Background: The COVID-19 pandemic was associated with a shift among people who use drugs away from injecting opioids and toward other routes of administration. We examined if specific routes of heroin administration were associated with overdose risk. Methods: ALIVE is a cohort of adults from Baltimore, MD who have a history of injecting drugs. At twice-annual visits, participants self-reported past-six-month drug use and related information. At visits when participants reported heroin use, we estimated the association of self-reported route of heroin administration (injecting, smoking, nasal inhalation ["snorting"], injecting & smoking, injecting & nasal inhalation, smoking & nasal inhalation, all three) with non-fatal overdose using conditional logistic regression. Results: At visits when heroin was reported (1121 participants, 4396 study visits, 88% age 40-79, 33% female, 77% Black) using heroin by all three routes of administration was associated with higher overdose odds than using injecting only (aOR 2.37, 95% CI 1.25-4.47), nasal inhalation only (aOR 2.87, 95% CI 1.47-5.63), and injecting and smoking (aOR 4.22, 95% CI 1.01-17.68); injecting and nasal inhalation was associated with overdose as compared to nasal inhalation alone (aOR 1.78, 95% 1.12-2.83). Conclusion: We found no evidence any individual route of administration was associated with higher heroin overdose risk; instead, use of a single route tended to be associated with lower overdose odds than use of multiple routes. Harm reduction programs that provide sterilized tools for drug administration may empower people who use drugs to avoid overdose risk.
Background People who use drugs in rural communities face barriers to accessing services that reduce overdose and infectious disease risk. Community-based navigation may help bridge these gaps, but limited evidence exists to support its effectiveness in real-world rural settings. This study aimed to estimate the effect of two adapted prevention navigation interventions on substance use outcomes among people who use drugs from rural communities. Methods We conducted a pooled analysis of two pragmatic trials using harmonized measures, one cluster-randomized trial and one quasi-experimental trial. Participants were adults who use opioids and/or stimulants, recruited through syringe service programs, jails, or pretrial service agencies. The intervention was an adaptation of Project START, delivered by trained prevention navigators; the comparator was usual care, consisting of standard harm reduction and referral services. The primary outcome was change in past 30-day opioid use between baseline and three-month follow-up. Secondary outcomes included days of stimulant use and self-identified drug of choice. Regression models were adjusted for age, gender, and race/ethnicity. Results Among 289 individuals with complete outcome data, intervention participants reported a greater reduction in opioid use compared with controls (pooled mean difference: −2.98 days; 95% CI: −5.53, −0.42). Changes in stimulant use and use of drug of choice were not statistically significant but trended in the same direction. Conclusions An adapted community-based prevention navigation intervention delivered by trained navigators was associated with a modest but significant reduction in past 30-day opioid use among people who use drugs in rural communities, compared with usual care.
Background: Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation intervention investigated as a treatment for substance use disorder (SUD) and its co-occurring disorders. As the number of rTMS SUD clinical trials increase, the safety and tolerability profile should be assessed. In this systematic review, we investigate adverse events (AEs) of rTMS in individuals with SUD and factors that may influence their occurrence. Methods: We performed a systematic PubMed search to identify all controlled trials of rTMS in SUD published up to January 2025. Eligible studies were assessed, and safety information was extracted for analysis. Results: A total of 141 clinical trials with 4299 participants were included in their active arms. rTMS trials recruited participants who were engaged in active substance use, were in the pre-treatment phase, in early recovery, or in sustained recovery. Twenty-two studies explicitly reported no AEs. Sixty-nine studies reported only mild AEs, while only six studies reported moderate AEs. Thirty-five studies did not report safety-outcomes/AEs. As expected, participants reported mild and temporary AEs such as headaches, pain or discomfort under the coil, or dizziness. Only nine studies reported serious AEs (7 studies in active TMS and 2 in sham TMS). Importantly, no seizures attributable to active rTMS were reported in these SUD samples. Conclusion: Overall, rTMS in SUD samples is safe and well-tolerated regardless of recovery stage and substance. Most reported side effects were mild, self-limiting, and tolerable. However, AE reporting was incomplete, as 35 of 141 trials reported no safety data, limiting conclusions to reported outcomes. This evidence supports the safety of rTMS as a potential stand-alone or adjunctive treatment for SUD.
