.

“Most of those people [flagged as high-risk] didn’t go on to have an ‘event’—a diagnosis of opioid use disorder or overdose. That’s the false positive rate,” Hooker explained. “The false negative rate is that most of the people who do go on to have an event are classified as not being at risk.”

Hooker believes the false negative rate is particularly concerning. Over 2,000 patients experienced an overdose or OUD diagnosis, but Epic’s system only flagged 185 of them as high-risk.

The Achilles heel of Epic’s model may be its reliance on EHR data. Integrating with a patient’s medical records is a seamless design, but health data give only a partial perspective on a person’s life circumstances.

“EHR data is somewhat limited … Sometimes the things that we have easily available may not be the most salient predictors.”

Filter reached out to Epic, but representatives were not able to provide comment by publication time.

“EHR data is somewhat limited in terms of the things that we collect regularly on people. Sometimes the things that we have easily available may not be the most salient predictors,” Hooker said. “We don’t have a lot of data on social situations or other risk factors that might be more related to actually developing a substance use disorder or having an overdose.”

Design choices made by engineers removed from health care settings may also impair the model. For example, the risk score was designed with an intentionally high tolerance for false positives. Physicians should expect only one out of every 10 people flagged as high-risk to experience an adverse outcome.

“I think in clinical practice, that’s too high,” Hooker said. “A clinician wants to know, ‘If I’m going to use this tool, is it actually going to improve my decision-making to an extent that I’m not wasting my time?’”

Another salient issue is that the risk score treats overdose and OUD diagnosis as a combined outcome.

“What that does is kick everybody with existing opioid use disorder out of the model—you can’t predict overdoses in people who have OUD, because [OUD itself is] an outcome,” Hooker said. “So that’s the main issue, I think—that those people are not included in this risk model.”

To improve future performance, Epic could consider developing separate models for OUD and overdose, or reducing the system’s tolerance for false positives. But on a more fundamental level, Hooker believes that health care companies need to think critically about developing AI tools, and test them thoroughly.

”What are the reasons we would actually want to implement something like this, before we do it? And is it going to improve patient care?” she asked. “In this case, I think that the model was just put out there.”

“Any tool that could affect a patient’s treatment should face a lot more scrutiny. The bar needs to be raised.”

Dr. Nicole Fitzgerald, a postdoctoral research fellow at Columbia University’s Mailman School of Public Health who specializes in the early detection of emerging drug trends and risks, was also alarmed that Hooker’s study was the first real test of Epic’s model.

“Any tool that could affect a patient’s treatment should face a lot more scrutiny,” she told Filter.  “The bar needs to be raised in terms of the requirements for external validation before widespread deployment of these models in commercial health systems.”

Fitzgerald also pointed out weaknesses with the data and math that underlie the Opioid Risk Score. The “training data” used to calibrate the model are from 2015 to 2018—a period largely out of sync with the contemporary drug landscape. Additionally, the mathematical formula that turns these data into a score is relatively rudimentary.

“Other machine learning approaches are more adaptive, multisource and real-time,” she explained. “The way that people are using opioids—and the opioids themselves—have changed dramatically over the last couple years, and the opioid overdose crisis has evolved. That’s not captured here.”

Despite the shortcomings of individualized risk predictions, data-driven approaches to harm reduction—including, but not limited to, machine learning and artificial intelligence—still hold promise.

“Right now, the applications showing the most promise are operating at the population and drug supply level—not necessarily at the level of an individual clinical prediction,” Fitzgerald said. 

Wastewater testing is one such intervention. It provides a passive, anonymous indicator of local drug consumption that can inform where and how community organizations provide safer use supplies. Machine learning may also supercharge drug checking by speeding up mass spectrometry.

“There is value in this technology, so I’m hoping we can deploy these tools where they’re most valuable and least harmful.”

Most importantly, these population-level innovations capitalize on the enormous predictive power of machine learning without introducing as many risks to the individuals and communities who use them.

“When a wastewater alert algorithm produces a false positive, a public health team might just end up deploying some resources slightly earlier than necessary, or distributing naloxone when they might not have needed to, but that’s a net benefit to the community,” Fitzgerald explained. “But when an EHR-embedded risk score produces a false positive, a patient’s clinical care may be impacted. They could be stigmatized … or denied pain treatment. Those are real clinical harms.”

Ultimately, effective implementation of AI boils down to the same principles that already guide harm reduction efforts: weighing the potential benefits and harms, making decisions in consultation with the community, and designing solutions based on evidence rather than stigma.

“There is value in this technology, so I’m hoping we can deploy these tools where they’re most valuable and least harmful,” Fitzgerald concluded.

Photograph (cropped) by Elen Sher on Unsplash

The post Primary Care “Opioid Risk Scores” Poorly Predict Individual OD Risk appeared first on Filter.

Harm reduction and recovery support haven’t always been priorities on campus. The student-led group that runs these programs, Recovery at Cal, was largely dormant until 2021, when a passionate group of students fought to bring it back to life.

“We identified three pillars … of what the program would require to be substantial and supported meaningfully,” co-founder Johnny Smith, who graduated from Berkeley in 2024, told Filter. “Those three things were having full-time staffing, some sort of recurring institutional funding and a fixed, dedicated private space.”

Drawing on Berkeley’s success, student advocates continue to urge the highest levels of university leadership to implement these pillars across all 10 University of California campuses.

California’s flagship universities aren’t the only schools reckoning with growing demand for harm reduction and recovery programs. Across the United States, colleges have steadily implemented opioid overdose trainings, naloxone distribution programs and other initiatives aimed at helping students navigate an uncertain drug supply.

Across a broad range of institutions, the pathway for implementing strong programming was strikingly similar.

A new study published in the American Journal of Health Education interviewed 25 university leaders to understand how colleges build support for this programming and what makes their initiatives successful. It reports that advocacy by students and staff, thoughtful collaborations with community partners and state policies mandating that colleges provide overdose prevention resources have driven the rapid expansion of campus harm reduction efforts.

“A growing number of schools are implementing overdose prevention policies or expanding access to naloxone on their campus,” study co-author Christina Freibott, of Boston University, told Filter. “Either there’s state policies requiring them to do so, or there’s advocacy … from the student level or the community level to have these resources available.”

The researchers selected their sample of 25 schools to maximize representation, interviewing upper-level student health staff from public and private universities with enrollment ranging from less than 3,000 to over 20,000 students. They also included community colleges and specialized schools, such as an arts college.

Even across such a broad range of institutions, the “pathway” for implementing strong programming, as Freibott calls it, was strikingly similar.

“A lot of schools have really creative and impactful collaborations with community-based organizations … That was the next step before implementing a more in-house program.”

Like at Berkeley, student advocacy was often the first step. Once students identified a need and rallied to fill it, universities tended to bring in external partners such as community organizations, to distribute resources or host training sessions.

“A lot of schools have really creative and impactful collaborations with community-based organizations that provide overdose prevention training or have access to naloxone that they can distribute throughout the school,” Freibott explained. “That was the next step before implementing a more in-house program, or something that [the universities] took ownership of themselves.”

For many schools, the biggest challenge to establishing these initial partnerships was convincing students and staff, particularly those in control of the budget, that such resources are necessary on campus.

“[T]here’s a perception that college students are sort of immune or not a population of major concern for opioid overdose,” Freibott said. “A lot of administrators that I spoke to were tasked with shifting the narrative.”

In an attempt to increase awareness, schools often reframed opioid overdose as “poisoning.” That’s language that many harm reductionists argue promotes punitive narratives about drug use or assigns blame unjustly.

Freibott acknowledged the problems of this approach, though she added that when “poisoning” language mirrors how many universities already talk to their students about the risks of alcohol, it “often helped just sort of flip a switch in people’s brains.”

Recent legislation, however, has decreased reliance on such tactics in some places. More state policies than previously require that publicly-funded higher education institutions provide naloxone access and overdose education to students and staff.

“It sort of removes the need to garner that internal support,” Freibott said. “Schools are finding it very helpful as a way to sort of reference, ‘Well, we’re doing this because the state requires it.’”

It’s still not enough. While most states now allow schools and staff to carry and administer naloxone, only a minority mandate it—though in 2024 alone, at least a dozen passed laws to increase access in settings including higher education.

“It’s so critical that it’s a student-led initiative that welcomes institutional support … that really makes up the most effective dynamic.”

The extent of these policies also varies. While Florida requires that universities maintain a supply of naloxone in all residence halls, for example, California’s Campus Opioid Safety Act mandates that university students also receive “educational and prevention information.” Maryland is another state that mandates both stocking naloxone on campus and providing students with overdose prevention education.

Advocates hope that the adoption of more state-level policies will help protect campus harm reduction, amid the Trump Administration’s systematic defunding of both higher education and harm reduction programs.

“[This study] happened before some of that federal shift happened, so it’s not yet known how that may affect the state-level policies, but I do know that a growing number of states are implementing these policies,” Freibott said.

Even as state policies push more universities to establish overdose-related programming, student support remains essential to their success. Reflecting on the impact of Recovery at Cal, Smith urged universities to embrace a bottom-up approach, deploying their institutional staff and funding in service of student-driven programming.

“It’s so critical that it’s a student-led initiative that welcomes institutional support,” he said. “It’s that sort of synergy that really makes up the most effective dynamic.”

Photograph (cropped) of UC Berkeley campus by Mizzlbrd via Wikimedia Commons/Creative Commons 2.0

The post Campus Harm Reduction Fueled by Student Advocacy, Some State Policies  appeared first on Filter.

Despite waning political support, researchers evaluating the impact of Canadian SOS programs continue to find profound benefits.

A new study published in the International Journal of Drug Policy followed 100 SOS participants in southwestern Ontario and found an extreme reduction in overdose risk. While 60 percent of participants had experienced an overdose in the six months prior to joining the program, only 15 percent experienced an overdose in the six months after.

“Seeing this type of very significant decrease in overdoses after people started a prescribed safer supply program is a very strong finding,” study co-author Dr. Gillian Kolla, of Memorial University of Newfoundland, told Filter. “Even people who continued to sometimes use fentanyl still had this significant decrease in overdose.”

“The value of this study is not just the results, but where it fits … Several other studies using different methodologies are all pointing to this significant decrease in overdose.”

The program, administered by Sanguen Health Centre, ran from July 2021 through October 2023. The researchers surveyed all participants about their overdose history, health, substance use and general wellbeing as they joined the program, and they repeated the survey six months later. Of 162 total participants, 100 completed both surveys.

To ensure that discounting the 62 participants who left the study did not inflate the results, the researchers also ran a worst-case scenario analysis, where they assumed that anyone who did not return for the follow-up survey experienced an overdose.

Even under the most conservative scenario, they still found that the SOS program substantially decreased overdose risk.

“The value of this study is not just the results—which are important—but where it fits within the larger research base on this topic,” Kolla said. “Several other studies using different methodologies are all pointing to this significant decrease in overdose among people receiving safer supply.”

Among them, an Ontario study found that the benefits of SOS rival methadone. Research from British Columbia reported a substantial decrease in overdose mortality following SOS prescription. Qualitative research has also suggested that SOS not only decreases overdose risk but also contributes to general health, feelings of stability and connection to resources like housing.

The program highlighted in Kolla’s study was itself discontinued in 2023, due to insufficient funding.

Positive findings continue to emerge around the country, even though its provinces implement SOS programs in quite different ways.

“In Canada, the health care system is largely provincially funded and directed,” Kolla explained. “[T]here’s a lot of latitude in how things can be quite different from one place to the next.”

In Ontario, SOS programs primarily operate through primary care settings, providing more robust linkage to general care. Programs in British Columbia, on the other hand, are more commonly attached to addiction medicine contexts. Studies have shown benefits to both.

But despite the growing consensus on the value of SOS programs among Canadian researchers, Canadian drug policy is moving in the opposite direction—cutting their funding and restricting their scope.

The program highlighted in Kolla’s study was itself discontinued in 2023, due to insufficient funding.

In Kolla’s opinion, Canada’s policy rollbacks on safe supply are motivated by a moral panic.

“While the program’s structure is changing, Sanguen remains deeply committed to harm reduction and advocating for innovative solutions to the ongoing drug poisoning crisis,” the program’s website reads.

In Kolla’s opinion, Canada’s policy rollbacks on safe supply and other elements of harm reduction, without careful consideration of the available science, are motivated by a moral panic.

“I think that, unfortunately, the idea of providing care and support to people who use drugs is sometimes so controversial in some quarters that we ignore our best available evidence,” she said. “And it’s a shame because we’re in the midst of such a devastating overdose crisis.”

Canada’s track record as a harm reduction pioneer has provided unprecedented data on the efficacy of safer supply and other harm reduction initiatives, including vending machines, decriminalization and overdose prevention centers. Political pushback, however unwelcome, can also inform international efforts to build lasting measures. Even as the future of Canadian harm reduction is uncertain, its past continues to serve as a powerful guide.

“We’ve seen a really significant growth in the amount of evidence on safer supply in the last five years,” Kolla said. “We’ve got this accumulating evidence that safer supply can be one of numerous tools in the toolbox.”

Photograph (cropped) courtesy of Darcie Dark

The post Discontinued Canadian Safe Supply Program Was Working, Study Shows appeared first on Filter.

A recent study published in Harm Reduction Journal appears to be the first scientific analysis of the naloxone box model. Researchers from HRMI and Facente Consulting found stakeholders “universally” perceived the boxes as a way to democratize naloxone distribution.

“Naloxone is such a safe, easy-to-use, lifesaving tool, and it’s often treated like, ‘Oh, this is a medicine—we have to safeguard it, we have to restrict it,’” co-author Shelley Facente told Filter. “The takeaway from this is just having it in a box—where people can open it and get to it 24/7—works.”

Researchers analyzed data that HRMI staff had been submitting to the state health department, logging how many kits had been taken and from which boxes. They also interviewed 11 people who had played a role in program implementation or accessed the boxes personally. They found that one critical factor in the program’s uptake was 24/7 accessibility—the boxes were placed outside, where the public could still reach them after business hours.

“If it’s 11 pm and they can’t access it, that naloxone isn’t doing any good,” co-author and HRMI founder Pam Lynch told Filter. “I mean, you’re hoping that people are taking kits ahead of time. But we’ve absolutely had situations where people actually drove up to one of our boxes with somebody overdosing in the car and ran up to the box and used the medication on the person in the car.”

A naloxone box outside Short’s Brewing Pull Barn, a “non-traditional” community partner in Elk Rapids, Michigan.

A brand-new HRMI box costs around $500, a fraction of the cost for a naloxone vending machine. But HRMI also got many boxes for free, from local news organizations that no longer needed them.

Compared to vending machines, naloxone boxes also have a much lower barrier to entry in terms of the installation process—they slide easily into the passenger seat or trunk of most cars, which makes them convenient not just to set up, but to relocate.

“While the vending machine model has been really important and really productive … it’s not super accessible,” co-author Katie Burk told Filter. “They’re expensive, they need electricity access, they’re heavy.”

Alongside more traditional venues like harm reduction and social services programs, many “non-traditional” naloxone box placements were initiated by librarians, gas station clerks and small-business owners looking to protect their customers and their neighborhoods. More than 50 of the boxes are stocked by community members, independently of HRMI. The boxes from which people took the most naloxone were the ones outside retail stores; bars and restaurants were popular locations as well.

Lynch told Filter that many business owners felt compelled to implement a naloxone box due to their personal experiences losing loved ones. One local veteran noticed a box stationed at a cannabis dispensary and requested one for her new restaurant.

“She had loved ones who she had done combat with who had overdosed on opioids fatally,” Lynch said. “It was very important to her to place a box outside her newly established restaurant in memory of her colleague and friend who had died.”

Burk pointed out that people often don’t think of overdose prevention as within the scope of work for a librarian, or someone running a cannabis dispensary.

“But I think that these folks, through caring about the issue … really stepped up to the plate and were willing to do the work,” she told Filter.

“Let’s find champions in other areas that have been highly impacted by overdose  … and be a little more intentional about placing boxes there.”

Enthusiasm from community partners was crucial to the HRMI program’s expansion and maintenance. But it also led the geographic distribution of the boxes to reflect interest, rather than need. Some of the counties with the highest rates of overdose deaths still have very few boxes, or none at all. Burk said this shows the importance of HRMI and other organizations seeking out community partners in high-impact areas—rather than waiting for partners to come to them.

“Let’s find champions in other areas that have been highly impacted by overdose and overdose deaths,” she said, “and be a little more intentional about placing boxes there.”

While some interviewees told the researchers that the boxes received initial pushback, they noted that over time the program sparked many productive conversations and changed the minds of community members who had initially been wary or confused. One person who worked at a “non-traditional” box location told the researchers that they’d seen “a lot of success with people in terms of broadening their horizons.”

More harm reduction organizations are beginning to implement the naloxone box model in free clinics, college campuses and other community spaces. With naloxone products increasingly accessible, Facente hopes her team’s research will encourage more people to embrace this low-threshold approach to naloxone distribution—making kits freely available in public spaces, without unnecessary barriers. 

“Naloxone hasn’t been treated that way,” she said, “but there’s really no reason that it can’t be.”

Images via Harm Reduction Michigan

The post Naloxone Boxes: New Strategy Makes OD Antidote Accessible 24/7, for Free appeared first on Filter.

Holistic definitions of recovery have sought to reflect this, as many more people, including government officials, recognize the problems of an abstinence-only model. But treatment providers that are moving beyond abstinence-only face a new challenge: how to reliably measure recovery in a way that is multifaceted and person-centered.

A new study published in the journal Addiction reviewed 90 unique patient-reported outcome measures (PROMs)—questionnaires issued by providers, where people undergoing treatment report their physical health, relationships to substance use, quality of life and other important indicators. 

Most notably, only two of the 90 PROMs were clearly developed with substantial input from directly impacted people.

While PROMs can promote a multidimensional understanding of recovery, they also have severe shortcomings. Most notably, only two of the 90 PROMs that the authors discovered were clearly developed with substantial input from directly impacted people.

“PROMs … help assess how things are going for a patient based on their own self-report as they receive treatment,” study co-author Dennis Pales, of the University of Colorado School of Medicine, told Filter. “This allows us to get good, objective data in a systematic way to guide treatment decisions based on how a patient is doing.”

According to the study, a typical PROM has around 16 items. While some ask general questions about the patient’s quality of life, most include specific items about substance use, psychological health, social relationships and physical health. Other common topics include time use, identity, financial stability and aspirations.

By measuring recovery across several domains, PROMs allow treatment providers to assess recovery in terms of wider wellbeing. Pales contrasted this with an abstinence-based approach, which centers around urine tests or other forms of drug screening.

“While those tools may have uses, they lack nuance,” he said. “They fail to encompass the full scope of what recovery might mean for somebody and can introduce stigma into patient care.”

PROMs also offer a standardized approach, helping treatment providers track a patient’s trajectory over time, though different areas of recovery might become more or less salient as a person progresses towards their goals.

While PROMs are poised to reduce stigma around continuing drug use in recovery, they have yet to achieve their full potential. The study troublingly revealed how rarely these tools were described as being developed with input from people with living experience.

Pales noted that the figure of just two PROMs out of 90 might be an underestimate; some researchers may have consulted the community but omitted that detail when describing their approach. Even so, he suspects that many PROMs are missing this crucial perspective.

“Integrating people who use drugs into the process of developing PROMs can allow for an assessment of recovery that is more comprehensive and grounded in things that are most important to people seeking care,” he said. “[Things] that clinicians, researchers or whoever’s developing the PROM may not be attuned to.”

“It may be an outstanding arrest warrant, a fine, child custody. Those kinds of things are important to get back to a life that is meaningful and manageable for you.”

One of the two PROMs that definitely incorporate lived perspectives is the Response to Addiction Recovery (R2AR), developed by Brandeis University professor Dr. Sharon Reif with Elisabeth Okrant and Constance Horgan.

Reif told Filter that interviews and focus groups with people in recovery helped her team identify important domains that previous PROMs had not adequately captured, such as spirituality and legal challenges.

“[W]e want to highlight where you’re going and how you’re getting better in your recovery,” she said. “It may be an outstanding arrest warrant, it may be a fine, it may be child custody. Those kinds of things are important to get back to a life that is meaningful and manageable for you.”

To capture the richest possible picture of recovery, Reif and her team sought feedback from providers as well.

“[P]roviders don’t always have lived experience—sometimes they do—but they’ve also worked with people for a long time,” she explained. “They have some insights that people … early in their stages of recovery may not see in the same way.”

While bringing these diverse perspectives into PROM development has major advantages, it can also introduce conflicts. Reif recalled that the spirituality item was particularly controversial: Some people insisted it was an essential part of recovery, while others felt it was irrelevant or inappropriate.

“Things have definitely changed in a … direction that looks at recovery multi-dimensionally. But there’s definitely still room to grow.”

Even when everyone agrees, length can quickly become problematic. With 20 items, Reif’s PROM is longer than most, and it continues to grow as her team pilots it across new sites. Including many items represents a broader range of goals, but it also makes a PROM unwieldy.

“[The length] is fine if you’re in a research study, but it’s really hard if you’re just doing something for yourself or in the course of a clinical meeting,” Reif said. She hopes to eventually narrow down the list, while still ensuring it represents diverse interests.

Despite their present shortcomings, Pales sees an important role for PROMs as treatment providers increasingly move away from abstinence models. He’s especially encouraged by recent efforts to expand the definition of recovery and set specific standards for what constitutes  meaningful improvement.

“Things have definitely changed in a more comprehensive direction that looks at recovery multi-dimensionally,” he said. “But there’s definitely still room to grow.”

Photograph via PxHere/Public Domain

The post To Move Beyond Abstinence-Only, We Need Better Tools to Measure Recovery appeared first on Filter.

A study recently published in the journal Socius illustrates how subjecting prospective hires to drug screenings knocks many people with past justice-system involvement out of the running. Drawing on interviews with dozens of formerly incarcerated people who use drugs, the authors report that drug screens discouraged applicants from applying to high-quality jobs—and led many to abandon their job search altogether.

At first, the researchers were studying barriers to employment among people with criminal records in general. But after conducting 140 interviews across central Ohio, they noticed that interviewees with a history of substance use faced unique challenges.

“[T]here is an enormous overlap between having a criminal record and having a substance use disorder,” lead author Mike Vuolo, professor of sociology at the Ohio State University, told Filter. “So [drug screening] became another mechanism that we thought was important.”

“I’m overly confident, right? Regardless of my record, let me tell you what my skills are. But it also said you have to submit to a urine test …. so, I didn’t do it.”

To understand how drug screens factored into applicants’ job search strategies, Vuolo and his team focused on 43 interviewees who had faced challenges related to substance use. They found that these jobseekers exhibited two main reactions to drug testing: continuing their job search but restricting their aspirations, or dropping out of formal employment entirely.

The first reaction, deciding not to apply for a job due to the potential for drug screening, was common across the substance use spectrum. Whether using drugs recreationally or experiencing a substance use disorder, 65 percent of interviewees reported hesitating to apply for jobs where their substance use history might disqualify them.

“There are examples of people who are ready to overcome their criminal record, but select out anyway because they saw the drug screen,” Vuolo explained. “And sometimes it was simply for cannabis.”

One jobseeker described going in for an interview at an automotive chain, feeling confident that despite his background, having the skills to do the job well would count for more.

“I’m overly confident, right? Regardless of my record, let me tell you what my skills are,” he said, noting that he immediately hit it off with the hiring manager. “So, but nevertheless it also said you have to submit to a urine test. [I was smoking] weed real heavy at the time …. so, I didn’t do it.”

Situations like these, where an applicant got relatively far in the hiring process but quit once the employer required a drug test, were common. For some jobseekers, however, fear of employers’ reactions to their substance-use history prevented them from even applying.

Job applications “don’t give you a chance to explain yourself,” one interviewee explained. “I was intimidated by filling out applications because of that. I know that a lot of employers, and I’ve been told this, [are not] hiring me because of any type of drug conviction.”

Seventy percent reported having abandoned their job search at least once.

Besides writing off certain opportunities, the second common response to drug screening was to leave the formal labor market entirely. Many interviewees alternated between these two strategies, and 70 percent reported having abandoned their job search at least once.

“Their main reason is that addiction is all-encompassing at that point in their lives,” Vuolo said. “And so the idea of working is simply out of the realm of possibility, either because they just don’t feel it’s possible, or because they fear working while under the influence.”

While only a minority of the sample (11 interviewees) replaced their formal job search with under-the-table work, those who did felt that the money was more reliable. One applicant waited to hear back from prospective employers, but after receiving no response, “found another way to make money” in order to cover his daily needs.

“Selling drugs is what my other option was,” he told the interviewers. “It was quick money. Dollars every day.”

Whether avoiding certain jobs, giving up the job search, or cycling through both strategies, formerly incarcerated people who use drugs must contend with unique barriers to employment—barriers that conventional second chance employment policies have not adequately considered.

One proposed solution is to promote “recovery-ready” workplaces, which aim to “[d]evelop and implement innovative approaches for recruiting and onboarding people in or seeking recovery,” according to the Department of Labor, which currently endorses the approach.

“The US Department of Labor actually is suggesting that the recovery-ready workplace should be part of the second chance framework for criminal records,” Vuolo said. “We basically can’t separate them.”

Some states have already made attempts to integrate these two approaches. In 2018, Indiana created its Workforce Recovery Employer Guidelines, as one example of how employers could seek to incorporate recovery-friendly policies that might complement second chance hiring initiatives. Employees or job applicants who test positive for drugs are not automatically terminated or ruled out, but are instead offered connections to treatment and the opportunity to return to work—at least in theory.

“If we’re gonna have efforts like ‘Ban the Box,’ we need to also account for the fact that people have substance use disorders.”

The continuation of drug screens, the potential for treatment being coerced, and a return to work being conditional on abstinence are among the barriers that could persist under this model. Nonetheless, it’s one potential first step towards equalizing employment opportunities for people who use drugs.

“People would be able to get their foot in the door,” Vuolo said. However, he questioned whether the bureaucratic guidelines were effective. “[E]ven though Indiana has this, I don’t know how often it’s being used, to be completely frank.”

In future research, Vuolo hopes to assess whether employers implement recovery-ready workplace guidelines, and whether such initiatives actually succeed in promoting employment opportunities for people who use drugs.

For now, however, he hopes that his study will shed light on the employment barriers erected against formerly incarcerated people who use drugs, even as progressive employment policies claim to give them a second chance.

“If we’re gonna have efforts like ‘Ban the Box’ for criminal records, we need to also account for the fact that people have substance use disorders or past substance use disorders,” Vuolo concluded.

Photograph (cropped) by Amtec Photos via Flickr/Creative Commons 2.0

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