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Background: Delay discounting (DD), the decrease in reward valuation as a function of delay to receipt, is a key process undergirding alcohol use. Narrative interventions, including episodic future thinking (EFT), have decreased delay discounting and demand for alcohol. Rate dependence, the relationship between a baseline rate and change in that rate after an intervention, has been evidenced as a marker of ef- ficacious substance use treatment, but whether narrative interventions have rate dependent effects needs to be better understood. We investigated the effects of narrative interventions on delay discounting and hypothetical demand for alcohol in this longitudinal, online study. Methods: Individuals (n = 696) reporting high-or low risk alcohol use were recruited for a longitudinal 3 week survey via Amazon Mechanical Turk. Delay discounting and alcohol demand breakpoint were assessed at baseline. Individuals returned at weeks 2 and 3 and were randomized into the EFT or scarcity narrative interventions and again completed the delay discounting tasks and alcohol breakpoint task. Oldham's correlation was used to explore the rate-dependent effects of narrative interventions. Study attrition as a function of delay discounting was assessed. Results: Episodic future thinking significantly decreased, while scarcity significantly increased delay discounting relative to baseline. No effects of EFT or scarcity on the alcohol demand breakpoint were observed. Significant rate-dependent effects were observed for both narrative intervention types. Higher delay discounting rates were associated with a greater likelihood of attrition from the study. Conclusion: The evidence of a rate-dependent effect of EFT on delay discounting rates offers a more nuanced, mechanistic understanding of this novel therapeutic intervention and can allow more precise treatment targeting by demonstrating who is likely to receive the most benefit from it. NIAAA [R01 AA027381]; Fralin Biomedical Research Institute at VTC Published version This work was supported by NIAAA R01 AA027381 and the Fralin Biomedical Research Institute at VTC. The funders had no role other than financial support.

Background and AimsOverdose deaths from synthetic opioids (e.g., fentanyl), increased 10-fold in the United States from 2013-2018, despite 88% of deaths occurring east of the Mississippi River. Public health professionals have long feared that further spread of fentanyl could greatly exacerbate the opioid epidemic. We aimed to measure and characterize recent fentanyl deaths in jurisdictions west of the Mississippi River.DesignSystematic search of states and counties in the Western U.S. for publicly available data on fentanyl-related deaths since the most recently published Centers for Disease Control and Prevention (CDC) statistics, which cover through December 2018. Longitudinal study using 2019 and 2020 mortality records to identify changes in fentanyl-involved mortality since most recent CDC statistics.SettingsU.S. states west of the Mississippi River.MeasurementsAnnual rate of fentanyl-involved deaths per 100,000 population. Proportion of fatal heroin-, stimulant, and prescription pill overdoses also involving fentanyl.FindingsWe identified nine jurisdictions with publicly available fentanyl death data through December 2019 or later - State of Arizona; Denver County, CO; Harris County, TX; Humboldt County, CA; King County, WA; Los Angeles County, CA; San Francisco County, CA; Siskiyou County, CA; Dallas-Fort Worth, TX metro area (Denton, Johnson, Parker, Tarrant counties. Fentanyl deaths increased in each jurisdiction. Their collective contribution to national synthetic narcotics mortality tripled from 2017 to 2019. First quarter 2020 data (available from all but San Francisco County) showed a 33% growth in fentanyl-mortality over 2019. Fentanyl-involvement in heroin, stimulant, and prescription pill deaths has grown substantially over time.ConclusionsFentanyl has spread westward, which could dramatically worsen the nation’s already severe opioid epidemic. Increasing standard-dose of naloxone, expanding Medicaid, improving coverage of addiction treatment, and public health educational campaigns should be prioritized.

Highlights • Fentanyl has meaningfully spread to U.S. illicit drug markets west of the Mississippi. • 2019 and 2020 mortality records were identified from seven jurisdictions. • Share of national synthetic narcotic mortality tripled from 2017 to 2019. • Fentanyl is increasingly involved in fatal stimulant, heroin, and pill overdoses., Background Overdose deaths from synthetic opioids (e.g., fentanyl) increased 10-fold in the United States from 2013 to 2018, despite such opioids being rare in illicit drug markets west of the Mississippi River. Public health professionals have feared a “fentanyl breakthrough” in western U.S. drug markets could further accelerate overdose mortality. We evaluated the number and nature of western U.S. fentanyl deaths using the most recent data available. Methods We systematically searched jurisdictions west of the Mississippi River for publicly available data on fentanyl-related deaths since 2018, the most recent Centers for Disease Control and Prevention (CDC) statistics. Using mortality data from 2019 and 2020, we identified changes in fentanyl-related mortality rate and proportion of fatal heroin-, stimulant, and prescription pill overdoses involving fentanyl. Results Seven jurisdictions had publicly available fentanyl death data through December 2019 or later: Arizona; California; Denver County, CO; Harris County, TX; King County, WA; Los Angeles County, CA; and Dallas-Fort Worth, TX (Denton, Johnson, Parker, and Tarrant counties). All reported increased fentanyl deaths over the study period. Their collective contribution to national synthetic narcotics mortality increased 371 % from 2017 to 2019. Available 2020 data shows a 63 % growth in fentanyl-mortality over 2019. Fentanyl-involvement in heroin, stimulant, and prescription pill deaths has substantially grown. Discussion Fentanyl has spread westward, increasing deaths in the short-term and threatening to dramatically worsen the nation’s already severe opioid epidemic in the long-term. Increasing the standard dose of naloxone, expanding Medicaid, improving coverage of addiction treatment, and public health educational campaigns should be prioritized.