Drug Policy Change Research Articles

Risk of selection and timelines for the continued spread of artemisinin and partner drug resistance in Africa.

The introduction of artemisinin combination therapies (ACTs) has significantly reduced the burden of Plasmodium falciparum malaria, yet the emergence of artemisinin partial resistance (ART-R) as well as partner drug resistance threatens these gains. Recent confirmations of prevalent de novo ART-R mutations in Africa, in particular in Rwanda, Uganda and Ethiopia, underscore the urgency of addressing this issue in Africa. Our objective is to characterise this evolving resistance landscape in Africa and understand the speed with which ART-R will continue to spread. We produce estimates of both ART-R and partner drug resistance by bringing together WHO, WWARN and MalariaGen Pf7k data on antimalarial resistance in combination with a literature review. We integrate these estimates within a mathematical modelling approach, aincorporating to estimate parameters known to impact the selection of ART-R for each malaria-endemic country and explore scenarios of ART-R spread and establishment. We identify 16 malaria-endemic countries in Africa to prioritise for surveillance and future deployment of alternative antimalarial strategies, based on ART-R reaching greater than 10% prevalence by 2040 under current malaria burden and effective-treatment coverage. If resistance continues to spread at current rates with no change in drug policy, we predict that partner drug resistance will emerge and the mean percentage of treatment failure across Africa will reach 30.74% by 2060 (parameter uncertainty range: 24.98% - 34.54%). This translates to an alarming number of treatment failures, with 52,980,600 absolute cases of treatment failure predicted in 2060 in Africa (parameter uncertainty range: 26,374,200 - 93,672,400) based on current effective treatment coverage. Our results provide a refined and updated prediction model for the emergence of ART-R to help guide antimalarial policy and prioritise future surveillance efforts and innovation in Africa. These results put into stark context the speed with which antimalarial resistance may spread in Africa if left unchecked, confirming the need for swift and decisive action in formulating antimalarial treatment policies focused on furthering malaria control and containing antimalarial resistance in Africa. The rise of artemisinin partial resistance (ART-R) and increasing partner drug tolerance by Plasmodium falciparum malaria in Africa threatens to undo malaria control efforts. Recent confirmations of de novo ART-R markers in Rwanda, Uganda, and Ethiopia highlight the urgent need to address this threat in Africa, where the vast majority of cases and deaths occur. This study characterises the resistance landscape and predicts the spread of antimalarial resistance across Africa. We estimate and map the current levels of resistance markers related to artemisinin and its partner drugs using WHO, WWARN, and MalariaGen Pf7k data. We combine these estimates with current malaria transmission and treatment data and use an established individual-based model of malaria resistance to simulate future resistance spread. We identify 16 African countries at highest risk of ART-R for prioritisation of enhanced surveillance and alternative antimalarial strategies. We project that, without policy changes, ART-R will exceed 10% in these regions by 2040. By 2060, if resistance spreads unchecked, we predict mean treatment failure rates will reach 30.74% (parameter uncertainty range: 24.98% - 34.54%) across Africa. This alarming spread of resistance is predicted to cause 52.98 million treatment failures (uncertainty range: 26.37 million - 93.67 million) in 2060. The impact of antimalarial resistance in Africa, if left unchecked, would hugely damage efforts to reduce malaria burden. Our results underscore the critical need for swift policy action to contain resistance and guide future surveillance and intervention efforts.

Meta-analysis on Plasmodium falciparum sulfadoxine-pyrimethamine resistance-conferring mutations in India identifies hot spots for genetic surveillance

BackgroundIndia is on track to eliminate malaria by 2030 but emerging resistance to first-line antimalarials is a recognised threat. Two instances of rapid development, spread, and natural selection of drug-resistant mutant parasites in India (chloroquine across the country and artesunate + sulfadoxine-pyrimethamine [AS+SP] in the northeastern states) translated into drug policy changes for Plasmodium falciparum malaria in 2010 and 2013, respectively. Considering these rapid changes in the SP drug resistance-conferring mutation profile of P. falciparum, there is a need to systematically monitor the validated mutations in Pfdhfr and Pfdhps genes across India alongside AS+SP therapeutic efficacy studies. There has been no robust, systematic countrywide surveillance reported for these parameters in India, hence the current study was undertaken. MethodsStudies that reported data on WHO-validated SP resistance markers in P. falciparum across India from 2008 to January 2023 were included. Five major databases, PubMedⓇ, Web of ScienceTM, ScopusⓇ, EmbaseⓇ, and Google Scholar, were exhaustively searched. Individual and pooled prevalence estimates of mutations were obtained through random- and fixed-effect models. Data were depicted using forest plots created with a 95% confidence interval. The study is registered with PROSPERO (CRD42021236012). ResultsA total of 37 publications, and 533 Pfdhfr and 134 Pfdhps National Centre of Biotechnology Information (NCBI) DNA sequences were included from >4000 samples. The study included information from 80 districts, 21 states and 3 union territories (UTs) from India. The two PfDHFR mutations, C59R (62%) and S108N (74%), were the most prevalent mutations (pooled estimates 61% and 71%, respectively) and appeared to be stabilised/fixed. Although rarest overall, the prevalence of I164L was observed to be as high as 32%. The PfDHFR double mutants were the most prevalent overall (51%; pooled 42%). The prevalence of triple and quadruple mutations was 6% and 5%, respectively, and is an immediate concern for some states. The most prevalent PfDHPS mutation was A437G (39%), followed by K540E (25%) and A581G (12%). There was a low overall prevalence of PfDHFR/PfDHPS quintuple and sextuple mutations but surveillance for these mutations is critical for some areas. ConclusionThe analyses span the two critical policy changes, highlight the areas of concern, and guide policymakers in strategising and refining the anti-malaria drug policy for malaria elimination. The results of the analyses also highlight the SP-resistance hot spots, critical gaps and challenges, and indicate that focal and local malaria genetic surveillance (including drug-resistance markers) is needed until malaria is successfully eliminated.

Reducing Drug Overdose Deaths: Significant Changes Needed in U.S. Drug Treatment Policy.

Slow and incremental changes in federal and state drug policies are neither meeting treatment needs nor reversing yearly increases in drug-related mortality. U.S. drug policies convey confounding messages that non-sanctioned substance use leads to health problems that need treatment while simultaneously being legal problems that must be punished. As a result, drug treatments remain a sequestered component of health care, with onerous treatment requirements for patients and providers that act as barriers to the treatment that policies seek to allow. A new direction in drug policy is needed that broadens rather than restricts access to care and that also focuses on prevention. Policies must consider the totality of health and wellness, not just "last resort" safety nets for urgent needs. For substantive change in drug-related morbidity and mortality, forward-thinking policy must focus more on addiction prevention and address the known risks of developing a substance use disorder. [Journal of Psychosocial Nursing and Mental Health Services, 61(6), 7-10.].

Critically explaining British policy responses to novel psychoactive substances using the policy constellations framework

Background A growing number of researchers are trying to provide explanations for continuity and change in drug policy in different contexts. Such research predominantly falls in the pluralist realm of public policy where various actors compete to have their policy proposals accepted. Method Using a critical framework called Policy Constellations (PC), developed by Stevens and Zampini, this paper attempts to explain reactions of the British Government to Novel Psychoactive Substances (NPS) between 2008 – 2016. Qualitative data comes from in-depth interviews with stakeholders (N = 15), including NGO workers, a former Home Secretary, drugs ministers, governmental advisors, a former senior police officer, former Deputy Drug Coordinator, and a former Advisory Council for the Misuse of Drugs (ACMD) member. Results Two ‘constellations’ competed in British NPS policy setting. The PC framework illustrates power imbalances between these competing stakeholders. Abstinence orientated actors (the conservative constellation) enjoyed strategic advantages and media power which allowed them to create a favourable policy setting. These advantages were not enjoyed by the liberal constellation who struggled to access the policy setting and influence policy developments. Conclusion The prohibitive nature of the policy used to counter NPS can be explained with the domination of actors whose values align with the conservative constellation.

Substances from unregulated drug markets - A retrospective data analysis of customer-provided samples from a decade of drug checking service in Zurich (Switzerland).

Drug checking services (DCS) are harm reduction interventions for people who consume illicit substances. Unregulated drug markets lead to samples with unexpected and variable contents. A retrospective data analysis of Zurich's DCS was performed to determine the nature of these samples. This study aims to investigate the qualitative and quantitative properties of 16,815 customer-provided psychoactive drug samples analyzed chemically through the DCS in Zurich from 1st January 2011 to 31st December 2021. The main analytical method utilized for characterizing these substances was high-performanceliquid chromatography and gas chromatography-mass spectrometry. Data sets are summarized using descriptive statistics. There was a 2.5-fold increase in the number of tested samples over the past decade. An overall proportion of 57.9% (weighted mean) of samples within our database demonstrates unexpected analytical findings and additional low sample contents during the observation period. Substantial differences in quality and quantity between substance groups were detected and an increase of sample quality and content over time was demonstrated. Chemical analysis reveals that over half of substances acquired from unregulated drug markets analyzed through DCS in Zurich are with low qualitative and quantitative properties, which may expose users to risks. Based on longitudinal analyses over a decade, this study contributes to the body of evidence that DCS may potentially manipulate unregulated drug markets towards providing better quality substances, as well as may stabilize these markets over time. The necessity for drug policy changes to make this service accessible in further settings was highlighted, as DCS still often take place in legal grey zones. None to declare.

Deterrence effect of penalties upon adolescent cannabis use.

Penalties are used in an effort to curtail drug use by citizens in most societies. There are growing calls for a reduction or elimination of such penalties. Deterrence theory suggests that use should increase if penalties reduce and vice versa. We sought to examine the relationship between changes to penalties for drug possession and adolescent cannabis use. Ten instances of penalty change occurred in Europe between 2000 and 2014, seven of which involved penalty reduction and three involved penalty increase. We conducted a secondary analysis of a series of cross-sectional surveys of 15-16-year-old school children, the ESPAD surveys, which are conducted every four years. We focused on past month cannabis use. We anticipated that an eight-year time span before and after each penalty change would yield two data points either side of the change. A simple trend line was fitted to the data points for each country. In eight cases, the trend slope in past month cannabis use was in the direction predicted by deterrence theory, the two exceptions being the UK policy changes. Using the principals of binomial distributions, the likelihood of this happening by chance is 56/1024 = 0.05. The median change in the baseline prevalence rate was by 21%. The science seems far from settled on this issue. There remains a distinct possibility that reducing penalties could contribute to small increases in adolescent cannabis use and consequently increase cannabis-related harms. This possibility should be considered in any political decision-making influencing drug policy changes.

National-scale simulation of human movement in a spatially coupled individual-based model of malaria in Burkina Faso

Malaria due to the Plasmodium falciparum parasite remains a threat to human health despite eradication efforts and the development of anti-malarial treatments, such as artemisinin combination therapies. Human movement and migration have been linked to the propagation of malaria on national scales, highlighting the need for the incorporation of human movement in modeling efforts. Spatially couped individual-based models have been used to study how anti-malarial resistance evolves and spreads in response to drug policy changes; however, as the spatial scale of the model increases, the challenges associated with modeling of movement also increase. In this paper we discuss the development, calibration, and validation of a movement model in the context of a national-scale, spatial, individual-based model used to study the evolution of drug resistance in the malaria parasite.

"It's just not the same": Exploring PWUD' perceptions of and experiences with drug policy and SCS services change in a Canadian City.

Shifting political contexts can significantly alter drug policy approaches and available supports for People Who Use Drugs (PWUD). The purpose of this study was to explore how shifts in provincial drug policy approaches, specifically the replacement of a Safe Consumption Site (SCS) with a smaller mobile Overdose Prevention Site (OPS) in Lethbridge, Alberta Canada, impacted PWUD' access to and experiences with harm reduction services. We conducted semi-structured interviews with 50 PWUD in the City of Lethbridge, Canada. Through traditional fieldwork, we recruited participants within, and just outside of, downtown Lethbridge. Using a standardized general prompt guide to begin interviews, participants were asked a variety of questions about their experiences with and perceptions of SCS access and changes to SCS provisions. Interviews were audio recorded, then transcribed, coded, and analyzed. Participants reported regular and frequent access and overall positive experiences with the SCS, despite also noting certain operational barriers (e.g., long wait times). By contrast, participants reported more limited use of the new OPS compared to the SCS because of three main reasons: (1) concerns about location; (2) smoking room elimination; and (3) lack of social space and activities. Overall, changes to SCS provision produced a range of negative consequences for PWUD in Lethbridge. These relate to perceived increases in drug-related harms (e.g., increased overdoses) as well as negative social impacts (e.g., lack of place to meet other people). Findings from this study provide preliminary indications of the importance of understanding how contextual and locally-specific elements (location, limits on permitted route administration, and social aspects) can work together to facilitate SCS uptake and even overcome traditional SCS barriers. Conversely, the absence of such elements can hinder SCS uptake. Results show that the value of SCS might differ across locations, pointing to the need for further locally-grounded examinations of harm reduction service uptake and experience.

Spatial Nature and Geographical Characteristics of Drug Crime in Hungary

Relatively few people in Hungary deal with the investigation of the spatial nature of crime. In connection with drug crime, we rarely find research dealing with this topic. The study shows why it is difficult to examine the spatiality of various drug-related crimes. It describes the main spatial trends of crime and the presence of criminal organizations in the field of drug trafficking by analyzing the criminal statistics data of the past decades. Political and drug policy changes, as well as the activities of criminal organizations at the international level, are usually hidden behind the spatial changes. In all cases, these also have a significant impact on the spatial distribution of drug use. The present research is primarily looking to answer whether there is a connection between the main focal points of organized crime and the centers of drug crime.

In vitro susceptibility profile of Plasmodium falciparum clinical isolates from Ghana to antimalarial drugs and polymorphisms in resistance markers.

Drug resistance in Plasmodium falciparum compromises the effectiveness of antimalarial therapy. This study aimed to evaluate the extent of drug resistance in parasites obtained from international travelers returning from Ghana to guide the management of malaria cases. Eighty-two clinical parasite isolates were obtained from patients returning from Ghana in 2016–2018, of which 29 were adapted to continuous in vitro culture. Their geometric mean IC50 values to a panel of 11 antimalarial drugs, assessed using the standard SYBR Green-I drug sensitivity assay, were 2.1, 3.8, 1.0, 2.7, 17.2, 4.6, 8.3, 8.3, 19.6, 55.1, and 11,555 nM for artemether, artesunate, dihydroartemisinin, lumefantrine, mefloquine, piperaquine, naphthoquine, pyronaridine, chloroquine, quinine, and pyrimethamine, respectively. Except for chloroquine and pyrimethamine, the IC50 values for other tested drugs were below the resistance threshold. The mean ring-stage survival assay value was 0.8%, with four isolates exceeding 1%. The mean piperaquine survival assay value was 2.1%, all below 10%. Mutations associated with chloroquine resistance (pfcrt K76T and pfmdr1 N86Y) were scarce, consistent with the discontinuation of chloroquine a decade ago. Instead, the pfmdr1 86N-184F-1246D haplotype was predominant, suggesting selection by the extensive use of artemether-lumefantrine. No mutations in the pfk13 propeller domain were detected. The pfdhfr/pfdhps quadruple mutant IRNGK associated with resistance to sulfadoxine-pyrimethamine reached an 82% prevalence. In addition, five isolates had pfgch1 gene amplification but, intriguingly, increased susceptibilities to pyrimethamine. This study showed that parasites originating from Ghana were susceptible to artemisinins and the partner drugs of artemisinin-based combination therapies. Genotyping drug resistance genes identified the signature of selection by artemether-lumefantrine. Parasites showed substantial levels of resistance to the antifolate drugs. Continuous resistance surveillance is necessary to guide timely changes in drug policy.

Paradoxical issues in eradicating opium cultivation in Myanmar: A perspective from local farmers’ voices

AbstractSupporting drug‐producing communities in alternative livelihoods from harm reduction activists is a common practice in Myanmar and other drug‐producing countries. And yet, the voices of opium farmers are rarely heard. This paper assesses why Myanmar farmers continue to grow opium poppy and analyzes their current concerns and the practical challenges in eradicating opium cultivation in Myanmar. This analysis combines field observations and secondary data from the Myanmar Opium Farmers' Forum (2013–2019) statements. The findings show five main reasons to cultivate poppy, as well as eight practical concerns of farmers relating to (1) rights to access land, (2) threats of insurgency groups, (3) forced eradication without alternative plans, (4) unsustainability in alternative developments, and (5) limitations of farmers’ rights to be involved in drug policy changes. The paper calls for further attention of policymakers and stakeholders to clarify these paradoxical issues with relevant proposals to support local farmers while implementing drug policy reform in Myanmar. The author argues for a balance of the national drug control strategies (supply, demand, and harm reduction) with opium farmers’ rights to encourage a harmonious relationship between both sides should be the new roadmap for drug reform in Myanmar.

Cost-Effectiveness Analysis of Gefitinib Alone and Combined with Chemotherapy as First-Line Treatment for Patients with Advanced Non-Small-Cell Lung Cancer.

BackgroundThe rational choice of drugs for treating patients with advanced non-small-cell lung cancer (NSCLC) is significantly impacted by changes in modern drug policy, health insurance negotiation, and budget impact analyses. Here, we provide a basis for rational drug use decisions in clinical practice and promote the widespread use of pharmacoeconomic methods in clinical decision-making based on current drug policies in China and real-world data.MethodsA Markov model was developed to evaluate the health and economic outcomes in patients with advanced NSCLC treated with first-line chemotherapy with gefitinib and gefitinib plus chemotherapy. Clinical data, cost, and utility data were extracted from published literature or real-world data; sensitivity analysis was performed to assess the uncertainty in the results. The results were summarized as QALYs and the ICER.ResultsThe average cost and QALYs associated with gefitinib and gefitinib plus chemotherapy strategies were $62,882.83 and 1.70 and $84,509.30 and 1.93, respectively. The ICER for gefitinib plus chemotherapy versus gefitinib alone was $95,135.50. The one-way sensitivity analysis showed that the utility value of progressive disease (PD) had the greatest impact on the treatment outcome. Probabilistic sensitivity analysis showed that if China’s willingness to pay threshold was $33,300/QALY, the probability of superiority of the gefitinib plus chemotherapy regimen was 0.ConclusionThe study suggests that, from the perspective of the Chinese health system, gefitinib plus chemotherapy is not a cost-effective option for NSCLC patients with EGFR mutations. These findings may help clinicians make the best treatment decisions for patients with NSCLC.

Genetic diversity of Plasmodium falciparum AMA-1 antigen from the Northeast Indian state of Tripura and comparison with global sequences: implications for vaccine development

BackgroundMalaria continues to be a major public health problem in the Northeastern part of India despite the implementation of vector control measures and changes in drug policies. To develop successful vaccines against malaria, it is important to assess the diversity of vaccine candidate antigens in field isolates. This study was done to assess the diversity of Plasmodium falciparum AMA-1 vaccine candidate antigen in a malaria-endemic region of Tripura in Northeast India and compare it with previously reported global isolates with a view to assess the feasibility of developing a universal vaccine based on this antigen.MethodsPatients with fever and malaria-like illness were screened for malaria and P. falciparum positive cases were recruited for the current study. The diversity of PfAMA-1 vaccine candidate antigen was evaluated by nested PCR and RFLP. A selected number of samples were sequenced using the Sanger technique.ResultsAmong 56 P. falciparum positive isolates, Pfama-1 was successfully amplified in 75% (n = 42) isolates. Allele frequencies of PfAMA-1 antigen were 16.6% (n = 7) for 3D7 allele and 33.3% (n = 14) in both K1 and HB3 alleles. DNA sequencing revealed 13 haplotypes in the Pfama-1 gene including three unique haplotypes not reported earlier. No unique amino-acid substitutions were found. Global analysis with 2761 sequences revealed 435 haplotypes with a very complex network composition and few clusters. Nucleotide diversity for Tripura (0.02582 ± 0.00160) showed concordance with South-East Asian isolates while recombination parameter (Rm = 8) was lower than previous reports from India. Population genetic structure showed moderate differentiation.ConclusionsBesides documenting all previously reported allelic forms of the vaccine candidate PfAMA-1 antigen of P. falciparum, new haplotypes not reported earlier, were found in Tripura. Neutrality tests indicate that the Pfama-1 population in Tripura is under balancing selection. This is consistent with global patterns. However, the high haplotype diversity observed in the global Pfama-1 network analysis indicates that designing a universal vaccine based on this antigen may be difficult. This information adds to the existing database of genetic diversity of field isolates of P. falciparum and may be helpful in the development of more effective vaccines against the parasite.

A qualitative study of patient experiences with telemedicine opioid use disorder treatment during COVID-19

Background: The drug-related overdose crisis worsened during the COVID-19 pandemic. Recent drug policy changes to increase access to medications for opioid use disorder (MOUD) during COVID-19 shifted some outpatient MOUD treatment into virtual settings to reduce the demand for in-person care. The objective of this study was to qualitatively explore what is gained and lost in virtual patient encounters for patients with opioid use disorder at a low-threshold, addiction treatment clinic that offers buprenorphine and harm reduction services. Methods: Patients were included in this study if they received care at the Harm Reduction and BRidges to Care (HRBR) clinic and utilized virtual visits between November 2019 and March 2021. The study was conceptualized using a health care access framework and prior studies of telemedicine acceptability. Semi-structured interviews were completed between March and April 2021. Interviews were dual-coded and analyzed using directed content analysis. Results: Nineteen interviews were conducted. The sample was predominantly White (84%) and stably housed (79%) with comparable gender (male, 53%) and employment status (employed, 42%). The majority (63%) of patients preferred virtual visits compared to in-person visits (16%) or a combination of access to both (21%). Two overarching tandem domains emerged: availability-accommodation and acceptability-appropriateness. Availability-accommodation reflected participants’ desires for immediate services and reduced transportation and work or caregiving scheduling barriers, which was facilitated by virtual visits. The acceptable-appropriate domain articulated how participants felt connected to their providers, whether through in-person interactions or the mutual trust experienced during virtual visits. Conclusions: Virtual visits were perceived by participants as a valuable and critical option for accessing treatment for OUD. While many participants preferred virtual visits, some favored face-to-face visits due to relational and physical interactions with providers. Participants desired flexibility and the ability to have a choice of treatment modality depending on their needs.

Prevalence and temporal changes of mutations linked to antimalarial drug resistance in Plasmodium falciparum and Plasmodium vivax in Palawan, Philippines

ObjectiveThis study provides 2016 data on the prevalence of key single nucleotide polymorphisms (SNPs) associated with antimalarial drug resistance in Palawan, Philippines. Findings were combined with historical data to model temporal changes in the prevalence of these SNPs in Plasmodium isolates. MethodsPlasmodium isolates were genotyped using drug resistance markers pfmdr1, pfcrt, pfdhfr, pfdhps, kelch-13, pvmdr1, pvdhfr, and pvdhps. Temporal trends in the probability of mutations were estimated as a function of time using a binomial generalised linear model. ResultsAll samples sequenced for Plasmodium falciparum chloroquine markers pfmdr1 and pfcrt had wild-type alleles. Varying mutation patterns were observed for the sulphadoxine/pyrimethamine markers pfdhps and pfdhfr; complete quintuplet mutations were not found. No SNPs were observed for the artemisinin marker kelch-13. For Plasmodium vivax, differing patterns were detected for pvmdr1, pvdhfr, and pvdhps. ConclusionsThe study findings suggest that the current drugs remain effective and that there is limited importation and establishment of resistant parasites in the area. Clear temporal trends were recognised, with prominent decreases in the proportions of pfcrt and pfmdr mutations detected within the past 15 years, consistent with a change in antimalarial drug policy. Continuous surveillance of antimalarial drug resistance is important to support malaria elimination efforts.

Coverage of medical cannabis by Canadian news media: Ethics, access, and policy.

The use of recreational cannabis by adults was legalized in Canada in 2018 (The Cannabis Act, 17 October 2018). This change in drug policy indirectly opened the doors to broader uses, including those for health-related conditions. As a first step towards understanding ethical, legal, and social shifts on this landscape, we examined messaging surrounding medical cannabis and health in Canadian news media before and after legalization. We retrieved news articles about medical cannabis and health from Canadian sources (2010-2020). Deductive and inductive content analytic approaches were applied to code eligible articles for both a priori ethical, legal, social, and issues, and emergent themes. Wilcoxon-Mann-Whitney U tests were used to test for thematic changes pre- and post-legalization. Two hundred and sixteen (216) articles met inclusion criteria. Analysis yielded three themes and eight subthemes, comprising 4931 coded references. The a priori theme of Ethical, Legal and Social Issues (access, benefits/risks of medical cannabis, public engagement, and conflicts of interest) dominated news media coverage across the decade (coded in 99% of articles). The emergent theme of Medical Applications (therapeutic use of cannabis, consumption considerations, comparisons to other drug and treatment options) was coded in 86% of articles; Resource Issues (research and education) in 50%. We found little discourse on ethics issues specific to exceptional populations. Coverage on aspects of access declined significantly post-legalization. Capturing the push of Canadian news coverage of medical cannabis is a powerful means of understanding how public opinions on the subject are shaped and then, by extension, inform public policy for well-being and healthcare. Continued examination of these issues, public consultation, engagement with diverse populations such as people with disabilities and neurologic and mental health conditions, and integration of diverse cultural views into the policy discourse are critical steps for future research and action.

Molecular surveillance of malaria scales up

Parasite and vector genetic data can guide malaria control, and technological advances are enabling more informative genetic data generation at unprecedented scales. Jacob et al. employ multiplexed amplicon sequencing to profile parasite genetic diversity from thousands of malaria samples, illuminating spatiotemporal patterns of drug resistance to inform regional drug policy change.

“We have to be uncomfortable and creative”: Reflections on the impacts of the COVID-19 pandemic on overdose prevention, harm reduction & homelessness advocacy in Philadelphia

The COVID-19 pandemic and ensuing service delivery interruptions had serious impacts on people who use drugs (PWUD) and people experiencing homelessness, including instability in the drug supply, decreased access to substance use disorder (SUD) treatment and harm reduction supplies, increased substance use and relapse due to stress and isolation, inability to properly isolate and quarantine without stable housing, and risk of COVID-19 spread in congregate living spaces. At the same time, many have noted a potential opportunity for rapid change in health, housing, and drug policy despite previous stagnation—referred to as a “punctuated equilibrium” by Baumgartner and Jones—in response to the pandemic. The pandemic forced some important policy interventions in the United States at both national and local levels, including eviction moratoriums and loosening of drug policy related to substance use treatment. However, to what extent some of these changes will be sustained past the current COVID-19 crisis is still unclear, as is how drug and housing related policy shifts have impacted the work of frontline overdose prevention, substance use treatment, and homelessness advocacy workers. In this qualitative study, we used semi-structured interviews to assess how Philadelphia’s harm reduction advocates, community organizers, and SUD treatment clinicians have responded to the overdose and homelessness crises during COVID-19, and how they predict the pandemic and ensuing policy changes will impact the future of overdose prevention, harm reduction efforts, and homelessness advocacy. We interviewed 30 eligible participants during July and August 2020. The analysis of these data yielded three themes: 1/“None of it should be new to anybody”: COVID-era issues impacting PWUD and people experiencing homelessness are extensions of existing problems; 2/“An opportunity to actually benefit in some way from this crisis”: Possibility for innovation and improved care for PWUD and people experiencing homelessness; and 3/“Nothing we’ve tried has worked, so we have to be uncomfortable and creative”: The uncertain path forward. Despite the many barriers that participants faced to promoting the health and well-being of marginalized communities during the pandemic, they also believed that the pandemic presented an important opportunity for positive policy change that has the potential to promote drug user health into the future, including a continuation of loosened federal restrictions on substance use disorder treatment, legalization of safe consumption spaces, safe supply of substances, and progressive, creative housing solutions.

“He was Drugged up on Something...” Portrayals of Drugs and Violence on Crime Scene Investigation (CSI) as System Justification

We conducted a content analysis of the first two and last two seasons of the popular crime drama Crime Scene Investigation ( CSI), to determine the extent to which depictions of the intersection of substance use and violence were consistent with research. Using the lens of system justification theory, we find that CSI focuses on aspects of crime that preserve the status quo, specifically it overemphasizes the negative impact of illicit substances as opposed to legal substances (such as alcohol), and it emphasizes the psychopharmacological role of drugs in violent crime compared to systemic violence related to the illegality of drug markets, even though research demonstrates that systemic violence makes up a large proportion of substance-related homicides. Despite significant changes in drug policy that occurred during the time that CSI was on the air, we find these portrayals are largely unchanged between episodes that were broadcast between 2000–2002 versus those that aired 2014–2015.

Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018

In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted. To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths. This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020. State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws. The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder. This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people). Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.