August 15, 2024

As partners of the Big Cities Health Coalition, the UHC has closely tracked the sharp rise in drug overdose deaths in big U.S. cities over the past decade. The latest analysis shows a continued pattern driven by inexpensive synthetic drugs. In 2019, the potent synthetic opioid fentanyl was found to be responsible for the majority of overdoses in big cities. Fentanyl is now being combined with other synthetic drugs, with deadly results.

“Synthetic non-opioid tranquilizers are being used to enhance the sedative effect of opioids. Xylazine, a low-cost tranquilizer also known as tranq, is approved for veterinary use but is not approved for humans and there is low regulatory oversight of the drug. Currently, xylazine is the most common adulterant (contaminant) in the street opioid supply; in Philadelphia, more than 90% of fentanyl now includes xylazine. Xylazine is increasingly involved with overdoses. Between 2019 and 2022, xylazine was involved in at least 2000 overdoses in BCHC cities.”

UHC researchers further note that “Given their role as entry points for emerging drugs, big cities serve as sentinel locations for the overdose crisis in North America.”

Unfortunately, this pattern has begun to bleed into neighboring countries. Research published this summer in the American Journal of Public Health by Drs. Rosie Mae Henson, Usama Bilal, and Brent Langellier sought to fill gaps in national estimates of drug use in Mexico. They found that drug overdose deaths increased by nearly 80% between 2014 and 2021, and that the risk was higher in cities closer to the US border.

“The research team highlights that the increase in overdose death rates is consistent with the increase in opioid use, mainly in the border area, driven in part by its social and economic ties to the US, a country currently experiencing an epidemic of opioid use, including synthetic ones such as fentanyl.”

What can cities do to stem overdose death rates and to prevent a similar epidemic in Mexico? New research in The Lancet Public Health, led by UHC affiliate Dr. Ayden Scheim looks to our neighbor to the north. During the same time period in Toronto, Ontario, Canada’s largest city, annual drug overdose deaths have increased by more than 300%. This increase is largely due to the introduction of synthetic fentanyl into the street drug supply. Toronto responded to this emergency by implementing nine supervised consumption sites (SCS).

According to the National Harm Reduction Coalition, SCS are “designated sites where people can use pre-obtained drugs under the safety and support of trained personnel.” Not only do they prevent drug overdose and allow for safe disposal of syringes, SCS use can also reduce the transmission of HIV and hepatitis C and increase access to medical care and social services for people who use drugs.

Dr. Scheim and team observed a 67% reduction in overdose mortality in Toronto neighborhoods where SCS were established – meaning that the effect extended beyond the immediate care and services provided at the site.

“In Toronto, SCS are part of a larger, comprehensive approach to overdose prevention, and are expected to facilitate access to substance use treatment and other harm reduction strategies. As such, the neighbourhood-level effects observed in our study are probably attributable not only to acute onsite overdose reversals but also to increased community access to naloxone, drug checking (eg, fentanyl test strips), sterile drug use equipment, and substance use treatment referrals, and to the dissemination of safer drug use practices by harm-reduction service providers.”

Overall, a city-wide reduction in overdose mortality rate of 42% (p=0·051) was observed after the SCS were implemented.

These findings are consistent with recommendations from the UHC research on cities in the US and Mexico, including:

• Creating national harm reduction strategies, coordinated with civil society organizations.
• Decriminalization of personal drug use and legalization of drug test strips
• Enhancing overdose prevention services, such as SCS, community-based drug checking facilities, community distribution of naloxolone and drug test strips, and education.
• Improving access to medication-assisted treatments like methadone and buprenorphine, and declassification of naloxone as psycho-tropic (Mexico).

Of course, there is also an ongoing need for data on drug-related behaviors and the effects of harm reduction services in cities. The UHC will continue to be a source for data and analysis in this crucial area.