Project Summary The drug supply is in enormous flux with illicitly manufactured fentanyl (IMF) and analogs creating a deadly environment for people who use drugs (PWUD). Claiming 93,311 lives in 2020, IMF is the underlying driver of the current crisis. Its fast onset leaves little time for emergency intervention and its presence as the dominant opioid in circulation undermines evidence-based treatments. Rhode Island (RI) is a site of early IMF devastation, subject of much epidemiologic investigation about IMF, and an innovation hub for expanded access to lifesaving naloxone and medications for opioid use disorder (MOUD) and structures to better provide them. Two recent innovations show promise even with IMF’s endemicity and the COVID-19 pandemic because they address the illicit drug supply head-on: non-traditional MOUD induction pathways and community drug checking. But treatment success may be undermined by the illicit drug supply unless we learn how to navigate it. One novel approach to doing so is with community drug checking. Drug checking gives insights into what drugs people use, engages PWUD in relevant exchange of health information, and generates data that could inform treatment. Application of these data for epidemiologic research to help better understand exposure, identify risk, measure consequence and consideration of their role in a clinical setting to inform treatment have not been examined. We propose an observational study that leverages recently acquired devices and capacities to carry out research on drug checking, multiple linkable individual level datasets, and state law and public health leadership supportive of drug checking. Consistent with the RFA, we seek to uncover how characteristics of IMF in the drug supply influence treatment regimens and ongoing drug use and risk in people intentionally or unwittingly using polysubstances (topics 2 and 4). Specific aims are to: Aim 1) Examine the anatomy of the illicit drug supply by establishing a community drug checking cohort (n=600) to learn how: a) IMF’s presence, form (i.e., powder, counterfeit pill), and potency in the opioid supply affect ongoing use and overdose risk; b) IMF’s presence in non-opioid drugs like stimulants affects use, overdose risk and clinical severity of health consequences; and c) use of drug checking affects uptake of MOUD. [UG3 and UH3]. Aim 2) Document clinicians’ perceptions about drug checking, and their experiences, innovations, barriers and facilitators of induction of patients onto MOUD, including micro- and macro-dosing, in RI. [UH3] Aim 3) Assess among community drug checking cohort members a) which drug supply characteristics are associated with ongoing drug use, overdose and MOUD interest; b) what drug supply factors impact incidence of induction problems like precipitated withdrawal and successful retention in buprenorphine care using administrative data. [UH3] Findings will help inform prevention and intervention approaches to the drug supply in IMF endemic areas, determine engagement in and clinical utility of community drug checking, and help identify factors influencing poor treatment experience and better retention.

Project Narrative In recent years, the increasing presence of illicitly manufactured fentanyl (IMF) in the drug supply has led to devastating loss of life to overdose and frustrated treatment systems already under-equipped to diagnose and treat people with opioid use disorder. A key to better addressing this new challenge is understanding the presence, form and use of IMF. This study uses community drug checking to characterize dynamics of the drug supply and examine how these characteristics influence ongoing use, overdose risk, and treatment uptake of people using fentanyl and other drugs, and patient and provider addiction care experiences in a state dominated by IMF.