Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009.

PubMed

Binswanger, Ingrid A; Blatchford, Patrick J; Mueller, Shane R; Stern, Marc F

2013-11-05

Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids. To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths. Cohort study. Prison system of the Washington State Department of Corrections. 76 208 persons released from prison. Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person's community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death. The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]). The study was done in only 1 state. Innovation is needed to reduce the risk for overdose among former prisoners. National Institute on Drug Abuse and the Robert Wood Johnson Foundation.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature.

PubMed

Martins, Silvia S; Sampson, Laura; Cerdá, Magdalena; Galea, Sandro

2015-11-01

Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.

PubMed

Park, Tae Woo; Saitz, Richard; Ganoczy, Dara; Ilgen, Mark A; Bohnert, Amy S B

2015-06-10

To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. Case-cohort study. Veterans Health Administration (VHA), 2004-09. US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics. Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion. © Park et al 2015.

Heroin and fentanyl overdoses in Kentucky: Epidemiology and surveillance.

PubMed

Slavova, Svetla; Costich, Julia F; Bunn, Terry L; Luu, Huong; Singleton, Michael; Hargrove, Sarah L; Triplett, Jeremy S; Quesinberry, Dana; Ralston, William; Ingram, Van

2017-08-01

The study aims to describe recent changes in Kentucky's drug overdose trends related to increased heroin and fentanyl involvement, and to discuss future directions for improved drug overdose surveillance. The study used multiple data sources (death certificates, postmortem toxicology results, emergency department [ED] records, law enforcement drug submissions, and prescription drug monitoring records) to describe temporal, geographic, and demographic changes in drug overdoses in Kentucky. Fentanyl- and heroin-related overdose death rates increased across all age groups from years 2011 to 2015 with the highest rates consistently among 25-34-year-olds. The majority of the heroin and fentanyl overdose decedents had histories of substantial exposures to legally acquired prescription opioids. Law enforcement drug submission data were strongly correlated with drug overdose ED and mortality data. The 2016 crude rate of heroin-related overdose ED visits was 104/100,000, a 68% increase from 2015 (62/100,000). More fentanyl-related overdose deaths were reported between October, 2015, and September, 2016, than ED visits, in striking contrast with the observed ratio of >10 to 1 heroin-related overdose ED visits to deaths. Many fatal fentanyl overdoses were associated with heroin adulterated with fentanyl; <40% of the heroin overdose ED discharge records listed procedure codes for drug screening. The lack of routine ED drug testing likely resulted in underreporting of non-fatal overdoses involving fentanyl and other synthetic drugs. In order to inform coordinated public health and safety responses, drug overdose surveillance must move from a reactive to a proactive mode, utilizing the infrastructure for electronic health records. Copyright © 2017 Elsevier B.V. All rights reserved.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature

PubMed Central

Sampson, Laura; Cerdá, Magdalena; Galea, Sandro

2015-01-01

Background. Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. Objectives. The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term “overdose” as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: “street drugs” and “overdose” yielded 180, “death” and “overdose” yielded 114, and “poisoning” and “drug users” yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. Results. We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. Conclusions. There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed. PMID:26451760

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

PubMed Central

Saitz, Richard; Ganoczy, Dara; Ilgen, Mark A; Bohnert, Amy S B

2015-01-01

Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. Design Case-cohort study. Setting Veterans Health Administration (VHA), 2004-09. Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics. Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion. PMID:26063215

Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-year Period

PubMed Central

Baggett, Travis P.; Hwang, Stephen W.; O'Connell, James J.; Porneala, Bianca C.; Stringfellow, Erin J.; Orav, E. John; Singer, Daniel E.; Rigotti, Nancy A.

2013-01-01

Background Homeless persons experience excess mortality, but U.S.-based studies on this topic are outdated or lack information about causes of death. No studies have examined shifts in causes of death for this population over time. Methods We assessed all-cause and cause-specific mortality rates in a cohort of 28,033 adults aged 18 years or older who were seen at Boston Health Care for the Homeless Program between January 1, 2003, and December 31, 2008. Deaths were identified through probabilistic linkage to the Massachusetts death occurrence files. We compared mortality rates in this cohort to rates in the 2003–08 Massachusetts population and a 1988–93 cohort of homeless adults in Boston using standardized rate ratios with 95% confidence intervals. Results 1,302 deaths occurred during 90,450 person-years of observation. Drug overdose (n=219), cancer (n=206), and heart disease (n=203) were the major causes of death. Drug overdose accounted for one-third of deaths among adults <45 years old. Opioids were implicated in 81% of overdose deaths. Mortality rates were higher among whites than non-whites. Compared to Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25–44 year olds and 4.5-fold higher in 45–64 year olds. In comparison to 1988–93, reductions in HIV deaths were offset by 3- and 2-fold increases in deaths due to drug overdose and psychoactive substance use disorders, resulting in no significant difference in overall mortality. Conclusions The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988–93 despite a major interim expansion in clinical services. Drug overdose has replaced HIV as the emerging epidemic. Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness. PMID:23318302

Prescription histories and dose strengths associated with overdose deaths.

PubMed

Hirsch, Anne; Proescholdbell, Scott K; Bronson, William; Dasgupta, Nabarun

2014-07-01

Misuse, abuse, and diversion of prescription drugs are large and growing public health problems that have resulted in an overdose epidemic. We investigated whether short-acting or extended-release opioids were more frequently prescribed to those who died of an overdose and whether there was a linear relationship between dose strength and associated overdose deaths. The study population was North Carolina residents in 2010. We conducted a retrospective, population-based, descriptive study of medication histories of overdose decedents using data from vital statistics, medical examiner records, and a prescription drug monitoring program. Unintentional or undetermined drug overdoses were responsible for 892 deaths. Out of 191 deaths involving methadone, only two were patients in opioid treatment programs. Immediate-release oxycodone was involved in the greatest number of opioid-related deaths. Out of 221 oxycodone deaths, 134 (61%) of the decedents filled a prescription for oxycodone in the 60 days prior to death. The most common strength dispensed within 60 days to a decedent who died of an oxycodone overdose was 10 mg for immediate-release (72 prescriptions). Immediate-release oxycodone products (rho = 1.00, P < 0.01) and extended-release fentanyl products (rho = 1.00, P < 0.01) showed strong increasing linear trends between dose strength and proportion of prescriptions dispensed to decedents. A significant proportion of overdose decedents had been prescribed the same type of drugs that contributed to their death, especially for decedents who died from overdoses involving oxycodone, hydrocodone, and alprazolam. Higher dose strengths for certain opioids had higher associated mortality, and certain immediate-release opioids may be considered for public health prevention efforts.

Heroin overdose deaths and heroin purity between 1990 and 2000 in Istanbul, Turkey*.

PubMed

Toprak, Sadik; Cetin, Ilhan

2009-09-01

Turkey has continuously experienced problems with abuse of, and addiction to, opium derivatives. In this study, we analyzed the relationship between heroin overdose deaths and the characteristics of seized opium derivatives. Data were gathered from the Council of Forensic Medicine of the Ministry of Justice in Istanbul from 1990 to 2000. There were 636 heroin-related deaths during this period, 595 of which were classified as heroin overdose deaths. Mean crude and weighted heroin purities remained relatively constant and were calculated to be 46% (57-34%) and 51% (39-59%), respectively. The weight of heroin and the number of heroin seizures, but not the heroin purity, were significantly associated with the number of heroin-related deaths. Prevention strategies are needed to reduce the number of deaths caused by overdoses in countries situated on drug trafficking routes. These strategies should focus on drug trafficking, by providing increased levels of, and support for, law enforcement, stopping the supply of precursor chemicals, and combating corruption among border officials.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas-United States.

PubMed

Mack, Karin A; Jones, Christopher M; Ballesteros, Michael F

2017-12-01

Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015. The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates. © 2017 The American Society of Transplantation and the American Society of Transplant Surgeons.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas — United States

PubMed Central

Jones, Christopher M.; Ballesteros, Michael F.

2017-01-01

Problem/Condition Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. Reporting Period Illicit drug use and drug use disorders during 2003–2014, and drug overdose deaths during 1999–2015. Description of Data The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers’ camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40–X44, X60–X64, X85, and Y10–Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC’s National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). Results Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003–2005 to 2012–2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12–17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003–2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). Interpretation Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012–2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. Public Health Actions Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC’s guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates. PMID:29049278

Strategies and policies to address the opioid epidemic: A case study of Ohio.

PubMed

Penm, Jonathan; MacKinnon, Neil J; Boone, Jill M; Ciaccia, Antonio; McNamee, Cameron; Winstanley, Erin L

To describe the strategies and policies implemented in Ohio to improve opioid safety and to discuss the role that pharmacists can play in implementing, promoting, and enhancing the effectiveness of these policies. Ohio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States. Unintentional drug overdose has become the leading cause of injury-related death in Ohio. In 2015, there were 3050 overdose deaths in Ohio, and in 2014 there were an estimated 12,847 overdose events reversed by emergency medical services with naloxone. Not applicable. In 2011, the Governor's Cabinet Opiate Action Team was created to implement a multifaceted strategy, in part (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. Innovations to assist these goals include the development of Ohio guidelines on the responsible use of opioids, mandatory use of Ohio's prescription drug monitoring program, closing pill mills, promotion of drug take-back programs and increased access to naloxone and public health campaigns. Not applicable. Since the development of the Governor's Cabinet Opiate Action Team, there were 81 million fewer doses of opioids dispensed to Ohio patients in 2015 compared with 782 million doses dispensed in 2011. As such, the proportion of unintentional drug overdose deaths involving prescription opioids has reduced from 45% in 2011 to 22% in 2015. Strong political support was crucial in Ohio to facilitate the rapid implementation opioid overdose prevention programs and the promotion of public awareness campaigns. However, the misuse and abuse of prescription opioids are complex problems requiring a comprehensive and multifaceted approach. Pharmacists are identified as a crucial component of the state strategy to addressing opioid abuse by promoting responsible prescribing and adopting prevention practices. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Opioid Deaths in Rural Virginia: A Description of the High Prevalence of Accidental Fatalities Involving Prescribed Medications

PubMed Central

Wunsch, Martha J.; Nakamoto, Kent; Behonick, George; Massello, William

2009-01-01

In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35–54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers. PMID:19219660

Prevalence of gabapentin in drug overdose postmortem toxicology testing results.

PubMed

Slavova, Svetla; Miller, Alison; Bunn, Terry L; White, Jessica R; Kirschke, David; Light, Tom; Christy, Daniel; Thompson, Gary; Winecker, Ruth

2018-05-01

The goal of this study was to establish and compare baseline data on the prevalence of gabapentin identified through postmortem toxicology testing among drug overdose decedents in several geographically diverse states/jurisdictions with differing levels of drug overdose fatality burdens in 2015. Death certificates and postmortem toxicology result reports from five U.S. jurisdictions were used to identify residents who died from drug overdoses in year 2015 and to calculate prevalence rates of gabapentin in postmortem toxicology by jurisdiction. On average, 22% of all drug overdose decedents in our study tested positive for gabapentin. The percentage of gabapentin-positive overdose deaths varied significantly among jurisdictions: 4% in Northeast Tennessee, 7% in Maricopa County, 15% in West Virginia, 20% in North Carolina, and 41% in Kentucky (p < 0.0001). Among the drug overdose decedents who tested positive for opioids (including heroin), 26% also tested positive for gabapentin, with significant variation among states/jurisdictions (p < 0.0001). There was a significant difference in the gender distribution among drug overdose decedents who tested positive for gabapentin (46% male) vs. those who tested negative for gabapentin (65% male) (p < 0.0001). In Kentucky, gabapentin was listed as a contributing drug on the death certificate in 40% of the overdose deaths with gabapentin-positive toxicology; in North Carolina this percentage was 57%. Routine gabapentin postmortem testing and linking of death certificate, medical examiner, coroner, toxicology, and prescription history data will provide more reliable information on the extent of gabapentin misuse, diversion, and implications for clinical care. Copyright © 2018 Elsevier B.V. All rights reserved.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas - United States.

PubMed

Mack, Karin A; Jones, Christopher M; Ballesteros, Michael F

2017-10-20

Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015. The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates.

Neighborhood-Level and Spatial Characteristics Associated with Lay Naloxone Reversal Events and Opioid Overdose Deaths.

PubMed

Rowe, Christopher; Santos, Glenn-Milo; Vittinghoff, Eric; Wheeler, Eliza; Davidson, Peter; Coffin, Philip O

2016-02-01

There were over 23,000 opioid overdose deaths in the USA in 2013, and opioid-related mortality is increasing. Increased access to naloxone, particularly through community-based lay naloxone distribution, is a widely supported strategy to reduce opioid overdose mortality; however, little is known about the ecological and spatial patterns of the distribution and utilization of lay naloxone. This study aims to investigate the neighborhood-level correlates and spatial relationships of lay naloxone distribution and utilization and opioid overdose deaths. We determined the locations of lay naloxone distribution sites and the number of unintentional opioid overdose deaths and reported reversal events in San Francisco census tracts (n = 195) from 2010 to 2012. We used Wilcoxon rank-sum tests to compare census tract characteristics across tracts adjacent and not adjacent to distribution sites and multivariable negative binomial regression models to assess the association between census tract characteristics, including distance to the nearest site, and counts of opioid overdose deaths and naloxone reversal events. Three hundred forty-two opioid overdose deaths and 316 overdose reversals with valid location data were included in our analysis. Census tracts including or adjacent to a distribution site had higher income inequality, lower percentage black or African American residents, more drug arrests, higher population density, more overdose deaths, and more reversal events (all p < 0.05). In multivariable analysis, greater distance to the nearest distribution site (up to a distance of 4000 m) was associated with a lower count of Naloxone reversals [incidence rate ratio (IRR) = 0.51 per 500 m increase, 95% CI 0.39-0.67, p < 0.001] but was not significantly associated with opioid overdose deaths. These findings affirm that locating lay naloxone distribution sites in areas with high levels of substance use and overdose risk facilitates reversals of opioid overdoses in those immediate areas but suggests that alternative delivery methods may be necessary to reach individuals in other areas with less concentrated risk.

Acetyl fentanyl overdose fatalities--Rhode Island, March-May 2013.

PubMed

2013-08-30

In May 2013, the Rhode Island State Health Laboratories noticed an unusual pattern of toxicology results among 10 overdose deaths of suspected illicit drug users that had occurred during March 7-April 11, 2013. An enzyme-linked immunosorbent assay (ELISA) for fentanyl in blood was positive for fentanyl in all 10 cases, but confirmatory gas chromatography/mass spectrometry (GC/MS) did not detect fentanyl. The mass spectrum was instead consistent with acetyl fentanyl, a fentanyl analog. Acetyl fentanyl, a synthetic opioid, has not been documented in illicit drug use or overdose deaths, and is not available as a prescription drug anywhere. Animal studies suggest that acetyl fentanyl is up to five times more potent than heroin as an analgesic.

Deaths Associated With Brotizolam Poisoning From a Single Drug Overdose: Four Reported Cases.

PubMed

Sakai, Kentaro; Saito, Kazuyuki; Takada, Aya; Hikiji, Wakako; Kikuchi, Yosuke; Fukunaga, Tatsushige

2018-03-01

Brotizolam is a short-acting hypnotic in the benzodiazepine family, and fatal poisonings by an overdose of brotizolam are rare. This report describes 4 cases of deaths associated with brotizolam poisoning from a single drug overdose. The ages ranged from 51 to 90 years, and the postmortem interval between death and tissue sampling was 1.5 to 2.5 days. These deaths were classified as 1 homicide and 3 suicides. The concentration of the brotizolam ranged from 0.05 to 0.21 mg/L in the blood samples. Ethanol, which could cause mild alcohol intoxication, was detected in the blood samples from 2 cases. Postmortem examinations did not find any significant pathologic conditions, except for a case of death by drowning in a bathtub due to brotizolam poisoning. These 4 cases suggest that a brotizolam overdose should not be underestimated in terms of its fatal effects, particularly when situations involve alcohol intoxication, injury subsequent to the poisoning, or underlying medical conditions including aging.

Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014.

PubMed

Wheeler, Eliza; Jones, T Stephen; Gilbert, Michael K; Davidson, Peter J

2015-06-19

Drug overdose deaths in the United States have more than doubled since 1999. During 2013, 43,982 drug overdose deaths (unintentional, intentional [suicide or homicide], or undetermined intent) were reported. Among these, 16,235 (37%) were associated with prescription opioid analgesics (e.g., oxycodone and hydrocodone) and 8,257 (19%) with heroin. For many years, community-based programs have offered opioid overdose prevention services to laypersons who might witness an overdose, including persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of programs provide laypersons with training and kits containing the opioid antagonist naloxone hydrochloride (naloxone) to reverse the potentially fatal respiratory depression caused by heroin and other opioids. In July 2014, the Harm Reduction Coalition (HRC), a national advocacy and capacity-building organization, surveyed 140 managers of organizations in the United States known to provide naloxone kits to laypersons. Managers at 136 organizations completed the survey, reporting on the amount of naloxone distributed, overdose reversals by bystanders, and other program data for 644 sites that were providing naloxone kits to laypersons as of June 2014. From 1996 through June 2014, surveyed organizations provided naloxone kits to 152,283 laypersons and received reports of 26,463 overdose reversals. Providing opioid overdose training and naloxone kits to laypersons who might witness an opioid overdose can help reduce opioid overdose mortality.

Report of Increasing Overdose Deaths that include Acetyl Fentanyl in Multiple Counties of the Southwestern Region of the Commonwealth of Pennsylvania in 2015-2016.

PubMed

Dwyer, Jessica B; Janssen, Jennifer; Luckasevic, Todd M; Williams, Karl E

2018-01-01

Acetyl fentanyl is a Schedule I controlled synthetic opioid that is becoming an increasingly detected "designer drug." Routine drug screening procedures in local forensic toxicology laboratories identified a total of 41 overdose deaths associated with acetyl fentanyl within multiple counties of the southwestern region of the state of Pennsylvania. The range, median, mean, and standard deviation of blood acetyl fentanyl concentrations for these 41 cases were 0.13-2100 ng/mL, 11 ng/mL, 169.3 ng/mL, and 405.3 ng/mL, respectively. Thirty-six individuals (88%) had a confirmed history of substance abuse, and all but one case (96%) were ruled multiple drug toxicities. This report characterizes this localized trend of overdose deaths associated with acetyl fentanyl and provides further evidence supporting an alarmingly concentrated opiate and opioid epidemic of both traditional and novel drugs within this region of the United States. © 2017 American Academy of Forensic Sciences.

Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review

PubMed Central

Brody, Jennifer K.; León, Casey; Baggett, Travis P.

2016-01-01

Drug overdose is a major cause of death among homeless people, but little is known about the characteristics of homeless overdose decedents. We conducted a retrospective record review of 219 adult patients of Boston Health Care for the Homeless Program (BHCHP) who died of drug overdose in 2003–2008. We assessed the substances implicated in overdose and the health and service use characteristics of decedents prior to death. Eighty-one percent of overdose deaths involved opioids and 40% involved multiple drugs. Problem substance use (85%), psychiatric illness (61%), and chronic pain (45%) were common, and 32% had documentation of all three. Half were well-connected to BHCHP, and 35% had a clinic visit within 90 days of death. The complex health histories and frequent health care contacts of homeless drug overdose decedents suggest that clinical facilities may be an important frontline venue for overdose education, naloxone distribution, and integrated substance use treatment programming. PMID:27180712

Community-based interventions to prevent fatal overdose from illegal drugs: a systematic review protocol.

PubMed

Okolie, Chukwudi; Evans, Bridie Angela; John, Ann; Moore, Chris; Russell, Daphne; Snooks, Helen

2015-11-03

Drug overdose is the most frequent cause of death among people who misuse illegal drugs. People who inject these drugs are 14-17 times more likely to die than their non-drug using peers. Various strategies to reduce drug-related deaths have failed to meet target reductions. Research into community-based interventions for preventing drug overdose deaths is promising. This review seeks to identify published studies describing community-based interventions and to evaluate their effectiveness at reducing drug overdose deaths. We will systematically search key electronic databases using a search strategy which groups terms into four facets: (1) Overdose event, (2) Drug classification, (3) Intervention and (4) Setting. Searches will be limited where possible to international literature published in English between 1998 and 2014. Data will be extracted by two independent reviewers using a predefined table adapted from the Cochrane Collaboration handbook. The quality of included studies will be evaluated using the Cochrane Collaboration's tool for assessing risk of bias. We will conduct a meta-analysis for variables which can be compared across studies, using statistical methods to control for heterogeneity where appropriate. Where clinical or statistical heterogeneity prevents a valid numerical synthesis, we will employ a narrative synthesis to describe community-based interventions, their delivery and use and how effectively they prevent fatal overdoses. We will publish findings from this systematic review in a peer-reviewed scientific journal and present results at national and international conferences. It will be disseminated electronically and in print. PROSPERO CRD42015017833. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Intranasal naloxone administration by police first responders is associated with decreased opioid overdose deaths.

PubMed

Rando, Jessica; Broering, Derek; Olson, James E; Marco, Catherine; Evans, Stephen B

2015-09-01

This study sought to answer the question, "Can police officers administer intranasal naloxone to drug overdose victims to decrease the opioid overdose death rate?" This prospective interventional study was conducted in Lorain County, OH, from January 2011 to October 2014. Starting October 2013, trained police officers administered naloxone to suspected opioid overdose victims through a police officer naloxone prescription program (NPP). Those found by the county coroner to be positive for opioids at the time of death and those who received naloxone from police officers were included in this study. The rate of change in the total number of opioid-related deaths in Lorain County per quarter year, before and after initiation of the NPP, and the trend in the survival rate of overdose victims who were given naloxone were analyzed by linear regression. Significance was established a priori at P < .05. Data from 247 individuals were eligible for study inclusion. Opioid overdose deaths increased significantly before initiation of the police officer NPP with average deaths per quarter of 5.5 for 2011, 15.3 for 2012, and 16.3 for the first 9 months of 2013. After initiation of the police officer NPP, the number of opioid overdose deaths decreased each quarter with an overall average of 13.4. Of the 67 participants who received naloxone by police officers, 52 (77.6%) survived, and 8 (11.9%) were lost to follow-up. Intranasal naloxone administration by police first responders is associated with decreased deaths in opioid overdose victims. Copyright © 2015 Elsevier Inc. All rights reserved.

Orienting patients to greater opioid safety: models of community pharmacy-based naloxone.

PubMed

Green, Traci C; Dauria, Emily F; Bratberg, Jeffrey; Davis, Corey S; Walley, Alexander Y

2015-08-06

The leading cause of adult injury death in the U.S.A. is drug overdose, the majority of which involves prescription opioid medications. Outside of the U.S.A., deaths by drug overdose are also on the rise, and overdose is a leading cause of death for drug users. Reducing overdose risk while maintaining access to prescription opioids when medically indicated requires careful consideration of how opioids are prescribed and dispensed, how patients use them, how they interact with other medications, and how they are safely stored. Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the U.S. and globally. Pharmacies provide a high-yield setting where patient and caregiver customers can access naloxone-an opioid antagonist that reverses opioid overdose-and overdose prevention counseling. This case study briefly describes and provides two US state-specific examples of innovative policy models of pharmacy-based naloxone, implemented to reduce overdose events and improve opioid safety: Collaborative Pharmacy Practice Agreements and Pharmacy Standing Orders.

Medical management of deliberate drug overdose: a neglected area for suicide prevention?

PubMed

Gunnell, D; Ho, D; Murray, V

2004-01-01

Overdoses account for a quarter of all suicides in England. The number of people who survive the immediate effects of their overdose long enough to reach medical attention, but who subsequently die in hospital is unknown. The aim of this study was to determine the proportion of overdose suicides dying in hospital and describe their sociodemographic characteristics. Cross sectional analysis of routinely collected Hospital Episode Statistics data for England (1997 to 1999) to identify hospital admissions for overdose among people aged 12+ and the outcome of these admissions. Between 1997 and 1999 there were 233 756 hospital admissions for overdose, 1149 (0.5%) of these ended in the death of the patient such deaths accounted for 28% [corrected] of all overdose suicides and 8% [corrected] of total suicides. The median time between admission and death was three days (interquartile range one to nine days). The most commonly identified drugs taken in fatal overdose were paracetamol compounds, benzodiazepines, and tricyclic/tetracyclic antidepressants. Around a quarter of all overdose suicide deaths occur subsequent to hospital admission. Further more detailed research is required to discover if better pre-admission and in-hospital medical management of those taking serious overdoses may prevent some of these deaths.

Understanding drug-related mortality in released prisoners: a review of national coronial records.

PubMed

Andrews, Jessica Y; Kinner, Stuart A

2012-04-04

The prisoner population is characterised by a high burden of disease and social disadvantage, and ex-prisoners are at increased risk of death following release. Much of the excess mortality can be attributed to an increased risk of unnatural death, particularly from drug overdose; however, relatively few studies have investigated the circumstances surrounding drug-related deaths among released prisoners. This study aimed to explore and compare the circumstances of death for those who died from accidental drug-related causes to those who died from all other reportable causes. A nationwide search of the Australian National Coroners Information System (NCIS) was conducted to identify reportable deaths among ex-prisoners from 2000 to 2007. Using a structured coding form, NCIS records for these cases were interrogated to explore causes and circumstances of death. Coronial records for 388 deceased ex-prisoners were identified. Almost half of these deaths were a result of accidental drug-related causes (45%). The majority of accidental drug-related deaths occurred in a home environment, and poly-substance use at or around the time of death was common, recorded in 72% of drug-related deaths. Ex-prisoners who died of accidental drug-related causes were on average younger and less likely to be Indigenous, born in Australia, married, or living alone at or around the time of death, compared with those who died from all other reportable causes. Evidence of mental illness or self-harm was less common among accidental drug-related deaths, whereas evidence of previous drug overdose, injecting drug use, history of heroin use and history of drug withdrawal in the previous six months were more common. Drug-related deaths are common among ex-prisoners and often occur in a home (vs. public) setting. They are often associated with use of multiple substances at or around the time of death, risky drug-use patterns, and even among this markedly disadvantaged group, extreme social disadvantage. These findings reflect the complex challenges facing prisoners upon release from custody and indicate a need to consider drug overdose within the wider framework of ex-prisoner experiences, so that preventive programmes can be appropriately structured and targeted.

Understanding the Opioid Epidemic

MedlinePlus

... Opioid Overdose Deaths Preventing Overdose Deaths Opioid Overdose Deaths From 1999-2016, more than 350,000 people ... counterfeit pills, and cocaine. 1,3 Preventing Overdose Deaths Combatting the Opioid Overdose Epidemic CDC is committed ...

Undocumented Immigration, Drug Problems, and Driving Under the Influence in the United States, 1990-2014.

PubMed

Light, Michael T; Miller, Ty; Kelly, Brian C

2017-09-01

To examine the influence of undocumented immigration in the United States on 4 different metrics of drug and alcohol problems: drug arrests, drug overdose fatalities, driving under the influence (DUI) arrests, and DUI deaths. We combined newly developed state-level estimates of the undocumented population between 1990 and 2014 from the Center for Migration Studies with arrest data from the Federal Bureau of Investigation Uniform Crime Reports and fatality information from the Fatality Analysis Reporting System and the Centers for Disease Control and Prevention Underlying Cause of Death database. We used fixed-effects regression models to examine the longitudinal association between increased undocumented immigration and drug problems and drunk driving. Increased undocumented immigration was significantly associated with reductions in drug arrests, drug overdose deaths, and DUI arrests, net of other factors. There was no significant relationship between increased undocumented immigration and DUI deaths. This study provides evidence that undocumented immigration has not increased the prevalence of drug or alcohol problems, but may be associated with reductions in these public health concerns.

Relationship of opioid prescription sales and overdoses, North Carolina.

PubMed

Modarai, F; Mack, K; Hicks, P; Benoit, S; Park, S; Jones, C; Proescholdbell, S; Ising, A; Paulozzi, L

2013-09-01

In the United States, fatal drug overdoses have tripled since 1991. This escalation in deaths is believed to be driven primarily by prescription opioid medications. This investigation compared trends and patterns in sales of opioids, opioid drug overdoses treated in emergency departments (EDs), and unintentional overdose deaths in North Carolina (NC). Our ecological study compared rates of opioid sales, opioid related ED overdoses, and unintentional drug overdose deaths in NC. Annual sales data, provided by the Drug Enforcement Administration, for select opioids were converted into morphine equivalents and aggregated by zip code. These opioid drug sales rates were trended from 1997 to 2010. In addition, opioid sales were correlated and compared to opioid related ED visits, which came from a Centers for Disease Control and Prevention syndromic surveillance system, and unintentional overdose deaths, which came from NC Vital Statistics, from 2008 to 2010. Finally, spatial cluster analysis was performed and rates were mapped by zip code in 2010. Opioid sales increased substantially from 1997 to 2010. From 2008 to 2010, the quarterly rates of opioid drug overdoses treated in EDs and opioid sales correlated (r=0.68, p=0.02). Specific regions of the state, particularly in the southern and western corners, had both high rates of prescription opioid sales and overdoses. Temporal trends in sales of prescription opioids correlate with trends in opioid related ED visits. The spatial correlation of opioid sales with ED visit rates shows that opioid sales data may be a timely way to identify high-risk communities in the absence of timely ED data. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Utility of Cardiac Troponin to Predict Drug Overdose Mortality

PubMed Central

Stimmel, Barry; Hoffman, Robert S.; Vlahov, David

2016-01-01

Drug overdose is now the leading cause of injury-related mortality in the USA, but the prognostic utility of cardiac biomarkers is unknown. We investigated whether serum cardiac troponin I (cTnI) was associated with overdose mortality. This prospective observational cohort studied adults with suspected acute drug overdose at two university hospital emergency departments (ED) over 3 years. The endpoint was in-hospital mortality, which was used to determine test characteristics of initial/peak cTnI. There were 437 overdoses analyzed, of whom there were 20 (4.6 %) deaths. Mean initial cTnI was significantly associated with mortality (1.2 vs. 0.06 ng/mL, p <0.001), and the ROC curve revealed excellent cTnI prediction of mortality (AUC 0.87, CI 0.76–0.98). Test characteristics for initial cTnI (90 % specificity, 99 % negative predictive value) were better than peak cTnI (88.2 % specificity, 99.2 % negative predictive value), and initial cTnI was normal in only one death out of the entire cohort (1/437, CI 0.1–1.4 %). Initial cTnI results were highly associated with drug overdose mortality. Future research should focus on high-risk overdose features to optimize strategies for utilization of cTnI as part of the routine ED evaluation for acute drug overdose. PMID:26541348

Prescription drug monitoring programs in the United States of America

PubMed Central

Félix, Sausan El Burai; Mack, Karin

2015-01-01

SYNOPSIS Since the late 1990s, the number of opioid analgesic overdose deaths has quadrupled in the United States of America (from 4 030 deaths in 1999 to 16 651 in 2010). The objectives of this article are to provide an overview of the problem of prescription drug overdose in the United States and to discuss actions that could help reduce the problem, with particular attention to the characteristics of prescription drug monitoring programs (PDMPs). These programs consist of state-level databases that monitor controlled substances. The information compiled in the databases is at the disposal of authorized persons (e.g., physicians, pharmacists, and other health-care providers) and may be used only for professional purposes. Suppliers can use such information to prevent interaction with other drugs or therapeutic duplication, or to identify drug-search behavior. Law enforcement agencies can use these programs to identify improper drug prescription or dispensing patterns, or drug diversion. PMID:25563153

Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved Overdose Deaths - 27 States, 2013-2014.

PubMed

Gladden, R Matthew; Martinez, Pedro; Seth, Puja

2016-08-26

In March and October 2015, the Drug Enforcement Administration (DEA) and CDC, respectively, issued nationwide alerts identifying illicitly manufactured fentanyl (IMF) as a threat to public health and safety (1,2). IMF is unlawfully produced fentanyl, obtained through illicit drug markets, includes fentanyl analogs, and is commonly mixed with or sold as heroin (1,3,4). Starting in 2013, the production and distribution of IMF increased to unprecedented levels, fueled by increases in the global supply, processing, and distribution of fentanyl and fentanyl-precursor chemicals by criminal organizations (3). Fentanyl is a synthetic opioid 50-100 times more potent than morphine (2).* Multiple states have reported increases in fentanyl-involved overdose (poisoning) deaths (fentanyl deaths) (2). This report examined the number of drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) and synthetic opioid-involved deaths other than methadone (synthetic opioid deaths), which include fentanyl deaths and deaths involving other synthetic opioids (e.g., tramadol). Fentanyl deaths are not reported separately in national data. Analyses also were conducted on data from 27 states(†) with consistent death certificate reporting of the drugs involved in overdoses. Nationally, the number of fentanyl submissions and synthetic opioid deaths increased by 426% and 79%, respectively, during 2013-2014; among the 27 analyzed states, fentanyl submission increases were strongly correlated with increases in synthetic opioid deaths. Changes in fentanyl submissions and synthetic opioid deaths were not correlated with changes in fentanyl prescribing rates, and increases in fentanyl submissions and synthetic opioid deaths were primarily concentrated in eight states (high-burden states). Reports from six of the eight high-burden states indicated that fentanyl-involved overdose deaths were primarily driving increases in synthetic opioid deaths. Increases in synthetic opioid deaths among high-burden states disproportionately involved persons aged 15-44 years and males, a pattern consistent with previously documented IMF-involved deaths (5). These findings, combined with the approximate doubling in fentanyl submissions during 2014-2015 (from 5,343 to 13,882) (6), underscore the urgent need for a collaborative public health and law enforcement response.

Magnitude and Trends in Heavy Episodic Drinking, Alcohol-Impaired Driving, and Alcohol-Related Mortality and Overdose Hospitalizations Among Emerging Adults of College Ages 18-24 in the United States, 1998-2014.

PubMed

Hingson, Ralph; Zha, Wenxing; Smyth, Daniel

2017-07-01

This article estimates percentages of U.S. emerging adults ages 18-24 engaging in past-month heavy episodic drinking and past-year alcohol-impaired driving, and numbers experiencing alcohol-related unintentional injury deaths and overdose hospitalizations between 1998 and 2014. We analyzed national injury mortality data from coroner, census, and college enrollment statistics, the National Survey on Drug Use and Health, and the Nationwide Inpatient Sample. From 1999 to 2005, percentages of emerging adults ages 18-24 reporting past-month heavy episodic drinking rose from 37.1% to 43.1% and then declined to 38.8% in 2014. Alcohol-impaired driving rose from 24% to 25.5% and then declined to 16.0%. Alcohol-related unintentional injury deaths increased from 4,807 in 1998 to 5,531 in 2005 and then declined to 4,105 in 2014, a reduction of 29% per 100,000 since 1998. Alcohol-related traffic deaths increased from 3,783 in 1998 to 4,114 in 2005 and then declined to 2,614 in 2014, down 43% per 100,000 since 1998. Alcohol-related overdose deaths increased from 207 in 1998 to 891 in 2014, a 254% increase per 100,000. Other types of nontraffic unintentional injury deaths declined. Alcohol-overdose hospitalizations rose 26% per 100,000 from 1998 to 2014, especially from increases in alcohol/other drug overdoses, up 61% (alcohol/opioid overdoses up 197%). Among emerging adults, a trend toward increased alcohol-related unintentional injury deaths, heavy episodic drinking, and alcohol-impaired driving between 1998 and 2005 was reversed by 2014. Persistent high levels of heavy episodic drinking and related problems among emerging adults underscore a need to expand individually oriented interventions, college/community collaborative programs, and evidence-supported policies to reduce their drinking and related problems.

Opiate users' knowledge about overdose prevention and naloxone in New York City: a focus group study

PubMed Central

Worthington, Nancy; Markham Piper, Tinka; Galea, Sandro; Rosenthal, David

2006-01-01

Background Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions. Methods In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program. Results Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use. Conclusion Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability. PMID:16822302

Fentanyl and Other Synthetic Opioids Drug Overdose Deaths

MedlinePlus

... Medicines Prescription Medicines Steroids (Anabolic) Synthetic Cannabinoids (K2/Spice) Synthetic Cathinones (Bath Salts) Tobacco/Nicotine and E- ... the Future 2017 Survey Results Synthetic Cannabinoids (K2/Spice) Unpredictable Danger Drug and Alcohol Use in College- ...

Overdose Deaths Related to Fentanyl and Its Analogs - Ohio, January-February 2017.

PubMed

Daniulaityte, Raminta; Juhascik, Matthew P; Strayer, Kraig E; Sizemore, Ioana E; Harshbarger, Kent E; Antonides, Heather M; Carlson, Robert R

2017-09-01

Ohio is experiencing unprecedented loss of life caused by unintentional drug overdoses (1), with illicitly manufactured fentanyl (IMF) emerging as a significant threat to public health (2,3). IMF is structurally similar to pharmaceutical fentanyl, but is produced in clandestine laboratories and includes fentanyl analogs that display wide variability in potency (2); variations in chemical composition of these drugs make detection more difficult. During 2010-2015, unintentional drug overdose deaths in Ohio increased 98%, from 1,544 to 3,050.* In Montgomery County (county seat: Dayton), one of the epicenters of the opioid epidemic in the state, unintentional drug overdose deaths increased 40% in 1 year, from 249 in 2015 to 349 in 2016 (estimated unadjusted mortality rate = 57.7 per 100,000) (4). IMFs have not been part of routine toxicology testing at the coroner's offices and other types of medical and criminal justice settings across the country (2,3). Thus, data on IMF test results in the current outbreak have been limited. The Wright State University and the Montgomery County Coroner's Office/Miami Valley Regional Crime Laboratory (MCCO/MVRCL) collaborated on a National Institutes of Health study of fentanyl analogs and metabolites and other drugs identified in 281 unintentional overdose fatalities in 24 Ohio counties during January-February 2017. Approximately 90% of all decedents tested positive for fentanyl, 48% for acryl fentanyl, 31% for furanyl fentanyl, and 8% for carfentanil. Pharmaceutical opioids were identified in 23% of cases, and heroin in 6%, with higher proportions of heroin-related deaths in Appalachian counties. The majority of decedents tested positive for more than one type of fentanyl. Evidence suggests the growing role of IMFs, and the declining presence of heroin and pharmaceutical opioids in unintentional overdose fatalities, compared with 2014-2016 data from Ohio and other states (3-5). There is a need to include testing for IMFs as part of standard toxicology panels for biological specimens used in the medical, substance abuse treatment, and criminal justice settings.

Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995–2009

PubMed Central

Gryczynski, Jan; O’Grady, Kevin E.; Sharfstein, Joshua M.; Warren, Gregory; Olsen, Yngvild; Mitchell, Shannon G.; Jaffe, Jerome H.

2013-01-01

Objectives. We examined the association between the expansion of methadone and buprenorphine treatment and the prevalence of heroin overdose deaths in Baltimore, Maryland from 1995 to 2009. Methods. We conducted a longitudinal time series analysis of archival data using linear regression with the Newey–West method to correct SEs for heteroscedasticity and autocorrelation, adjusting for average heroin purity. Results. Overdose deaths attributed to heroin ranged from a high of 312 in 1999 to a low of 106 in 2008. While mean heroin purity rose sharply (1995–1999), the increasing number of patients treated with methadone was not associated with a change in the number of overdose deaths, but starting in 2000 expansion of opioid agonist treatment was associated with a decline in overdose deaths. Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002). Conclusions. Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths. Implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths. PMID:23488511

Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997-2007.

PubMed

Green, Traci C; Grau, Lauretta E; Carver, H Wayne; Kinzly, Mark; Heimer, Robert

2011-06-01

The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths ("overdoses") in CT over an 11-year period. We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type. Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities. The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Characteristics of Fentanyl Overdose - Massachusetts, 2014-2016.

PubMed

Somerville, Nicholas J; O'Donnell, Julie; Gladden, R Matthew; Zibbell, Jon E; Green, Traci C; Younkin, Morgan; Ruiz, Sarah; Babakhanlou-Chase, Hermik; Chan, Miranda; Callis, Barry P; Kuramoto-Crawford, Janet; Nields, Henry M; Walley, Alexander Y

2017-04-14

Opioid overdose deaths in Massachusetts increased 150% from 2012 to 2015 (1). The proportion of opioid overdose deaths in the state involving fentanyl, a synthetic, short-acting opioid with 50-100 times the potency of morphine, increased from 32% during 2013-2014 to 74% in the first half of 2016 (1-3). In April 2015, the Drug Enforcement Agency (DEA) and CDC reported an increase in law enforcement fentanyl seizures in Massachusetts, much of which was believed to be illicitly manufactured fentanyl (IMF) (4). To guide overdose prevention and response activities, in April 2016, the Massachusetts Department of Public Health and the Office of the Chief Medical Examiner collaborated with CDC to investigate the characteristics of fentanyl overdose in three Massachusetts counties with high opioid overdose death rates. In these counties, medical examiner charts of opioid overdose decedents who died during October 1, 2014-March 31, 2015 were reviewed, and during April 2016, interviews were conducted with persons who used illicit opioids and witnessed or experienced an opioid overdose. Approximately two thirds of opioid overdose decedents tested positive for fentanyl on postmortem toxicology. Evidence for rapid progression of fentanyl overdose was common among both fatal and nonfatal overdoses. A majority of interview respondents reported successfully using multiple doses of naloxone, the antidote to opioid overdose, to reverse suspected fentanyl overdoses. Expanding and enhancing existing opioid overdose education and prevention programs to include fentanyl-specific messaging and practices could help public health authorities mitigate adverse effects associated with overdoses, especially in communities affected by IMF.

Heroin overdose.

PubMed

Darke, Shane

2016-11-01

This narrative review aims to provide a brief history of the development of the heroin overdose field by discussing a selection of major 'classics' from the latter part of the 20th century. Papers considered landmarks were selected from 1972, 1977, 1983, 1984 and 1999. Findings of earlier works suggest much of what later research was to demonstrate. These include arguing that overdoses occurred primarily among tolerant older users, that most 'overdose' deaths involved low morphine concentrations, that most overdoses involve polypharmacy, that drug purity has only a moderate influence on overdose rates and that instant death following heroin administration is rare. Landmark studies of heroin overdose from the 1970s, 1980s and 1990s laid the foundations for subsequent overdose research, mainly by identifying the major demographic characteristics of overdose cases, risk factors, survival times and behaviours at overdose events. © 2016 Society for the Study of Addiction.

Opioid overdose mortality in Kansas, 2001-2011: toxicologic evaluation of intent.

PubMed

Okic, Merisa; Cnossen, Leslie; Crifasi, Joseph A; Long, Christopher; Mitchell, Erik K

2013-01-01

Drug concentration is a factor in the determination of the manner of death, but considerable overlap exists between therapeutic and toxic concentrations. This study aims to quantify opioid mortality in Kansas from use of fentanyl, methadone and oxycodone and to evaluate utility of drug concentrations for the determination of the manner of death. Cases referred to a forensic pathology practice in Kansas for autopsy from 1 January 2001 to 31 December 2011 were considered. The criterion for inclusion was detection of fentanyl, methadone and/or oxycodone in postmortem toxicology. Of 9,789 cases, 3,315 had positive toxicology: 180 of fentanyl, 299 of methadone and 310 of oxycodone. There were 207 single opioid fatalities, 264 polydrug overdoses and 318 deaths where an opioid was present but not contributory to the mechanism of death. In line with published studies, incidence of opioid overdose deaths increased over the time of the study. Drug concentrations within each cause and manner of death covered broad ranges. Non-natural and natural manners had less overlap than existed within non-natural manners in limited comparisons. This study shows that drug concentration is independent of manner for non-natural deaths and although insufficient to identify intent, can provide a guideline in differentiating non-natural from natural deaths.

Trends in heroin and pharmaceutical opioid overdose deaths in Australia.

PubMed

Roxburgh, Amanda; Hall, Wayne D; Dobbins, Timothy; Gisev, Natasa; Burns, Lucinda; Pearson, Sallie; Degenhardt, Louisa

2017-10-01

There has been international concern over the rise in fatal pharmaceutical opioid overdose rates, driven by increased opioid analgesic prescribing. The current study aimed to examine trends in opioid overdose deaths by: 1) opioid type (heroin and pharmaceutical opioids); and 2) age, gender, and intent of the death assigned by the coroner. Analysis of data from the National Coronial Information System (NCIS) of opioid overdose deaths occurring between 2001 and 2012. Deaths occurred predominantly (98%) among Australians aged 15-74 years. Approximately two-thirds of the decedents (68%) were male. The heroin overdose death rate remains unchanged over the period; these were more likely to occur among males. Pharmaceutical opioid overdose deaths increased during the study period (from 21.9 per million population in 2001-36.2), and in 2012 they occurred at 2.5 times the incident rate of heroin overdose deaths. Increases in pharmaceutical opioid deaths were largely driven by accidental overdoses. They were more likely to occur among males than females, and highest among Australians aged 45-54 years. Rates of fentanyl deaths in particular showed an increase over the study period (from a very small number at the beginning of the period) but in 2012 rates of morphine deaths were higher than those for oxycodone, fentanyl and tramadol. Given the increase in rates of pharmaceutical opioid overdose deaths, it is imperative to implement strategies to reduce pharmaceutical opioid-related mortality, including more restrictive prescribing practices and increasing access to treatment for opioid dependence. Copyright © 2017 Elsevier B.V. All rights reserved.

Housing and overdose: an opportunity for the scale-up of overdose prevention interventions?

PubMed

Bardwell, Geoff; Collins, Alexandra B; McNeil, Ryan; Boyd, Jade

2017-12-06

North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings. There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also "supervised" spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated. Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.

Mortality among young injection drug users in San Francisco: a 10-year follow-up of the UFO study.

PubMed

Evans, Jennifer L; Tsui, Judith I; Hahn, Judith A; Davidson, Peter J; Lum, Paula J; Page, Kimberly

2012-02-15

This study examined associations between mortality and demographic and risk characteristics among young injection drug users in San Francisco, California, and compared the mortality rate with that of the population. A total of 644 young (<30 years) injection drug users completed a baseline interview and were enrolled in a prospective cohort study, known as the UFO ("U Find Out") Study, from November 1997 to December 2007. Using the National Death Index, the authors identified 38 deaths over 4,167 person-years of follow-up, yielding a mortality rate of 9.1 (95% confidence interval: 6.6, 12.5) per 1,000 person-years. This mortality rate was 10 times that of the general population. The leading causes of death were overdose (57.9%), self-inflicted injury (13.2%), trauma/accidents (10.5%), and injection drug user-related medical conditions (13.1%). Mortality incidence was significantly higher among those who reported injecting heroin most days in the past month (adjusted hazard ratio = 5.8, 95% confidence interval: 1.4, 24.3). The leading cause of death in this group was overdose, and primary use of heroin was the only significant risk factor for death observed in the study. These findings highlight the continued need for public health interventions that address the risk of overdose in this population in order to reduce premature deaths.

Trends and characteristics of heroin overdoses in Wisconsin, 2003-2012.

PubMed

Meiman, Jon; Tomasallo, Carrie; Paulozzi, Leonard

2015-07-01

Heroin abuse has increased substantially during the past decade in the United States. This study describes trends and demographic shifts of heroin overdoses and heroin-related fatalities in Wisconsin and contrasts these with prescription opioid overdoses. This study was cross-sectional using databases of emergency department (ED) visits, hospital admissions, and death certificates in Wisconsin, United States, during 2003-2012. Cases were Wisconsin residents treated for heroin or prescription opioid overdose, and residents who died of heroin-related drug poisoning. Primary measurements were rates over time and by geographic region, and rates and rate ratios for selected demographic characteristics. During 2003-2012, age-adjusted rates of heroin overdoses treated in EDs increased from 1.0 to 7.9/100,000 persons; hospitalized heroin overdoses increased from 0.7 to 3.5/100,000. Whites accounted for 68% of hospitalized heroin overdoses during 2003-2007 but 80% during 2008-2012. Heroin-related deaths were predominantly among urban residents; however, rural fatalities accounted for zero deaths in 2003 but 31 (17%) deaths in 2012. Among patients aged 18-34 years, those hospitalized with heroin overdose were more often men (73.0% versus 54.9%), uninsured (44.2% versus 29.9%), and urban (84.3% versus 73.2%) than those with prescription opioid overdose. Rates of ED visits for heroin overdose in this age group exceeded rates for prescription opioid overdose in 2012 (26.1/100,000 versus 12.6/100,000 persons, respectively). An epidemic of heroin abuse is characterized by demographic shifts toward whites and rural residents. Rates of heroin overdose in younger persons now exceed rates of prescription opioid overdose. Published by Elsevier Ireland Ltd.

Increase in Drug Overdose Deaths Involving Fentanyl-Rhode Island, January 2012-March 2014.

PubMed

Mercado, Melissa C; Sumner, Steven A; Spelke, M Bridget; Bohm, Michele K; Sugerman, David E; Stanley, Christina

2018-03-01

This study identified sociodemographic, substance use, and multiple opioid prescriber and dispenser risk factors among drug overdose decedents in Rhode Island, in response to an increase in overdose deaths (ODs) involving fentanyl. This cross-sectional investigation comprised all ODs reviewed by Rhode Island's Office of the State Medical Examiners (OSME) during January 2012 to March 2014. Data for 536 decedents were abstracted from OSME's charts, death certificates, toxicology reports, and Prescription Monitoring Program (PMP) databases. Decedents whose cause of death involved illicit fentanyl (N = 69) were compared with decedents whose causes of death did not involve fentanyl (other drug decedents; N = 467). Illicit-fentanyl decedents were younger than other drug decedents (P = 0.005). While more other-drug decedents than illicit fentanyl decedents had postmortem toxicological evidence of consuming heroin (31.9% vs 19.8%, P < 0.001) and various pharmaceutical substances (P = 0.002-0.027), third party reports indicated more recent heroin use among illicit fentanyl decedents (62.3% vs 45.6%, P = 0.002). Approximately 35% of decedents filled an opioid prescription within 90 days of death; of these, one-third had a mean daily dosage greater than 100 morphine milligram equivalents (MME/day). Most decedents' opioid prescriptions were filled at one to two dispensers (83.9%) and written by one to two prescribers (75.8%). Notably, 29.2% of illicit fentanyl and 10.5% of other drug decedents filled prescriptions for buprenorphine, which is used to treat opioid use disorders. Illicit-fentanyl deaths frequently involved other illicit drugs (e.g., cocaine, heroin). The proportion of all decedents acquiring greater than 100 MME/day prescription dosages written and/or filled by few prescribers and dispensers is concerning. To protect patients, prescribers and dispensers should review PMP records and substance abuse history prior to providing opioids.

Mortality Among Young Injection Drug Users in San Francisco: A 10-Year Follow-up of the UFO Study

PubMed Central

Evans, Jennifer L.; Tsui, Judith I.; Hahn, Judith A.; Davidson, Peter J.; Lum, Paula J.; Page, Kimberly

2012-01-01

This study examined associations between mortality and demographic and risk characteristics among young injection drug users in San Francisco, California, and compared the mortality rate with that of the population. A total of 644 young (<30 years) injection drug users completed a baseline interview and were enrolled in a prospective cohort study, known as the UFO (“U Find Out”) Study, from November 1997 to December 2007. Using the National Death Index, the authors identified 38 deaths over 4,167 person-years of follow-up, yielding a mortality rate of 9.1 (95% confidence interval: 6.6, 12.5) per 1,000 person-years. This mortality rate was 10 times that of the general population. The leading causes of death were overdose (57.9%), self-inflicted injury (13.2%), trauma/accidents (10.5%), and injection drug user-related medical conditions (13.1%). Mortality incidence was significantly higher among those who reported injecting heroin most days in the past month (adjusted hazard ratio = 5.8, 95% confidence interval: 1.4, 24.3). The leading cause of death in this group was overdose, and primary use of heroin was the only significant risk factor for death observed in the study. These findings highlight the continued need for public health interventions that address the risk of overdose in this population in order to reduce premature deaths. PMID:22227793

Using Poison Center Exposure Calls to Predict Methadone Poisoning Deaths

PubMed Central

Dasgupta, Nabarun; Davis, Jonathan; Jonsson Funk, Michele; Dart, Richard

2012-01-01

Purpose There are more drug overdose deaths in the Untied States than motor vehicle fatalities. Yet the US vital statistics reporting system is of limited value because the data are delayed by four years. Poison centers report data within an hour of the event, but previous studies suggested a small proportion of poisoning deaths are reported to poison centers (PC). In an era of improved electronic surveillance capabilities, exposure calls to PCs may be an alternate indicator of trends in overdose mortality. Methods We used PC call counts for methadone that were reported to the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System in 2006 and 2007. US death certificate data were used to identify deaths due to methadone. Linear regression was used to quantify the relationship of deaths and poison center calls. Results Compared to decedents, poison center callers tended to be younger, more often female, at home and less likely to require medical attention. A strong association was found with PC calls and methadone mortality (b = 0.88, se = 0.42, t = 9.5, df = 1, p<0.0001, R2 = 0.77). These findings were robust to large changes in a sensitivity analysis assessing the impact of underreporting of methadone overdose deaths. Conclusions Our results suggest that calls to poison centers for methadone are correlated with poisoning mortality as identified on death certificates. Calls received by poison centers may be used for timely surveillance of mortality due to methadone. In the midst of the prescription opioid overdose epidemic, electronic surveillance tools that report in real-time are powerful public health tools. PMID:22829925

"There's nothing here": Deindustrialization as risk environment for overdose.

PubMed

McLean, Katherine

2016-03-01

Applying the "risk environment" approach proposed by Rhodes (2002, 2009), this study considers the diverse contextual factors contributing to drug overdose in a deindustrialized region of the United States. The Monongahela Valley of Pennsylvania, once a global center of steel production, has suffered a mass exodus of jobs, residents, and businesses since a national manufacturing crisis erupted in the early 1980s; more recently, it has seen a dramatic uptick in accidental drug poisoning deaths. Where recent local and national media attention to overdose has focused on suburban areas and middle class victims, this study concentrates instead on the deteriorating mill city of McKeesport, Pennsylvania. Eighteen clients of the city's sole drug treatment facility participated in in-depth interviews concerning their direct experience with accidental overdose. Specifically, participants were asked to describe their own most recent overdose event and/or the last overdose they had personally witnessed. They were also asked to speculate upon the roots of the local overdose epidemic, while venturing possible remedies. In relating their overdose experiences, participants characterized a micro-level risk environment that was hidden behind closed doors, and populated by unprepared, ambivalent overdose "assistants." Tasked with explaining a geographic concentration of overdose in and around McKeesport, interviewees referenced the hopelessness of the area and its lack of opportunity as driving the use of heroin, with many explicitly suggesting the need for jobs and community reinvestment to reduce fatalities. While state and county efforts to ameliorate overdose mortality have focused upon creating an open market in naloxone, this study suggests the need for interventions that address the poverty and social isolation of opiate users in the post-industrial periphery. Copyright © 2016 Elsevier B.V. All rights reserved.

Increases in Fentanyl-Related Overdose Deaths - Florida and Ohio, 2013-2015.

PubMed

Peterson, Alexis B; Gladden, R Matthew; Delcher, Chris; Spies, Erica; Garcia-Williams, Amanda; Wang, Yanning; Halpin, John; Zibbell, Jon; McCarty, Carolyn Lullo; DeFiore-Hyrmer, Jolene; DiOrio, Mary; Goldberger, Bruce A

2016-08-26

In March and October 2015, the Drug Enforcement Administration (DEA) and CDC issued nationwide alerts identifying fentanyl, particularly illicitly manufactured fentanyl (IMF), as a threat to public health and safety (1,2). IMF is pharmacologically similar to pharmaceutical fentanyl (PF), but is unlawfully produced in clandestine laboratories, obtained via illicit drug markets, and includes fentanyl analogs. Fentanyl is a synthetic opioid 50-100 times more potent than morphine and approved for the management of surgical/postoperative pain, severe chronic pain, and breakthrough cancer pain.* DEA's National Forensic Laboratory Information System (NFLIS) collects drug identification results from drug cases analyzed by federal, state, and local forensic laboratories throughout the United States.(†) In 2014, 80% of fentanyl submissions (i.e., drug products obtained by law enforcement that tested positive for fentanyl) in NFLIS were identified from 10 states, including Florida and Ohio (2), and seven of these 10 states reported sharp increases in fentanyl-related overdose deaths (fentanyl deaths) (3). This report presents findings of increased fentanyl deaths during 2013-2015 from investigations conducted by the University of Florida and the Ohio Department of Public Health, in collaboration with CDC. Analyses examined the association between trends in fentanyl-related law enforcement submissions and fentanyl deaths and describes groups at risk for fentanyl death using medical examiner and coroner reports. The marked increases in fentanyl death in Florida and Ohio during 2013-2015 were closely associated with parallel increases in fentanyl submissions, with the largest impact on persons who use heroin, consistent with reports that IMF is commonly mixed with or sold as heroin (1,4). In Ohio, circumstances associated with fentanyl deaths included a current diagnosed mental health disorder(§) and recent release from an institution such as a jail, rehabilitation facility, or hospital.

Community-based opioid overdose prevention programs providing naloxone - United States, 2010.

PubMed

2012-02-17

Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved . Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids. Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) . In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern.

Clinical risk factors for death after release from prison in Washington State: A nested case control study

PubMed Central

Binswanger, Ingrid A.; Stern, Marc F.; Yamashita, Traci E.; Mueller, Shane R.; Baggett, Travis P.; Blatchford, Patrick J.

2015-01-01

Background and aims While mortality rates after prison release are high, little is known about clinical risk factors for death. We sought to identify risk and protective factors for all-cause and accidental poisoning (overdose) death. Design Nested case control study of people released from prison. Setting Washington State Department of Corrections, Washington, USA. Participants Cases (699 all-cause deaths, of which 88 were among women, and 206 additional overdose deaths, of which 76 were among women) between 1999 and 2009 matched 1:1 to controls on sex, age and year of release using risk set sampling. Measurements Prison medical charts were abstracted for clinical information. Independent associations between clinical characteristics and all-cause and overdose mortality were assessed using conditional logistic regression. Findings Key independent risk factors for all-cause mortality included homelessness (Odds Ratio [OR] 1.53, 95% Confidence Interval [CI] 1.06, 2.23), injection drug use (OR 1.54, 95% CI 1.15, 2.05), tobacco use (OR 1.50, 95% CI 1.06, 2.12), cirrhosis (OR 4.42, 95% CI 1.63, 11.98), and psychiatric medications before release (OR 2.37, 95% CI 1.71, 3.29). Independent risk factors for overdose mortality included substance dependence (OR 2.33, 95% CI 1.32, 4.11), injection drug use (OR 2.43, 95% CI 1.53, 3.86), panic disorder (OR 3.87, 95% CI 1.62, 9.21), psychiatric prescriptions before release (OR 2.44, 95% CI 1.55, 3.85), and problems with opiates/sedatives (OR 2.81, 95% CI 1.40, 5.63). Substance use disorder treatment during the index incarceration was protective for all-cause (OR 0.67, 95% CI 0.49, 0.91) and overdose (OR 0.57, 95% CI 0.35, 0.90) mortality. Conclusions Injection drug use and substance use disorders are risk factors for death after release from prison. In-prison substance use treatment services may reduce the risk. PMID:26476210

National Trends in Pharmaceutical Opioid Related Overdose Deaths Compared to other Substance Related Overdose Deaths: 1999-2009

PubMed Central

Calcaterra, Susan; Glanz, Jason; Binswanger, Ingrid A.

2014-01-01

Background: Pharmaceutical opioid related deaths have increased. This study aimed to place pharmaceutical opioid overdose deaths within the context of heroin, cocaine, psychostimulants, and pharmaceutical sedative hypnotics, examine demographic trends, and describe common combinations of substances involved in opioid related deaths. Methods: We reviewed deaths among 15-64 year olds in the US from 1999-2009 using death certificate data available through the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Database. We identified International Classification of Disease-10 codes describing accidental overdose deaths, including poisonings related to stimulants, pharmaceutical drugs, and heroin. We used crude and age adjusted death rates (deaths/100,000 person years [p-y] and 95% confidence interval [CI] and multivariable Poisson regression models, yielding incident rate ratios (IRRs), for analysis. Results: The age adjusted death rate related to pharmaceutical opioids increased almost 4-fold from 1999 to 2009 (1.54/100,000 p-y [95% CI 1.49-1.60] to 6.05/100,000 p-y [95% CI 5.95-6.16; p<0.001). From 1999 to 2009, pharmaceutical opioids were responsible for the highest relative increase in overdose death rates (IRR 4.22, 95% CI 3.03-5.87) followed by sedative hypnotics (IRR 3.53, 95% CI 2.11-5.90). Heroin related overdose death rates increased from 2007 to 2009 (1.05/100,000 persons [95% CI 1.00-1.09] to 1.43/100,000 persons [95% CI 1.38-1.48; p<0.001). From 2005-2009 the combination of pharmaceutical opioids and benzodiazepines was the most common cause of polysubstance overdose deaths (1.27/100,000 p-y (95% CI 1.25-1.30). Conclusion: Strategies, such as wider implementation of naloxone, expanded access to treatment, and development of new interventions are needed to curb the pharmaceutical opioid overdose epidemic. PMID:23294765

A social gradient in fatal opioids and cocaine related overdoses?

PubMed

Origer, Alain; Le Bihan, Etienne; Baumann, Michèle

2015-01-01

To determine the existence of a social gradient in fatal overdose cases related to non-prescribed opioids and cocaine use, recorded in Luxembourg between 1994 and 2011. Overdose cases were individually matched with four controls in a nested case-control study design, according to sex, year of birth, drug administration route and duration of drug use. The study sample, composed of 272 cases and 1,056 controls, was stratified according to a Social Inequality Accumulation Score (SIAS), based on educational attainment, employment, income, financial situation of subjects and the professional status of their father or legal guardian. Least squares linear regression analysis on overdose mortality rates and ridit scores were applied to determine the Relative Index of Inequality (RII) of the study sample. A negative linear relationship between the overdose mortality rate and the relative socioeconomic position was observed. We found a difference in mortality of 29.22 overdose deaths per 100 drug users in the lowest socioeconomic group compared to the most advantaged group. In terms of the Relative Inequality Index, the overdose mortality rate of opioid and cocaine users with lowest socioeconomic profiles was 9.88 times as high as that of their peers from the highest socioeconomic group (95% CI 6.49-13.26). Our findings suggest the existence of a marked social gradient in opioids and cocaine related overdose fatalities. Harm reduction services should integrate socially supportive offers, not only because of their general aim of social (re)integration but crucially in order to meet their most important objective, that is to reduce drug-related mortality.

Improving Organ Utilization to Help Overcome the Tragedies of the Opioid Epidemic

PubMed Central

Goldberg, D. S.; Blumberg, E.; McCauley, M.; Abt, P.; Levine, M.

2017-01-01

Death rates from drug overdoses have nearly doubled since 2003, with over 47 000 deaths in 2014. This is largely attributable to the opioid epidemic. If the unfortunate deaths of otherwise healthy people have yielded an increase in organ donors, then this might serve as perhaps the only comforting factor among this tragic and unnecessary loss of life. In this viewpoint, we present data from the Organ Procurement and Transplantation Network (OPTN) that show how the greatest relative increases in the mechanism of death among deceased donors from 2003 to 2014 were drug overdoses. Unfortunately, despite the absolute increase in the number of donors who died from a drug overdose, the mean organ yield was significantly lower than in other categories, in part due to concerns about disease transmission. In this paper, we present data on the changes in donation from donors with a drug overdose as a result of the opioid epidemic and discuss the need to educate transplant candidates and their physicians about the low risk of disease transmission compared to the greater risk of dying on a transplant waitlist. PMID:27438538

A Comparison of Liver Disease Mortality With HIV and Overdose Mortality Among Georgia Prisoners and Releasees: A 2-Decade Cohort Study of Prisoners Incarcerated in 1991

PubMed Central

Sharma, Akshay; Messina, Lauren C.; Zlotorzynska, Maria; Miller, Lesley; Binswanger, Ingrid A.

2015-01-01

Objectives. We investigated whether eventual causes of death among a cohort of inmates imprisoned in the southeastern United States differed from those in previous prisoner studies. Methods. We matched 23 510 prisoners in Georgia, a state with historically low levels of heroin consumption but moderate amounts of injection drug use, who were incarcerated on June 30, 1991, to death registries through 2010. Main exposure was 4-year time intervals over 2 decades of observation; main outcome was mortality from liver disease, HIV, and overdose. Results. Although the HIV-related mortality rate exceeded that from liver-related conditions before 2003, liver disease subsequently surpassed HIV as a cause of death. Among 3863 deaths, 22 (0.6%) occurred within 2 weeks after release from prison. Of these, only 2 were caused by accidental poisoning (likely drug overdose). Cardiovascular disease and cancer were the most frequent causes of death in this aging cohort. Conclusions. Our study design deemphasized immediate deaths but highlighted long-term sequelae of exposure to viral hepatitis and alcohol. Treating hepatitis C and implementing interventions to manage alcohol use disorders may improve survival among prisoners in the Southeast. PMID:25790417

The Source of Methadone in Overdose Deaths in Western Virginia in 2004

PubMed Central

Weimer, Melissa B.; Korthuis, P. Todd; Behonick, George S.; Wunsch, Martha J.

2011-01-01

Objectives Methadone-related overdose deaths increased in the United States by 468% from 1999 to 2005. Current studies associate the nonmedical use of methadone with methadone-related deaths. This study describes medical examiner cases in rural Virginia in 2004 with methadone identified by toxicology and compares cases according to source of methadone. Methods In 2004, all intentional and unintentional poisoning deaths from the Office of The Chief Medical Examiner, Western District of Virginia, were reviewed to identify cases in which methadone was a direct or contributing cause of death. The Virginia Prescription Monitoring Program was reviewed for prescription opioids in the name of these identified decedents. Decedent participation in local opioid treatment programs (OTP) was also assessed. Results The source of methadone in the 61 methadone-related overdose deaths was mostly nonprescribed (67%), although 28% of decedents were prescribed methadone for analgesia. Only 5% of decedents were actively enrolled in an OTP. The majority of deaths were attributed to polysubstance overdose. Conclusions The majority of methadone overdose deaths in this study were related to illicit methadone use, rather than prescribed or OTP uses. Interventions to decrease methadone-related deaths should focus on reduction of nonprescription use of methadone. PMID:21844834

Validation of a computer case definition for sudden cardiac death in opioid users.

PubMed

Kawai, Vivian K; Murray, Katherine T; Stein, C Michael; Cooper, William O; Graham, David J; Hall, Kathi; Ray, Wayne A

2012-08-31

To facilitate the use of automated databases for studies of sudden cardiac death, we previously developed a computerized case definition that had a positive predictive value between 86% and 88%. However, the definition has not been specifically validated for prescription opioid users, for whom out-of-hospital overdose deaths may be difficult to distinguish from sudden cardiac death. We assembled a cohort of persons 30-74 years of age prescribed propoxyphene or hydrocodone who had no life-threatening non-cardiovascular illness, diagnosed drug abuse, residence in a nursing home in the past year, or hospital stay within the past 30 days. Medical records were sought for a sample of 140 cohort deaths within 30 days of a prescription fill meeting the computer case definition. Of the 140 sampled deaths, 81 were adjudicated; 73 (90%) were sudden cardiac deaths. Two deaths had possible opioid overdose; after removing these two the positive predictive value was 88%. These findings are consistent with our previous validation studies and suggest the computer case definition of sudden cardiac death is a useful tool for pharmacoepidemiologic studies of opioid analgesics.

Post-mortem review of fentanyl-related overdose deaths among identified drug users in Southern Bavaria, Germany, 2005-2014.

PubMed

Sinicina, Inga; Sachs, Hans; Keil, Wolfgang

2017-11-01

Two decades ago, there were only single case reports on deaths in Europe following the consumption of illicitly manufactured fentanyl by problem drug users. Today, lethal fentanyl intoxication is now no longer a rarity. Since 2005, a rapid increase of lethal fentanyl-related intoxications in the drug scene has been observed at the Institute of Legal Medicine, Ludwig Maximilians University, Munich. We hypothesized that this rise is the result of the launch of fentanyl matrix patches in Germany in 2004, their broad acceptance, their diversion from the regulated supply chain, and incautious prescription by medical care providers. Post-mortem toxicological reports were reviewed for lethal fentanyl-related intoxications between 2004 und 2014. Blood and tissue samples were tested by GC/MS or LC-MS/MS. The results of police investigations, autopsy reports, and the database of the Institute of Legal Medicine, LMU, were analysed to identify problem drug users and to detect the source of fentanyl as well as the routes of administration. Between 2005 and 2014, 242 overdose victims with post-mortem toxicological detection of fentanyl were found. In the majority of cases, fentanyl matrix patches were the source of fentanyl. The onset of fentanyl-related deaths coincided with the launch of transdermal fentanyl matrix patches in Germany in 2004. Several approaches, such as providing drug users with information on the possible risks of fentanyl consumption, education of medical caregivers, and also monitoring of the prescription of fentanyl patches, are required to reduce the number of fentanyl-related deaths in drug addicts. Copyright © 2017 Elsevier B.V. All rights reserved.

Maternal Deaths From Suicide and Overdose in Colorado, 2004–2012

PubMed Central

Metz, Torri D.; Rovner, Polina; Hoffman, M. Camille; Allshouse, Amanda A.; Beckwith, Krista M.; Binswanger, Ingrid A.

2016-01-01

Objective To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) in order to identify opportunities for prevention. Methods We report a case series of pregnancy-associated deaths due to self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado. Results Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% CI 3.4, 7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0, 6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21 ± 3.3 months postpartum) with only 6 maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). While half (n=27) of the women with deaths from self-harm were noted to be taking psycho-pharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21). Conclusion Self-harm was the most common cause of pregnancy-associated mortality with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, providers, health care systems, and both governments and organizations at the community and national level may allow for a reduction in maternal deaths. PMID:27824771

Law enforcement attitudes toward overdose prevention and response

PubMed Central

Green, Traci C.; Zaller, Nickolas; Palacios, Wilson R.; Bowman, Sarah E.; Ray, Madeline; Heimer, Robert; Case, Patricia

2014-01-01

Background Law enforcement is often the first to respond to medical emergencies in the community, including overdose. Due to the nature of their job, officers have also witnessed first-hand the changing demographic of drug users and devastating effects on their community associated with the epidemic of nonmedical prescription opioid use in the United States. Despite this seminal role, little data exist on law enforcement attitudes toward overdose prevention and response. Methods We conducted key informant interviews as part of a 12-week Rapid Assessment and Response (RAR) process that aimed to better understand and prevent nonmedical prescription opioid use and overdose deaths in locations in Connecticut and Rhode Island experiencing overdose “outbreaks.” Interviews with 13 law enforcement officials across three study sites were analyzed to uncover themes on overdose prevention and naloxone. Results Findings indicated support for law enforcement involvement in overdose prevention. Hesitancy around naloxone administration by laypersons was evident. Interview themes highlighted officers’ feelings of futility and frustration with their current overdose response options, the lack of accessible local drug treatment, the cycle of addiction, and the pervasiveness of easily accessible prescription opioid medications in their communities. Overdose prevention and response, which for some officers included law enforcement-administered naloxone, were viewed as components of community policing and good police-community relations. Conclusion Emerging trends, such as existing law enforcement medical interventions and Good Samaritan Laws, suggest the need for broader law enforcement engagement around this pressing public health crisis, even in suburban and small town locations, to promote public safety. PMID:24051061

A toxicology-based review of fentanyl-related deaths in New Mexico (1986-2007).

PubMed

Krinsky, Clarissa S; Lathrop, Sarah L; Crossey, Michael; Baker, Ginger; Zumwalt, Ross

2011-12-01

Since its approval in the United States, fentanyl has become increasingly popular for the medical management of pain and as a substance of abuse. Fentanyl is unique among the opioids in its widespread use with a transdermal delivery system, which contributes to its unique pharmacokinetics and abuse potential. We examined the demographics of deaths with fentanyl identified on toxicologic analysis and reviewed specific challenges in the laboratory detection of postmortem fentanyl levels. The New Mexico Office of the Medical Investigator database was searched for all cases from January 1986 through December 2007 with fentanyl reported as present or quantified. Those deaths with a cause of death identified as drug overdose were then analyzed separately. From 1986 to 2007, 154 cases were identified with fentanyl present in postmortem samples, with 96 of the cases identified as fentanyl-related drug overdoses. The number of fentanyl-related deaths has increased over the past 20 years, corresponding to both statewide increases in the medical use of fentanyl and the abuse of prescription opioids. The demographics of these fentanyl-related overdoses showed that subjects were more likely to be female, white non-Hispanic, and older than those in previously described overdose deaths. Several cases were identified with central and peripheral blood samples and antemortem and postmortem samples available for fentanyl quantification. Given the uncharacteristic demographics of fentanyl-related deaths and the complexity of the laboratory analysis of fentanyl, forensic scientists must use caution in both the detection and interpretation of fentanyl concentrations.

Oxycodone-induced tolerance to respiratory depression: reversal by ethanol, pregabalin and protein kinase C inhibition.

PubMed

Hill, Rob; Dewey, William L; Kelly, Eamonn; Henderson, Graeme

2018-06-01

Oxycodone, a prescription opioid, is a major drug of abuse, especially in the USA, and contributes significantly to opioid overdose deaths each year. Overdose deaths result primarily from respiratory depression. We have studied respiratory depression by oxycodone and have characterized how tolerance develops on prolonged exposure to the drug. We have investigated the role of PKC in maintaining tolerance and have examined whether ethanol or pregabalin reverses oxycodone-induced tolerance. Respiration was measured in male CD-1 mice by whole-body plethysmography. Mice were preinjected with oxycodone then implanted with mini-pumps (s.c.) delivering 20, 45 or 120 mg·kg -1 ·day -1 oxycodone for 6 days and subsequently challenged with oxycodone (3 mg·kg -1 , i.p.) or morphine (10 mg·kg -1 , i.p.) to assess the level of tolerance. Oxycodone-treated mice developed tolerance to oxycodone and cross tolerance to morphine-induced respiratory depression. Tolerance was less with 20 mg·kg -1 ·day -1 than with 45 or 120 mg·kg -1 ·day -1 oxycodone treatment. At doses that do not depress respiration, ethanol (0.3 g·kg -1 ), pregabalin (20 mg·kg -1 ) and calphostin C (45 μg·kg -1 ) all reversed oxycodone-induced tolerance resulting in significant respiratory depression. Reversal of tolerance was less in mice treated with oxycodone (120 mg·kg -1 ·day -1 ). In mice receiving ethanol and calphostin C or ethanol and pregabalin, there was no greater reversal of tolerance than seen with either drug alone. These data suggest that oxycodone-induced tolerance is mediated by PKC and that reversal of tolerance by ethanol or pregabalin may be a contributory factor in oxycodone overdose deaths. © 2018 The British Pharmacological Society.

Location of fatal prescription opioid-related deaths in 12 states, 2008–2010: Implications for prevention programs☆,☆☆

PubMed Central

Easterling, Keith W.; Mack, Karin A.; Jones, Christopher M.

2016-01-01

Introduction Prescription opioid pain reliever overdose is a major public health issue in the United States. To characterize the location of drug-related deaths, we examined fatal prescription opioid and illicit drug-related deaths reported in 12 states. Methods Data are from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network (DAWN). Medical examiners or coroners in 12 states (MA, MD, ME, NH, NM, OK, OR, RI, UT, VA, VT, WV) reported details of state-wide drug-related mortality during 2008–2010. DAWN data included location and manner of death, age, race, and drugs involved. Deaths were coded into three categories: prescription opioid-related, illicit drug-related, and cases that involved both a prescription opioid and an illicit drug. Results During a 3-year period, there were 14,091 opioid or illicit drug-related deaths in 12 states. More than half of the prescription opioid-related deaths in all states, except Maryland, occurred at home, rather than in public or in a health care facility. Although it was still the predominant category, lower percentages of illicit drug-related deaths occurred at home. Conclusion Prescription opioid overdoses have increased substantially, and the location of the person at the time of death can have important public health implications for interventions. Practical applications This paper highlights that bystander support can be a critical lifesaving factor in drug related deaths but may be more likely for illicit drug-related deaths than for prescription opioid-related deaths. PMID:27620940

Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012.

PubMed

Metz, Torri D; Rovner, Polina; Hoffman, M Camille; Allshouse, Amanda A; Beckwith, Krista M; Binswanger, Ingrid A

2016-12-01

To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) to identify opportunities for prevention. We report a case series of pregnancy-associated deaths resulting from self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care, and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado. Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% confidence interval [CI] 3.4-7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0-6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21±3.3 months postpartum) with only six maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). Although half (n=27) of the women with deaths from self-harm were noted to be taking psychopharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21). Self-harm was the most common cause of pregnancy-associated mortality, with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, health care providers, health care systems, and both governments and organizations at the community and national levels may allow for a reduction in maternal deaths.

Antidepressant poisoning deaths in New Zealand for 2001.

PubMed

Reith, David; Fountain, John; Tilyard, Murray; McDowell, Rebecca

2003-10-24

To compare the rates of death per volume of drug dispensed for antidepressants in New Zealand. Deaths from antidepressant poisonings were identified from the reports of coronial inquiries for New Zealand in 2001. Prescriptions for antidepressant medications were identified from the PharmHouse database from 1 January 2001 to 31 December 2001. The rates of deaths (95% CI) per prescription, tablet/capsule or defined daily dose were calculated for individual antidepressants and classes of antidepressant. There were 200 poisoning deaths recorded in the database for New Zealand in 2001. Antidepressants were involved in 41 deaths, and death was attributed to an antidepressant in 23 cases. There were 5.52 (95% CI 3.85-7.68) deaths per 100 000 prescriptions for tricyclic antidepressants (TCAs) and 2.51 (1.57-3.79) deaths per 100 000 prescriptions for selective serotonin reuptake inhibitors (SSRIs). There was marked variability in rates of death per volume of drug dispensed between individual antidepressants. SSRIs have lower rates of death per volume of drug dispensed than TCAs and there is also variation in these rates within these classes of drugs. Toxicity in overdose should be considered when prescribing antidepressants.

Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula.

PubMed

Ratycz, Madison C; Papadimos, Thomas J; Vanderbilt, Allison A

2018-12-01

Substance abuse is a growing public health concern in the USA (US), especially now that the US faces a national drug overdose epidemic. Over the past decade, the number of drug overdose deaths has rapidly grown, largely driven by increases in prescription opioid-related overdoses. In recent years, increased heroin and illicitly manufactured fentanyl overdoses have substantially contributed to the rise of overdose deaths. Given the role of physicians in interacting with patients who are at risk for or currently abusing opioids and heroin, it is essential that physicians are aware of this issue and know how to respond. Unfortunately, medical school curricula do not devote substantial time to addiction education and many physicians lack knowledge regarding assessment and management of opioid addiction. While some schools have modified curricula to include content related to opioid prescription techniques and pain management, an added emphasis about the growing role of heroin and fentanyl is needed to adequately address the epidemic. By adapting curricula to address the rising opioid and heroin epidemic, medical schools have the potential to ensure that our future physicians can effectively recognize the signs, symptoms, and risks of opioid/heroin abuse and improve patient outcomes. This article proposes ways to include heroin and fentanyl education into medical school curricula and highlights the potential of simulation-based medical education to enable students to develop the skillset and emotional intelligence necessary to work with patients struggling with opioid and heroin addiction. This will result in future doctors who are better prepared to both prevent and recognize opioid and heroin addiction in patients, an important step in helping reduce the number of addicted patients and address the drug overdose epidemic.

Working together: Expanding the availability of naloxone for peer administration to prevent opioid overdose deaths in the Australian Capital Territory and beyond.

PubMed

Lenton, Simon; Dietze, Paul; Olsen, Anna; Wiggins, Nicole; McDonald, David; Fowlie, Carrie

2015-07-01

Since the mid-1990s, there have been calls to make naloxone, a prescription-only medicine in many countries, available to heroin and other opioid users and their peers and family members to prevent overdose deaths. In Australia there were calls for a trial of peer naloxone in 2000, yet at the end of that year, heroin availability and harm rapidly declined, and a trial did not proceed. In other countries, a number of peer naloxone programs have been successfully implemented. Although a controlled trial had not been conducted, evidence of program implementation demonstrated that trained injecting drug-using peers and others could successfully administer naloxone to reverse heroin overdose, with few, if any, adverse effects. In 2009 Australian drug researchers advocated the broader availability of naloxone for peer administration in cases of opioid overdose. Industrious local advocacy and program development work by a number of stakeholders, notably by the Canberra Alliance for Harm Minimisation and Advocacy, a drug user organisation, contributed to the rollout of Australia's first prescription naloxone program in the Australian Capital Territory (ACT). Over the subsequent 18 months, prescription naloxone programs were commenced in four other Australian states. The development of Australia's first take-home naloxone program in the ACT has been an 'ice-breaker' for development of other Australian programs. Issues to be addressed to facilitate future scale-up of naloxone programs concern scheduling and cost, legal protections for lay administration, prescribing as a barrier to scale-up; intranasal administration, administration by service providers and collaboration between stakeholders. © 2014 Australasian Professional Society on Alcohol and other Drugs.

Preventing deaths from rising opioid overdose in the US – the promise of naloxone antidote in community-based naloxone take-home programs

PubMed Central

Straus, Michele M; Ghitza, Udi E; Tai, Betty

2013-01-01

The opioid overdose epidemic is an alarming and serious public health problem in the United States (US) that has been escalating for 11 years. The 2011 National Survey on Drug Use and Health (NSDUH) demonstrated that 1 in 20 persons in the US aged 12 or older reported nonmedical use of prescription painkillers in the past year. Prescription drug overdose is now the leading cause of accidental death in the United States – surpassing motor vehicle accidents. Great efforts have been initiated to curb the overdose crisis. Notable examples of these efforts are (1) the Drug Enforcement Administration’s (DEA) National Take-Back Initiative instituted in 2010; (2) the Prescription Drug Monitoring Programs (PDMPs) implemented in most US states to provide practitioners with point-of-care information regarding a patient’s controlled substance use; (3) the naloxone rescue programs initiated in the community to avert mortality resulting from overdose. The use of naloxone rescue strategies has gained traction as an effective measure to prevent fatal opioid overdose. Many US federal-government agencies are working to make these strategies more accessible to first responders and community participants. This new approach faces many challenges, such as accessibility to naloxone and the equipment and training needed to administer it, but none is more challenging than the fear of legal repercussions. US federal-government agencies, local governments, health care institutions, and community-based organizations have begun to tackle these barriers, and naloxone take-home programs have gained recognition as a feasible and sensible preventive strategy to avoid a fatal result from opioid overdose. Although many challenges still need to be overcome, it is important for federal government research agencies to initiate and support independent and rigorous evaluation of these programs to inform policymakers how effective these programs can be to save lives and curb the opioid overdose public health crisis. PMID:24273417

Law enforcement attitudes toward overdose prevention and response.

PubMed

Green, Traci C; Zaller, Nickolas; Palacios, Wilson R; Bowman, Sarah E; Ray, Madeline; Heimer, Robert; Case, Patricia

2013-12-01

Law enforcement is often the first to respond to medical emergencies in the community, including overdose. Due to the nature of their job, officers have also witnessed first-hand the changing demographic of drug users and devastating effects on their community associated with the epidemic of nonmedical prescription opioid use in the United States. Despite this seminal role, little data exist on law enforcement attitudes toward overdose prevention and response. We conducted key informant interviews as part of a 12-week Rapid Assessment and Response (RAR) process that aimed to better understand and prevent nonmedical prescription opioid use and overdose deaths in locations in Connecticut and Rhode Island experiencing overdose "outbreaks." Interviews with 13 law enforcement officials across three study sites were analyzed to uncover themes on overdose prevention and naloxone. Findings indicated support for law enforcement involvement in overdose prevention. Hesitancy around naloxone administration by laypersons was evident. Interview themes highlighted officers' feelings of futility and frustration with their current overdose response options, the lack of accessible local drug treatment, the cycle of addiction, and the pervasiveness of easily accessible prescription opioid medications in their communities. Overdose prevention and response, which for some officers included law enforcement-administered naloxone, were viewed as components of community policing and good police-community relations. Emerging trends, such as existing law enforcement medical interventions and Good Samaritan Laws, suggest the need for broader law enforcement engagement around this pressing public health crisis, even in suburban and small town locations, to promote public safety. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010.

PubMed

Jones, Christopher M; Paulozzi, Leonard J; Mack, Karin A

2014-10-10

The abuse of prescription drugs has led to a significant increase in emergency department (ED) visits and drug-related deaths over the past decade. Opioid pain relievers (OPRs) and benzodiazepines are the prescription drugs most commonly involved in these events. Excessive alcohol consumption also accounts for a significant health burden and is common among groups that report high rates of prescription drug abuse. When taken with OPRs or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose. Data describing alcohol involvement in OPR or benzodiazepine abuse are limited. To quantify alcohol involvement in OPR and benzodiazepine abuse and drug-related deaths and to inform prevention efforts, the Food and Drug Administration (FDA) and CDC analyzed 2010 data for drug abuse-related ED visits in the United States and drug-related deaths that involved OPRs and alcohol or benzodiazepines and alcohol in 13 states. The analyses showed alcohol was involved in 18.5% of OPR and 27.2% of benzodiazepine drug abuse-related ED visits and 22.1% of OPR and 21.4% of benzodiazepine drug-related deaths. These findings indicate that alcohol plays a significant role in OPR and benzodiazepine abuse. Interventions to reduce the abuse of alcohol and these drugs alone and in combination are needed.

Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention.

PubMed

Wagner, Karla D; Liu, Lin; Davidson, Peter J; Cuevas-Mota, Jazmine; Armenta, Richard F; Garfein, Richard S

2015-08-01

Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs. 573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs. Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months. Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

On the Alert: Preparing for Medical Emergencies in Schools

ERIC Educational Resources Information Center

Mahoney, Dan

2012-01-01

Medical emergencies can happen in any school at any time. They can be the result of preexisting health problems, accidents, violence, unintentional actions, natural disasters, and toxins. Premature deaths in schools from sudden cardiac arrest, blunt trauma to the chest, firearm injuries, asthma, head injuries, drug overdose, allergic reactions,…

Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics.

PubMed

Jann, Michael; Kennedy, William Klugh; Lopez, Gaylord

2014-02-01

The misuse and abuse of prescription medications in the United States continues to increase despite interventions by health care professionals, regulatory, and law enforcement agencies. Opioid analgesics are the leading class of prescription drugs that have caused unintentional overdose deaths. Benzodiazepines when taken alone are relatively safe agents in overdose. However, a 5-fold increase in deaths attributed to benzodiazepines occurred from 1999 to 2009. Emergency department visits related to opioid analgesics increased by 111% followed by benzodiazepines 89%. During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression. Physician and pharmacy shopping by patients occurs, and prescription drug-monitoring programs can provide important information on benzodiazepine and opioid analgesic prescribing patterns and patient usage. Health care professionals need to inform patients and work closely with regulatory agencies and legislatures to stem the increasing fatalities from prescription drug unintentional overdoses.

Fentanyl related overdose in Indianapolis: Estimating trends using multilevel Bayesian models.

PubMed

Phalen, Peter; Ray, Bradley; Watson, Dennis P; Huynh, Philip; Greene, Marion S

2018-03-20

The opioid epidemic has been largely attributed to changes in prescribing practices over the past 20 years. Although current overdose trends appear driven by the opioid fentanyl, heroin has remained the focus of overdose fatality assessments. We obtained full toxicology screens on lethal overdose cases in a major US city, allowing more accurate assessment of the time-course of fentanyl-related deaths. We used coroner data from Marion County, Indiana comprising 1583 overdose deaths recorded between January 1, 2010 and April 30, 2017. Bayesian multilevel models were fitted to predict likelihood of lethal fentanyl-related overdose using information about the victim's age, race, sex, zip code, and date of death. Three hundred and seventy-seven (23.8%) overdose deaths contained fentanyl across the seven-year period. Rates rose exponentially over time, beginning well below 15% from 2010 through 2013 before rising to approximately 50% by 2017. At the beginning of the study period, rates of fentanyl overdose were lowest among Black persons but increased more rapidly, eventually surpassing Whites. Currently, White females are at particularly low risk of fentanyl overdose whereas Black females are at high risk. Rates were highest for younger and middle-aged groups. Over time, fentanyl was more likely detected without the presence of other opioids. Fentanyl has increasingly been detected in fatal overdose deaths in Marion County. Policy and program responses must focus on education for those at highest risk of fentanyl exposure and death. These responses should also be tailored to meet the unique needs of high-risk demographics. Copyright © 2018 Elsevier Ltd. All rights reserved.

Validation of a computer case definition for sudden cardiac death in opioid users

PubMed Central

2012-01-01

Background To facilitate the use of automated databases for studies of sudden cardiac death, we previously developed a computerized case definition that had a positive predictive value between 86% and 88%. However, the definition has not been specifically validated for prescription opioid users, for whom out-of-hospital overdose deaths may be difficult to distinguish from sudden cardiac death. Findings We assembled a cohort of persons 30-74 years of age prescribed propoxyphene or hydrocodone who had no life-threatening non-cardiovascular illness, diagnosed drug abuse, residence in a nursing home in the past year, or hospital stay within the past 30 days. Medical records were sought for a sample of 140 cohort deaths within 30 days of a prescription fill meeting the computer case definition. Of the 140 sampled deaths, 81 were adjudicated; 73 (90%) were sudden cardiac deaths. Two deaths had possible opioid overdose; after removing these two the positive predictive value was 88%. Conclusions These findings are consistent with our previous validation studies and suggest the computer case definition of sudden cardiac death is a useful tool for pharmacoepidemiologic studies of opioid analgesics. PMID:22938531

Overdose prevention in injecting opioid users: the role of substance abuse treatment and training programs.

PubMed

Sarasa-Renedo, Ana; Espelt, Albert; Folch, Cinta; Vecino, Carmen; Majó, Xavier; Castellano, Yolanda; Casabona, Jordi; Brugal, M Teresa

2014-01-01

Opioid overdose is still the first cause of preventable death among young men in Barcelona. Sound knowledge of opioid overdose prevention is important to avoid complications and deaths. This study aimed to identify the factors associated with limited knowledge of overdose prevention and to assess the possible effect of treatment and overdose prevention training programs on this variable. From October 2008 to March 2009, current injecting opioid users attending harm reduction centers in Catalonia (Spain) were interviewed. Crude and adjusted prevalence ratios of limited knowledge about overdose prevention were calculated by adjusting Poisson regression models with a robust variance. In this sample, 28.7% of clients had limited knowledge of overdose prevention. Factors associated with limited knowledge were country of origin, never having received treatment for drug dependency, having a low educational level, and never having experienced an overdose. In contrast, treatment at the time of the interview was not associated with a lower prevalence of limited knowledge about overdose prevention. These findings suggest that preventive programs would benefit from accounting for linguistic and educational limitations and from participation in every treatment episode. Comprehensiveness and broad coverage of such programs could help to maximize their impact. Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.

Supply-side response to declining heroin purity: fentanyl overdose episode in New Jersey.

PubMed

Hempstead, Katherine; Yildirim, Emel O

2014-06-01

The inelastic price demand observations characteristic of illegal drug markets have led to the conclusion that the burden of a negative supply shock would be completely reflected to consumers. This paper argues that the increasing availability of prescription opioids may threaten heroin sellers' profit margin and force them to find alternative methods to compensate buyers in the event of a supply shock. We investigate the 2006 fentanyl overdose episode in New Jersey and argue that the introduction of non-pharmaceutical fentanyl, its spatial distribution, and the timing of overdose deaths may have been related to trends in heroin purity. Using medical examiner data, as well as data from the Drug Enforcement Administration, Office of Diversion Control on retail sales of prescription opioids in a negative binomial specification, we show that month-to-month fluctuations in heroin purity have a significant effect on fentanyl-related overdoses, particularly in those areas where prescription opioids are highly available. Copyright © 2013 John Wiley & Sons, Ltd.

Risk factors for all-cause, overdose and early deaths after release from prison in Washington state.

PubMed

Binswanger, Ingrid A; Blatchford, Patrick J; Lindsay, Rebecca G; Stern, Marc F

2011-08-01

High mortality rates after release from prison have been well-documented, particularly from overdose. However, little is known about the risk factors for death after release from prison. Therefore, the objective of this study was to determine the demographic and incarceration-related risk factors for all-cause, overdose and early mortality after release from prison. We conducted a retrospective cohort study of inmates released from a state prison system from 1999 through 2003. The cohort included 30,237 who had a total of 38,809 releases from prison. Potential risk factors included gender, race/ethnicity, age, length of incarceration, and community supervision. Cox proportional hazards regression was used to determine risk factors for all-cause, overdose and early (within 30 days of release) death after release from prison. Age over 50 was associated with an increased risk for all-cause mortality (hazard ratio [HR] 2.67 for each decade increase, 95% confidence interval [CI] 2.23, 3.20) but not for overdose deaths or early deaths. Latinos were at decreased risk of death compared to Whites only for all-cause mortality (HR 0.61, 95% CI 0.42, 0.87). Increasing years of incarceration were associated with a decreased risk of all-cause mortality (HR 0.95, 95% CI 0.91, 0.99) and overdose deaths (HR 0.80, 95% CI 0.68, 0.95), but not early deaths. Gender and type of release were not significantly associated with all-cause, overdose or early deaths. Age, ethnicity and length of incarceration were associated with mortality after release from prison. Interventions to reduce mortality among former inmates are needed. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Drug suicide: a sex-equal cause of death in 16 European countries.

PubMed

Värnik, Airi; Sisask, Merike; Värnik, Peeter; Wu, Jing; Kõlves, Kairi; Arensman, Ella; Maxwell, Margareth; Reisch, Thomas; Gusmão, Ricardo; van Audenhove, Chantal; Scheerder, Gert; van der Feltz-Cornelis, Christina M; Coffey, Claire; Kopp, Maria; Szekely, Andras; Roskar, Saska; Hegerl, Ulrich

2011-01-29

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84). Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated. No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk. Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Drug suicide: a sex-equal cause of death in 16 European countries

PubMed Central

2011-01-01

Background There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84). Methods Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated. Results No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk. Conclusions Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level. PMID:21276260

Postmortem stability of lung surfactant phospholipids.

PubMed

Lorente, J A; Lorente, M; Villanueva, E

1992-09-01

The postmortem stability of the main phospholipids of lung surfactant-phosphatidyl choline (PC), phosphatidyl ethanolamine (PE), phosphatidyl inositol (PI), phosphatidyl serine (PS) and sphingomyelin (S) in three different deaths; one caused by fresh-water drowning, one by salt-water drowning, and one from a sodium-pentobarbital overdose has been studied. The drug overdose was considered the control because there was no surfactant involvement. The results show the stability of these kinds of lipids in the first 24 h, with a progressive decrease from 48 h on until 96 h, with a significant correlation to the time of P less than 0.01 in most cases.

Effects of naloxone distribution to likely bystanders: Results of an agent-based model.

PubMed

Keane, Christopher; Egan, James E; Hawk, Mary

2018-05-01

Opioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed. We conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose. Our baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths. Community-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs. Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.

Medicalizing the Opioid Epidemic in the U.S. in the Era of Health Care Reform.

PubMed

Smith, David E

2017-01-01

The medicalization of the current opioid epidemic in the era of health care reform and parity, and its possible dismantling, poses many challenges. Between 2002 and 2013, drug overdose rates quadrupled. Parallel to an increase in prescription opioid overdose, heroin overdose deaths are increasing as patients shift to cheaper and more accessible heroin from the prescription opioids which physicians are prescribing less often due to increasing regulatory restrictions, as well as enhanced education and awareness. In many areas, the leading cause of death for young adults is drug overdose. Unlike previous heroin use in the U.S., the nexus of spread is coming primarily out of the medical system, as the line between legal and illicit narcotics has become blurred. The economic and social benefits of bringing the previously excluded addicted population into the mainstream health care system will be substantial and will bring changes in three major areas: mental health and substance abuse services in health plans; parity protection in all insurance plans; substance abuse and mental health services. Long-term implementation of these changes in a medically oriented system will require the development of many new systems and procedures.

Opioid Overdose Deaths and Florida’s Crackdown on Pill Mills

PubMed Central

Richey, Matthew; McGinty, Emma E.; Stuart, Elizabeth A.; Barry, Colleen L.; Webster, Daniel W.

2016-01-01

Objectives. We examined the effect on opioid overdose mortality of Florida state laws and law enforcement operations targeting “pill mills.” Methods. We collected 2003 to 2012 mortality data from the Florida Department of Health and the North Carolina State Center for Health Statistics (the comparison state) to estimate changes in the rates of death from prescription opioid, heroin, or any opioid overdose. Results. Florida’s actions were associated with an estimated 1029 lives saved from prescription opioid overdose over a 34-month period. Estimated reductions in deaths grew over the intervention period, with rates per 100 000 population that were 0.6 lower in 2010, 1.8 lower in 2011, and 3.0 lower in 2012 than what would have been expected had the changes in mortality rate trends in Florida been the same as changes in trends in North Carolina. Florida’s mortality rates from heroin and total opioid overdose were also lower than anticipated relative to changes in trends in North Carolina. Conclusions. Findings from this study indicate that laws regulating pain clinics and enforcement of these laws may, in combination, reduce opioid overdose deaths. PMID:26691121

[Injecting drug abuse: survival after intensive care admission and forensic toxicology reports at death].

PubMed

Sigvaldason, Kristinn; Ingvarsson, Thoroddur; Thordardottir, Svava; Kristinsson, Jakob; Karason, Sigurbergur

2014-10-01

Injecting drug abuse is a worldwide problem with serious consequences for the individual and for society. The purpose of this study was to gather information on the most serious complications of injecting drug use from two perspectives, intensive care admissions and forensic toxicology reports. Firstly, intensive care admissions related to injecting drug abuse during a five year period were reviewed for demographics, complications and 5 year survival. Secondly, information from forensic toxicology reports regarding deaths amongst known injecting drug abusers were gathered for the same period. A total of 57 patients with a history of active injecting drug use were admitted to intensive care or approximately 1% of admissions, most often for overdose (52%) or life threatening infections (39%). Median age was 26, males were 66%. The most common substances used were prescription drugs. Hospital mortality was 16% and five year survival 65%. Average time from hospital discharge to death was 916±858 days. During the study period 38 deaths of individuals with a history of injecting drugs were identified by forensic toxicology reports or 4.1/10(5) population/year (age 15-59). Cause of death was most often overdose (53%), usually from prescription opiates but multiple drug use was common. The life expectancy of injecting drug abusers after intensive care admission is substantially decreased, with 35% death rate within five years. A widespread use of prescription drugs is of concern. Injecting drug abuse seems to be a similar health problem in magnitude in Iceland as in other Scandinavian countries.

The relative risk of fatal poisoning by methadone or buprenorphine within the wider population of England and Wales

PubMed Central

Marteau, Dave

2015-01-01

Objective To examine the population-wide overdose risk emerging from the prescription of methadone and buprenorphine for opioid substitution treatment in England and Wales. Design Retrospective administrative data study. Setting National databases for England and Wales. Participants/cases Drug-related mortality data were drawn from the Office for National Statistics, and prescription data for methadone and buprenorphine were obtained from the National Health Service for the years 2007–2012. During this 6-year period, a total of 2366 methadone-related deaths and 52 buprenorphine-related deaths were registered, corresponding to 17 333 163 methadone and 2 602 374 buprenorphine prescriptions issued. The analysis encompassed poisoning deaths among members of the wider population of England and Wales who consumed, but were not prescribed these medications, in addition to patients prescribed methadone or buprenorphine. Main outcome measures Mortality risk: substance-specific overdose rate per 1000 prescriptions issued; relative risk ratio of methadone in relation to buprenorphine. Results During the years 2007–2012, the pooled overdose death rate was 0.137/1000 prescriptions of methadone, compared to 0.022/1000 prescriptions of buprenorphine (including buprenorphine-naloxone). The analysis generated a relative risk ratio of 6.23 (95% CI 4.79 to 8.10) of methadone in relation to buprenorphine. UK Borders Agency data were taken into consideration and revealed that only negligible amounts of methadone and buprenorphine were seized on entering UK territory between 2007 and 2012, suggesting domestic diversion. Conclusions Our analysis of the relative safety of buprenorphine and methadone for opioid substitution treatment reveals that buprenorphine is six times safer than methadone with regard to overdose risk among the general population. Clinicians should be aware of the increased risk of prescribing methadone, and tighter regulations are needed to prevent its diversion. PMID:26024998

Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment.

PubMed

Stam, Nathan C; Pilgrim, Jennifer L; Drummer, Olaf H; Smith, Karen; Gerostamoulos, Dimitri

2018-06-06

The aim of this study was to investigate the safety of the management of non-fatal heroin overdose in the out-of-hospital environment; irrespective of whether or not naloxone had been administered. Heroin toxicity-related deaths as well as heroin intoxication-related traumatic deaths following patient-initiated refusal of transport were investigated. Heroin-related deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated and data linkage to pre-hospital Emergency Medical Services performed, in order to identify whether the death was related to the last episode of care by paramedics. The number of non-fatal heroin overdose events over the study period were also examined. There were a total of 3921 heroin-related attendances by paramedics during the study period, including 2455 cases that involved treatment but where the patient was not transported to hospital. There were also 243 heroin-related deaths identified over the study period and 93% (n = 225) of those cases were matched with Ambulance Victoria electronic patient care records. Data linkage revealed 31 heroin-related deaths where there had been a recent presentation with a non-fatal heroin overdose to paramedics; however, none of these deaths were related to that episode of care, including for 11 individuals that were treated on scene by paramedics but not transported to the hospital. This study demonstrated that the treatment of uncomplicated heroin overdose in the out-of-hospital environment was safe in terms of mortality, irrespective of whether or not naloxone had been administered. In all of the non-fatal heroin toxicity cases attended by paramedics, whether or not transported to hospital, death occurred as a result of a subsequent and unrelated heroin overdose.

Performance Measures of Diagnostic Codes for Detecting Opioid Overdose in the Emergency Department.

PubMed

Rowe, Christopher; Vittinghoff, Eric; Santos, Glenn-Milo; Behar, Emily; Turner, Caitlin; Coffin, Phillip O

2017-04-01

Opioid overdose mortality has tripled in the United States since 2000 and opioids are responsible for more than half of all drug overdose deaths, which reached an all-time high in 2014. Opioid overdoses resulting in death, however, represent only a small fraction of all opioid overdose events and efforts to improve surveillance of this public health problem should include tracking nonfatal overdose events. International Classification of Disease (ICD) diagnosis codes, increasingly used for the surveillance of nonfatal drug overdose events, have not been rigorously assessed for validity in capturing overdose events. The present study aimed to validate the use of ICD, 9th revision, Clinical Modification (ICD-9-CM) codes in identifying opioid overdose events in the emergency department (ED) by examining multiple performance measures, including sensitivity and specificity. Data on ED visits from January 1, 2012, to December 31, 2014, including clinical determination of whether the visit constituted an opioid overdose event, were abstracted from electronic medical records for patients prescribed long-term opioids for pain from any of six safety net primary care clinics in San Francisco, California. Combinations of ICD-9-CM codes were validated in the detection of overdose events as determined by medical chart review. Both sensitivity and specificity of different combinations of ICD-9-CM codes were calculated. Unadjusted logistic regression models with robust standard errors and accounting for clustering by patient were used to explore whether overdose ED visits with certain characteristics were more or less likely to be assigned an opioid poisoning ICD-9-CM code by the documenting physician. Forty-four (1.4%) of 3,203 ED visits among 804 patients were determined to be opioid overdose events. Opioid-poisoning ICD-9-CM codes (E850.2-E850.2, 965.00-965.09) identified overdose ED visits with a sensitivity of 25.0% (95% confidence interval [CI] = 13.6% to 37.8%) and specificity of 99.9% (95% CI = 99.8% to 100.0%). Expanding the ICD-9-CM codes to include both nonspecified and general (i.e., without a decimal modifier) drug poisoning and drug abuse codes identified overdose ED visits with a sensitivity of 56.8% (95% CI = 43.6%-72.7%) and specificity of 96.2% (95% CI = 94.8%-97.2%). Additional ICD-9-CM codes not explicitly relevant to opioid overdose were necessary to further enhance sensitivity. Among the 44 overdose ED visits, neither naloxone administration during the visit, whether the patient responded to the naloxone, nor the specific opioids involved were associated with the assignment of an opioid poisoning ICD-9-CM code (p ≥ 0.05). Tracking opioid overdose ED visits by diagnostic coding is fairly specific but insensitive, and coding was not influenced by administration of naloxone or the specific opioids involved. The reason for the high rate of missed cases is uncertain, although these results suggest that a more clearly defined case definition for overdose may be necessary to ensure effective opioid overdose surveillance. Changes in coding practices under ICD-10 might help to address these deficiencies. © 2016 by the Society for Academic Emergency Medicine.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

PubMed Central

Kripke, Daniel F.

2016-01-01

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics’ mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia. PMID:27303633

National Institute on Drug Abuse International Program: improving opioid use disorder treatment through international research training.

PubMed

Gust, Steven W; McCormally, Judy

2018-07-01

For more than 25 years, the National Institute on Drug Abuse (NIDA) has supported research-training programs, establishing a global research network and expanding the knowledge base on substance use disorders. International research to inform approaches to opioid addiction is particularly important and relevant to the United States, where opioid misuse, addiction, and overdose constitute an emerging public health crisis. This article summarizes the NIDA International Program and illustrates its impact by reviewing recent articles about treatment approaches for opioid use disorders (OUD). Studies in several countries have demonstrated the effectiveness of physician office-based opioid substitution therapies. Other research has demonstrated the effectiveness of different formulations and doses of the opioid antagonist naltrexone, as well as different approaches to providing naloxone to treat opioid overdose. Continuing research into implementation of evidence-based treatment in international settings with limited resources is applicable to US regions that face similar structural, legal, and fiscal constraints. The current review describes international research on OUD treatment and opioid overdose, most coauthored by former NIDA fellows. The findings from outside the United States have important implications for best practices domestically and in other countries that are experiencing increases in OUD prevalence and related overdose deaths.

Trends in young adult mortality in three European cities: Barcelona, Bologna and Munich, 1986-1995

PubMed Central

Borrell, C; Pasarin, M; Cirera, E; Klutke, P; Pipitone, E; Plasencia, A

2001-01-01

OBJECTIVE—In recent decades, in most European countries young adult mortality has risen, or at best has remained stable. The aim of this study was to describe trends in mortality attributable to the principal causes of death: AIDS, drug overdose, suicide and motor vehicle traffic accidents, among adults aged between 15 and 34 years in three European cities (Barcelona, Bologna and Munich), over the period 1986 to 1995.
METHODS—The population studied consisted of all deaths that occurred between 1986 and 1995 among residents of Barcelona, Bologna and Munich aged from 15 to 34 years. Information about deaths was obtained from mortality registers. The study variables were sex, age, the underlying cause of death and year of death. Causes of death studied were: drug overdose, AIDS, suicide and motor vehicle traffic accidents. Age standardised mortality rates (direct adjustment) were obtained in all three cities for the age range 15-34. To investigate trends in mortality over the study period Poisson regression models were fitted, obtaining the average relative risk (RR) associated with a one year increment.
RESULTS—Young adult mortality increased among men in Barcelona and Bologna (RR per year: 1.04, 95% confidence intervals (95%CI): 1.03, 1.06 in Barcelona and RR:1.03, 95%CI:1.01, 1.06 in Bologna) and among women in Barcelona (RR:1.02, 95%CI: 1.01, 1.04), with a change in the pattern of the main causes of death attributable to the increase in AIDS and drug overdose mortality. In Munich, the pattern did not change as much, suicides being the main cause of death during the 10 years studied, although they have been decreasing since 1988 (RR:0.92, 95%CI:0.88, 0.96 for men and 0.81, 95%CI: 0.75-0.87 for women).
CONCLUSION—The increase in AIDS mortality observed in the three European cities in the mid-80s and mid-90s has yielded to substantial changes in the pattern of the main causes of death at young ages in Barcelona and Bologna. Munich presented a more stable pattern, with suicide as the main cause of death.


Keywords: young adult mortality; AIDS; drug overdose; suicide; traffic accidents PMID:11449016

Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically.

PubMed

Macmadu, Alexandria; Carroll, Jennifer J; Hadland, Scott E; Green, Traci C; Marshall, Brandon D L

2017-05-01

The rate of overdose deaths caused by fentanyl-contaminated heroin (FCH) use is increasing rapidly in the United States. We examined risk factors for exposure to FCH and experiences with FCH use among young adult non-medical prescription opioids (NMPO) users. We analyzed data from the Rhode Island Young Adult Prescription Drug Study (RAPiDS), which enrolled young adults aged 18 to 29 reporting prior 30day NMPO use between January 2015 and February 2016. Participants completed questionnaires ascertaining drug use patterns and risk behaviors, including FCH exposure. Logistic regression was used to assess factors associated with known or suspected FCH exposure. Of 199 participants, the median age was 25 (IQR: 22, 27), 130 (65.3%) were male, and 122 (61.3%) were of White, non-Hispanic race/ethnicity. In total, 22 (11%) reported known or suspected FCH exposure in the prior six months. Several drug use patterns and risk behaviors were associated with FCH exposure, including: regular heroin and cocaine use; diverted pharmaceutical fentanyl use in the prior six months; NMPO use to avoid withdrawal symptoms; longer duration of NMPO use; regular injection drug use; and prior overdose (all p<0.001). Among participants who reported FCH exposure, 59% were unaware that their heroin was contaminated with fentanyl prior to last use, 59% reported that FCH provides a better high, and all recognized that fentanyl increases overdose risk. Exposure to fentanyl-contaminated heroin is an emerging trend among young adult NMPO users in Rhode Island. Overdose prevention programs addressing FCH use are urgently needed. Copyright © 2017 Elsevier Ltd. All rights reserved.

High risk and little knowledge: Overdose experiences and knowledge among young adult nonmedical prescription opioid users

PubMed Central

Frank, David; Mateu-Gelabert, Pedro; Guarino, Honoria; Bennett, Alex; Wendel, Travis; Jessell, Lauren; Teper, Anastasia

2014-01-01

Background Opioid-involved overdoses in the United States have dramatically increased in the last 15 years, largely due to a rise in prescription opioid (PO) use. Yet few studies have examined the overdose knowledge and experience of nonmedical PO users. Methods In depth, semi-structured, audio-recorded interviews were conducted with 46 New York City young adults (ages 18–32) who reported using POs nonmedically within the past 30 days. Verbatim interview transcripts were coded for key themes in an analytic process informed by grounded theory. Results Despite significant experience with overdose (including overdose deaths), either personally or within opioid-using networks, participants were relatively uninformed about overdose awareness, avoidance and response strategies, in particular the use of naloxone. Overdose experiences typically occurred when multiple pharmaceuticals were used (often in combination with alcohol) or after participants had transitioned to heroin injection. Participants tended to see themselves as distinct from traditional heroin users, and were often outside of the networks reached by traditional opioid safety/overdose prevention services. Consequently, they were unlikely to utilize harm reduction services, such as syringe exchange programs (SEPs), that address drug users' health and safety. Conclusions These findings suggest that many young adult nonmedical PO users are at high risk of both fatal and non-fatal overdose. There is a pressing need to develop innovative outreach strategies and overdose prevention programs to better reach and serve young PO users and their network contacts. Prevention efforts addressing risk for accidental overdose, including opioid safety/overdose reversal education and naloxone distribution, should be tailored for and targeted to this vulnerable group. PMID:25151334

Project Lazarus: community-based overdose prevention in rural North Carolina.

PubMed

Albert, Su; Brason, Fred W; Sanford, Catherine K; Dasgupta, Nabarun; Graham, Jim; Lovette, Beth

2011-06-01

In response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Western North Carolina. The Wilkes County unintentional poisoning mortality rate was quadruple that of the state's in 2009 and due almost exclusively to prescription opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone. The program is ongoing. The overdose prevention program involves five components: community activation and coalition building; monitoring and surveillance data; prevention of overdoses; use of rescue medication for reversing overdoses by community members; and evaluating project components. Principal efforts include education of primary care providers in managing chronic pain and safe opioid prescribing, largely through the creation of a tool kit and face-to-face meetings. Preliminary unadjusted data for Wilkes County revealed that the overdose death rate dropped from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. There was a decrease in the number of victims who received prescriptions for the substance implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of overdose decedents received a prescription for an opioid analgesic from a Wilkes prescriber compared with 10% in 2010. While the results from this community-based program are preliminary, the number and nature of prescription opioid overdose deaths in Wilkes County changed during the intervention. Further evaluation is required to understand the localized effect of the intervention and its potential for replication in other areas. Wiley Periodicals, Inc.

Focused use of drug screening in overdose patients increases impact on management.

PubMed

Erdmann, Andreas; Werner, Dominique; Hugli, Olivier; Yersin, Bertrand

2015-01-01

Drug poisoning is a common cause for attendance in the emergency department. Several toxicology centres suggest performing urinary drug screens, even though they rarely influence patient management. Measuring the impact on patient management, in a University Emergency Department with approximately 40 000 admissions annually, of a rapid urinary drug screening test using specifically focused indications. Drug screening was restricted to patients having a first psychotic episode or cases demonstrating respiratory failure, coma, seizures, a sympathomimetic toxidrome, severe opiate overdose necessitating naloxone, hypotension, ventricular arrhythmia, acquired long QT or QRS >100 ms, and high-degree heart block. Retrospective analysis of Triage® TOX drug screen tests performed between September 2009 and November 2011, and between January 2013 and March 2014. A total of 262 patients were included, mean age 35 ± 14.6 (standard deviation) years, 63% men; 29% poisoning with alcohol, and 2.3% deaths. Indications for testing were as follows: 34% were first psychotic episodes; 20% had acute respiratory failure; 16% coma; 8% seizures; 8% sympathomimetic toxidromes; 7% severe opioid toxidromes; 4% hypotension; 3% ventricular arrhythmias or acquired long QT intervals on electrocardiogram. A total of 78% of the tests were positive (median two substances, maximum five). The test resulted in drug-specific therapy in 6.1%, drug specific diagnostic tests in 13.3 %, prolonged monitoring in 10.7% of methadone-positive tests, and psychiatric admission in 4.2%. Overall, 34.3% tests influenced patient management. In contrast to previous studies showing modest effects of toxicological testing, restricted use of rapid urinary drug testing increases the impact on management of suspected overdose patients in the ED.

An Innovative Model for Naloxone Use Within an OTP Setting: A Prospective Cohort Study

PubMed Central

Katzman, Joanna G.; Takeda, Mikiko Y.; Bhatt, Snehal R.; Moya Balasch, Monica; Greenberg, Nina; Yonas, Howard

2018-01-01

Objectives: Unintentional opioid overdose deaths are a public health crisis, and naloxone is the most effective harm reduction tool to curb many of these deaths. There is growing evidence that take-home naloxone can prevent opioid overdose in targeted populations. The goal of this study is to measure the opioid overdose reversal rate with take-home naloxone among participants with a diagnosis of opioid use disorder (OUD) in an opioid treatment program (OTP) setting. Methods: Patients enrolled in an outpatient OTP program were eligible for this prospective cohort study between April 4, 2016 and July 4, 2016. Two hundred forty-four study participants received overdose education, instruction on how to use naloxone, and were provided with 2 doses of a take-home naloxone auto-injector kit. They were subsequently followed for 3 months. Results: Thirty-one study participants reported overdose reversals using naloxone auto-injector kits on 38 community members. All overdose reversals were heroin-related. Eighty-seven per cent of the community members reversed with naloxone were friends or relatives of the study participants. Conclusions: This study validates that naloxone is not commonly used on the index study participant, but is often used on a secondary target among people who inject drugs. The large number of overdose reversals reported in this prospective study suggests that this novel model for naloxone use may be replicated at other OTP settings to reduce opioid overdose deaths. PMID:29227321

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.

PubMed

Collett, Garen A; Song, Kangwon; Jaramillo, Carlos A; Potter, Jennifer S; Finley, Erin P; Pugh, Mary Jo

2016-03-01

The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse. We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors. This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans (N = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model. We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes. Further research should evaluate whether CNS polypharmacy may be used as a trigger for evaluation of the current care provided to these individuals.

Knowledge of the 911 Good Samaritan Law and 911-calling behavior of overdose witnesses.

PubMed

Jakubowski, Andrea; Kunins, Hillary V; Huxley-Reicher, Zina; Siegler, Anne

2017-10-03

Overdose deaths tripled between 1999 and 2014. Most fatal overdoses are witnessed, offering an opportunity for bystanders to call 911. However, fear of arrest may prevent them from calling authorities. Many states have passed 911 Good Samaritan laws that protects the 911 caller and overdose victim from prosecution for drug possession. Little is known, however, about whether the law affects 911-calling behavior of overdose witnesses. This study investigated the relationship between knowledge of a 911 Good Samaritan Law (GSL) and 911-calling behavior of study participants trained in opioid overdose rescue. 351 individuals (N = 351) trained in overdose rescue and educated about the New York State GSL were enrolled in a prospective longitudinal study. Trained researchers conducted baseline and 3-, 6-, and 12-month follow-up surveys with study participants to assess participant knowledge of the GSL and responses to witnessed overdoses. At the 12-month follow-up, participants had witnessed 326 overdoses. In the overdose events where the participant had correct knowledge of the GSL at the time of the event, the odds of a bystander calling 911 were over 3 times greater than when the witness had incorrect knowledge of the GSL (odds ratio [OR] = 3.3, 95% confidence interval [CI]: 1.4-7.5). This association remained significant after adjusting for age, gender, race of the witness, and overdose setting (adjusted OR [AOR] = 3.6, 95% CI: 1.4-9.4). This study shows a clear association between knowledge of the GSL and 911-calling behavior. Legislation that protects overdose responders along with public awareness of the law may be an effective strategy to increase rates of 911-calling in response to overdose events and decrease overdose-related mortality.

Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications.

PubMed

Nolan, Michelle L; Kunins, Hillary V; Lall, Ramona; Paone, Denise

Recent increases in drug overdose deaths, both in New York City and nationally, highlight the need for timely data on psychoactive drug-related morbidity. We developed drug syndrome definitions for syndromic surveillance to monitor drug-related emergency department (ED) visits in real time. We used 2012 archived syndromic surveillance data from New York City hospitals to develop definitions for psychoactive drug-related syndromes. The dataset contained ED visit-level information that included patients' chief complaints, dates of visits, ZIP codes of residence, discharge diagnoses, and dispositions. After manually reviewing chief complaints, we developed a classification scheme comprising 3 categories (overdose, drug mention, and drug abuse/misuse), which we used to define 25 psychoactive drug syndromes. From July 2013 through December 2015, the New York City Department of Health and Mental Hygiene performed daily syndromic surveillance of psychoactive drug-related ED visits using the 25 syndrome definitions. Syndromic surveillance triggered 4 public health investigations, supported 8 other public health investigations that had been triggered by other mechanisms, and resulted in the identification of 5 psychoactive drug-related outbreaks. Syndromic surveillance also identified a substantial increase in synthetic cannabinoid-related visits (from an average of 3 per week in January 2014 to >300 per week in July 2015) and an increase in heroin overdose visits (from 80 to 171 in the first 3 quarters of 2012 and 2014, respectively) in a single neighborhood. Syndromic surveillance using these novel definitions enabled monitoring of trends in psychoactive drug-related morbidity, initiation and support of public health investigations, and targeting of interventions. Health departments can refine these definitions for their jurisdictions using the described methods and integrate them into existing syndromic surveillance systems.

Modeling the impact of simulated educational interventions on the use and abuse of pharmaceutical opioids in the United States: a report on initial efforts.

PubMed

Wakeland, Wayne; Nielsen, Alexandra; Schmidt, Teresa D; McCarty, Dennis; Webster, Lynn R; Fitzgerald, John; Haddox, J David

2013-10-01

Three educational interventions were simulated in a system dynamics model of the medical use, trafficking, and nonmedical use of pharmaceutical opioids. The study relied on secondary data obtained in the literature for the period of 1995 to 2008 as well as expert panel recommendations regarding model parameters and structure. The behavior of the resulting systems-level model was tested for fit against reference behavior data. After the base model was tested, logic to represent three educational interventions was added and the impact of each intervention on simulated overdose deaths was evaluated over a 7-year evaluation period, 2008 to 2015. Principal findings were that a prescriber education intervention not only reduced total overdose deaths in the model but also reduced the total number of persons who receive opioid analgesic therapy, medical user education not only reduced overdose deaths among medical users but also resulted in increased deaths from nonmedical use, and a "popularity" intervention sharply reduced overdose deaths among nonmedical users while having no effect on medical use. System dynamics modeling shows promise for evaluating potential interventions to ameliorate the adverse outcomes associated with the complex system surrounding the use of opioid analgesics to treat pain.

Characteristics of medication overdose presentations to the ED: how do they differ from illicit drug overdose and self-harm cases?

PubMed

Buykx, Penny; Dietze, Paul; Ritter, Alison; Loxley, Wendy

2010-07-01

Medication overdose accounts for >80% of hospital presentations for self-harm. Previous research has identified typical characteristics of medication overdose cases; however, these cases have not been well differentiated from other similar presentations, namely (1) illicit drug overdose and (2) self-harm by means other than overdose. A 12-month audit of medication overdose cases (both intentional and unintentional) attending the emergency department (ED) of a major metropolitan public hospital in Melbourne, Australia was conducted. Comparison was made with patients attending for illicit drug overdose or for self-harm by means other than overdose. Medication overdose cases (n=453) showed a broadly comparable profile with those found in earlier studies (predominantly female gender, aged in their 30s and referred for psychosocial assessment). A similar though not identical profile was noted for self-harm cases (n=545). In contrast, patients attending for illicit drug overdose (n=409) could be characterised as male, in their 20s and not referred for psychosocial assessment. Illicit drug overdose cases were more likely than either the medication overdose or self-harm cases to be triaged in the most urgent category (19.3, 3.8 and 3.9% respectively), suggesting a high level of acuity in this group. However, the illicit drug overdose group on average spent less time in the ED than medication overdose patients, and were less likely to require hospital admission. On both demographic and treatment variables, patients attending the ED following a medication overdose more closely resemble those attending for self-harm by means other than overdose than those attending for illicit drug overdose.

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.

PubMed

Collett, Garen A; Song, Kangwon; Jaramillo, Carlos A; Potter, Jennifer S; Finley, Erin P; Pugh, Mary Jo

The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse. We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors. This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans ( N  = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model. We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes. Further research should evaluate whether CNS polypharmacy may be used as a trigger for evaluation of the current care provided to these individuals.

Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence - North Carolina, 2010-2015.

PubMed

Fleischauer, Aaron T; Ruhl, Laura; Rhea, Sarah; Barnes, Erin

2017-06-09

Opioid dependence and overdose have increased to epidemic levels in the United States. The 2014 National Survey on Drug Use and Health estimated that 4.3 million persons were nonmedical users of prescription pain relievers (1). These users are 40 times more likely than the general population to use heroin or other injection drugs (2). Furthermore, CDC estimated a near quadrupling of heroin-related overdose deaths during 2002-2014 (3). Although overdose contributes most to drug-associated mortality, infectious complications of intravenous drug use constitute a major cause of morbidity leading to hospitalization (4). In addition to infections from hepatitis C virus (HCV) and human immunodeficiency virus (HIV), injecting drug users are at increased risk for acquiring invasive bacterial infections, including endocarditis (5,6). Evidence that hospitalizations for endocarditis are increasing in association with the current opioid epidemic exists (7-9). To examine trends in hospitalizations for endocarditis among persons in North Carolina with drug dependence during 2010-2015, data from the North Carolina Hospital Discharge database were analyzed. The incidence of hospital discharge diagnoses for drug dependence combined with endocarditis increased more than twelvefold from 0.2 to 2.7 per 100,000 persons per year over this 6-year period. Correspondingly, hospital costs for these patients increased eighteenfold, from $1.1 million in 2010 to $22.2 million in 2015. To reduce the risk for morbidity and mortality related to opioid-associated endocarditis, public health programs and health care systems should consider collaborating to implement syringe service programs, harm reduction strategies, and opioid treatment programs.

Reducing drug related deaths: a pre-implementation assessment of knowledge,barriers and enablers for naloxone distribution through general practice

PubMed Central

2014-01-01

Background The Scottish Naloxone Programme aims to reduce Scotland’s high number of drug-related deaths (DRDs) caused by opiate overdose. It is currently implemented through specialist drug services but General Practitioners (GPs) are likely to have contact with drug using patients and their families and are therefore in an ideal position to direct them to naloxone schemes, or provide it themselves. This research gathered baseline data on GP’s knowledge of and willingness to be involved in DRD prevention, including naloxone administration, prior to the implementation of primary care based delivery. Methods Mixed methods were used comprising a quantitative, postal survey and qualitative telephone interviews. A questionnaire was sent to 500 GPs across Scotland. An initial mailing was followed by a reminder. A shortened questionnaire containing seven key questions was posted as a final reminder. Telephone interviews were conducted with 17 GPs covering a range of demographic characteristics and drug user experience. Results A response rate of 55% (240/439) was achieved. There was some awareness of the naloxone programme but little involvement (3.3%), 9% currently provided routine overdose prevention, there was little involvement in displaying overdose prevention information (<20%). Knowledge of DRD risk was mixed. There was tentative willingness to be involved in naloxone prescribing with half of respondents willing to provide this to drug users or friends/family. However half were uncertain GP based naloxone provision was essential to reduce DRDs. Factors enabling naloxone distribution were: evidence of effectiveness, appropriate training, and adding to the local formulary. Interviewees had limited awareness of what naloxone distribution in primary care may involve and considered naloxone supply as a specialist service rather than a core GP role. Wider attitudinal barriers to involvement with this group were expressed. Conclusions There was poor awareness of the Scottish National Naloxone Programme in participants. Results indicated GPs did not currently feel sufficiently skilled or knowledgeable to be involved in naloxone provision. Appropriate training was identified as a key requirement. PMID:24428947

Misclassification of suicide deaths: examining the psychiatric history of overdose decedents.

PubMed

Bohnert, Amy S B; McCarthy, John F; Ignacio, Rosalinda V; Ilgen, Mark A; Eisenberg, Anna; Blow, Frederic C

2013-10-01

The intent of a death from overdose can be difficult to determine. The goal of this study was to examine the association of psychiatric diagnoses among overdose deaths ruled by a medical examiner as intentional, unintentional and indeterminate intent. All Veterans Health Administration patients in Fiscal Year 1999 (n=3 291 891) were followed through Fiscal Year 2006. We tested the relative strength of association between psychiatric disorders among types of overdoses (categorised by intent) using multinomial models, adjusted for age, sex, Veterans Affairs priority status and Charlson comorbidity scores. Data were from National Death Index records and patient medical records. Substance use disorders (SUD) had a stronger association with indeterminate intent overdoses than intentional overdoses (adjusted OR (AOR)=1.80, 95% CI 1.47 to 2.22). SUDs also had a stronger association with unintentional overdoses than intentional (AOR=1.48, 95% CI 1.27 to 1.72), but the reverse was true for all other psychiatric disorders (except post-traumatic stress disorder). Overdoses ruled indeterminate may be misclassified suicide deaths and are important to suicide surveillance and prevention efforts. Additionally, overdose deaths not classified as suicides may include some cases due to suicidal-like thinking without overt suicidal intent.

Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia

PubMed Central

Marasović Šušnjara, Ivana; Definis Gojanović, Marija; Vodopija, Davor; Čapkun, Vesna; Smoljanović, Ankica

2011-01-01

Aim To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County. Methods We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed. Results There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P = 0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P = 0.008). The most common site of death was the deceased person’s home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides. Conclusion The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate. PMID:21990081

Talking about screening, brief intervention, and referral to treatment for adolescents: An upstream intervention to address the heroin and prescription opioid epidemic.

PubMed

Harris, Brett R

2016-10-01

Overdose deaths from heroin and prescription opioids have reached epidemic proportions in recent years. Deaths specifically involving heroin have more than tripled since 2011, and for the first time, drug overdose deaths have exceeded deaths resulting from motor vehicle accidents. This epidemic has been receiving attention among policymakers and the media which has resulted in efforts to provide training and education on prescribing practices, increase the use of naloxone, and expand the availability and use of Medication-Assisted Treatment (MAT). What is not being talked about is the relationship between early initiation of less harmful substances such as alcohol and marijuana and subsequent use of prescription opioids and heroin. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a model which shows promise for preventing initiation and reducing risky substance use among adolescents before it progresses to use of harder drugs such as heroin. Unfortunately, though recommended by the American Academy of Pediatrics, health care providers are not even screening their adolescent patients for substance use. The heroin and prescription opioid epidemic and the dissemination of information regarding federal, state, and local efforts to combat the epidemic provide a platform for increasing awareness of SBIRT, garnering support for more research, and facilitating uptake and integration into practice. It is time to add SBIRT to the conversation. Copyright © 2016 Elsevier Inc. All rights reserved.

Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia.

PubMed

Marasovic Susnjara, Ivana; Definis Gojanovic, Marija; Vodopija, Davor; Capkun, Vesna; Smoljanovic, Ankica

2011-10-15

To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County. We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed. There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P=0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P=0.008). The most common site of death was the deceased person's home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides. CONCLUSION; The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate.

Macroeconomic conditions and opioid abuse.

PubMed

Hollingsworth, Alex; Ruhm, Christopher J; Simon, Kosali

2017-12-01

We examine how deaths and emergency department (ED) visits related to use of opioid analgesics (opioids) and other drugs vary with macroeconomic conditions. As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%). Macroeconomic shocks also increase the overall drug death rate, but this increase is driven by rising opioid deaths. Our findings hold when performing a state-level analysis, rather than county-level; are primarily driven by adverse events among whites; and are stable across time periods. Copyright © 2017 Elsevier B.V. All rights reserved.

Characteristics and trends of emergency patients with drug overdose in Osaka

PubMed Central

Kubota, Yoshie; Hasegawa, Kohei; Taguchi, Hirokazu; Kitamura, Tetsuhisa; Nishiyama, Chika; Iwami, Taku; Nishiuchi, Tatsuya

2015-01-01

Aim Drug overdose is an important issue in emergency medicine. However, studies covering overdose patients transported by ambulance have not been sufficiently carried out. We attempted to clarify problems of suspected drug overdose patients transported by ambulance. Methods This is a prospective population‐based cohort study. Data were collected by emergency medical service crews in Osaka City, Japan, between January 1998 and December 2010. Results Drug overdose cases increased annually from 1,136 in 1998 to 1,822 in 2010 (P < 0.0001 for trend). In these cases, the dominant age range was between 16 and 40 years and the age distribution did not change over time. The age of non‐overdose cases increased (P < 0.0001 for trend), with patients aged ≥66 years becoming most common in recent years, reflecting the aging of society. Males comprised most non‐overdose patients, but the percentage of females increased annually (P < 0.0001 in trend). Females comprised approximately 70% in overdose cases annually throughout the study period. The duration from the emergency call to the arrival at the hospital for overdose patients has increased markedly in recent years. It also takes more time to obtain acceptance from hospitals to care for patients of suspected overdose. Conclusion The characteristics of drug overdose patients are clearly different from those of non‐overdose patients. Recent trends of drug overdose patients indicate the accelerated burden on emergency medical services system. PMID:29123730

Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting

PubMed Central

Albizu-García, Carmen E; Hernández-Viver, Adriana; Feal, Jacqueline; Rodríguez-Orengo, José F

2009-01-01

Background Although prevention of opiate overdose has been gaining attention as a harm reduction measure with community drug users, there is scarce information about drug overdose in prison. In correctional institutions without a drug free environment, awareness of overdose events is an important public health concern. This study explores the frequency with which inmates in a state penitentiary system report having witnessed drug overdose events in prison. It also explores whether participants who have witnessed an overdose in prison and know someone who died from an overdose in prison significantly differ from those that do not in selected sociodemographic variables and drug use history to identify a target population for prevention interventions. Methods Data comes from a cross-sectional survey of sentenced inmates in the state prisons of Puerto Rico. A complex probabilistic, multistage sampling design was used. A total of 1,179 individuals participated for an 89% response rate. Results Factors associated with witnessing an overdose event in prison include: male sex, age 25 or older, drug use during current incarceration, and drug injection in prison. Factors associated with knowing someone who died from an overdose in prison include: male sex, age between 25–35, previous incarcerations, and drug use during current incarceration. Conclusion Witnessing a drug overdose is a frequent occurrence within the prison system. The likelihood of witnessing an overdose is greater with being male, polydrug use and drug injection in prison. Findings signal an urgent public health challenge that requires prompt interventions to reduce this drug related harm within the correctional system, including adequate access to medication with opiate agonists. PMID:19589157

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality.

PubMed

Dasgupta, Nabarun; Funk, Michele Jonsson; Proescholdbell, Scott; Hirsch, Annie; Ribisl, Kurt M; Marshall, Steve

2016-01-01

Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds. We quantify dose-dependent overdose mortality over a large spectrum of clinically common doses. We also examine the contributions of benzodiazepines and extended release opioid formulations to mortality. Prospective observational cohort with one year follow-up. One year in one state (NC) using a controlled substances prescription monitoring program, with name-linked mortality data. Residential population of North Carolina (n = 9,560,234), with 2,182,374 opioid analgesic patients. Exposure was dispensed prescriptions of solid oral and transdermal opioid analgesics; person-years calculated using intent-to-treat principles. Outcome was overdose deaths involving opioid analgesics in a primary or additive role. Poisson models were created, implemented using generalized estimating equations. Opioid analgesics were dispensed to 22.8% of residents. Among licensed clinicians, 89.6% prescribed opioid analgesics, and 40.0% prescribed ER formulations. There were 629 overdose deaths, half of which had an opioid analgesic prescription active on the day of death. Of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Mortality rates increased gradually across the range of average daily milligrams of morphine equivalents. 80.0% of opioid analgesic patients also received benzodiazepines. Rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher (7.0 per 10,000 person-years, 95 percent CI: 6.3, 7.8) than opioid analgesics alone (0.7 per 10,000 person years, 95 percent CI: 0.6, 0.9). Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. There is urgent need for guidance about combined classes of medicines to facilitate a better balance between pain relief and overdose risk. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. 2016. This work is written by US Government employees and is in the public domain in the US.

Policing and risk of overdose mortality in urban neighborhoods

PubMed Central

Bohnert, Amy S.B.; Nandi, Arijit; Tracy, Melissa; Cerdá, Magdalena; Tardiff, Kenneth J; Vlahov, David; Galea, Sandro

2010-01-01

Background Accidental drug overdose is a major cause of mortality among drug users. Fears of police arrest may deter witnesses of drug overdose from calling for medical help and may be a determinant of drug overdose mortality. To our knowledge, no studies have empirically assessed the relation between levels of policing and drug overdose mortality. We hypothesized that levels of police activity, congruent with fears of police arrest, are positively associated with drug overdose mortality. Methods We assembled cross-sectional time-series data for 74 New York City (NYC) police precincts over the period 1990–1999 using data collected from the Office of the Chief Medical Examiner of NYC, the NYC Police Department, and the US Census Bureau. Misdemeanor arrest rate—reflecting police activity—was our primary independent variable of interest, and overdose rate our primary dependent variable of interest. Results The mean overdose rate per 100,000 among police precincts in NYC between 1990 and 1999 was 10.8 (standard deviation = 10.0). In a Bayesian hierarchical model that included random spatial and temporal effects and a space-time interaction, the misdemeanor arrest rate per 1,000 was associated with higher overdose mortality (posterior median = 0.003, 95% Credible Interval = 0.001, 0.005) after adjustment for overall drug use in the precinct and demographic characteristics. Conclusions Levels of police activity in a precinct are associated with accidental drug overdose mortality. Future research should examine aspects of police-community interactions that contribute to higher overdose mortality. PMID:20727684

Drug overdose surveillance using hospital discharge data.

PubMed

Slavova, Svetla; Bunn, Terry L; Talbert, Jeffery

2014-01-01

We compared three methods for identifying drug overdose cases in inpatient hospital discharge data on their ability to classify drug overdoses by intent and drug type(s) involved. We compared three International Classification of Diseases, Ninth Revision, Clinical Modification code-based case definitions using Kentucky hospital discharge data for 2000-2011. The first definition (Definition 1) was based on the external-cause-of-injury (E-code) matrix. The other two definitions were based on the Injury Surveillance Workgroup on Poisoning (ISW7) consensus recommendations for national and state poisoning surveillance using the principal diagnosis or first E-code (Definition 2) or any diagnosis/E-code (Definition 3). Definition 3 identified almost 50% more drug overdose cases than did Definition 1. The increase was largely due to cases with a first-listed E-code describing a drug overdose but a principal diagnosis that was different from drug overdose (e.g., mental disorders, or respiratory or circulatory system failure). Regardless of the definition, more than 53% of the hospitalizations were self-inflicted drug overdoses; benzodiazepines were involved in about 30% of the hospitalizations. The 2011 age-adjusted drug overdose hospitalization rate in Kentucky was 146/100,000 population using Definition 3 and 107/100,000 population using Definition 1. The ISW7 drug overdose definition using any drug poisoning diagnosis/E-code (Definition 3) is potentially the highest sensitivity definition for counting drug overdose hospitalizations, including by intent and drug type(s) involved. As the states enact policies and plan for adequate treatment resources, standardized drug overdose definitions are critical for accurate reporting, trend analysis, policy evaluation, and state-to-state comparison.

Drug Overdose Surveillance Using Hospital Discharge Data

PubMed Central

Bunn, Terry L.; Talbert, Jeffery

2014-01-01

Objectives We compared three methods for identifying drug overdose cases in inpatient hospital discharge data on their ability to classify drug overdoses by intent and drug type(s) involved. Methods We compared three International Classification of Diseases, Ninth Revision, Clinical Modification code-based case definitions using Kentucky hospital discharge data for 2000–2011. The first definition (Definition 1) was based on the external-cause-of-injury (E-code) matrix. The other two definitions were based on the Injury Surveillance Workgroup on Poisoning (ISW7) consensus recommendations for national and state poisoning surveillance using the principal diagnosis or first E-code (Definition 2) or any diagnosis/E-code (Definition 3). Results Definition 3 identified almost 50% more drug overdose cases than did Definition 1. The increase was largely due to cases with a first-listed E-code describing a drug overdose but a principal diagnosis that was different from drug overdose (e.g., mental disorders, or respiratory or circulatory system failure). Regardless of the definition, more than 53% of the hospitalizations were self-inflicted drug overdoses; benzodiazepines were involved in about 30% of the hospitalizations. The 2011 age-adjusted drug overdose hospitalization rate in Kentucky was 146/100,000 population using Definition 3 and 107/100,000 population using Definition 1. Conclusion The ISW7 drug overdose definition using any drug poisoning diagnosis/E-code (Definition 3) is potentially the highest sensitivity definition for counting drug overdose hospitalizations, including by intent and drug type(s) involved. As the states enact policies and plan for adequate treatment resources, standardized drug overdose definitions are critical for accurate reporting, trend analysis, policy evaluation, and state-to-state comparison. PMID:25177055

Psychiatric intervention and repeated admission to emergency centres due to drug overdose.

PubMed

Kanehara, Akiko; Yamana, Hayato; Yasunaga, Hideo; Matsui, Hiroki; Ando, Shuntaro; Okamura, Tsuyoshi; Kumakura, Yousuke; Fushimi, Kiyohide; Kasai, Kiyoto

2015-10-01

Repeated drug overdose is a major risk factor for suicide. Data are lacking on the effect of psychiatric intervention on preventing repeated drug overdose. To investigate whether psychiatric intervention was associated with reduced readmission to emergency centres due to drug overdose. Using a Japanese national in-patient database, we identified patients who were first admitted to emergency centres for drug overdose in 2010-2012. We used propensity score matching for patient and hospital factors to compare readmission rates between intervention (patients undergoing psychosocial assessment) and unexposed groups. Of 29 564 eligible patients, 13 035 underwent psychiatric intervention. In the propensity-matched 7938 pairs, 1304 patients were readmitted because of drug overdose. Readmission rate was lower in the intervention than in the unexposed group (7.3% v . 9.1% respectively, P <0.001). Psychiatric intervention was associated with reduced readmission in patients who had taken a drug overdose. None. © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

The Contribution of Drug Overdose to Educational Gradients in Life Expectancy in the United States, 1992-2011.

PubMed

Ho, Jessica Y

2017-06-01

Since the mid-1990s, the United States has witnessed a dramatic rise in drug overdose mortality. Educational gradients in life expectancy widened over the same period, and drug overdose likely plays a role in this widening, particularly for non-Hispanic whites. The contemporary drug epidemic is distinctive in terms of its scope, the nature of the substances involved, and its geographic patterning, which influence how it impacts different education groups. I use vital statistics and National Health Interview Survey data to examine the contribution of drug overdose to educational gradients in life expectancy from 1992-2011. I find that over this period, years of life lost due to drug overdose increased for all education groups and for both males and females. The contribution of drug overdose to educational gradients in life expectancy has increased over time and is greater for non-Hispanic whites than for the population as a whole. Drug overdose accounts for a sizable proportion of the increases in educational gradients in life expectancy, particularly at the prime adult ages (ages 30-60), where it accounts for 25 % to 100 % of the widening in educational gradients between 1992 and 2011. Drug overdose mortality has increased more rapidly for females than for males, leading to a gender convergence. These findings shed light on the processes driving recent changes in educational gradients in life expectancy and suggest that effective measures to address the drug overdose epidemic should take into account its differential burden across education groups.

Factors associated with knowledge of a Good Samaritan Law among young adults who use prescription opioids non-medically.

PubMed

Evans, Tristan I; Hadland, Scott E; Clark, Melissa A; Green, Traci C; Marshall, Brandon D L

2016-07-26

To date, no studies have examined the extent of knowledge and perceptions of Good Samaritan Laws (GSLs) among young adults who engage in non-medical prescription opioid (NMPO) use. We sought to determine awareness of and factors associated with knowledge of Rhode Island's Good Samaritan Law (RIGSL) among young adult NMPO users. We compared the sociodemographic and overdose-related characteristics of participants who were aware and unaware of the RIGSL and determined independent correlates of knowledge of the RIGSL via modified stepwise logistic regression. Among 198 eligible participants, 15.7 % were black, 62.1 % white, and 20.7 % mixed or other race. The mean age was 24.5 (SD = 3.2) and 129 (65.2 %) were male. Fewer than half (45.5 %) were aware of the RIGSL; nonetheless, the majority (95.5 %) reported a willingness to call 911 in the event of an overdose. Knowledge of the RIGSL was associated with older age, white race, a history of incarceration, a history of injection drug use, lifetime heroin use, ever witnessing or experiencing an overdose, having heard of naloxone, knowledge of where to obtain naloxone, and experience administering naloxone (all p < 0.05). In the final explanatory regression model, lifetime injection drug use, having heard of naloxone, and knowledge of where to obtain naloxone were independently associated with awareness of the RIGSL. Fewer than half of NMPO users surveyed knew of the RIGSL. Targeted harm reduction education is needed to address a vulnerable population of NMPO users who have not initiated injection drug use and are unaware of naloxone. Additional research is needed to determine how the effectiveness of GSLs could be improved to prevent overdose deaths among young adults.

Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study.

PubMed

Carroll, Jennifer J; Marshall, Brandon D L; Rich, Josiah D; Green, Traci C

2017-08-01

Illicit fentanyl use has become wide spread in the US, causing high rates of overdose deaths among people who use drugs. This study describes patterns and perceptions of fentanyl exposure among opioid users in Rhode Island. A mixed methods study was conducted via questionnaire with a convenience sample of 149 individuals using illicit opioids or misusing prescription opioids in Rhode Island between January and November 2016. Of these, 121 knew of fentanyl and reported known or suspected exposure to fentanyl in the past year. Semi-structured interviews were conducted with the first 47 participants. Study participants were predominantly male (64%) and white (61%). Demographic variables were similar across sample strata. Heroin was the most frequently reported drug of choice (72%). Self-reported exposure to illicit fentanyl in the past year was common (50.4%, n=61). In multivariate models, regular (at least weekly) heroin use was independently associated with known or suspected fentanyl exposure in the past year (adjusted prevalence ratio (APR)=4.07, 95% CI: 1.24-13.3, p=0.020). In interviews, users described fentanyl as unpleasant, potentially deadly, and to be avoided. Participants reporting fentanyl exposure routinely experienced or encountered non-fatal overdose. Heroin users reported limited ability to identify fentanyl in their drugs. Harm reduction strategies used to protect themselves from fentanyl exposure and overdose, included test hits, seeking prescription opioids in lieu of heroin, and seeking treatment with combination buprenorphine/naloxone. Participants were often unsuccessful in accessing structured treatment programs. Among illicit opioid users in Rhode Island, known or suspected fentanyl exposure is common, yet demand for fentanyl is low. Fentanyl-contaminated drugs are generating user interest in effective risk mitigation strategies, including treatment. Responses to the fentanyl epidemic should be informed by the perceptions and experiences of local users. The rapid scale-up of buprenorphine/naloxone provision may slow the rate of fentanyl-involved overdose deaths. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Family Carers and the Prevention of Heroin Overdose Deaths: Unmet Training Need and Overlooked Intervention Opportunity of Resuscitation Training and Supply of Naloxone

ERIC Educational Resources Information Center

Strang, John; Manning, Victoria; Mayet, Soraya; Titherington, Emily; Offor, Liz; Semmler, Claudia; Williams, Anna

2008-01-01

Aim: To assess (a) carers' experiences of witnessing overdose; (b) their training needs; and (c) their interest in receiving training in overdose management. Design: Postal questionnaire distributed through consenting participating local carer group coordinators in England. Sample: 147 carers attending local support groups for friends and families…

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

PubMed

Larochelle, Marc R; Bernson, Dana; Land, Thomas; Stopka, Thomas J; Wang, Na; Xuan, Ziming; Bagley, Sarah M; Liebschutz, Jane M; Walley, Alexander Y

2018-06-19

Opioid overdose survivors have an increased risk for death. Whether use of medications for opioid use disorder (MOUD) after overdose is associated with mortality is not known. To identify MOUD use after opioid overdose and its association with all-cause and opioid-related mortality. Retrospective cohort study. 7 individually linked data sets from Massachusetts government agencies. 17 568 Massachusetts adults without cancer who survived an opioid overdose between 2012 and 2014. Three types of MOUD were examined: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. Exposure to MOUD was identified at monthly intervals, and persons were considered exposed through the month after last receipt. A multivariable Cox proportional hazards model was used to examine MOUD as a monthly time-varying exposure variable to predict time to all-cause and opioid-related mortality. In the 12 months after a nonfatal overdose, 2040 persons (11%) enrolled in MMT for a median of 5 months (interquartile range, 2 to 9 months), 3022 persons (17%) received buprenorphine for a median of 4 months (interquartile range, 2 to 8 months), and 1099 persons (6%) received naltrexone for a median of 1 month (interquartile range, 1 to 2 months). Among the entire cohort, all-cause mortality was 4.7 deaths (95% CI, 4.4 to 5.0 deaths) per 100 person-years and opioid-related mortality was 2.1 deaths (CI, 1.9 to 2.4 deaths) per 100 person-years. Compared with no MOUD, MMT was associated with decreased all-cause mortality (adjusted hazard ratio [AHR], 0.47 [CI, 0.32 to 0.71]) and opioid-related mortality (AHR, 0.41 [CI, 0.24 to 0.70]). Buprenorphine was associated with decreased all-cause mortality (AHR, 0.63 [CI, 0.46 to 0.87]) and opioid-related mortality (AHR, 0.62 [CI, 0.41 to 0.92]). No associations between naltrexone and all-cause mortality (AHR, 1.44 [CI, 0.84 to 2.46]) or opioid-related mortality (AHR, 1.42 [CI, 0.73 to 2.79]) were identified. Few events among naltrexone recipients preclude confident conclusions. A minority of opioid overdose survivors received MOUD. Buprenorphine and MMT were associated with reduced all-cause and opioid-related mortality. National Center for Advancing Translational Sciences of the National Institutes of Health.

Injection drug users trained by overdose prevention programs: Responses to witnessed overdoses

PubMed Central

Lankenau, Stephen E.; Wagner, Karla D.; Silva, Karol; Kecojevic, Aleksander; Iverson, Ellen; McNeely, Miles; Kral, Alex H.

2012-01-01

In response to the growing public health problem of drug overdose, community-based organizations have initiated overdose prevention programs (OPP), which distribute naloxone, an opioid antagonist, and teach overdose response techniques. Injection drug users (IDUs) have been targeted for this intervention due to their high risk for drug overdose. Limited research attention has focused on factors that may inhibit or prevent IDUs who have been trained by OPPs to undertake recommended response techniques when responding to a drug overdose. IDUs (n=30) trained by two OPPs in Los Angeles were interviewed in 2010–11 about responses to their most recently witnessed drug overdose using an instrument containing both open and closed-ended questions. Among the 30 witnessed overdose events, the victim recovered in 29 cases while the outcome was unknown in one case. Participants responded to overdoses using a variety of techniques taught by OPP. Injecting the victim with naloxone was the most common recommended response while other recommended responses included stimulating the victim with knuckles, calling 911, and giving rescue breathing. Barriers preventing participants from employing recommended response techniques in certain circumstances included prior successes using folk remedies to revive a victim, concerns over attracting police to the scene, and issues surrounding access to or use of naloxone. Practical solutions, such as developing booster sessions to augment OPP, are encouraged to increase the likelihood that trained participants respond to a drug overdose with the full range of recommended techniques. PMID:22847602

The Contribution of Drug Overdose to Educational Gradients in Life Expectancy in the United States, 1992–2011

PubMed Central

Ho, Jessica Y.

2017-01-01

Over the past two decades, the United States has witnessed a dramatic rise in drug overdose mortality. Educational gradients in life expectancy widened over the same period, and it is likely that drug overdose plays a role in this widening, particularly for non-Hispanic whites. The contemporary drug epidemic is distinctive in terms of its scope, the nature of the substances involved, and its geographic patterning, which influence how it impacts different education groups. I use data from vital statistics and from the National Health Interview Survey to examine the contribution of drug overdose to educational gradients in life expectancy from 1992–2011. I find that over this period, years of life lost due to drug overdose increased for all education groups and for both males and females. The contribution of drug overdose to educational gradients in life expectancy has increased over time and is greater for non-Hispanic whites than for the population as a whole. Drug overdose accounts for a sizeable proportion of the increases in educational gradients in life expectancy, particularly at the prime adult ages (ages 30–60) where it accounts for 25–100% of the widening in educational gradients between 1992–2011. Over time, drug overdose mortality has increased more rapidly for females than for males, leading to a gender convergence. These findings shed light on the processes driving recent changes in educational gradients in life expectancy and suggest that effective measures to address the drug overdose epidemic should take into account its differential burden across education groups. PMID:28324483

Department of Defense Suicide Event Report (DoDSER) Calendar Year 2011 Annual Report

DTIC Science & Technology

2012-11-15

methods were most frequently drug overdose and use of military issue firearm. Drug and alcohol use during suicide events was less frequent among deployed...use of non-military issue firearms and hanging. Suicide attempt methods were most frequently drug overdose , harming oneself with a sharp or blunt...communicating intent to suicide (e.g., text). Prescription Overdose 176 40.00% 42.86% 39.13% 36 19.15% 21.94% 23.05% Used, no overdose 27

[Overdose of heroin and influencing factors in intravenous drug users in parts of Yunnan].

PubMed

Zhou, Y; Luo, W; Cao, X B; Zhang, B; Wu, Z Y

2016-05-01

To assess the prevalence of overdose of heroin and risk factors in intravenous drug users(IDUs)in Yunnan Province. During July-August of 2015, IDUs were recruited from four methadone maintenance treatment(MMT)clinics and two compulsory drug rehabilitation centers in Honghe and Dehong prefectures, Yunnan province. The information about IDUs ' demographic characteristics and drug use history, overdose of heroin in previous12 months and the latest overdose of heroin were collected through face to face questionnaire survey. The factors associated with overdose of heroin were evaluated with logistic regression models. Of the 340 IDUs surveyed, 85.3%(290/340)were males, the mean age was 37.7±8.7 years, 65.6%(223/340)were Han ethnicity, and 49.4%(167/338)were HIV positive, 22.6%(77/340)reported having used club-related drugs(such as ephedrine, methamphetamine, benzodiazepines and ketamine)in the previous 12 months. Of the 340 IDUs, 41.8%(142/340)had at least one overdose of heroin in their lifetime(median: 3 overdoses)and 15.6%(53/340)had at least one overdose of heroin(median : 1 overdose use)in previous 12 months. The mean age of the 53 IDUs was(36.7 ± 8.4)years, and 83.0%(44/53)of them were males, the average drug use history was(16.5 ± 7.6)years. Dosage increase(26.4%, 14/53)and multidrug use(28.3%, 15/53)were the main causes for overdose of heroin. Multiple logistic regression analysis indicated that methadone maintenance treatment during the past year(OR=0.534, 95%CI: 0.290-0.980)was independently associated with decreased risk of overdose of heroin, needle sharing in the past 6 months(OR=2.735, 95%CI: 1.383-5.407)and being forced to receive drug rehabilitation for less than one year(OR=2.881, 95% CI: 1.226-6.767)were independently associated with increased risk of overdose of heroin. Overdose of heroin is common among IDUs in Yunnan. It is necessary to encourage IDUs to receive MMT and strengthen the health education about the prevention of overdose of heroin, especially before they leave drug rehabilitation centers. And it is important to establish a referral mechanism from drug rehabilitation center to MMT clinic for drug users.

Social and structural aspects of the overdose risk environment in St. Petersburg, Russia.

PubMed

Green, Traci C; Grau, Lauretta E; Blinnikova, Ksenia N; Torban, Mikhail; Krupitsky, Evgeny; Ilyuk, Ruslan; Kozlov, Andrei; Heimer, Robert

2009-05-01

While overdose is a common cause of mortality among opioid injectors worldwide, little information exists on opioid overdoses or how context may influence overdose risk in Russia. This study sought to uncover social and structural aspects contributing to fatal overdose risk in St. Petersburg and assess prevention intervention feasibility. Twenty-one key informant interviews were conducted with drug users, treatment providers, toxicologists, police, and ambulance staff. Thematic coding of interview content was conducted to elucidate elements of the overdose risk environment. Several factors within St. Petersburg's environment were identified as shaping illicit drug users' risk behaviours and contributing to conditions of suboptimal response to overdose in the community. Most drug users live and experience overdoses at home, where family and home environment may mediate or moderate risk behaviours. The overdose risk environment is also worsened by inefficient emergency response infrastructure, insufficient cardiopulmonary or naloxone training resources, and the preponderance of abstinence-based treatment approaches to the exclusion of other treatment modalities. However, attitudes of drug users and law enforcement officials generally support overdose prevention intervention feasibility. Modifiable aspects of the risk environment suggest community-based and structural interventions, including overdose response training for drug users and professionals that encompasses naloxone distribution to the users and equipping more ambulances with naloxone. Local social and structural elements influence risk environments for overdose. Interventions at the community and structural levels to prevent and respond to opioid overdoses are needed for and integral to reducing overdose mortality in St. Petersburg.

Low expression of D2R and Wntless correlates with high motivation for heroin.

PubMed

Tacelosky, Diana M; Alexander, Danielle N; Morse, Megan; Hajnal, Andras; Berg, Arthur; Levenson, Robert; Grigson, Patricia S

2015-12-01

Drug overdose now exceeds car accidents as the leading cause of accidental death in the United States. Of those drug overdoses, a large percentage of the deaths are due to heroin and/or pharmaceutical overdose, specifically misuse of prescription opioid analgesics. It is imperative, then, that we understand the mechanisms that lead to opioid abuse and addiction. The rewarding actions of opioids are mediated largely by the mu-opioid receptor (MOR), and signaling by this receptor is modulated by various interacting proteins. The neurotransmitter dopamine also contributes to opioid reward, and opioid addiction has been linked to reduced expression of dopamine D2 receptors (D2R) in the brain. That said, it is not known if alterations in the expression of these proteins relate to drug exposure and/or to the "addiction-like" behavior exhibited for the drug. Here, we held total drug self-administration constant across acquisition and showed that reduced expression of the D2R and the MOR interacting protein, Wntless, in the medial prefrontal cortex was associated with greater addiction-like behavior for heroin in general and with a greater willingness to work for the drug in particular. In contrast, reduced expression of the D2R in the nucleus accumbens and hippocampus was correlated with greater seeking during signaled nonavailability of the drug. Taken together, these data link reduced expression of both the D2R and Wntless to the explicit motivation for the drug rather than to differences in total drug intake per se. (c) 2015 APA, all rights reserved).

Pattern and risk factors for intentional drug overdose in Saudi Arabia.

PubMed

Al-Jahdali, Hamdan; Al-Johani, Abdulaziz; Al-Hakawi, Ahmad; Arabi, Yassen; Ahmed, Qanta A; Altowirky, Jamal; Al Moamary, Mohamed; Binsalih, Salih

2004-05-01

Attempted suicide by intentional drug overdose is an understudied subject in Saudi Arabia. Saudi Arabia is an Islamic country where suicide or attempted suicide is strictly prohibited. Despite the strong religious and constitutional sanctions against suicide, cases of intentional drug overdose occasionally occur. Our study represents the first attempt to better understand and characterize this sensitive topic. Using a retrospective chart review of patients aged 12 years and over with a diagnosis of intentional drug overdose between 1997 and 1999, we studied the demographic characteristics, the risk factors, the most commonly used drugs, and the resulting morbidities and mortalities of study subjects. Most of the patients were young (mean age 22 years, SD 4.6, range 15 to 40 years), and most were Saudi nationals (n = 76; 96%). Eighty percent of the patients were women. The occurrence of intentional drug overdose peaked during the month of September (that is, 20% of total cases). Previous suicide attempts, family conflicts, and psychiatric disorders represented significant risk factors. Single-agent overdose occurred in 30% of the patients, and most of the drugs used were prescribed medications (53%). Acetaminophen represented the most common drug (30%). While some patients required prolonged hospital stay or admission to the intensive care unit, no mortalities occurred. Intentional drug overdose is a relatively uncommon reason for hospital admission in Saudi Arabia. This study identifies certain risk factors relevant to the Saudi community and raises awareness about intentional drug overdose.

Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics: considerations for palliative care practice.

PubMed

Gudin, Jeffrey

2012-06-01

Prescription opioid analgesics are an essential treatment option for patients with moderate to severe pain. Over the last decade the increased medical use of these agents has contributed to a public health epidemic of abuse, addiction, and overdose-related deaths. These medications remain mainstays in both primary care and pain management practices. As palliative services are incorporated at earlier stages of the disease process and the number of individuals with chronic illness increases, palliative care specialists may encounter an increasing number of patients with opioid abuse and addiction problems. Extended-release (ER) and long-acting (LA) opioid formulations are administered to patients with moderate to severe chronic pain requiring around-the-clock analgesia. Given the large quantity of active ingredient contained within some dosage strengths, this medication class is associated with serious risks when taken improperly. In response to growing reports of abuse and overdose deaths, the US Food and Drug Administration (FDA) announced the need for a risk mitigation strategy for the entire class of medication. The class-wide Risk Evaluation and Mitigation Strategy (REMS) for ER/LA opioids will emphasize prescriber training and patient education to ensure that the therapeutic benefits outweigh the risks of addiction, unintentional overdose, and death. As primary care, pain management, and palliative care clinicians often encounter patients who require ER/LA opioids, an understanding of the suggested requirements and potential impact of this regulation is essential.

Gender and geographical inequalities in fatal drug overdose in Iran: A province-level study in 2006 and 2011.

PubMed

Rostami, Mehran; Karamouzian, Mohammad; Khosravi, Ardeshir; Rezaeian, Shahab

2018-06-01

We aimed to compare the fatal drug overdose rates in Iran in 2006 and 2011. This analysis was performed based on data on fatal drug overdose cases from the Iranian death registration system. The crude and adjusted rates per 100,000 populations for geographical regions stratified by gender and age groups were calculated using the 2006 and 2011 census of Iranian population. Annual percentage change was calculated to examine annual changes of fatal drug overdose rates across different regions. The overall age-adjusted rate of fatal drug overdose decreased from 3.62 in 2006 to 2.77 in 2011. A substantial difference in the distribution of fatal drug overdoses was found across geographical regions by gender and age groups. Rates of fatal drug overdose were higher among Iranian men and in both younger and older age groups which call for scaling up harm reduction and increasing access to gender- and age-specific substance use treatment services. Copyright © 2018 Elsevier Ltd. All rights reserved.

The effect of state laws designed to prevent nonmedical prescription opioid use on overdose deaths and treatment.

PubMed

Popovici, Ioana; Maclean, Johanna Catherine; Hijazi, Bushra; Radakrishnan, Sharmini

2018-02-01

Nonmedical use of prescription opioids has reached epidemic levels in the United States and globally. In response, federal, state, and local governments are taking actions to address substantial increases in prescription opioid addiction and its associated harms. This study examines the effect of two state laws specifically designed to curtail access to prescription opioids to nonmedical users: pain management clinic and doctor shopping laws. We use administrative data on overdose deaths and admissions to specialty substance use disorder treatment coupled with a differences-in-differences design. Our findings suggest that both pain management clinic and doctor shopping laws have the potential to reduce prescription opioid overdose deaths. Moreover, doctor shopping laws appear to reduce prescription opioid treatment admissions. As many states have adopted these laws in recent years, the full effects of the laws may not yet be realized. Future research using more postlaw passage data should reevaluate the effectiveness of these laws. Copyright © 2017 John Wiley & Sons, Ltd.

Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts.

PubMed

Rose, Mark Edmund

2018-04-01

Sharp increases in opioid prescriptions, and associated increases in overdose deaths in the 2000s, evoked widespread calls to change perceptions of opioid analgesics. Medical literature discussions of opioid analgesics began emphasizing patient and public health hazards. Repetitive exposure to this information may influence physician assumptions. While highly consequential to patients with pain whose function and quality of life may benefit from opioid analgesics, current assumptions about prescription opioid analgesics, including their role in the ongoing opioid overdose epidemic, have not been scrutinized. Information was obtained by searching PubMed, governmental agency websites, and conference proceedings. Opioid analgesic prescribing and associated overdose deaths both peaked around 2011 and are in long-term decline; the sharp overdose increase recorded in 2014 was driven by illicit fentanyl and heroin. Nonmethadone prescription opioid analgesic deaths, in the absence of co-ingested benzodiazepines, alcohol, or other central nervous system/respiratory depressants, are infrequent. Within five years of initial prescription opioid misuse, 3.6% initiate heroin use. The United States consumes 80% of the world opioid supply, but opioid access is nonexistent for 80% and severely restricted for 4.1% of the global population. Many current assumptions about opioid analgesics are ill-founded. Illicit fentanyl and heroin, not opioid prescribing, now fuel the current opioid overdose epidemic. National discussion has often neglected the potentially devastating effects of uncontrolled chronic pain. Opioid analgesic prescribing and related overdoses are in decline, at great cost to patients with pain who have benefited or may benefit from, but cannot access, opioid analgesic therapy.

Prescription drug abuse: problem, policies, and implications.

PubMed

Phillips, Janice

2013-01-01

This article provides an overview on prescription drug abuse and highlights a number of related legislative bills introduced during the 112th Congress in response to this growing epidemic. Prescription drug abuse has emerged as the nation's fastest growing drug problem. Although prescription drugs have been used effectively and appropriately for decades, deaths from prescription pain medicine in particular have reached epidemic proportions. Bills related to prescription drug abuse introduced during the 112th Congress focus on strengthening provider and consumer education, tracking and monitoring prescription drug abuse, improving data collection on drug overdose fatalities, combating fraud and abuse in Medicare and Medicaid programs, reclassifying drugs to make them more difficult to prescribe and obtain, and enforcing stricter penalties for individuals who operate scam pain clinics and sell pain pills illegitimately. This article underscores the importance of a multifaceted approach to combating prescription drug abuse and concludes with implications for nursing. Copyright © 2013. Published by Mosby, Inc.

Psychosocial and contextual correlates of opioid overdose risk among drug users in St. Petersburg, Russia.

PubMed

Grau, Lauretta E; Green, Traci C; Torban, Mikhail; Blinnikova, Ksenia; Krupitsky, Evgeny; Ilyuk, Ruslan; Kozlov, Andrei P; Heimer, Robert

2009-07-24

Opioid overdose in Russia is a problem that has grown more severe as heroin abuse expanded over the past decade, yet few studies have explored it in detail. In order to gain a clearer understanding of the situation, 60 drug users, both in and out of drug treatment in St. Petersburg, were interviewed concerning their overdose experience and knowledge about overdose recognition and prevention. Using a semi-structured interview, we sought to identify and describe local attitudes, knowledge and experience (both self-sustained and witnessed) of opioid overdose. Bi-variate and multiple logistic regressions were performed in order to identify the relationship between overdose experience and sociodemographic factors, risk behaviors, and clinical psychiatric measures. We found that having experienced or witnessed an opioid overdose within the previous year was common, overdose knowledge was generally high, but nearly half the participants reported low self-efficacy for effectively intervening in an overdose situation. In bivariate analyses, self-reported family problems (i.e., perceived problematic family interactions) were positively associated with both experiencing (t56 = 2.49; p < 0.05) and with witnessing a greater number of overdoses in the previous year (rhos = 0.31; p < 0.05). Having previously overdosed [Adjusted Risk Ratio (ARR) 1.7, 95% Confidence Interval (CI) 1.1-2.6] and higher SCL-90-R somatization scores (ARR 1.2, 95% CI 0.96 - 1.5) were independently associated in multivariable analyses with self-sustained overdose experience in the past year. Greater perceived likelihood of experiencing a future overdose and concern about medical problems were independently associated with witnessing a higher number of overdoses within the previous year. Over two thirds of the participants expressed interest in receiving training in overdose prevention and response. Opioid overdose experience is very common among drug users in St. Petersburg, Russia, and interest in receiving training for overdose recognition and prevention was high. Future research should target the development of effective overdose recognition and prevention interventions, especially ones that include naloxone distribution and involve drug users' families.

A decline in the prevalence of injecting drug users in Estonia, 2005–2009

PubMed Central

Uusküla, A; Rajaleid, K; Talu, A; Abel-Ollo, K; Des Jarlais, DC

2013-01-01

Aims and setting Descriptions of behavioural epidemics have received little attention compared with infectious disease epidemics in Eastern Europe. Here we report a study aimed at estimating trends in the prevalence of injection drug use between 2005 and 2009 in Estonia. Design and methods The number of injection drug users (IDUs) aged 15–44 each year between 2005 and 2009 was estimated using capture-recapture methodology based on 4 data sources (2 treatment data bases: drug abuse and non-fatal overdose treatment; criminal justice (drug related offences) and mortality (injection drug use related deaths) data). Poisson log-linear regression models were applied to the matched data, with interactions between data sources fitted to replicate the dependencies between the data sources. Linear regression was used to estimate average change over time. Findings there were 24305, 12292, 238, 545 records and 8100, 1655, 155, 545 individual IDUs identified in the four capture sources (Police, drug treatment, overdose, and death registry, accordingly) over the period 2005 – 2009. The estimated prevalence of IDUs among the population aged 15–44 declined from 2.7% (1.8–7.9%) in 2005 to 2.0% (1.4–5.0%) in 2008, and 0.9% (0.7–1.7%) in 2009. Regression analysis indicated an average reduction of over 1700 injectors per year. Conclusion While the capture-recapture method has known limitations, the results are consistent with other data from Estonia. Identifying the drivers of change in the prevalence of injection drug use warrants further research. PMID:23290632

Suicide by means of opioid overdose in patients with chronic pain.

PubMed

Madadi, Parvaz; Persaud, Nav

2014-11-01

Deaths from prescription opioid use continue to rise in North America. The main focus to date has been developing strategies to prevent nonintentional (accidental) fatalities, which constitute the majority of opioid deaths across all jurisdictions. Often overlooked is the complex group of individuals whose cause of death was suicide by opioid overdose. Although most opioid prescribing tools focus on identifying risk factors for potential abuse, diversion, and propensity for opioid addiction, physicians who consider prescribing opioids should also screen and optimize chronic pain treatment for patients at risk for suicide.

Circumstances and witness characteristics associated with overdose fatality

PubMed Central

Bohnert, Amy S.B.; Tracy, Melissa; Galea, Sandro

2009-01-01

Objective Emergency physicians have an opportunity to provide overdose fatality prevention interventions to individuals at risk for experiencing or witnessing an overdose to reduce fatality. The present study uses data about the most recent overdose observed by a sample of inner-city drug users to determine the circumstances of overdose that are associated with overdose fatality. Methods Participants (n = 690), age 18+, were recruited using targeted street outreach. All participants had used heroin and/or cocaine in the prior 2 months, and had witnessed at least one overdose. Survey data included the circumstances of the last overdose witnessed, including actions taken, drug use behavior, the location of the event, and whether or not the overdose was fatal (the outcome measure). Results 152 (21.7%) of the witnessed overdoses were fatal. Witness powder cocaine use (Adjusted Odds Ratio [AOR] = 1.64, 95% Confidence Interval [CI] 1.03–2.60) and injection drug history (AOR = 0.55, 95% CI 0.32–0.90) were associated with the last witnessed overdose being fatal. Witnessed overdoses that occurred in public or abandoned buildings, compared to homes, were more likely to be fatal (AOR = 1.90, 95% CI 1.03–3.02), as were overdoses where witnesses sought outside medical help (AOR = 1.46, 95% CI 1.01–2.13). Conclusions Future prevention interventions may fruitfully target users of powder cocaine, drug users without a history of injecting, and individuals who use drugs in public or abandoned buildings for brief interventions on responding when witnessing an overdose to reduce mortality. PMID:19540622

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility.

PubMed

Irwin, Amos; Jozaghi, Ehsan; Weir, Brian W; Allen, Sean T; Lindsay, Andrew; Sherman, Susan G

2017-05-12

In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Overdose and adverse drug event experiences among adult patients in the emergency department.

PubMed

Bohnert, Amy S B; Walton, Maureen A; Cunningham, Rebecca M; Ilgen, Mark A; Barry, Kristen; Chermack, Stephen T; Blow, Frederic C

2017-11-16

Overdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk. Patients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011-2013 (n=4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent. 12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs=1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p<0.05). Most overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users. Published by Elsevier Ltd.

Preventing death among the recently incarcerated: an argument for naloxone prescription before release.

PubMed

Wakeman, Sarah E; Bowman, Sarah E; McKenzie, Michelle; Jeronimo, Alexandra; Rich, Josiah D

2009-01-01

Death from opiate overdose is a tremendous source of mortality, with a heightened risk in the weeks following incarceration. The goal of this study is to assess overdose experience and response among long-term opiate users involved in the criminal justice system. One hundred thirty-seven subjects from a project linking opiate-dependent individuals being released from prison with methadone maintenance programs were asked 73 questions regarding overdose. Most had experienced and witnessed multiple overdoses; 911 was often not called. The majority of personal overdoses occurred within 1 month of having been institutionalized. Nearly all participants expressed an interest in being trained in overdose prevention with Naloxone. The risk of death from overdose is greatly increased in the weeks following release from prison. A pre-release program of overdose prevention education, including Naloxone prescription, for inmates with a history of opiate addiction would likely prevent many overdose deaths.

Social and structural aspects of the overdose risk environment in St. Petersburg, Russia

PubMed Central

Grau, Lauretta E.; Blinnikova, Ksenia N.; Torban, Mikhail; Krupitsky, Evgeny; Ilyuk, Ruslan; Kozlov, Andrei; Heimer, Robert

2009-01-01

Background While overdose is a common cause of mortality among opioid injectors worldwide, little information exists on opioid overdoses or how context may influence overdose risk in Russia. This study sought to uncover social and structural aspects contributing to fatal overdose risk in St. Petersburg and assess prevention intervention feasibility. Methods Twenty-one key informant interviews were conducted with drug users, treatment providers, toxicologists, police, and ambulance staff. Thematic coding of interview content was conducted to elucidate elements of the overdose risk environment. Results Several factors within St. Petersburg’s environment were identified as shaping illicit drug users’ risk behaviors and contributing to conditions of suboptimal response to overdose in the community. Most drug users live and experience overdoses at home, where family and home environment may mediate or moderate risk behaviors. The overdose risk environment is also worsened by inefficient emergency response infrastructure, insufficient cardiopulmonary or naloxone training resources, and the preponderance of abstinence-based treatment approaches to the exclusion of other treatment modalities. However, attitudes of drug users and law enforcement officials generally support overdose prevention intervention feasibility. Modifiable aspects of the risk environment suggest community-based and structural interventions, including overdose response training for drug users and professionals that encompasses naloxone distribution to the users and equipping more ambulances with naloxone. Conclusion Local social and structural elements influence risk environments for overdose. Interventions at the community and structural levels to prevent and respond to opioid overdoses are needed for and integral to reducing overdose mortality in St. Petersburg. PMID:18774283

DRUG USE PATTERNS PREDICT RISK OF NON-FATAL OVERDOSE AMONG STREET-INVOLVED YOUTH IN A CANADIAN SETTING

PubMed Central

Mitra, Goldis; Wood, Evan; Nguyen, Paul; Kerr, Thomas; DeBeck, Kora

2015-01-01

Background Non-fatal drug overdose is a major cause of morbidity among people who use drugs, although few studies have examined this risk among street-involved youth. We sought to determine the risk factors associated with non-fatal overdose among Canadian street-involved youth who reported illicit drug use. Methods Using data from a prospective cohort of street-involved youth in Vancouver, Canada, we identified youth without a history of overdose and employed Cox regression analyses to determine factors associated with time to non-fatal overdose between September 2005 and May 2012. Results Among 615 participants, 98 (15.9%) reported a non-fatal overdose event during follow-up, resulting in an incidence density of 7.67 cases per 100 person-years. In multivariate Cox regression analyses, binge drug use (adjusted hazard ratio [AHR] = 1.85; 95% confidence interval [CI] = 1.20 – 2.84), non-injection crystal methamphetamine use (AHR = 1.70; 95% CI = 1.12 – 2.58), non-injection prescription opiate use (AHR = 2.56; 95% CI = 1.36 – 4.82), injection prescription opiate use (AHR = 2.49; 95% CI = 1.40 – 4.45) and injection heroin use (AHR = 1.85; 95% CI = 1.14 – 3.00) were positively associated with time to non-fatal overdose. Social, behavioural and demographic factors were not significantly associated with time to non-fatal overdose event. Conclusions Rates of non-fatal overdose were high among street-involved youth. Drug use patterns, in particular prescription opiate use, were associated with overdose. These findings underscore the importance of addiction treatment and prevention efforts aimed at reducing the risk of overdose among youth. PMID:26096535

The Rhode Island community responds to opioid overdose deaths.

PubMed

Bowman, Sarah; Engelman, Ariel; Koziol, Jennifer; Mahoney, Linda; Maxwell, Christopher; McKenzie, Michelle

2014-10-01

The challenge of addressing the epidemic of opioid overdose in Rhode Island, and nationwide, is only possible through collaborative efforts among a wide breadth of stakeholders. This article describes the range of efforts by numerous partners that have come together to facilitate community, and treatment-related approaches to address opioid-involved overdose and substance use disorder. Strategies to address this crisis have largely focused on increasing access both to the opioid overdose antidote naloxone and to high quality and timely treatment and recovery services. [Full text available at http://rimed.org/rimedicaljournal-2014-10.asp, free with no login].

Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors.

PubMed

Binswanger, Ingrid A; Nowels, Carolyn; Corsi, Karen F; Glanz, Jason; Long, Jeremy; Booth, Robert E; Steiner, John F

2012-01-01

Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners. This qualitative study included former prison inmates (N=29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis. The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family. Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.

Circumstances and toxicology of sudden or unnatural deaths involving alprazolam.

PubMed

Darke, Shane; Torok, Michelle; Duflou, Johan

2014-05-01

There has been a great deal of clinical concern regarding alprazolam abuse. This paper reported on alprazolam positive cases of sudden or unnatural deaths presenting to the New South Wales Department of Forensic Medicine (DOFM), 1/1/1997-31/12/2012. Case series. 412 cases were identified. There was a large increase in the annual number of cases, from 3 in 1997 to 86 in 2012. By 2012, 4.5% of all DOFM case presentations involved alprazolam. The mean age was 41.3 years, and 66.5% were male. Circumstances of death were: accidental drug toxicity (57.0%), deliberate drug toxicity (10.4%), suicide by means other than drug overdose (12.6%), disease (10.0%), accident (5.1%), homicide (2.4%). The major factor driving the increase in cases was accidental drug toxicity involving alprazolam, rising from 0 in 1997 to 58 in 2012. A history of drug/alcohol problems was noted in 80.4%, and 56.6% were injecting drug users. The median alprazolam concentration was 0.08 mg/L (range 0.005-2.10mg/L), with 37.4% of cases having concentrations of ≥ 0.1 mg/L. In 94.9% of cases, drugs other than alprazolam and its metabolites were present, including all accidental overdoses. The most commonly detected drugs were opioids (64.6%), other benzodiazepines (44.4%) and alcohol (34.5%). A third (31.8%) of cases were HCV positive. Cases involving alprazolam increased markedly, driven mostly by toxicity deaths amongst people with known drug and alcohol problems. Caution in prescribing alprazolam would appear appropriate, particularly to those with known drug dependence. Copyright © 2014. Published by Elsevier Ireland Ltd.

Missed paracetamol (acetaminophen) overdose due to confusion regarding drug names.

PubMed

Hewett, David G; Shields, Jennifer; Waring, W Stephen

2013-07-01

Immediate management of drug overdose relies upon the patient account of what was ingested and how much. Paracetamol (acetaminophen) is involved in around 40% of intentional overdose episodes, and remains the leading cause of acute liver failure in many countries including the United Kingdom. In recent years, consumers have had increasing access to medications supplied by international retailers via the internet, which may have different proprietary or generic names than in the country of purchase. We describe a patient that presented to hospital after intentional overdose involving 'acetaminophen' purchased via the internet. The patient had difficulty recalling the drug name, which was inadvertently attributed to 'Advil', a proprietary non-steroidal anti-inflammatory drug. The error was later recognised when the drug packaging became available, but the diagnosis of paracetamol overdose and initiation of acetylcysteine antidote were delayed. This case illustrates the benefit of routinely measuring paracetamol concentrations in all patients with suspected poisoning, although this is not universally accepted in practice. Moreover, it highlights the importance of the internet as a source of medications for intentional overdose, and emphasises the need for harmonisation of international drug names to improve patient safety.

Ethanol Reversal of Tolerance to the Respiratory Depressant Effects of Morphine

PubMed Central

Hill, Rob; Lyndon, Abi; Withey, Sarah; Roberts, Joanne; Kershaw, Yvonne; MacLachlan, John; Lingford-Hughes, Anne; Kelly, Eamonn; Bailey, Chris; Hickman, Matthew; Henderson, Graeme

2016-01-01

Opioids are the most common drugs associated with unintentional drug overdose. Death results from respiratory depression. Prolonged use of opioids results in the development of tolerance but the degree of tolerance is thought to vary between different effects of the drugs. Many opioid addicts regularly consume alcohol (ethanol), and post-mortem analyses of opioid overdose deaths have revealed an inverse correlation between blood morphine and ethanol levels. In the present study, we determined whether ethanol reduced tolerance to the respiratory depressant effects of opioids. Mice were treated with opioids (morphine, methadone, or buprenorphine) for up to 6 days. Respiration was measured in freely moving animals breathing 5% CO2 in air in plethysmograph chambers. Antinociception (analgesia) was measured as the latency to remove the tail from a thermal stimulus. Opioid tolerance was assessed by measuring the response to a challenge dose of morphine (10 mg/kg i.p.). Tolerance developed to the respiratory depressant effect of morphine but at a slower rate than tolerance to its antinociceptive effect. A low dose of ethanol (0.3 mg/kg) alone did not depress respiration but in prolonged morphine-treated animals respiratory depression was observed when ethanol was co-administered with the morphine challenge. Ethanol did not alter the brain levels of morphine. In contrast, in methadone- or buprenorphine-treated animals no respiratory depression was observed when ethanol was co-administered along with the morphine challenge. As heroin is converted to morphine in man, selective reversal of morphine tolerance by ethanol may be a contributory factor in heroin overdose deaths. PMID:26171718

Chronic Pain, Chronic Opioid Addiction: a Complex Nexus.

PubMed

Salsitz, Edwin A

2016-03-01

Over the past two decades, there has been a significant increase in the prescribing of opioids, with associated increases in opioid addiction and overdose deaths. This article reviews the evidence for the effectiveness and risk of developing an opioid use disorder (OUD) in those patients treated with chronic opioid therapy (COT) for chronic non-cancer pain (CNCP). Rates of development of OUD range from 0-50 %, and aberrant drug related behaviors (ADRBs) are reported to be 20 %. Health care providers must properly assess, screen, and carefully monitor patients on COT utilizing evidence-based tools.

The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study.

PubMed

Durand, Christine M; Bowring, Mary G; Thomas, Alvin G; Kucirka, Lauren M; Massie, Allan B; Cameron, Andrew; Desai, Niraj M; Sulkowski, Mark; Segev, Dorry L

2018-05-15

The epidemic of drug overdose deaths in the United States has led to an increase in organ donors. To characterize donors who died of overdose and to analyze outcomes among transplant recipients. Prospective observational cohort study. Scientific Registry of Transplant Recipients, 1 January 2000 to 1 September 2017. 138 565 deceased donors; 337 934 transplant recipients at 297 transplant centers. The primary exposure was donor mechanism of death (overdose-death donor [ODD], trauma-death donor [TDD], or medical-death donor [MDD]). Patient and graft survival and organ discard (organ recovered but not transplanted) were compared using propensity score-weighted standardized risk differences (sRDs). A total of 7313 ODDs and 19 897 ODD transplants (10 347 kidneys, 5707 livers, 2471 hearts, and 1372 lungs) were identified. Overdose-death donors accounted for 1.1% of donors in 2000 and 13.4% in 2017. They were more likely to be white (85.1%), aged 21 to 40 years (66.3%), infected with hepatitis C virus (HCV) (18.3%), and increased-infectious risk donors (IRDs) (56.4%). Standardized 5-year patient survival was similar for ODD organ recipients compared with TDD organ recipients (sRDs ranged from 3.1% lower to 3.9% higher survival) and MDD organ recipients (sRDs ranged from 2.1% to 5.2% higher survival). Standardized 5-year graft survival was similar between ODD and TDD grafts (minimal difference for kidneys and lungs, marginally lower [sRD, -3.2%] for livers, and marginally higher [sRD, 1.9%] for hearts). Kidney discard was higher for ODDs than TDDs (sRD, 5.2%) or MDDs (sRD, 1.5%); standardization for HCV and IRD status attenuated this difference. Inability to distinguish between opioid and nonopioid overdoses. In the United States, transplantation with ODD organs has increased dramatically, with noninferior outcomes in transplant recipients. Concerns about IRD behaviors and hepatitis C among donors lead to excess discard that should be minimized given the current organ shortage. National Institutes of Health.

Psychosocial and contextual correlates of opioid overdose risk among drug users in St. Petersburg, Russia

PubMed Central

Grau, Lauretta E; Green, Traci C; Torban, Mikhail; Blinnikova, Ksenia; Krupitsky, Evgeny; Ilyuk, Ruslan; Kozlov, Andrei P; Heimer, Robert

2009-01-01

Background Opioid overdose in Russia is a problem that has grown more severe as heroin abuse expanded over the past decade, yet few studies have explored it in detail. In order to gain a clearer understanding of the situation, 60 drug users, both in and out of drug treatment in St. Petersburg, were interviewed concerning their overdose experience and knowledge about overdose recognition and prevention. Methods Using a semi-structured interview, we sought to identify and describe local attitudes, knowledge and experience (both self-sustained and witnessed) of opioid overdose. Bi-variate and multiple logistic regressions were performed in order to identify the relationship between overdose experience and sociodemographic factors, risk behaviors, and clinical psychiatric measures. Results We found that having experienced or witnessed an opioid overdose within the previous year was common, overdose knowledge was generally high, but nearly half the participants reported low self-efficacy for effectively intervening in an overdose situation. In bivariate analyses, self-reported family problems (i.e., perceived problematic family interactions) were positively associated with both experiencing (t56 = 2.49; p < 0.05) and with witnessing a greater number of overdoses in the previous year (rhos = 0.31; p < 0.05). Having previously overdosed [Adjusted Risk Ratio (ARR) 1.7, 95% Confidence Interval (CI) 1.1–2.6] and higher SCL-90-R somatization scores (ARR 1.2, 95% CI 0.96 – 1.5) were independently associated in multivariable analyses with self-sustained overdose experience in the past year. Greater perceived likelihood of experiencing a future overdose and concern about medical problems were independently associated with witnessing a higher number of overdoses within the previous year. Over two thirds of the participants expressed interest in receiving training in overdose prevention and response. Conclusion Opioid overdose experience is very common among drug users in St. Petersburg, Russia, and interest in receiving training for overdose recognition and prevention was high. Future research should target the development of effective overdose recognition and prevention interventions, especially ones that include naloxone distribution and involve drug users' families. PMID:19630963

Drug-related deaths and the sales of needles through pharmacies

PubMed Central

Davidson, Peter J.; Martinez, Alexis; Lutnick, Alexandra; Kral, Alex H.; Bluthenthal, Ricky N.

2014-01-01

Background Providing needles to people who inject drugs is a well-proven public health response to the transmission of HIV and other blood borne viruses. Despite over a quarter of a century of research, new concerns about potential unintended negative consequences of needle distribution continue to emerge. Specifically, a claim was recently made that the introduction of pharmacy sales of needles was followed by an increase in overdoses in pharmacy parking lots. If true, this would have serious implications for the design of needle access programs, particularly those involving pharmacy sales of needles. Methods We examine spatial relationships between drug-related deaths and pharmacies in Los Angeles County (population 9·8 million) before and after the 2007 enactment of a California law allowing pharmacy sales of needles without a prescription. 7,049 drug related deaths occurred in Los Angeles county from 2000-2009 inclusive. 4,275 of these deaths could be geocoded, and were found to be clustered at the census tract level. Results We used three methods to examine spatial relationships between overdose death locations and pharmacy locations for two years on either side of the enactment of the pharmacy sales law, and found no statistically significant changes. Among the 711 geocodable deaths occurring in the two years following the change in law, no death was found to occur within 50 meters of a pharmacy which sold needles. Conclusion These results are consistent with prior studies which suggest pharmacy sales of needles improve access to needles without causing increased harms to the surrounding community. PMID:25499730

Programmatic Impact of 5 Years of Mortality Surveillance of New York City Homeless Populations

PubMed Central

Marder, Dova; Begier, Elizabeth; Gutkovich, Alexander; Mos, Robert; Griffin, Angela; Zimmerman, Regina; Madsen, Ann

2013-01-01

A homeless mortality surveillance system identifies emerging trends in the health of the homeless population and provides this information to key stakeholders in a timely and ongoing manner to effect evidence-based, programmatic change. We describe the first 5 years of the New York City homeless mortality surveillance system and, for the first time in peer-reviewed literature, illustrate the impact of key elements of sustained surveillance (i.e., timely dissemination of aggregate mortality data and real-time sharing of information on individual homeless decedents) on the programs of New York City’s Department of Homeless Services. These key elements had a positive impact on the department’s programs that target sleep-related infant deaths and hypothermia, drug overdose, and alcohol-related deaths among homeless persons. PMID:24148068

A prospective cohort study of non-fatal accidental overdose among street youth: the link with suicidal ideation.

PubMed

Richer, Isabelle; Bertrand, Karine; Vandermeerschen, Jill; Roy, Elise

2013-07-01

Drug overdose and suicide are the two leading causes of death among street youth. The literature discusses the two faces of drug overdose: accidental act and suicide attempt. Some authors have stated that accidental overdoses may be a hidden expression of suicidal ideation. This study longitudinally examined the relationship between recent suicidal ideations and non-fatal accidental drug overdoses among street youth. Between July 2001 and December 2005, 858 street youth (14-23 years old) were recruited for a prospective cohort study. Youth were eligible if, in the previous year, they had been without a place to sleep more than once or had used the services of street youth agencies on a regular basis (≥3). Participants completed baseline questionnaires and follow-up interviews were carried out every 6 months. Mixed-effect logistic regression models were conducted. Apart from suicidal ideation and accidental drug overdose, variables considered in the model were age, sex, problematic alcohol use, homelessness, injection drug use and polydrug use (≥3 drugs). Accidental drug overdose was significantly associated with suicidal ideation (adjusted odds ratio 1.88; 95% confidence interval 1.23-2.54). Homelessness, injection drug use and polydrug use were also significant in the final model. Results show that, during follow up, suicidal ideation independently increased risks of accidental overdose. They also underscore the need for interventions beyond educational prevention. Primary care practitioners should investigate suicidal ideations and behaviours of street youth in treatment for accidental overdose. © 2012 Australasian Professional Society on Alcohol and other Drugs.

Data Overview: Overview of an Epidemic

MedlinePlus

... the Epidemic Commonly Used Terms Prescription Opioids Heroin Fentanyl Data Opioid Data Analysis Drug Overdose Death Data ... Overdose Data Heroin Overdose Data Synthetic Opioid Data Fentanyl Encounters Data Overdose Prevention Improve Opioid Prescribing Prevent ...

Drug checking: a potential solution to the opioid overdose epidemic?

PubMed

Bardwell, Geoff; Kerr, Thomas

2018-05-25

North America is experiencing an overdose epidemic driven in part by the proliferation of illicitly-manufactured fentanyl and related analogues. In response, communities are scaling up novel overdose prevention interventions. Included are drug checking technologies. Drug checking technologies aim to identify the contents of illicit drugs. These technologies vary considerably in terms of cost, accuracy, and usability, and while efforts are now underway to implement drug checking programs for people who inject drugs, there remains a lack of rigorous evaluation of their impacts. Given the ongoing overdose crisis and the urgent need for effective responses, research on drug checking should be prioritized. However, while such research should be supported, it should be completed before these technologies are widely implemented.

Department of Defense Suicide Event Report (DoDSER) Calendar Year 2010 Annual Report

DTIC Science & Technology

2011-09-01

n = 69, 24.56%). Drug overdose was the most frequent method for suicide attempt (n = 496, 57.47%), followed by injury with a sharp or blunt object...who died by suicide were non-military issue firearm use and hanging. Suicide attempt methods were most often drug overdose , harming oneself with a...military issue firearm use. Suicide attempt methods were most often drug overdose and use of military issue firearm. Drug and alcohol use was less

Randomized controlled pilot trial of naloxone‐on‐release to prevent post‐prison opioid overdose deaths

PubMed Central

Parmar, Mahesh K. B.; Strang, John; Choo, Louise; Meade, Angela M.

2016-01-01

Abstract Background and Aims Naloxone is an opioid antagonist used for emergency resuscitation following opioid overdose. Prisoners with a history of heroin injection have a high risk of drug‐related death soon after release from prison. The NALoxone InVEstigation (N‐ALIVE) pilot trial (ISRCTN34044390) tested feasibility measures for randomized provision of naloxone‐on‐release (NOR) to eligible prisoners in England. Design. Parallel‐group randomized controlled pilot trial. Setting English prisons. Participants A total of 1685 adult heroin injectors, incarcerated for at least 7 days pre‐randomization, release due within 3 months and more than 6 months since previous N‐ALIVE release. Intervention Using 1 : 1 minimization, prisoners were randomized to receive on release a pack containing either a single ‘rescue’ injection of naloxone or a control pack with no syringe. Measurements Key feasibility outcomes were tested against prior expectations: on participation (14 English prisons; 2800 prisoners), consent (75% for randomization), returned prisoner self‐questionnaires (RPSQs: 207), NOR‐carriage (75% in first 4 weeks) and overdose presence (80%). Findings Prisons (16) and prisoners (1685) were willing to participate [consent rate, 95% confidence interval (CI) = 70–74%]; 218 RPSQs were received; NOR‐carriage (95% CI = 63–79%) and overdose presence (95% CI = 75–84%) were as expected. We randomized 842 to NOR and 843 to control during 30 months but stopped early, because only one‐third of NOR administrations were to the ex‐prisoner. Nine deaths within 12 weeks of release were registered for 1557 randomized participants released before 9 December 2014. Conclusions Large randomized trials are feasible with prison populations. Provision of take‐home emergency naloxone prior to prison release may be a life‐saving interim measure to prevent heroin overdose deaths among ex‐prisoners and the wider population. PMID:27776382

Heroin overdose

MedlinePlus

... 156. National Institute on Drug Abuse website. Overdose death rates. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates . Updated January 2017. Accessed August 15, 2017. Zosel ...

Fentanyls: Are we missing the signs? Highly potent and on the rise in Europe.

PubMed

Mounteney, Jane; Giraudon, Isabelle; Denissov, Gleb; Griffiths, Paul

2015-07-01

Fentanyl is a synthetic opioid analgesic historically used as a pain reliever and an anaesthetic. Recent concerns have arisen around the illicit use of fentanyl and its analogues in a number of European countries, linked to their high potency and associated risk of fatal overdose. Evidence has been emerging from Estonia for over a decade of entrenched patterns of fentanyl use, including injection of the drug and hundreds of overdose deaths. More recently, reports indicate that both fentanyl and 3-methylfentanyl (TMF) have been marketed as a replacement for heroin in European countries (e.g. Bulgaria, Slovakia) affected by heroin shortages. In addition, Germany, Finland and the United Kingdom, reported new outbreaks of fentanyl-related deaths. This combination of increasing mortality data alongside law enforcement intelligence suggesting both diversion and illicit production of fentanyls, prompted wider investigation using a targeted multi-source data collection exercise and analysis. This identified that in the European context, fentanyls are 'low use but high risk/harm' substances. Evidence shows that Estonia stands out as having an endemic problem, while the use of fentanyls in other European countries appears to be geographically localised. Developments in illicit supply of fentanyls reflect the complexity of Europe's contemporary drug market: manifesting illicit production and use, the diversion and misuse of medicines, and the online sale of non-controlled new psychoactive substances. Likewise effective and integrated responses will need to address fentanyl production, diversion as well as ensuring the availability of harm reduction measures to users. Copyright © 2015 Elsevier B.V. All rights reserved.

Cologne poisoning

MedlinePlus

... Winchester's Clinical Management of Poisoning and Drug Overdose . 4th ed. Philadelphia, PA: Elsevier Saunders; 2007:chap 100. ... Winchester's Clinical Management of Poisoning and Drug Overdose . 4th ed. Philadelphia, PA: Elsevier Saunders; 2007:chap 32. ...

Addressing excess risk of overdose among recently incarcerated people in the USA: harm reduction interventions in correctional settings.

PubMed

Brinkley-Rubinstein, Lauren; Cloud, David H; Davis, Chelsea; Zaller, Nickolas; Delany-Brumsey, Ayesha; Pope, Leah; Martino, Sarah; Bouvier, Benjamin; Rich, Josiah

2017-03-13

Purpose The purpose of this paper is to discuss overdose among those with criminal justice experience and recommend harm reduction strategies to lessen overdose risk among this vulnerable population. Design/methodology/approach Strategies are needed to reduce overdose deaths among those with recent incarceration. Jails and prisons are at the epicenter of the opioid epidemic but are a largely untapped setting for implementing overdose education, risk assessment, medication assisted treatment, and naloxone distribution programs. Federal, state, and local plans commonly lack corrections as an ingredient in combating overdose. Harm reduction strategies are vital for reducing the risk of overdose in the post-release community. Findings Therefore, the authors recommend that the following be implemented in correctional settings: expansion of overdose education and naloxone programs; establishment of comprehensive medication assisted treatment programs as standard of care; development of corrections-specific overdose risk assessment tools; and increased collaboration between corrections entities and community-based organizations. Originality/value In this policy brief the authors provide recommendations for implementing harm reduction approaches in criminal justice settings. Adoption of these strategies could reduce the number of overdoses among those with recent criminal justice involvement.

A mortality index for postmarketing surveillance of new medications.

PubMed

Rose, J C; Unis, A S

2000-03-01

The rate of introduction of new pharmaceuticals is growing as a result of advances in molecular pharmacology and targeted drug development. The Fatal Toxicity Index (FTI) has been proposed as a means for monitoring drug toxicity through post-marketing surveillance. The FTI requires data regarding the general availability of a particular agent in the community which, in the US, is proprietary. The authors propose a Mortality Index as an alternative method for calculating relative lethality that does not rely on proprietary information for postmarketing surveillance. Using data from the Toxic Exposure Surveillance System (TESS) a Mortality Index was calculated from the proportion of deaths occurring among all patients who present to a health care facility with an overdose on the same agent or class of agents. The average Mortality Index for various drugs or drug classes for the years 1989 to 1997 is reported. Because the Mortality Index for desipramine appeared much greater than that for the other tricyclics, a chi-squared analysis was performed. The authors conclude, based on this analysis, that desipramine is significantly more likely to lead to death after overdosage than any other tricyclic antidepressant in the study. Also, the Mortality Index appeared to identify the impact of pediatric formulations on overdose lethality. We conclude that the Mortality Index may be a useful tool for determining the safety of agents during the postmarketing surveillance phase.

The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting

PubMed Central

Pabayo, Roman; Alcantara, Carmela; Kawachi, Ichiro; Wood, Evan; Kerr, Thomas

2013-01-01

Objectives Non-fatal overdose remains a significant source of morbidity among people who inject drugs (IDU). Although depression and social support are important in shaping the health of IDU, little is known about the relationship between these factors and overdose. Therefore, we sought to determine whether depressive symptoms and social support predicted non-fatal overdose among IDU in a Canadian setting. Methods Data were derived from three prospective cohorts of people who use drugs: the Vancouver Injection Drug Users Study (VIDUS), the ACCESS Cohort, and the At-Risk Youth Study (ARYS). Multilevel modeling was used to determine if depression and social support were significant predictors of non-fatal overdose across time. Analyses were stratified by sex. Results There were 1,931 participants included in this analysis, including 653 (33.8%) females and 69 (3.6%) youth 20 years old or younger. Depressed men (Adjusted odds ratio [AOR] =1.53, 95% confidence intervals [CI] =1.25, 1.87) and women (Adjusted odds ratio [AOR] =2.23, 95% confidence intervals [CI] =1.65, 3.00) were more likely to experience a non-fatal overdose. Further, among women, those who reported having 3 or more persons they could rely upon for social support were less likely to experience a non-fatal overdose (AOR=0.54, 95% 0.31, 0.93). Conclusion Although depression was a significant predictor of non-fatal drug overdose, social support was a significant predictor among women only. Possible strategies to prevent non-fatal overdose may include identifying IDU experiencing severe depressive symptoms and providing targeted mental health treatments and mobilizing interpersonal social support among IDU, especially among women. PMID:23647731

What explains the association between neighborhood-level income inequality and the risk of fatal overdose in New York City?

PubMed

Nandi, Arijit; Galea, Sandro; Ahern, Jennifer; Bucciarelli, Angela; Vlahov, David; Tardiff, Kenneth

2006-08-01

Accidental drug overdose is a substantial cause of mortality for drug users. Using a multilevel case-control study we previously have shown that neighborhood-level income inequality may be an important determinant of overdose death independent of individual-level factors. Here we hypothesized that the level of environmental disorder, the level of police activity, and the quality of the built environment in a neighborhood mediate this association. Data from the New York City (NYC) Mayor's Management Report, the NYC Police Department, and the NYC Housing and Vacancy Survey were used to define constructs for the level of environmental disorder, the level of police activity and the quality of the built environment, respectively. In multivariable models the odds of death due to drug overdose in neighborhoods in the top decile of income inequality compared to the most equitable neighborhoods decreased from 1.63 to 1.12 when adjusting for the three potential mediators. Path analyses show that the association between income inequality and the rate of drug overdose mortality was primarily explained by an indirect effect through the level of environmental disorder and the quality of the built environment in a neighborhood. Implications of these findings for the reduction of drug overdose mortality associated with the distribution of income are discussed.

Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members.

PubMed

Wagner, Karla D; Bovet, L James; Haynes, Bruce; Joshua, Alfred; Davidson, Peter J

2016-08-01

Training law enforcement officers (LEOs) to administer naloxone to opioid overdose victims is increasingly part of comprehensive efforts to reduce opioid overdose deaths. Such efforts could yield positive interactions between LEOs and community members and might ultimately help lower overdose death rates. We evaluated a pilot LEO naloxone program by (1) assessing opioid overdose knowledge and attitudes (competency in responding, concerns about naloxone administration, and attitudes towards overdose victims) before and after a 30min training on overdose and naloxone administration, and (2) conducting qualitative interviews with LEOs who used naloxone to respond to overdose emergencies after the training. Eighty-one LEOs provided pre- and post-training data. Nearly all (89%) had responded to an overdose while serving as an LEO. Statistically significant increases were observed in nearly all items measuring opioid overdose knowledge (p's=0.04 to <0.0001). Opioid overdose competencies (p<0.001) and concerns about naloxone administration (p<0.001) significantly improved after the training, while there was no change in attitudes towards overdose victims (p=0.90). LEOs administered naloxone 11 times; nine victims survived and three of the nine surviving victims made at least one visit to substance abuse treatment as a result of a LEO-provided referral. Qualitative data suggest that LEOs had generally positive experiences when they employed the skills from the training. Training LEOs in naloxone administration can increase knowledge and confidence in managing opioid overdose emergencies. Perhaps most importantly, training LEOs to respond to opioid overdose emergencies may have positive effects for LEOs and overdose victims. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Clinical Risk Factors for In-Hospital Adverse Cardiovascular Events After Acute Drug Overdose

PubMed Central

Manini, Alex F.; Hoffman, Robert S.; Stimmel, Barry; Vlahov, David

2015-01-01

Objectives It was recently demonstrated that adverse cardiovascular events (ACVE) complicate a high proportion of hospitalizations for patients with acute drug overdoses. The aim of this study was to derive independent clinical risk factors for ACVE in patients with acute drug overdoses. Methods This prospective cohort study was conducted over 3 years at two urban university hospitals. Patients were adults with acute drug overdoses enrolled from the ED. In-hospital ACVE was defined as any of myocardial injury, shock, ventricular dysrhythmia, or cardiac arrest. Results There were 1,562 patients meeting inclusion/exclusion criteria (mean age, 41.8 years; female, 46%; suicidal, 38%). ACVE occurred in 82 (5.7%) patients (myocardial injury, 61; shock, 37; dysrhythmia, 23; cardiac arrests, 22) and there were 18 (1.2%) deaths. On univariate analysis, ACVE risk increased with age, lower serum bicarbonate, prolonged QTc interval, prior cardiac disease, and altered mental status. In a multivariable model adjusting for these factors as well as patient sex and hospital site, independent predictors were: QTc > 500 msec (3.8% prevalence, odds ratio [OR] 27.6), bicarbonate < 20 mEql/L (5.4% prevalence, OR 4.4), and prior cardiac disease (7.1% prevalence, OR 9.5). The derived prediction rule had 51.6% sensitivity, 93.7% specificity, and 97.1% negative predictive value; while presence of two or more risk factors had 90.9% positive predictive value. Conclusions The authors derived independent clinical risk factors for ACVE in patients with acute drug overdose, which should be validated in future studies as a prediction rule in distinct patient populations and clinical settings. PMID:25903997

Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency.

PubMed

Mars, Sarah G; Ondocsin, Jeff; Ciccarone, Daniel

2018-05-16

Internationally, overdose is the primary cause of death among people injecting drugs. However, since 2001, heroin-related overdose deaths in the United States (US) have risen sixfold, paralleled by a rise in the death rate attributed to synthetic opioids, particularly the fentanyls. This paper considers the adaptations some US heroin injectors are making to protect themselves from these risks. Between 2015 and 2016, a team of ethnographers collected data through semi-structured interviews and observation captured in field notes and video recording of heroin preparation/consumption. Ninety-one current heroin injectors were interviewed (Baltimore, n = 22; Chicago, n = 24; Massachusetts and New Hampshire, n = 36; San Francisco, n = 9). Experience injecting heroin ranged from < 1-47 years. Eight participants, who were exclusively heroin snorters, were also interviewed. Data were analyzed thematically. Across the study sites, multiple methods of sampling "heroin" were identified, sometimes used in combination, ranging from non-injecting routes (snorting, smoking or tasting a small amount prior to injection) to injecting a partial dose and waiting. Partial injection took different forms: a "slow shot" where the user injected a portion of the solution in the syringe, keeping the needle in the injection site, and continuing or withdrawing the syringe or a "tester shot" where the solution was divided into separate injections. Other techniques included getting feedback from others using heroin of the same batch or observing those with higher tolerance injecting heroin from the same batch before judging how much to inject themselves. Although a minority of those interviewed described using these drug sampling techniques, there is clearly receptivity among some users to protecting themselves by using a variety of methods. The use of drug sampling as a means of preventing an overdose from injection drug use reduces the quantity absorbed at any one time allowing users to monitor drug strength and titrate their dose accordingly. Given the highly unpredictable potency of the drugs currently being sold as heroin in the US, universal precautions should be adopted more widely. Further research is needed into facilitators and barriers to the uptake of these drug sampling methods.

Changes in causes of death among persons with AIDS: San Francisco, California, 1996-2011.

PubMed

Schwarcz, Sandra K; Vu, Annie; Hsu, Ling Chin; Hessol, Nancy A

2014-10-01

The increased life expectancy among HIV-infected persons treated with combination antiretroviral therapy (ART), risk behaviors, and co-morbidities associated with ART place HIV-infected persons at risk for non-HIV-related causes of death. We used the San Francisco HIV/AIDS registry to identify deaths that occurred from January 1996 through December 2011. Temporal trends in AIDS- and non-AIDS-related mortality rates, the proportion of underlying and contributory causes of death, and the ratio of observed deaths in the study population to expected number of deaths among California men aged 20-79 (standardized mortality ratio [SMR]) of underlying causes of death were examined. A total of 5338 deaths were identified. The annual AIDS-related death rate (per 100 deaths) declined from 10.8 in 1996 to 0.9 in 2011 (p<0.0001), while the annual death rate from non-AIDS-related causes declined from 2.1 in 1996 to 0.9 in 2011 (p<0.0001). The proportion of deaths due to all types of heart disease combined, all non-AIDS cancers combined, mental disorders resulting from substance abuse, drug overdose, suicide and chronic obstructive pulmonary disease increased significantly over time. The SMRs for liver diseased decreased significantly over time but remained elevated. Our data highlight the importance of age-related causes of death as well as deaths from causes that are, at least in part, preventable.

Prescription opioid mortality trends in New York City, 1990–2006: Examining the emergence of an epidemic☆

PubMed Central

Ransome, Yusuf; Keyes, Katherine M.; Koenen, Karestan C.; Tracy, Melissa; Tardiff, Kenneth J.; Vlahov, David; Galea, Sandro

2013-01-01

Background The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990–2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas. Methods We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990–2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas. Results Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990–2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents. Conclusions The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts. PMID:23357743

Reemergence of Intravenous Drug Use as Risk Factor for Candidemia, Massachusetts, USA

PubMed Central

Poowanawittayakom, Nongnooch; Dutta, Anamika; Stock, Shannon; Touray, Sunkaru; Ellison, Richard T.

2018-01-01

The epidemic of illicit intravenous drug use (IVDU) in the United States has been accompanied by a surge in drug overdose deaths and infectious sequelae. Candida albicans infections were associated with injection of contaminated impure brown heroin in the 1970s–1990s; however, candidiasis accompanying IVDU became considerably rarer as the purity of the heroin supply increased. We reviewed cases of candidemia occurring over a recent 7-year period in persons >14 years of age at a tertiary care hospital in central Massachusetts. Of the 198 patients with candidemia, 24 cases occurred in patients with a history of IVDU. Compared with non-IVDU patients, those with a history of IVDU were more likely to have non-albicans Candida, be co-infected with hepatitis C, and have end-organ involvement, including endocarditis and osteomyelitis. Thus, IVDU appears to be reemerging as a risk factor for invasive candidiasis. PMID:29553923

Patterns of Drug Use, Risky Behavior, and Health Status Among Persons Who Inject Drugs Living in San Diego, California: A Latent Class Analysis

PubMed Central

Roth, Alexis M.; Armenta, Richard A.; Wagner, Karla D.; Roesch, Scott C.; Bluthenthal, Ricky N.; Cuevas-Mota, Jazmine; Garfein, Richard S.

2015-01-01

Background Among persons who inject drugs (PWID), polydrug use (the practice of mixing multiple drugs/alcohol sequentially or simultaneously) increases risk for HIV transmission and unintentional overdose deaths. Research has shown local drug markets influence drug use practices. However, little is known about the impact of drug mixing in markets dominated by black tar heroin and methamphetamine, such as the western United States. Methods Data were collected through an ongoing longitudinal study examining drug use, risk behavior, and health status among PWID. Latent class analysis (LCA) was used to identify patterns of substance use (heroin, methamphetamine, prescription drugs, alcohol, and marijuana) via multiple administration routes (injecting, smoking, and swallowing). Logistic regression was used to identify behaviors and health indicators associated with drug use class. Results The sample included 511 mostly white (51.5%) males (73.8%), with mean age of 43.5 years. Two distinct classes of drug users predominated: methamphetamine by multiple routes (51%) and heroin by injection (49%). In multivariable logistic regression, class membership was associated with age, race, and housing status. PWID who were HIV-seropositive and reported prior sexually transmitted infections had increased odds of belonging to the methamphetamine class. Those who were HCV positive and reported previous opioid overdose had an increased odds of being in the primarily heroin injection class (all P-values < .05). Conclusion Risk behaviors and health outcomes differed between PWID who primarily inject heroin vs. those who use methamphetamine. The findings suggest that in a region where PWID mainly use black tar heroin or methamphetamine, interventions tailored to sub-populations of PWID could improve effectiveness. PMID:25313832

Brugada like pattern in ECG with drug overdose.

PubMed

Kiran, H S; Ravikumar, Y S; Jayasheelan, M R; Prashanth

2010-02-01

Tricyclic antidepressants (TCAs) may have dangerous cardiac effects in overdose. ECG is useful as both a screening tool for tricyclic antidepressant exposure and as a prognostic indicator. TCA overdose may produce various ECG changes. We report a case of Dothiepin overdose resulting in Brugada like pattern including RBBB which resolved spontaneously.

Development of an Incarceration-Specific Overdose Prevention Video: "Staying Alive on the Outside"

ERIC Educational Resources Information Center

Green, Traci C.; Bowman, Sarah E.; Ray, Madeline; McKenzie, Michelle; Lord, Sarah E.; Rich, Josiah D.

2015-01-01

Objectives: The first 2 weeks following release from prison are associated with extraordinary risk of fatal drug overdose. However, bystanders can reverse opioid overdoses using rescue breathing and naloxone, an overdose antidote. We reviewed overdose prevention and naloxone administration training videos for incarceration specific and behaviour…

COMMUNICATING RISK IN THE CONTEXT OF METHADONE FORMULATION CHANGES: A QUALITATIVE STUDY OF OVERDOSE WARNING POSTERS IN VANCOUVER, CANADA

PubMed Central

Markwick, Nicole; McNeil, Ryan; Anderson, Solanna; Small, Will; Kerr, Thomas

2015-01-01

BACKGROUND British Columbia, Canada’s provincial methadone program recently replaced their existing methadone formulation with a formulation ten times more concentrated. The transition raised concerns about heightened risk of accidental overdose, leading two organizations to disseminate methadone overdose warning posters during the transitional period. This study explores people who use drugs’ (PWUD) perceptions of these warning posters. METHODS Qualitative interviews were conducted with thirty-four PWUD enrolled in methadone maintenance treatment in Vancouver. Participants were recruited from ongoing cohort studies of drug-using individuals. Interview transcripts were analyzed thematically, focusing on participants’ perceptions of the warning posters and potential impacts on drug-related risks. RESULTS Overdose warning posters constituted a key source of information about the methadone formulation change, but did not provide adequate information for all participants. Participants articulated a preference for descriptive language, focusing on changes in concentration rather than “strength”, and universal hazard symbols to effectively communicate overdose risks. CONCLUSION Participants indicated that warnings employing descriptive language more effectively communicated risk of methadone overdose. Future overdose warnings for drug-using populations must provide adequate information for the intended audience, and be communicated to PWUD through multiple channels. PMID:26644025

Carbamazepine overdose after exposure to simethicone: a case report.

PubMed

Guneysel, Ozlem; Onur, Ozge; Denizbasi, Arzu; Saritemur, Murat

2008-07-24

Carbamazepine is an anticonvulsant drug and is also used as a treatment for patients with manic-depressive illness, post-herpetic neuralgia or phantom limb pain. The drug itself has many drug interactions. Simethicone is an antifoaming agent and is reported to be an inert material with no known drug interaction with carbamazepine. We present a case of a patient who was routinely using carbamazepine 400 mg three times per day and levetiracetam 500 mg twice daily, and experienced carbamazepine overdose after exposure to simethicone. After cessation of simethicone therapy normal drug levels of carbamazepine were obtained again with the standard dose of the drug. The mechanism of interaction is unknown but the risk of overdose should be considered when prescribing simethicone to a patient who is using carbamazepine. Simethicone and carbamazepine, when taken together, may be a cause of carbamazepine toxicity. The risk of carbamazepine overdose should be considered when prescribing simethicone to a patient who is using carbamazepine.

Carbamazepine overdose after exposure to simethicone: a case report

PubMed Central

Guneysel, Ozlem; Onur, Ozge; Denizbasi, Arzu; Saritemur, Murat

2008-01-01

Introduction Carbamazepine is an anticonvulsant drug and is also used as a treatment for patients with manic-depressive illness, post-herpetic neuralgia or phantom limb pain. The drug itself has many drug interactions. Simethicone is an antifoaming agent and is reported to be an inert material with no known drug interaction with carbamazepine. Case presentation We present a case of a patient who was routinely using carbamazepine 400 mg three times per day and levetiracetam 500 mg twice daily, and experienced carbamazepine overdose after exposure to simethicone. After cessation of simethicone therapy normal drug levels of carbamazepine were obtained again with the standard dose of the drug. The mechanism of interaction is unknown but the risk of overdose should be considered when prescribing simethicone to a patient who is using carbamazepine. Conclusion Simethicone and carbamazepine, when taken together, may be a cause of carbamazepine toxicity. The risk of carbamazepine overdose should be considered when prescribing simethicone to a patient who is using carbamazepine. PMID:18652684

Emergency department utilization and subsequent prescription drug overdose death

PubMed Central

Brady, Joanne E.; DiMaggio, Charles J.; Keyes, Katherine M.; Doyle, John J.; Richardson, Lynne D.; Li, Guohua

2015-01-01

Purpose Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. Methods Using data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. Results The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. Conclusions Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality. PMID:25935710

Drug-related deaths and the sales of needles through pharmacies.

PubMed

Davidson, Peter J; Martinez, Alexis; Lutnick, Alexandra; Kral, Alex H; Bluthenthal, Ricky N

2015-02-01

Providing needles to people who inject drugs is a well-proven public health response to the transmission of HIV and other blood borne viruses. Despite over a quarter of a century of research, new concerns about potential unintended negative consequences of needle distribution continue to emerge. Specifically, a claim was recently made that the introduction of pharmacy sales of needles was followed by an increase in overdoses in pharmacy parking lots. If true, this would have serious implications for the design of needle access programs, particularly those involving pharmacy sales of needles. We examine spatial relationships between drug-related deaths and pharmacies in Los Angeles County (population 9.8 million) before and after the 2007 enactment of a California law allowing pharmacy sales of needles without a prescription. Seven thousand and forty-nine drugs related deaths occurred in Los Angeles county from 2000 to 2009 inclusive. Four thousand two hundred and seventy-five of these deaths could be geocoded, and were found to be clustered at the census tract level. We used three methods to examine spatial relationships between overdose death locations and pharmacy locations for two years on either side of the enactment of the pharmacy sales law, and found no statistically significant changes. Among the 711 geocodable deaths occurring in the two years following the change in law, no death was found to occur within 50m of a pharmacy which sold needles. These results are consistent with prior studies which suggest pharmacy sales of needles improve access to needles without causing increased harms to the surrounding community. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Suicide and fatal drug overdose in child sexual abuse victims: a historical cohort study.

PubMed

Cutajar, Margaret C; Mullen, Paul E; Ogloff, James R P; Thomas, Stuart D; Wells, David L; Spataro, Josie

2010-02-15

To determine the rate and risk of suicide and accidental fatal drug overdose (ie, overdose deemed not to have been suicide) in individuals who had been medically ascertained as having been sexually abused during childhood. A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA). Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years. Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases. Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.96-29.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.11-67.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder. Our data highlight that CSA victims are at increased risk of suicide and accidental fatal drug overdose. CSA is a risk factor that mediates suicide and fatal overdose.

An Initial evaluation of law enforcement overdose training in Rhode Island.

PubMed

Saucier, Cory D; Zaller, Nickolas; Macmadu, Alexandria; Green, Traci C

2016-05-01

To assess initial change in knowledge, self-efficacy, and anticipated behaviors among Rhode Island law enforcement officers on drug overdose response and prevention. Law enforcement officers (N=316) voluntarily completed a pre-post evaluation immediately before and after taking part in overdose prevention and response trainings. Assessment items included measures of knowledge (Brief Overdose Recognition and Response Assessment (BORRA)), self-efficacy, attitudes toward drugs and overdose prevention, awareness of the Good Samaritan Law, and open-ended items pertaining to overdose knowledge and response behaviors. Non-parametric tests measured within-group and between-group differences. Wilcoxon Signed Rank tests and Kruskal-Wallis tests evaluated changes in BORRA scores and self-efficacy items. McNemar's tests assessed changes regarding the Good Samaritan law and open-ended items. Wilcoxon Signed Rank tests measured post-training change in attitudes. Law enforcement officers demonstrated statistically significant improvements in self-efficacy (identifying signs of opioid overdose, naloxone indication, counseling witnesses in overdose prevention, and referring witnesses for more information), overdose identification knowledge (BORRA mean increased from 7.00 to 10.39), naloxone administration knowledge (BORRA mean increased from 10.15 to 12.59), Good Samaritan Law awareness (17.9% increase after training), and anticipated behaviors in response to future observed overdose (65.7% changed from passive to active response post training). Harm reduction programs can provide law enforcement officers with the knowledge and skills necessary to intervene and reduce overdose mortality. Given the statistically significant improvements in self-efficacy, attitudinal changes, and Good Samaritan law awareness, law enforcement officers are more prepared to actively interact with drug users during a drug-involved emergency. Copyright © 2016. Published by Elsevier Ireland Ltd.

Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work?

PubMed

Jain, Abhishek; Christopher, Paul; Appelbaum, Paul S

2018-04-01

Many states are turning to civil commitment for substance use disorders as a potential solution to address rising rates of overdose deaths. Civil commitment allows family members or others to seek court-ordered involuntary treatment for a substance-abusing person. In contrast to mandatory treatment ordered by drug courts, civil commitment does not require involvement with the criminal justice system. Although these laws are understandably appealing, statutes and their implementation are highly variable, ethical concerns about deprivation of liberty continue to be raised, and outcome data are limited and often not generalizable. Above all, more studies are needed to determine effectiveness.

Drug Prohibition and Public Health: 25 Years of Evidence

PubMed Central

Drucker, Ernest

1999-01-01

FOR THE PAST 25 YEARS, the US has pursued a drug policy based on prohibition and the vigorous application of criminal sanctions for the use and sale of illicit drugs. The relationship of a prohibition-based drug policy to prevalence patterns and health consequences of drug use has never been fully evaluated. To explore that relationship, the author examines national data on the application of criminal penalties for illegal drugs and associated trends in their patterns of use and adverse health outcomes for 1972–1997. Over this 25-year period, the rate at which criminal penalties are imposed for drug offenses has climbed steadily, reaching 1.5 million arrests for drug offenses in 1996, with a tenfold increase in imprisonment for drug charges since 1979. Today, drug enforcement activities constitute 67% of the $16 billion Federal drug budget and more than $20 billion per year in state and local enforcement expenditures, compared with $7.6 billion for treatment, prevention, and research. Despite an overall decline in the prevalence of drug use since 1979, we have seen dramatic increases in drugrelated emergency department visits and drug-related deaths coinciding with this period of increased enforcement. Further, while black, Hispanic, and white Americans use illegal drugs at comparable rates, there are dramatic differences in the application of criminal penalties for drug offenses. African Americans are more than 20 times as likely as whites to be incarcerated for drug offenses, and drug-related emergency department visits, overdose deaths, and new HIV infections related to injecting drugs are many times higher for blacks than whites. These outcomes may be understood as public health consequences of policies that criminalize and marginalize drug users and increase drug-related risks to life and health. Imagesp14-ap15-ap16-ap21-ap24-a PMID:9925168

Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality.

PubMed

Dasgupta, Nabarun; Mandl, Kenneth D; Brownstein, John S

2009-11-18

Historical studies of news media have suggested an association between reporting and increased drug abuse. Period effects for substance use have been documented for different classes of legal and illicit substances, with the suspicion that media publicity may have played major roles in their emergence. Previous analyses have drawn primarily from qualitative evidence; the temporal relationship between media reporting volume and adverse health consequences has not been quantified nationally. We set out to explore whether we could find a quantitative relationship between media reports about prescription opioid abuse and overdose mortality associated with these drugs. We assessed whether increases in news media reports occurred before or after increases in overdose deaths. Our ecological study compared a monthly time series of unintentional poisoning deaths involving short-acting prescription opioid substances, from 1999 to 2005 using multiple cause-of-death data published by the National Center for Health Statistics, to monthly counts of English-language news articles mentioning generic and branded names of prescription opioids obtained from Google News Archives from 1999 to 2005. We estimated the association between media volume and mortality rates by time-lagged regression analyses. There were 24,272 articles and 30,916 deaths involving prescription opioids during the seven-year study period. Nationally, the number of articles mentioning prescription opioids increased dramatically starting in early 2001, following prominent coverage about the nonmedical use of OxyContin. We found a significant association between news reports and deaths, with media reporting preceding fatal opioid poisonings by two to six months and explaining 88% (p<0.0001, df 78) of the variation in mortality. While availability, structural, and individual predispositions are key factors influencing substance use, news reporting may enhance the popularity of psychoactive substances. Albeit ecological in nature, our finding suggests the need for further evaluation of the influence of news media on health. Reporting on prescription opioids conforms to historical patterns of news reporting on other psychoactive substances.

Breaking the News or Fueling the Epidemic? Temporal Association between News Media Report Volume and Opioid-Related Mortality

PubMed Central

Dasgupta, Nabarun; Mandl, Kenneth D.; Brownstein, John S.

2009-01-01

Background Historical studies of news media have suggested an association between reporting and increased drug abuse. Period effects for substance use have been documented for different classes of legal and illicit substances, with the suspicion that media publicity may have played major roles in their emergence. Previous analyses have drawn primarily from qualitative evidence; the temporal relationship between media reporting volume and adverse health consequences has not been quantified nationally. We set out to explore whether we could find a quantitative relationship between media reports about prescription opioid abuse and overdose mortality associated with these drugs. We assessed whether increases in news media reports occurred before or after increases in overdose deaths. Methodology/Principal Findings Our ecological study compared a monthly time series of unintentional poisoning deaths involving short-acting prescription opioid substances, from 1999 to 2005 using multiple cause-of-death data published by the National Center for Health Statistics, to monthly counts of English-language news articles mentioning generic and branded names of prescription opioids obtained from Google News Archives from 1999 to 2005. We estimated the association between media volume and mortality rates by time-lagged regression analyses. There were 24,272 articles and 30,916 deaths involving prescription opioids during the seven-year study period. Nationally, the number of articles mentioning prescription opioids increased dramatically starting in early 2001, following prominent coverage about the nonmedical use of OxyContin. We found a significant association between news reports and deaths, with media reporting preceding fatal opioid poisonings by two to six months and explaining 88% (p<0.0001, df 78) of the variation in mortality. Conclusions/Significance While availability, structural, and individual predispositions are key factors influencing substance use, news reporting may enhance the popularity of psychoactive substances. Albeit ecological in nature, our finding suggests the need for further evaluation of the influence of news media on health. Reporting on prescription opioids conforms to historical patterns of news reporting on other psychoactive substances. PMID:19924221

Harm reduction in the USA: the research perspective and an archive to David Purchase.

PubMed

Des Jarlais, Don C

2017-07-26

The history of harm reduction in the USA has led to the development of some of the most important methods for treating persons for drug use disorders, such as methadone and buprenorphine for opiate use disorder. However, there has been fierce political resistance to implementation and scale-up of harm reduction in the USA. This resistance is rooted in historical demonization of particular psychoactive drugs that were associated with stigmatized racial/ethnic groups.With the discovery of acquired immunodeficiency syndrome (AIDS) in 1981, harm reduction became important not only for treating substance use disorders, but for reducing transmission of blood-borne infection. However, within the context of the crack cocaine epidemic in the 1980s, it was very difficult to implement any programs that appeared to "condone" drug use.It was not until the late 1980s that syringe exchange programs began at the state and local level in the USA. With funding primarily from state and local governments and the support of the North American Syringe Exchange Network (NASEN), there are now approximately 200 programs for syringe exchange in the USA. Research has shown that these programs have been extremely effective in reducing human immunodeficiency virus (HIV) transmission among persons who inject drugs (PWID). The programs in the USA also offer many additional services for drug users, including condom distribution, referrals to substance abuse treatment, HIV, hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing, overdose education and naloxone distribution to reverse for overdose.Currently, the USA is experiencing an opioid/heroin epidemic, with significant increases in overdose deaths among drug users. Much of this epidemic is occurring in suburban and rural of the country without harm reduction services. The current challenges for harm reduction and harm reduction research involve expansion of services to suburban and rural areas and implementation science on how to effectively and efficiently address HCV transmission and overdose. Most importantly, continued research efforts are needed to reduce the stigma of psychoactive drug use. While political opposition continues, harm reduction activists and researchers have developed a highly effective partnership based on a common core values.

Characteristics of drug overdose in young suicide attempters.

PubMed

Kweon, Yong-Sil; Hwang, Sunyoung; Yeon, Bora; Choi, Kyoung Ho; Oh, Youngmin; Lee, Hae-Kook; Lee, Chung Tai; Lee, Kyoung-Uk

2012-12-01

Few studies have focused on the characteristic features of drug overdose in children and adolescents who have attempted suicide in Korea. The present study examined the characteristics of drug overdose in children and adolescents who visited the emergency room following drug ingestion for a suicide attempt. The medical records of 28 patients who were treated in the emergency room following a drug overdose from January 2008 to March 2011 were analyzed. Demographic and clinical variables related to the suicide attempts were examined. The mean age of the patients was 16.6±1.7 years (range 11-19 years), and 20 of the patients (71.4%) were female. Most of the patients (n=23, 82.1%) overdosed on a single drug; acetaminophen-containing analgesics were the most common (n=12, 42.9%). Depression was the most common psychiatric disorder (n=22, 78.6%), and interpersonal conflict was the most common precipitating factor of the suicide attempts (n=11, 39.3%). This was the first suicide attempt for approximately 80% of the patients. About one fourth of the patients (n=7, 25%) had follow-up visits at the psychiatric outpatient clinic. Early screening and psychiatric intervention for depression may be an important factor in preventing childhood and adolescent suicide attempts. Developing coping strategies to manage interpersonal conflicts may also be helpful. Moreover, policies restricting the amount and kind of drugs purchased by teenagers may be necessary to prevent drug overdose in this age group.

Accidental Overdose Intoxication: A Hazard of Drug Smuggling

PubMed Central

Arora, Sudhir; Tafreshi, Michael; Sobo, Steven; Krochmal, Paul; Alexander, Leslie L.

1982-01-01

Three patients involved in illicit drug smuggling via the swallowing of high dose, high purity drugs packed in multiple condoms are reported. Two of these patients experienced drug overdose symptoms due to leakage or rupture of the condoms in the GI tract. They were treated successfully. ImagesFigure 1Figure 2Figure 3Figure 4 PMID:7120497

Mortality at Music Festivals: Academic and Grey Literature for Case Finding.

PubMed

Turris, Sheila A; Lund, Adam

2017-02-01

Deaths at music festivals are not infrequently reported in the media; however, the true mortality burden is difficult to determine as the deaths are not yet systematically documented in the academic literature. This was a literature search for case examples using academic and gray literature sources, employing both retrospective and prospective searches of media sources from 1999-2014. The gray literature documents a total of 722 deaths, including traumatic (594/722; 82%) and non-traumatic (128/722; 18%) causes. Fatalities were caused by trampling (n=479), motor-vehicle-related (n=39), structural collapses (n=28), acts of terror (n=26), drowning (n=8), assaults (n=6), falls (n=5), hanging (n=2), and thermal injury (n=2). Non-traumatic deaths included overdoses (n=96/722; 13%), environmental causes (n=8/722; 1%), natural causes (n=10/722; 1%), and unknown/not reported (n=14/722; 2%). The majority of non-trauma-related deaths were related to overdose (75%). The academic literature documents trauma-related deaths (n=368) and overdose-related deaths (n=12). One hundred percent of the trauma-related deaths reported in the academic literature also were reported in the gray literature (n=368). Mortality rates cannot be reported as the total attendance at events is not known. The methodology presented in this manuscript confirms that deaths occur not uncommonly at music festivals, and it represents a starting point in the documentation and surveillance of mortality. Turris SA , Lund A . Mortality at music festivals: academic and grey literature for case finding. Prehosp Disaster Med. 2017;32(1):58-63.

Beware the yellow slimming pill: fatal 2,4-dinitrophenol overdose.

PubMed

Holborow, Alexander; Purnell, Richard M; Wong, Jenny Frederina

2016-04-04

An industrial chemical, 2,4-dinitrophenol (DNP), has found use as a weight loss drug. It is extremely toxic in overdose and has a narrow therapeutic window with significant interindividual variability in metabolism. The rise in internet-based sales and distribution of this drug has seen an increased incidence of both accidental and intentional overdose presenting to emergency departments across the UK. No antidote currently exists and overdose is often fatal despite management based on current recommendations. We report a case of intentional overdose of DNP in a young man and discuss the current treatment guidelines. The case highlights the need for an increased awareness among frontline medical staff of the effects of DNP poisoning and questions the need for a more aggressive approach in the management of acute toxicity. 2016 BMJ Publishing Group Ltd.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic.

PubMed

Fairbairn, Nadia; Coffin, Phillip O; Walley, Alexander Y

2017-08-01

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone. Copyright © 2017 Elsevier B.V. All rights reserved.

Fatal heroin intoxication in body packers in northern Thailand during the last decade: two case reports.

PubMed

Sribanditmongkol, Pongruk; Supasingsiripreecha, Wiroon; Thampitak, Subharat; Junkuy, Anongphan

2006-01-01

A body packer is an important means of drug trafficking. While drug packets are inside the body, they can leak or rupture causing acute substance toxicity. Most of the reports of body packer syndrome have come from Europe and North America, which are destination targets. In the present study, the authors reported two cases of fatal heroin body packers from the northern part of Thailand. Both cases were foreign tourists who came to Chiang Mai and stayed in a hotel or a guesthouse room in which the deaths occurred. The autopsy findings revealed rupturing of heroin packages in the stomach. The packaging used in both cases was not sophisticated. The powder was packed inside condoms without extra covering, as observed in some other professional packers. The amount of heroin transported was about 30-50 gm. The purity of heroin in this powder was about 50-90%. Their destinations were their home countries and not directly to Europe or North America. Deaths occurred just prior to their return. The cause of death was a heroin overdose. A significant level of heroin metabolites, 6-MAM and morphine were detected in the blood and urine.

Drug overdose resulting in quadriplegia.

PubMed

Wang, Teresa S; Grunch, Betsy H; Moreno, Jessica R; Bagley, Carlos A; Gottfried, Oren N

2012-06-01

To describe a case of cervical flexion myelopathy resulting from a drug overdose. A 56-year-old male presented to the emergency department unable to move his extremities following drug overdose. Neurological examination revealed him to be at C6 ASIA A spinal cord injury. The CT of his cervical spine revealed no fracture; however, an MRI revealed cord edema extending from C3 to C6 as well as posterior paraspinal signal abnormalities suggestive of ligamentous injury. The patient underwent a posterior cervical laminectomy and fusion from C3 to C7. Neurologically he regained 3/5 bilateral tricep function and 2/5 grip; otherwise, he remained at ASIA A spinal cord injury at 6 months. Our patient suffered a spinal cord injury likely due to existing cervical stenosis, and in addition to an overdose of sedating medications, he likely sat in flexed neck position for prolonged period of time with the inability to modify his position. This likely resulted in cervical spine vascular and/or neurological compromise producing an irreversible spinal cord injury. Spinal cord injury is a rare finding in patients presenting with drug overdose. The lack of physical exam findings suggestive of trauma may delay prompt diagnosis and treatment, and thus clinicians must have a high index of suspicion when evaluating patients in this setting.

21 CFR 876.5870 - Sorbent hemoperfusion system.

Code of Federal Regulations, 2014 CFR

2014-04-01

... extracorporeal blood system. The device is used in the treatment of poisoning, drug overdose, hepatic coma, or... the treatment of poisoning and drug overdose. The special controls for this device are: (i) The device... electrical components, appropriate analysis and testing must be conducted to verify electrical safety and...

The relationship between US heroin market dynamics and heroin-related overdose, 1992–2008

PubMed Central

Unick, George; Rosenblum, Daniel; Mars, Sarah; Ciccarone, Daniel

2017-01-01

Background and Aims Heroin-related overdose is linked to polydrug use, changes in physiological tolerance and social factors. Individual risk can also be influenced by the structural risk environment including the illicit drug market. We hypothesized that components of the US illicit drug market, specifically heroin source/type, price and purity, will have independent effects on the number of heroin-related overdose hospital admissions. Methods Yearly, from 1992 to 2008, Metropolitan Statistical Area (MSA) price and purity series were estimated from the US Drug Enforcement Administration data. Yearly heroin overdose hospitalizations were constructed from the Nationwide Inpatient Sample. Socio-demographic variables were constructed using several databases. Negative binomial models were used to estimate the effect of price, purity and source region of heroin on yearly hospital counts of heroin overdoses controlling for poverty, unemployment, crime, MSA socio-demographic characteristics and population size. Results Purity was not associated with heroin overdose, but each $100 decrease in the price per pure gram of heroin resulted in a 2.9% [95% confidence interval (CI) = 4.8%, 1.0%] increase in the number of heroin overdose hospitalizations (P = 0.003). Each 10% increase in the market share of Colombian-sourced heroin was associated with a 4.1% (95% CI = 1.7%, 6.6%) increase in number of overdoses reported in hospitals (P = 0.001) independent of heroin quality. Conclusions Decreases in the price of pure heroin in the United States are associated with increased heroin-related overdose hospital admissions. Increases in market concentration of Colombian-source/type heroin is also associated with an increase in heroin-related overdose hospital admissions. Increases in US heroin-related overdose admissions appear to be related to structural changes in the US heroin market. PMID:24938727

The relationship between US heroin market dynamics and heroin-related overdose, 1992-2008.

PubMed

Unick, George; Rosenblum, Daniel; Mars, Sarah; Ciccarone, Daniel

2014-11-01

Heroin-related overdose is linked to polydrug use, changes in physiological tolerance and social factors. Individual risk can also be influenced by the structural risk environment including the illicit drug market. We hypothesized that components of the US illicit drug market, specifically heroin source/type, price and purity, will have independent effects on the number of heroin-related overdose hospital admissions. Yearly, from 1992 to 2008, Metropolitan Statistical Area (MSA) price and purity series were estimated from the US Drug Enforcement Administration data. Yearly heroin overdose hospitalizations were constructed from the Nationwide Inpatient Sample. Socio-demographic variables were constructed using several databases. Negative binomial models were used to estimate the effect of price, purity and source region of heroin on yearly hospital counts of heroin overdoses controlling for poverty, unemployment, crime, MSA socio-demographic characteristics and population size. Purity was not associated with heroin overdose, but each $100 decrease in the price per pure gram of heroin resulted in a 2.9% [95% confidence interval (CI) = 4.8%, 1.0%] increase in the number of heroin overdose hospitalizations (P = 0.003). Each 10% increase in the market share of Colombian-sourced heroin was associated with a 4.1% (95% CI = 1.7%, 6.6%) increase in number of overdoses reported in hospitals (P = 0.001) independent of heroin quality. Decreases in the price of pure heroin in the United States are associated with increased heroin-related overdose hospital admissions. Increases in market concentration of Colombian-source/type heroin is also associated with an increase in heroin-related overdose hospital admissions. Increases in US heroin-related overdose admissions appear to be related to structural changes in the US heroin market. © 2014 Society for the Study of Addiction.

CDC Vital Signs: Today's Heroin Epidemic

MedlinePlus

... is increasing, and so are heroin-related overdose deaths. How is heroin harmful? Heroin is an illegal, ... can cause slow and shallow breathing, coma, and death. People often use heroin along with other drugs ...

Characterization and Management of Patients with Heroin versus Nonheroin Opioid Overdoses: Experience at an Academic Medical Center.

PubMed

Morizio, Kate M; Baum, Regan A; Dugan, Adam; Martin, Julia E; Bailey, Abby M

2017-07-01

To characterize the differences between patients who had heroin and nonheroin opioid overdoses and to determine whether there were any significant differences in their management with regard to the naloxone use. Retrospective cohort study. Large academic medical center. A total of 923 patients admitted to the medical center who were identified for overdose by heroin or other opiate-related narcotics between January 2010 and September 2015; 480 patients experienced a nonheroin opioid overdose event, and 443 patients experienced a heroin overdose event. Patients presenting with heroin overdose tended to be younger and male, with higher rates of hepatitis C virus (HCV) infection compared with those presenting with nonheroin opioid overdose (p<0.05). Patients in the heroin group were also more likely to have a previous overdose event, history of injection drug use, and history of prescription opioid abuse compared with the nonheroin group (p<0.05). Those presenting with heroin overdose were more likely to receive naloxone in the prehospital setting (p<0.05) but were less likely to receive naloxone once admitted (p<0.05). Patients with nonheroin opioid overdoses required more continuous infusions of naloxone (p<0.05) and admission to the intensive care unit (p<0.05). Of all 923 patients, 178 (19.3%) had a repeat admission for any reason, and 70 (7.6%) were readmitted over the course of the study period for another overdose event with the same drug. The proportion of patients presenting with a heroin overdose steadily increased from 2010-2015; the number of patients presenting to the emergency department with nonheroin opioid overdoses steadily decreased. As rates of heroin overdose increased each year, the incidence of HCV infection increased dramatically. This study indicates that the incidence of heroin overdoses has significantly increased over the last several years, and the rates of HCV infection 4-fold since the start of the study period. Patients admitted for nonheroin opioid overdose were more likely to be admitted to the hospital and intensive care unit compared with those admitted for heroin overdose. The rise in overdose events only further illustrates a gap in our understanding of the cycle of addiction, drug abuse, and overdose events. © 2017 Pharmacotherapy Publications, Inc.

Distribution of naloxone for overdose prevention to chronic pain patients.

PubMed

Coe, Marion A; Walsh, Sharon L

2015-11-01

In this commentary, we reflect on the growing opioid overdose epidemic and propose that chronic pain patients prescribed opioids are contributing to growing mortality rates. We advocate for expanding naloxone access and overdose prevention training, which has historically been directed when available to injection drug users, to chronic pain patients who may be at high risk for accidental opioid overdose. Copyright © 2015 Elsevier Inc. All rights reserved.

"Caught with a body" yet protected by law? Calling 911 for opioid overdose in the context of the Good Samaritan Law.

PubMed

Latimore, Amanda D; Bergstein, Rachel S

2017-12-01

To address soaring opioid overdose fatality rates, 41U.S. states have passed Good Samaritan Laws (GSLs) extending legal immunity to overdose bystanders who call for emergency assistance. This study, conducted during the period that followed implementation of a GSL, aimed to characterize current factors determining the decision to call for emergency medical help (911) at the scene of an overdose with specific attention to exploring the role of the GSL as one such factor in decision-making. We conducted 22 in-depth interviews with needle exchange program clients in Baltimore, MD. Most participants reported calling 911 or witnessing a 911 call after drug overdose, but widely remained fearful of arrest for drug or paraphernalia possession, homicide, outstanding warrants, and/or trespassing. These concerns were underpinned by a history of police maltreatment and threat, and strong distrust of police; concerns which were specifically related to perceptions of police conduct at the scene of an overdose as well as perceptions of police conduct in general. Additional considerations included: fear of losing housing, informal shelter or custody of children; encountering social stigma; and facing violent and fatal repercussions at the hands of local drug dealers. Additionally, some participants did not perceive a significant enough medical risk to call 911. Two thirds of participants were unaware of the GSL. Some believed a GSL would positively impact law enforcement behaviour and increase the likelihood of a bystander call; but due to distrust of police, others believed the GSL would have little influence on bystander decisions. Insights from overdose bystanders during the post-implementation period of a Good Samaritan Law demonstrate persistent deterrents to bystanders calling 911 after overdose. Additional measures are needed to align policy aims with lived experiences of overdose bystanders, and to achieve overdose prevention aims. Copyright © 2017 Elsevier B.V. All rights reserved.

Pattern of drug overdose and chemical poisoning among patients attending an emergency department, western Saudi Arabia.

PubMed

Bakhaidar, Mohamad; Jan, Saber; Farahat, Fayssal; Attar, Ahmad; Alsaywid, Basim; Abuznadah, Wesam

2015-02-01

Poisoning is a medical emergency that represent a major health problem all over the world. Studies on drug overdose and chemical poisoning are very limited in Saudi Arabia (SA). We aimed to describe the current pattern and assess risk factors of drug overdose and chemical poisoning in King Khalid National Guard hospital, Jeddah, SA. Medical records of patients attended emergency department in King Khalid National Guard hospital during the period from January 2008 to December 2012 due to drug overdose and chemical poisoning were reviewed. A total of 129 cases were included in the study. The majority of the population was Saudi (97.7 %), and almost half of them were females (54.3 %). Children under 12 years were the most affected age group (44.2 %). Drug overdose was the most common cause of poisoning (92.2 %). Analgesics and non-steroidal anti-inflammatory drugs represented the highest percentage of used medications (20.4 %). The most commonly reported symptoms were symptoms of the central nervous system (57.4 %) followed by GIT symptoms (41.9 %). Intentional poisoning was reported in 34 cases (26.4 %). Female patients were significantly more likely to attempt suicide than male patients (OR = 7.22, 95 % CI = 1.70, 30.62). Children continue to be at high risk for medication and chemical poisoning. Accessibility to medications at homes encountered for most of poisoning cases among children. Implementing methods to raise public awareness and minimize children access to medications would significantly contribute to reducing burden of this problem on the community.

The cost of antidepressant overdose.

PubMed

D'Mello, D A; Finkbeiner, D S; Kocher, K N

1995-11-01

Ninety percent of suicide attempts referred to a general hospital are by self-poisoning. Among women, drug overdose is the commonest means of suicide. In a retrospective naturalistic review of 200 patients who were treated in the Critical Care Unit of a general hospital following medication overdose, 12% were antidepressant overdoses. The mean duration of hospital stay for overdose with tricyclic antidepressants (TCA) was more than double that for overdose with selective serotonin reuptake inhibitors (SSRI) (7 vs 3 days; z = 2.20, p < 0.05). The dollar cost of hospital treatment for patients who overdosed on TCAs was four times greater than that for patients who overdosed on SSRIs ($22,923 vs $5,379; z = 2.30, p < 0.05). The tricyclic compounds clearly have a price advantage over more recently introduced antidepressant agents fluoxetine, sertraline, paroxetine, venlafaxine, and bupropion. The apparent cost advantage of prescribing a less expensive drug may be nullified by the cost associated with adverse consequences.

Naproxen sodium overdose

MedlinePlus

... page: //medlineplus.gov/ency/article/002507.htm Naproxen sodium overdose To use the sharing features on this page, please enable JavaScript. Naproxen sodium is a nonsteroidal anti-inflammatory drug (NSAID) used ...

The outcome of drug smuggling by 'body packers'--the British experience.

PubMed Central

Bulstrode, N.; Banks, F.; Shrotria, S.

2002-01-01

Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry. Images Figure 1 PMID:11890624

The outcome of drug smuggling by 'body packers'--the British experience.

PubMed

Bulstrode, N; Banks, F; Shrotria, S

2002-01-01

Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry.

Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis.

PubMed

Collins, Alexandra B; Bluthenthal, Ricky N; Boyd, Jade; McNeil, Ryan

2018-05-01

Language has significant implications for how we view and respond to public health issues. Conventional moralistic messaging around drug use stigmatizes people who use drugs and inhibits the implementation of evidence-based harm reduction interventions that do not condemn drug use. However, within the context of the unprecedented North American opioid overdose crisis, we argue that shifting conventional moral messaging around overdose prevention and response strategies is key to supporting the rapid roll-out of evidence-based harm reduction interventions. Reframing overdose prevention to highlight the imperative to address the ongoing public health emergency is an important first step in implementing urgently needed response strategies. Copyright © 2018 Elsevier B.V. All rights reserved.

Overdose and prescribed opioids: Associations among chronic non-cancer pain patients

PubMed Central

Dunn, Kate M; Saunders, Kathleen W; Rutter, Carolyn M; Banta-Green, Caleb J; Merrill, Joseph O; Sullivan, Mark D; Weisner, Constance M; Silverberg, Michael J; Campbell, Cynthia I; Psaty, Bruce M; Von Korff, Michael

2010-01-01

Background Chronic opioid therapy for chronic non-cancer pain (CNCP) is increasingly common in community practice. Concomitant with this practice change, rates of fatal opioid overdose have increased. It is not known to what extent overdose risks are elevated among patients receiving medically prescribed chronic opioid therapy. Objective To estimate rates of opioid overdose and their association with average prescribed daily opioid dose among patients receiving medically prescribed chronic opioid therapy. Design Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at time of overdose. Setting Health maintenance organization. Patients Individuals (n=9940) who received 3+ opioid prescriptions within 90-days for CNCP between 1997 and 2005. Measurements Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes, non-fatal and fatal overdoses, were identified through diagnostic codes from inpatient and outpatient care and death certificates and confirmed by medical record review. Results Fifty-one opioid-related overdoses were identified, including six deaths. Compared to patients receiving 1-20mg of opioids per day (0.2% annual overdose rate), patients receiving 50-99 mg had a 3.7 fold increase in overdose risk (95% C.I. 1.5, 9.5) and a 0.7% annual overdose rate. Patients receiving 100mg or more per day had an 8.9 fold increase in overdose risk (95% C.I. 4.0, 19.7) and a 1.8% annual overdose rate. Limitations Increased overdose risk among patients on higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. Conclusions Patients receiving higher doses of prescribed opioids are at increased risk of opioid overdose, underscoring the need for close supervision of these patients. PMID:20083827

Associations among Pain, Non-Medical Prescription Opioid Use, and Drug Overdose History

PubMed Central

Bonar, Erin E.; Ilgen, Mark A.; Walton, Maureen; Bohnert, Amy S.B.

2014-01-01

Background and Objective Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in Substance Use Disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients. Methods Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics. Results Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship. Conclusions The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use. PMID:24313240

Opioid Prescribing Practices of Neurosurgeons: Analysis of Medicare Part D.

PubMed

Khalid, Syed I; Adogwa, Owoicho; Lilly, Daniel T; Desai, Shyam A; Vuong, Victoria D; Mehta, Ankit I; Cheng, Joseph

2018-04-01

The Centers for Disease Control have declared that the United States is amidst a continuing opioid epidemic, with drug overdose-related death tripling between 1999 and 2014. Among the 47,055 overdose-related deaths that occurred in 2014, 28,647 (60.9%) of them involved an opioid. The Part D Prescriber Public Use File, which is based on beneficiaries enrolled in the Medicare Part D prescription drug program, was used to query information on prescription drug events incurred by Medicare beneficiaries with a Part D prescription drug plan from 31 June 2014 to 30 June 2015. Only those providers with the specialty description of neurosurgeon, as reported on the provider's Part B claims, were included in this study. A total of 271,502 beneficiaries, accounting for 971,581 claims and 22,152,689 day supplies of medication, accounted for the $52,956,428.40 paid by the Centers for Medicare and Medicaid Services for medication that the 4085 neurosurgeons submitted to the Centers for Medicare and Medicaid Services Part D program in the 2014 calendar year. During the same year, 402,767 (41.45%) claims for 158,749 (58.47%) beneficiaries accounted for 6,458,624 (29.16%) of the day supplies of medications and $13,962,630.11 (26.37%) of the total money spent by the Centers for Medicare and Medicaid Services Part D that year. Nationwide, the ratio of opioid claims to total Medicare Part D beneficiaries was 1.48. No statistically significant regional differences were found. The opioid misuse epidemic is a complex and national issue with patterns of prescription not significantly different between regions. All neurosurgeons must be cognizant of their prescribing practices so as to best support the resolution of this public health crisis. Copyright © 2017. Published by Elsevier Inc.

High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study

PubMed Central

Bazazi, Alexander R.; Zelenev, Alexei; Fu, Jeannia J.; Yee, Ilias; Kamarulzaman, Adeeba; Altice, Frederick L.

2014-01-01

Background Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia. Methods In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression. Results All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9–16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI 0.5–0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI 1.9–3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI 1.1–4.2), as was methamphetamine use (AOR 2.3, CI 1.3–4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI 1.5–5.9). Conclusion This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment. PMID:25532449

Descriptive Epidemiology for Community-wide Naloxone Administration by Police Officers and Firefighters Responding to Opioid Overdose.

PubMed

Heavey, Sarah Cercone; Delmerico, Alan M; Burstein, Gale; Moore, Cheryll; Wieczorek, William F; Collins, R Lorraine; Chang, Yu-Ping; Homish, Gregory G

2018-04-01

Recently implemented New York State policy allows police and fire to administer intranasal naloxone when responding to opioid overdoses. This work describes the geographic distribution of naloxone administration (NlxnA) by police and fire when responding to opioid overdoses in Erie County, NY, an area of approximately 920,000 people including the City of Buffalo. Data are from opioid overdose reports (N = 800) filed with the Erie County Department of Health (July 2014-June 2016) by police/fire and include the overdose ZIP code, reported drug(s) used, and NlxnA. ZIP code data were geocoded and mapped to examine spatial patterns of NlxnA. The highest NlxnA rates (range: 0.01-84.3 per 10,000 population) were concentrated within the city and first-ring suburbs. Within 3 min 27.3% responded to NlxnA and 81.6% survived the overdose. The average individual was male (70.3%) and 31.4 years old (SD = 10.3). Further work is needed to better understand NlxnA and overdose, including exploring how the neighborhood environment creates a context for drug use, and how this context influences naloxone use and overdose experiences.

High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study.

PubMed

Bazazi, Alexander R; Zelenev, Alexei; Fu, Jeannia J; Yee, Ilias; Kamarulzaman, Adeeba; Altice, Frederick L

2015-07-01

Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia. In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression. All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9-16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI: 0.5-0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI: 1.9-3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI: 1.1-4.2), as was methamphetamine use (AOR 2.3, CI: 1.3-4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI: 1.5-5.9). This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment. Copyright © 2014 Elsevier B.V. All rights reserved.

Opioid-Involved Overdose Among Male Afghanistan/Iraq-Era U.S. Military Veterans: A Multidimensional Perspective.

PubMed

Bennett, Alex S; Elliott, Luther; Golub, Andrew; Wolfson-Stofko, Brett; Guarino, Honoria

2017-11-10

Mirroring nationwide trends in a broad range of U.S. populations, an alarming number of Afghanistan/Iraq-era U.S. Military veterans have experienced opioid-related overdoses. A growing body of research has examined the proximal behaviors that can precipitate an overdose; considerably less is known about more distal physiological, psychosocial and structural influences on these risk behaviors. This study adopts a multidimensional approach to better understand opioid-related overdose among U.S. Military veterans, and seeks to explore not only the proximal behavioral precipitants of overdose events, but also the complex nexus of physiological, psychological, and sociological influences that undergird overdose events. This qualitative examination is based on interview data from 36 male veterans who were discharged from the military after September 2001 and experienced at least one opioid-related overdose during or after military service. Participants were recruited in New York City during 2014 to share narrative accounts of their overdoses. Veterans' accounts indicate that background experiences, such as self-medication for social and psychological pain, trauma, social alienation and isolation, and histories of illicit drug use, precondition the more immediate factors and behaviors that precipitate overdose (including bingeing on drugs, mixing drugs, naiveté about dosage, and ambivalence about life/death). Findings suggest the need for comprehensive drug safety and overdose education that is sensitive to veterans' physiological, psychological, and sociological conditions. A multidimensional understanding of the distal and proximal overdose risks faced by veterans and other vulnerable groups may help lay a foundation for more inclusive/holistic approaches to overdose prevention and education.

“I Felt Like a Superhero”: The Experience of Responding to Drug Overdose Among Individuals Trained in Overdose Prevention

PubMed Central

Wagner, Karla D.; Davidson, Peter J.; Iverson, Ellen; Washburn, Rachel; Burke, Emily; Kral, Alex H.; McNeeley, Miles; Bloom, Jennifer Jackson; Lankenau, Stephen E.

2013-01-01

Background Overdose prevention programs (OPPs) train people who inject drugs and other community members to prevent, recognise and respond to opioid overdose. However, little is known about the experience of taking up the role of an “overdose responder” for the participants. Methods We present findings from qualitative interviews with 30 participants from two OPPs in Los Angeles, CA, USA from 2010–2011 who had responded to at least one overdose since being trained in overdose prevention and response. Results Being trained by an OPP and responding to overdoses had both positive and negative effects for trained “responders”. Positive effects include an increased sense of control and confidence, feelings of heroism and pride, and a recognition and appreciation of one’s expertise. Negative effects include a sense of burden, regret, fear, and anger, which sometimes led to cutting social ties, but might also be mitigated by the increased empowerment associated with the positive effects. Conclusion Findings suggest that becoming an overdose responder can involve taking up a new social role that has positive effects, but also confers some stress that may require additional support. OPPs should provide flexible opportunities for social support to individuals making the transition to this new and critical social role. Equipping individuals with the skills, technology, and support they need to respond to drug overdose has the potential to confer both individual and community-wide benefits. PMID:23932166

Cocaine-related deaths.

PubMed

Lora-Tamayo, C; Tena, T; Rodriguez, A

1994-07-15

Cocaine availability has been increasing in Spain in the past few years. A review of all the toxicological analyses carried out at the Madrid Department of the Instituto Nacional de Toxicología, with subjects who had died of drugs from 1990 to 1992, found 533 persons who had cocaine in their blood and/or tissues; 450 (84%) deaths involved cocaine and heroin together whereas 83 (16%) deaths involved cocaine with an absence of heroin. This paper reports the circumstances, cocaine and benzoylecgonine concentrations in the blood and other toxicological findings for the two major groups of deaths where cocaine was found with an absence of heroin, i.e., possible overdose cases (35 cases) and traffic accidents (23 cases).

Protocol: changes in rates of opioid overdose and poisoning events in an integrated health system following the introduction of a formulation of OxyContin® with abuse-deterrent properties.

PubMed

Janoff, Shannon L; Perrin, Nancy A; Coplan, Paul M; Chilcoat, Howard D; Campbell, Cynthia I; Green, Carla A

2016-05-14

Addiction, overdoses and deaths resulting from prescription opioids have increased dramatically over the last decade. In response, several manufacturers have developed formulations of opioids with abuse-deterrent properties. For many of these products, the Food and Drug Administration (FDA) recognized the formulation with labeling claims and mandated post-marketing studies to assess the abuse-deterrent effects. In response, we assess differences in rates of opioid-related overdoses and poisonings prior to and following the introduction of a formulation of OxyContin® with abuse-deterrent properties. To assess effects of this formulation, electronic medical record (EMR) data from Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Northern California (KPNC) are linked to state death data and compared to chart audits. Overdose and poisoning events will be categorized by intentionality and number of agents involved, including illicit drugs and alcohol. Using 6-month intervals over a 10-year period, trends will be compared in rates of opioid-related overdoses and poisoning events associated with OxyContin® to rates of events associated with other oxycodone and opioid formulations. Qualitative interviews with patients and relatives of deceased patients will be conducted to capture circumstances surrounding events. This study assesses and tracks changes in opioid-related overdoses and poisoning events prior to and following the introduction of OxyContin® with abuse-deterrent properties. Public health significance is high because these medications are designed to reduce abuse-related behaviors that lead to important adverse outcomes, including overdoses and deaths.

A history of being prescribed controlled substances and risk of drug overdose death.

PubMed

Paulozzi, Leonard J; Kilbourne, Edwin M; Shah, Nina G; Nolte, Kurt B; Desai, Hema A; Landen, Michael G; Harvey, William; Loring, Larry D

2012-01-01

The abuse of prescription drugs has increased dramatically since 1990. Persons who overdose on such drugs frequently consume large doses and visit multiple providers. The risk of fatal overdose for different patterns of use of opioid analgesics and sedative/hypnotics has not been fully quantified. Matched case-control study. Cases were 300 persons who died of unintentional drug overdoses in New Mexico during 2006-2008, and controls were 5,993 patients identified through the state prescription monitoring program with matching 6-month exposure periods. Death from drug overdose or death from opioid overdose. Exposures were demographic variables and characteristics of prescription history. Crude and adjusted odds ratios (AOR) were calculated. Increased risk was associated with male sex (AOR 2.4, 95% confidence interval [CI] 1.8-3.1), one or more sedative/hypnotic prescriptions (AOR 3.0, CI 2.2-4.2), greater age (AOR 1.3, CI 1.2-1.4 for each 10-year increment), number of prescriptions (AOR 1.1, CI 1.1-1.1 for each additional prescription), and a prescription for buprenorphine (AOR 9.5, CI 3.0-30.0), fentanyl (AOR 3.5, CI 1.7-7.0), hydromorphone (AOR 3.3, CI 1.4-7.5), methadone (AOR 4.9, CI 2.5-9.6), or oxycodone (AOR 1.9, CI 1.4-2.6). Patients receiving a daily average of >40 morphine milligram equivalents had an OR of 12.2 (CI 9.2-16.0). Patients being prescribed opioid analgesics frequently or at high dosage face a substantial overdose risk. Prescription monitoring programs might be the best way for prescribers to know their patients' prescription histories and accurately assess overdose risk. Wiley Periodicals, Inc.

Successful use of haemodialysis to treat phenobarbital overdose

PubMed Central

Hoyland, Kimberley; Hoy, Michael; Austin, Richard; Wildman, Martyn

2013-01-01

A 50-year-old woman presented with coma caused by a phenobarbital overdose, requiring intubation and admission to critical care. She was an international visitor and had been prescribed the drug for night-sedation. Phenobarbital is a long-acting barbiturate, which in an overdose can cause central nervous system depression, respiratory failure and haemodynamic instability; these patients can remain obtunded for many days. After initial supportive therapy, she was dialysed to help in the elimination of the drug. Haemodialysis resulted in a markedly reduced plasma level of phenobarbital, which decreased the length of intubation and stay in the critical care unit and aided full recovery. PMID:24265338

Associations among pain, non-medical prescription opioid use, and drug overdose history.

PubMed

Bonar, Erin E; Ilgen, Mark A; Walton, Maureen; Bohnert, Amy S B

2014-01-01

Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in substance use disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients. Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics. Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship. The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use. © American Academy of Addiction Psychiatry.

Evaluation of an Overdose Prevention and Response Training Programme for Injection Drug Users in the Skid Row Area of Los Angeles, California

PubMed Central

Wagner, Karla D.; Valente, Thomas W.; Casanova, Mark; Partovi, Susan M.; Mendenhall, Brett M.; Hundley, James H.; Gonzalez, Mario; Unger, Jennifer B.

2014-01-01

Background Fatal opioid overdose is a significant cause of mortality among injection drug users (IDUs). Methods We evaluated an overdose prevention and response training programme for IDUs implemented by a community-based organization in Los Angeles, California. During a 1-hour training session participants learned skills to prevent, recognize, and respond to opioid overdoses, including: calling for emergency services, performing rescue breathing, and administering an intramuscular injection of naloxone (an opioid antagonist). Ninety-three IDUs were trained from September 2006 to January 2008. Of those, 66 (71%) enrolled in the evaluation study. In total, 47 of 66 participants (71%) completed both a baseline interview and three-month follow-up interview. Results Participants were 21% female, 42% White, 29% African American, and 18% Latino. Most were homeless and reported living predominantly in the street (44%), temporary housing such as hotels or motels (15%), or shelters (14%). Significant increases were found in overdose knowledge, driven largely by increase in knowledge about the appropriate use of naloxone. Twenty-two participants witnessed and responded to 35 overdoses during the follow-up period. Twenty-six overdose victims were reported to have recovered, four died, and the outcome of five cases was unknown. The most commonly reported response techniques included: staying with the victim (85%), administering naloxone (80%), providing rescue breathing (66%), and calling emergency services (60%). The average number of appropriate response techniques used by participants increased significantly from baseline to follow-up (p<0.05). Half (53%) of programme participants reported that their drug use decreased at follow-up. Conclusion Results suggest that overdose prevention and response training programmes may be associated with improvements in knowledge and overdose response behaviour among IDUs, with few adverse consequences and some unforeseen benefits, such as reductions in drug use. PMID:19268564

Homeless drug users' awareness and risk perception of peer "Take Home Naloxone" use – a qualitative study

PubMed Central

Wright, Nat; Oldham, Nicola; Francis, Katharine; Jones, Lesley

2006-01-01

Background Peer use of take home naloxone has the potential to reduce drug related deaths. There appears to be a paucity of research amongst homeless drug users on the topic. This study explores the acceptability and potential risk of peer use of naloxone amongst homeless drug users. From the findings the most feasible model for future treatment provision is suggested. Methods In depth face-to-face interviews conducted in one primary care centre and two voluntary organisation centres providing services to homeless drug users in a large UK cosmopolitan city. Interviews recorded, transcribed and analysed thematically by framework techniques. Results Homeless people recognise signs of a heroin overdose and many are prepared to take responsibility to give naloxone, providing prior training and support is provided. Previous reports of the theoretical potential for abuse and malicious use may have been overplayed. Conclusion There is insufficient evidence to recommend providing "over the counter" take home naloxone" to UK homeless injecting drug users. However a programme of peer use of take home naloxone amongst homeless drug users could be feasible providing prior training is provided. Peer education within a health promotion framework will optimise success as current professionally led health promotion initiatives are failing to have a positive impact amongst homeless drug users. PMID:17014725

Analysis of benzonatate overdoses among adults and children from 1969-2010 by the United States Food and Drug Administration.

PubMed

McLawhorn, Melinda W; Goulding, Margie R; Gill, Rajdeep K; Michele, Theresa M

2013-01-01

To augment the December 2010 United States Food and Drug Administration (FDA) Drug Safety Communication on accidental ingestion of benzonatate in children less than 10 years old by summarizing data on emergency department visits, benzonatate exposure, and reports of benzonatate overdoses from several data sources. Retrospective review of adverse-event reports and drug utilization data of benzonatate. The FDA Adverse Event Reporting System (AERS) database (1969-2010), the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project (NEISS-CADES, 2004-2009), and the IMS commercial data vendor (2004-2009). Any patient who reported an adverse event with benzonatate captured in the AERS or NEISS-CADES database or received a prescription for benzonatate according to the IMS commercial data vendor. Postmarketing adverse events with benzonatate were collected from the AERS database, emergency department visits due to adverse events with benzonatate were collected from the NEISS-CADES database, and outpatient drug utilization data were collected from the IMS commercial data vendor. Of 31 overdose cases involving benzonatate reported in the AERS database, 20 had a fatal outcome, and five of these fatalities occurred from accidental ingestions in children 2 years of age and younger. The NEISS-CADES database captured emergency department visits involving 12 cases of overdose from accidental benzonatate ingestions in children aged 1-3 years. Signs and symptoms of overdose included seizures, cardiac arrest, coma, brain edema or anoxic encephalopathy, apnea, tachycardia, and respiratory arrest and occurred in some patients within 15 minutes of ingestion. Dispensed benzonatate prescriptions increased by approximately 52% from 2004 to 2009. Although benzonatate has a long history of safe use, accumulating cases of fatal overdose, especially in children, prompted the FDA to notify health care professionals about the risks of benzonatate overdose. Pharmacists may have a role in preventing benzonatate overdoses by counseling patients on signs and symptoms of benzonatate overdose, the need for immediate medical care, and safe storage and disposal of benzonatate. © 2013 Pharmacotherapy Publications, Inc.

Trends in the Distribution of Opioids in Puerto Rico, 1999-2013.

PubMed

El Burai Félix, Sausan; Mack, Karin A; Jones, Christopher M

2016-09-01

Limited information has been published about opioid prescribing practices in Puerto Rico. The objective of this study was to create baseline trends of opioids distributed over a period of fourteen years in Puerto Rico. We examined data from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) for the period 1999-2013. ARCOS data reflects the amount of controlled substances legally dispensed. Analyses include the distribution of opioids (in morphine milligram equivalent kg per 10,000 persons) by year and entity (pharmacy, hospital, practitioner). The distribution of four drugs (fentanyl, hydromorphone, methadone, oxycodone) increased over 100% between 1999 and 2013. The distribution of two drugs (hydrocodone and meperidine) declined between 1999 and 2013. Oxycodone distribution grew from 0.13 MME kg grams per 10,000 persons in 1999 to 0.29 MME kg in 2013. ARCOS data showed that the overall amount of opioid pain relievers distributed in Puerto Rico increased by 68% between 1999 and 2013. Currently, prescription opioid pain reliever overdose deaths in Puerto Rico do not appear to be skyrocketing as they are in the mainland U.S. However, the ongoing problem with prescription opioid pain reliever overdoses in certain areas should serve as a warning to monitor consumption of opioid pain relievers, as well as changes in prescription drug abuse, overdoses, and deaths.

Exploratory study of factors associated with adverse clinical features in patients presenting with non-fatal drug overdose/self-poisoning to the ambulance service.

PubMed

Gwini, Stella May; Shaw, Deborah; Iqbal, Mohammad; Spaight, Anne; Siriwardena, Aloysius Niroshan

2011-10-01

To investigate the factors associated with adverse clinical features presented by drug overdose/self-poisoning patients and the treatments provided. Historical patient records collected over 3 months from ambulance crews attending non-fatal overdoses/self-poisoning incidents were reviewed. Logistic regression was used to investigate predictors of adverse clinical features (reduced consciousness, obstructed airway, hypotension or bradycardia, hypoglycaemia) and treatment. Of 22,728 calls attended to over 3 months, 585 (rate 26/1000 calls) were classified as overdose or self-poisoning. In the 585 patients identified, paracetamol-containing drugs were most commonly involved (31.5%). At least one adverse clinical feature occurred in 103 (17.7%) patients, with higher odds in men and opiate overdose or illegal drugs. Older patients and patients with reduced consciousness were more likely to receive oxygen. The latter also had a greater chance of receiving saline. Non-fatal overdose/self-poisoning accounted for 2.6% of patients attended by an ambulance. Gender, illegal drugs or opiates were important predictors of adverse clinical features. The treatments most often provided to patients were oxygen and saline.

Mobile Technology to Increase HIV/HCV Testing and Overdose Prevention/Response among People Who Inject Drugs

PubMed Central

Aronson, Ian David; Bennett, Alexander; Marsch, Lisa A.; Bania, Theodore C.

2017-01-01

The United States faces dramatically increasing rates of opioid overdose deaths, as well as persistent ongoing problems of undiagnosed HIV and HCV infection. These problems commonly occur together in substance using populations that have limited, if any, access to primary care and other routine health services. To collectively address all three issues, we developed the Mobile Intervention Kit (MIK), a tablet computer-based intervention designed to provide overdose prevention and response training and to facilitate HIV/HCV testing in community settings. Intervention content was produced in collaboration with experienced street outreach workers who appear onscreen in a series of educational videos. A preliminary pilot test of the MIK in a Bronx, NY street outreach syringe exchange program found the MIK is feasible and highly acceptable to a population of people who inject drugs. Participants accepted HIV and HCV testing post-intervention, as well as naloxone training to reverse overdose events. Pre-post tests also showed significant increases in knowledge of overdose prevention, HIV testing procedures, and asymptomatic HCV infection. Future iterations of the MIK can be optimized for use in community as well as clinical settings nationwide, and perhaps globally, with a focus on underserved urban populations. PMID:28879174

Mobile Technology to Increase HIV/HCV Testing and Overdose Prevention/Response among People Who Inject Drugs.

PubMed

Aronson, Ian David; Bennett, Alexander; Marsch, Lisa A; Bania, Theodore C

2017-01-01

The United States faces dramatically increasing rates of opioid overdose deaths, as well as persistent ongoing problems of undiagnosed HIV and HCV infection. These problems commonly occur together in substance using populations that have limited, if any, access to primary care and other routine health services. To collectively address all three issues, we developed the Mobile Intervention Kit (MIK), a tablet computer-based intervention designed to provide overdose prevention and response training and to facilitate HIV/HCV testing in community settings. Intervention content was produced in collaboration with experienced street outreach workers who appear onscreen in a series of educational videos. A preliminary pilot test of the MIK in a Bronx, NY street outreach syringe exchange program found the MIK is feasible and highly acceptable to a population of people who inject drugs. Participants accepted HIV and HCV testing post-intervention, as well as naloxone training to reverse overdose events. Pre-post tests also showed significant increases in knowledge of overdose prevention, HIV testing procedures, and asymptomatic HCV infection. Future iterations of the MIK can be optimized for use in community as well as clinical settings nationwide, and perhaps globally, with a focus on underserved urban populations.

Widening social inequalities in mortality: the case of Barcelona, a southern European city.

PubMed Central

Borrell, C; Plasència, A; Pasarin, I; Ortún, V

1997-01-01

OBJECTIVE: To analyse trends in mortality inequalities in Barcelona between 1983 and 1994 by comparing rates in those electoral wards with a low socioeconomic level and rates in the remaining wards. DESIGN: Mortality trends study. SETTING: The city of Barcelona (Spain). SUBJECTS: The study included all deaths among residents of the two groups of city wards. Details were obtained from death certificates. MAIN OUTCOME MEASURES: Age standardised mortality rates, age standardised rates of years of potential life lost, and age specific mortality rates in relation to cause of death, sex, and year were computed as well as the comparative mortality figure and the ratio of standardised rates of years of potential life lost. RESULTS: Rates of premature mortality increased from 5691.2 years of potential life lost per 100,000 inhabitants aged 1 to 70 years in 1983 to 7606.2 in 1994 in the low socioeconomic level wards, and from 3731.2 to 4236.9 in the other wards, showing an increase in inequalities over the 12 years, mostly due to AIDS and drug overdose as causes of death. Conversely, cerebrovascular disease showed a reduction in inequality over the same period. Overall mortality in the 15-44 age group widened the gap between both groups of wards. CONCLUSION: AIDS and drug overdose are emerging as the causes of death that are contributing to a substantial increase in social inequality in terms of premature mortality, an unreported observation in European urban areas. PMID:9519129

Identifying mortality risks in patients with opioid use disorder using brief screening assessment: Secondary mental health clinical records analysis.

PubMed

Bogdanowicz, Karolina Magda; Stewart, Robert; Chang, Chin-Kuo; Downs, Johnny; Khondoker, Mizanur; Shetty, Hitesh; Strang, John; Hayes, Richard Derek

2016-07-01

Risk assessments are widely used, but their ability to predict outcomes in opioid use disorder (OUD) treatment remains unclear. Therefore, the aim was to investigate if addiction-specific brief risk screening is effective in identifying high mortality risk groups and if subsequent clinical actions following risk assessment impacts on mortality levels. Opioid use disorder (OUD) patients were identified in the South London and Maudsley Case Register. Deaths were identified through database linkage to the national mortality dataset. Cox and competing-risk regression were used to model associations between brief risk assessment domains and all-cause and overdose mortality in 4488 OUD patients, with up-to 6-year follow-up time where 227 deaths were registered. Data were stratified by admission to general mental health services. All-cause mortality was significantly associated with unsafe injecting (HR 1.53, 95% CI 1.10-2.11) and clinically appraised likelihood of accidental overdose (HR 1.48, 95% CI 1.00-2.19). Overdose-mortality was significantly associated with unsafe injecting (SHR 2.52, 95% CI 1.11-5.70) and clinically appraised suicidality (SHR 2.89, 95% CI 1.38-6.03). Suicidality was associated with a twofold increase in mortality risk among OUD patients who were not admitted to mental health services within 2 months of their risk assessment (HR 2.03, 95% CI 1.67-3.24). Diagnosis-specific brief risk screening can identify OUD patient subgroups at increased risk of all-cause and overdose mortality. OUD patients, where suicidality is evident, who are not admitted into services are particularly vulnerable. Copyright © 2016 The Author(s). Published by Elsevier Ireland Ltd.. All rights reserved.

Successful use of haemodialysis to treat phenobarbital overdose.

PubMed

Hoyland, Kimberley; Hoy, Michael; Austin, Richard; Wildman, Martyn

2013-11-21

A 50-year-old woman presented with coma caused by a phenobarbital overdose, requiring intubation and admission to critical care. She was an international visitor and had been prescribed the drug for night-sedation. Phenobarbital is a long-acting barbiturate, which in an overdose can cause central nervous system depression, respiratory failure and haemodynamic instability; these patients can remain obtunded for many days. After initial supportive therapy, she was dialysed to help in the elimination of the drug. Haemodialysis resulted in a markedly reduced plasma level of phenobarbital, which decreased the length of intubation and stay in the critical care unit and aided full recovery.

Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States.

PubMed

Davidson, Peter J; Lopez, Andrea M; Kral, Alex H

2018-03-01

Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an 'underground' facility since September 2014. Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples' lives, including the impact of lack of formal legal sanction on service provision. Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being 'underground' included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services. Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction. Copyright © 2017 Elsevier B.V. All rights reserved.

Mortality among people who inject drugs: a systematic review and meta-analysis

PubMed Central

Degenhardt, Louisa; Bucello, Chiara; Lemon, James; Wiessing, Lucas; Hickman, Mathew

2013-01-01

Abstract Objective To systematically review cohort studies of mortality among people who inject drugs, examine mortality rates and causes of death in this group, and identify participant- and study-level variables associated with a higher risk of death. Methods Tailored search strings were used to search EMBASE, Medline and PsycINFO. The grey literature was identified through online grey literature databases. Experts were consulted to obtain additional studies and data. Random effects meta-analyses were performed to estimate pooled crude mortality rates (CMRs) and standardized mortality ratios (SMRs). Findings Sixty-seven cohorts of people who inject drugs were identified, 14 of them from low- and middle-income countries. The pooled CMR was 2.35 deaths per 100 person–years (95% confidence interval, CI: 2.12–2.58). SMRs were reported for 32 cohorts; the pooled SMR was 14.68 (95% CI: 13.01–16.35). Comparison of CMRs and the calculation of CMR ratios revealed mortality to be higher in low- and middle-income country cohorts, males and people who injected drugs that were positive for human immunodeficiency virus (HIV). It was also higher during off-treatment periods. Drug overdose and acquired immunodeficiency syndrome (AIDS) were the primary causes of death across cohorts. Conclusion Compared with the general population, people who inject drugs have an elevated risk of death, although mortality rates vary across different settings. Any comprehensive approach to improving health outcomes in this group must include efforts to reduce HIV infection as well as other causes of death, particularly drug overdose. PMID:23554523

Brief Opioid Overdose Knowledge (BOOK): A Questionnaire to Assess Overdose Knowledge in Individuals Who Use Illicit or Prescribed Opioids.

PubMed

Dunn, Kelly E; Barrett, Frederick S; Yepez-Laubach, Claudia; Meyer, Andrew C; Hruska, Bryce J; Sigmon, Stacey C; Fingerhood, Michael; Bigelow, George E

2016-01-01

Opioid overdose is a public health crisis. This study describes efforts to develop and validate the Brief Opioid Overdose Knowledge (BOOK) questionnaire to assess patient knowledge gaps related to opioid overdose risks. Two samples of illicit opioid users and a third sample of patients receiving an opioid for the treatment of chronic pain (total N = 848) completed self-report items pertaining to opioid overdose risks. A 3-factor scale was established, representing Opioid Knowledge (4 items), Opioid Overdose Knowledge (4 items), and Opioid Overdose Response Knowledge (4 items). The scale had strong internal and face validity. Patients with chronic pain performed worse than illicit drug users in almost all items assessed, highlighting the need to increase knowledge of opioid overdose risk to this population. This study sought to develop a brief, internally valid method for quickly assessing deficits in opioid overdose risk areas within users of illicit and prescribed opioids, to provide an efficient metric for assessing and comparing educational interventions, facilitate conversations between physicians and patients about overdose risks, and help formally identify knowledge deficits in other patient populations.

Buprenorphine implants in medical treatment of opioid addiction.

PubMed

Chavoustie, Steven; Frost, Michael; Snyder, Ole; Owen, Joel; Darwish, Mona; Dammerman, Ryan; Sanjurjo, Victoria

2017-08-01

Opioid use disorder is a chronic, relapsing disease that encompasses use of both prescription opioids and heroin and is associated with a high annual rate of overdose deaths. Medical treatment has proven more successful than placebo treatment or psychosocial intervention, and the partial µ-opioid receptor agonist and κ-opioid receptor antagonist buprenorphine is similar in efficacy to methadone while offering lower risk of respiratory depression. However, frequent dosing requirements and potential for misuse and drug diversion contribute to significant complications with treatment adherence for available formulations. Areas covered: This review describes the development of and preliminary data from clinical trials of an implantable buprenorphine formulation. Efficacy and safety data from comparative studies with other administrations of buprenorphine, including tablets and sublingual film, will be described. Key premises of the Risk Evaluation and Mitigation Strategy program for safely administering buprenorphine implants, which all prescribing physicians must complete, are also discussed. Expert commentary: Long-acting implantable drug formulations that offer consistent drug delivery and lower risk of misuse, diversion, or accidental pediatric exposure over traditional formulations represent a promising development for the effective treatment of opioid use disorder.

Characterizing Mortality from Substance Abuse in Iran: An Epidemiological Study during March 2014 to February 2015

PubMed Central

Shahbazi, Fatemeh; Mirtorabi, Seyed Davood; Ghadirzadeh, Mohammad Reza; Hashemi-Nazari, Seyed Saeed; Barzegar, Abdolrazagh

2017-01-01

Background Drug abuse is a severe and chronic disorder that leaves morbidity, disability and premature mortality in the society. The study of death due to substance abuse provides useful information for local, national and international administrators. Thus, by identifying the factors that have an impact on overdose-related mortality we can provide suitable intervention for vulnerable groups. The aim of this study was an investigation of mortality rate caused by consumption of narcotic and psychoactive substances in Iran. Methods In this cross-sectional study, demographic and epidemiological data about all people whose cause of death was substance abuse in March 2014 to February 2015 were collected from Legal Medicine Organization (LMO). Finally, the information that was extracted from two checklists was analyzed by descriptive statistics. Findings In this study, 2986 cases died from substances abuse were evaluated. Most deaths have befallen in unmarried young men with mean age of 36.9 ± 12.3, in the private locations. The mortality rate of drug abuse in the whole country was 38.4 per 1000000 population. The proportion of mortality was higher in Iranian nationality and in people who had a diploma and less education. History of overdose, suicide, hospitalization in a psychiatric hospital, staying in prison and substance abuse in the family were investigated in the study population. Conclusion The present study revealed that mortality rate from substance abuse is more among unmarried young men aged 30-39 years with low education level and also in the self-employed group. We suggest that policies should be taken to prevent these people from accessing and using the drug. PMID:29657697

Dipyridamole and paracetamol overdose resulting in multi-organ failure.

PubMed

Cullis, P S; Watson, D; Cameron, A; McKee, R F

2013-08-01

Dipyridamole intoxication is rare and few reports exist amongst the current literature. A case of dipyridamole and paracetamol overdose is described in a previously healthy 58-year-old woman, which resulted in multi-organ failure requiring dialysis, inotropic support, ventilation and extensive surgical intervention for small bowel ischaemia. This case highlights the dangers of an unusually large overdose of a commonly prescribed drug, and reviews current knowledge of dipyridamole intoxication.

Patterns of antiepileptic drug overdose differ between men and women: admissions to the Edinburgh Poisons Unit, 2000-2007.

PubMed

Nixon, A C; Doak, M W; Crozier, H; Crooks, D P; Waring, W S

2009-01-01

Antiepileptic drugs are increasingly used in patients with psychiatric disorders who are at increased risk of self-harm. This might increase the likelihood that these agents are used as a means of overdose. This study was designed to examine the rate of occurrence of antiepileptic drug overdose between 2000 and 2007. A retrospective observational study examined patterns of antiepileptic drug overdose in patients admitted to the Edinburgh Poisons Unit, and compared prescription data for the corresponding region. Data were compared using chi-square trend tests. There were 18 010 admissions to the Toxicology Unit, and 613 patients ingested at least one antiepileptic drug (3.4%). The most frequently implicated were carbamazepine, sodium valproate, phenytoin and lamotrigine, which corresponded with those most commonly prescribed. Women were more likely to ingest lamotrigine than men (P < 0.0001), and less likely to ingest sodium valproate (P = 0.0234). Patients that ingested antiepileptic drugs were more likely to be admitted to hospital for >1 day (22% vs. 8%, P < 0.0001) and need transfer to a psychiatric facility (14% vs. 7%, P < 0.0001). Patients that ingested antiepileptic drugs required more intensive medical and psychiatric intervention compared to ingestion of other agents. Significant gender differences were noted in the specific antiepileptic drug ingested. Further work is required to establish whether this discrepancy may be explained by gender-based prescribing practices.

What is known about community pharmacy supply of naloxone? A scoping review.

PubMed

Nielsen, Suzanne; Van Hout, Marie Claire

2016-06-01

There is growing evidence that expanded supply of take-home naloxone to prevent opioid overdose deaths is needed. Potential routes for expansion of naloxone provision include through community pharmacies. The aim of this scoping review is to establish what is known about community pharmacy supply of naloxone, in light of unique challenges and opportunities present in pharmacy settings. A scoping review methodology was employed using the six stage iterative process advocated by Arksey and O'Malley (2005) and Levac et al. (2010). Searches used key words and terms such as 'naloxone'; 'overdose prevention/drug overdose/opiate overdose'; 'community/retail pharmacy'; 'pharmacist/pharmacy/community pharmacy/pharmaceutical services'; 'professional practice/role'; 'community care'; attitude of health personnel'; 'training/supply/cost'. Appropriate search terms were selected for each database. After initial exploratory searches, comprehensive searches were conducted with Cochrane Database of Systematic Reviews, Medline, Medline in Process, Embase, PsycINFO and CINAHL. Eligibility criteria centered on whether studies broadly described supply of naloxone in community pharmacy or had content relating to community pharmacy supply. The search identified 95 articles, of which 16 were related to pharmacy supply of naloxone. Five themes were presented after initial review of the data and consultation with the project Expert Group, and are; 'Pharmacists Perceptions of Naloxone: Facilitators and Barriers', 'Patient Populations: Identification and Recruitment', 'Supply Systems and Cost', 'Legal Issues', and 'Training of Pharmacists and Community Pharmacy Naloxone Recipients'. Findings from this scoping review suggest that community pharmacy based supply of take-home naloxone warrants the community pharmacy based route for distribution of take home naloxone provision warrants further consideration and development. Existing strengths include a range of established supply models, and training curricula, few direct concerns regarding legal liability of pharmacists in the supply of naloxone (once legal supply systems have been established) and the wide range of potential identifiable patient populations, which include pain patients that may not be in contact with existing naloxone supply programmes. Copyright © 2016 Elsevier B.V. All rights reserved.

Social and economic inequalities in fatal opioid and cocaine related overdoses in Luxembourg: a case-control study.

PubMed

Origer, Alain; Le Bihan, Etienne; Baumann, Michèle

2014-09-01

To investigate social and economic inequalities in fatal overdose cases related to opioid and cocaine use, recorded in Luxembourg between 1994 and 2011. Cross-examination of national data from law enforcement and drug use surveillance sources and of forensic evidence in a nested case-control study design. Overdose cases were individually matched with four controls, when available, according to sex, year of birth, drug administration route and duration of drug use. 272 cases vs 1056 controls were analysed. Conditional logistic regression analysis was performed to assess the respective impact of a series of socioeconomic variables. Being professionally active [OR=0.66 (95% CI 0.45-0.99)], reporting salary as main legal income source [OR=0.42 (95% CI 0.26-0.67)] and education attainment higher than primary school [OR=0.50 (95% CI 0.34-0.73)] revealed to be protective factors, whereas the professional status of the father or legal guardian of victims was not significantly associated to fatal overdoses. Socioeconomic inequalities in drug users impact on the occurrence of fatal overdoses. Compared to their peers, users of illicit drugs with lower socioeconomic profiles show increased odds of dying from overdose. However, actual and self-referred socioeconomic characteristics of drug users, such as educational attainment and employment, may have a greater predictive value of overdose mortality than the parental socioeconomic status. Education, vocational training and socio-professional reintegration should be part of drug-related mortality prevention policies. Copyright © 2014 Elsevier B.V. All rights reserved.

Reliability of history of acetaminophen ingestion in intentional drug overdose patients.

PubMed

Bentur, Yedidia; Lurie, Yael; Tamir, Ada; Keyes, Daniel C; Basis, Fuad

2011-01-01

The objective of this study was to determine the reliability of denial of acetaminophen ingestion in intentional drug overdose patients. All intentional drug overdose patients admitted to an emergency department who were able to provide a history were included. A detailed history was obtained on names, timing and number of medications ingested, and serum acetaminophen was assayed. Multidrug ingestion was defined as the reporting of ≥2 medications. Patients were considered 'reliable' if they reported acetaminophen ingestion and had detectable acetaminophen levels or the other way around. Validity parameters of acetaminophen history were assessed by sensitivity, specificity and positive and negative predictive values. A total of 154 patients were included. History was significantly more reliable in patients who denied ingestion of acetaminophen (n = 107) compared with patients who reported it (n = 47; 95.3% vs 65.9%, respectively; p < 0.0001, 95% CI of the difference 17.5%-41.2%). No suicidal patient who denied both acetaminophen and multidrug ingestions had a detectable acetaminophen level (negative predictive value 1, 95% CI 0.93-1.0). It is suggested that denial of both acetaminophen and multidrug ingestions by intentional drug overdose patients after a thorough history taking can be considered reliable for acetaminophen history. In facilities with limited resources, these patients may not require routine acetaminophen screening.

Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting.

PubMed

Dunn, Kelly E; Barrett, Frederick S; Yepez-Laubach, Claudia; Meyer, Andrew C; Hruska, Bryce J; Petrush, Kathy; Berman, Suzan; Sigmon, Stacey C; Fingerhood, Michael; Bigelow, George E

2016-12-01

Opioid use is highly prevalent in the United States and there has been an increased incidence in the rate of opioid-related overdose. While evidence suggests there are substantial differences in opioid use among rural versus urban settings, the rate of overdose and corresponding frequency of opioid overdose risk behaviors and overdose knowledge between rural and urban settings have not been examined. Individuals with opioid use disorder from rural (N=98) and urban (N=247) settings completed a self-report survey regarding their lifetime history of overdose and overdose risk behaviors. Participants also completed the Brief Opioid Overdose Knowledge (BOOK) questionnaire, a 12-item self-report measure of opioid overdose knowledge. Overall, 35.6% of participants had experienced an overdose, and prevalence of overdose was significantly higher (p<.01) among rural (45.9%) vs. urban (31.6%) participants, though fewer rural participants reported past 30-day risk behaviors. There were few differences observed between the subset of rural and urban participants who had experienced an overdose, and fewer rural participants with a history of overdose reported past 30-day risk behaviors. Both rural and urban participants performed poorly on the BOOK, though the percent of correct responses was lowest among rural participants with a history of overdose. Results demonstrate higher rates of overdose among rural opioid users, though rural participants were less likely to report recent risk behaviors. Results also suggest that knowledge regarding key factors related to opioid overdose is severely lacking, particularly among rural opioid users, which could be a potential target for future intervention efforts.

Suicidal drug overdose in patients with systemic lupus erythematosus, a nationwide population-based case-control study.

PubMed

Tang, K T; Lin, C H; Chen, H H; Chen, Y H; Chen, D Y

2016-02-01

A four-fold increase of suicide mortality has been demonstrated in systemic lupus erythematosus (SLE) patients. Prior studies showed that the most common method of suicide attempts in SLE patients involves drug overdose. Therefore, we conducted a nationwide population-based case-control study to elucidate factors associated with drug overdose as suicide attempt in SLE patients. This study was based on the National Health Insurance Research Database in Taiwan. We identified all SLE patients from January 1, 2000 to December 31, 2010. Patients who had suicidal drug overdose (SDO) were selected as cases while age- and gender-matched patients who did not have SDO were selected as controls. The incidence rate of SDO in SLE patients was 291 cases per 100,000 person-years, higher than that in the general population (160 cases per 100,000 person-years). In a multivariate logistic regression analysis, we observed that SDO was associated with psychiatric disorders such as depressive disorders (odds ratio: 8.36, 95% confidence interval (CI): 5.60-12.48) and insomnia (odds ratio: 2.71, 95% CI: 1.73-4.25), and lower monthly income (odds ratios: 2.74 to 3.50) in SLE patients. SDO is associated with psychiatric disorders such as depressive disorders and insomnia, and lower monthly income in SLE patients. © The Author(s) 2015.

'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting.

PubMed

Kerr, Thomas; Small, Will; Hyshka, Elaine; Maher, Lisa; Shannon, Kate

2013-07-01

To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses. Semi-structured qualitative interviews. Vancouver, Canada. Eighteen active heroin injectors. Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations. Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages. Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk. © 2013 Society for the Study of Addiction.

Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling study.

PubMed

Uyei, Jennifer; Fiellin, David A; Buchelli, Marianne; Rodriguez-Santana, Ramon; Braithwaite, R Scott

2017-03-01

In the USA, an epidemic of opioid overdose deaths is occurring, many of which are from heroin. Combining naloxone distribution with linkage to addiction treatment or pre-exposure prophylaxis (PrEP) for HIV prevention through syringe service programmes has the potential to save lives and be cost-effective. We estimated the outcomes and cost-effectiveness of five alternative strategies: no additional intervention, naloxone distribution, naloxone distribution plus linkage to addiction treatment, naloxone distribution plus PrEP, and naloxone distribution plus linkage to addiction treatment and PrEP. We developed a decision analytical Markov model to simulate opioid overdose, HIV incidence, overdose-related deaths, and HIV-related deaths in people who inject drugs in Connecticut, USA. Model input parameters were derived from published sources. We compared each strategy with no intervention, as well as simultaneously considering all strategies. Sensitivity analysis was done for all variables. Linkage to addiction treatment was referral to an opioid treatment programme for methadone. Endpoints were survival, life expectancy, quality-adjusted life-years (QALYs), number and percentage of overdose deaths averted, number of HIV-related deaths averted, total costs (in 2015 US$) associated with each strategy, and incremental cost per QALY gained. In the base-case analysis, compared with no additional intervention, the naloxone distribution strategy yielded an incremental cost-effectiveness ratio (ICER) of $323 per QALY, and naloxone distribution plus linkage to addiction treatment was cost saving compared with no additional intervention (greater effectiveness and less expensive). The most efficient strategies (ie, those conferring the greatest health benefit for a particular budget) were naloxone distribution combined with linkage to addiction treatment (cost saving), and naloxone distribution combined with PrEP and linkage to addiction treatment (ICER $95 337 per QALY) at a willingness-to-pay threshold of $100 000. In probabilistic sensitivity analysis, the combination of naloxone distribution, PrEP, and linkage to addiction treatment was the optimal strategy in 37% of iterations and the combination of naloxone distribution and linkage to addiction treatment was the optimal strategy in 34% of iterations. Naloxone distribution through syringe service programmes is cost-effective compared with syringe distribution alone, but when combined with linkage to addiction treatment is cost saving compared with no additional services. A strategy that combines naloxone distribution, PrEP, and linkage to addiction treatment results in greater health benefits in people who inject drugs and is also cost-effective. State of Connecticut Department of Public Health and the National Institute of Mental Health. Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. Published by Elsevier Ltd.. All rights reserved.

HIV infection and risk of overdose: a systematic review and meta-analysis

PubMed Central

Green, Traci C.; McGowan, Samuel K.; Yokell, Michael A.; Pouget, Enrique R.; Rich, Josiah D.

2012-01-01

Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for people who inject drugs. People with HIV are often exposed to opioid medications during their HIV care experience; others may continue to use illicit opioids despite their disease status. In either situation, there may be a heightened risk for nonfatal or fatal overdose. The potential mechanisms for this elevated risk remain controversial. We systematically reviewed the literature on the HIV–overdose association, meta-analyzed results, and investigated sources of heterogeneity, including study characteristics related to hypothesize biological, behavioral, and structural mechanisms of the association. Forty-six studies were reviewed, 24 of which measured HIV status serologically and provided data quantifying an association. Meta-analysis results showed that HIV seropositivity was associated with an increased risk of overdose mortality (pooled risk ratio 1.74, 95% confidence interval 1.45, 2.09), although the effect was heterogeneous (Q = 80.3, P <0.01, I2 = 71%). The wide variability in study designs and aims limited our ability to detect potentially important sources of heterogeneity. Causal mechanisms considered in the literature focused primarily on biological and behavioral factors, although evidence suggests structural or environmental factors may help explain the greater risk of overdose among HIV-infected drug users. Gaps in the literature for future research and prevention efforts as well as recommendations that follow from these findings are discussed. PMID:22112599

Buprenorphine physician supply: Relationship with state-level prescription opioid mortality

PubMed Central

Havens, Jennifer R.; Lofwall, Michelle R.; Studts, Jamie L.; Walsh, Sharon L.

2017-01-01

Background Buprenorphine is an effective treatment for opioid use disorder but the supply of buprenorphine physicians is currently inadequate to address the nation’s prescription opioid crisis. Perception of need due to rising opioid overdose rates is one possible reason for physicians to adopt buprenorphine. This study examined associations between rates of growth in buprenorphine physicians and prescription opioid overdose mortality rates in US states. Methods The total buprenorphine physician supply and number of physicians approved to treat 100 patients (per 100,000 population) were measured from June, 2013 to January, 2016. States were divided into two groups: those with rates of prescription opioid overdose mortality in 2013 at or above the median (>5.5 deaths per 100,000 population) and those with rates below the median. State-level growth curves were estimated using mixed-effects regression to compare rates of growth between high and low overdose states. Results The total supply and the supply of 100-patient buprenorphine physicians grew significantly (total supply from 7.7 to 9.9 per 100,000 population, p<.001; 100-patient supply from 2.2 to 3.4 per 100,000 population, p<.001). Rates of growth were significantly greater in high overdose states when compared to low overdose states (total supply b=.033, p<.01; 100-patient b=.022, p<.01). Conclusions The magnitude of the US prescription opioid crisis, as measured by the rate of prescription opioid overdose mortality, is associated with growth in the number of buprenorphine physicians. Because this observational design cannot establish causality, further research is needed to elucidate the factors influencing physicians’ decisions to begin prescribing buprenorphine. PMID:28363321

Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series.

PubMed

Vignesh, C; Kumar, Madhan; Venkataraman, Ramesh; Rajagopal, Senthilkumar; Ramakrishnan, Nagarajan; Abraham, Babu K

2018-02-01

Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried. Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy. We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy. Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support. Despite the occurrence of device-associated complications, the outcome was good and all patients survived. VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose.

Sharing Overdose Data Across State Agencies to Inform Public Health Strategies: A Case Study.

PubMed

Cherico-Hsii, Sara; Bankoski, Andrea; Singal, Pooja; Horon, Isabelle; Beane, Eric; Casey, Meghan; Rebbert-Franklin, Kathleen; Sharfstein, Joshua

2016-01-01

Data sharing and analysis are important components of coordinated and cost-effective public health strategies. However, legal and policy barriers have made data from different agencies difficult to share and analyze for policy development. To address a rise in overdose deaths, Maryland used an innovative and focused approach to bring together data on overdose decedents across multiple agencies. The effort was focused on developing discrete intervention points based on information yielded on decedents' lives, such as vulnerability upon release from incarceration. Key aspects of this approach included gubernatorial leadership, a unified commitment to data sharing across agencies with memoranda of understanding, and designation of a data management team. Preliminary results have yielded valuable insights and have helped inform policy. This process of navigating legal and privacy concerns in data sharing across multiple agencies may be applied to a variety of public health problems challenging health departments across the country.

Fatal combination of moclobemide overdose and whisky.

PubMed

Bleumink, G S; van Vliet, A C M; van der Tholen, A; Stricker, B H Ch

2003-03-01

The antidepressant moclobemide (Aurorix) is a reversible inhibitor of monoamine oxidase-A. Pure moclobemide overdose is considered to be relatively safe. Mixed drug overdoses including moclobemide are potentially lethal, especially when serotonergical drugs are involved. So far, only one fatality due to moclobemide mono-overdose has been reported. We report here on a fatality following the ingestion of a moclobemide overdose in combination with half a bottle of whisky. Although dietary restrictions during moclobemide therapy are not considered necessary, the combination of large quantities of moclobemide and tyramine-containing products seems to be lethal, probably because monoamine oxidase-A selectivity is overwhelmed after massive overdoses. Since there is no specific antidote and treatment is only symptomatic, the severity of an overdose with moclobemide must not be underestimated.

Co-proxamol overdose is associated with a 10-fold excess mortality compared with other paracetamol combination analgesics

PubMed Central

Afshari, R; Good, AM; Maxwell, SRJ; Bateman, DN

2005-01-01

Aims To assess the relative toxicity of co-proxamol in overdose in comparison to the 2 other paracetamol-opioid combination products, co-codamol and co-dydramol. Methods Data collected over a 2-year period (July 2000–June 2002) was used to estimate the frequency of overdose and death for the three most popular paracetamol-opioid compound analgesics. Prescription data for Scotland and Edinburgh, the number of overdoses (derived from overdose admissions in Edinburgh) or Poisons Information Service contacts in Scotland, and national death records were used to calculate a series of indicators relating morbidity (admissions), surrogates of morbidity (poisons enquiries by telephone or internet) and mortality to prescriptions. Results When related to prescription volume overdoses involving co-proxamol in Scotland were 10 times more likely to be fatal (24.6 (19.7, 30.4)) when compared with co-codamol (2.0 (0.88, 4.0)) or co-dydramol (2.4 (0.5, 7.2)). In contrast there was no difference in the presentation rate or enquiry rates for these analgesics when corrected for prescriptions. Conclusions The excess hazard from co-proxamol is due to inherent toxicity rather than increased use in overdose. We estimate from this study that withdrawal of co-proxamol would prevent 39 excess deaths per annum in Scotland alone. PMID:16187978

The Very High Premature Mortality Rate among Active Professional Wrestlers Is Primarily Due to Cardiovascular Disease

PubMed Central

Herman, Christopher W.; Conlon, Anna S. C.; Rubenfire, Melvyn; Burghardt, Andrew R.; McGregor, Stephen J.

2014-01-01

Purpose Recently, much media attention has been given to the premature deaths in professional wrestlers. Since no formal studies exist that have statistically examined the probability of premature mortality in professional wrestlers, we determined survival estimates for active wresters over the past quarter century to establish the factors contributing to the premature mortality of these individuals. Methods Data including cause of death was obtained from public records and wrestling publications in wrestlers who were active between January 1, 1985 and December 31, 2011. 557 males were considered consistently active wrestlers during this time period. 2007 published mortality rates from the Center for Disease Control were used to compare the general population to the wrestlers by age, BMI, time period, and cause of death. Survival estimates and Cox hazard regression models were fit to determine incident premature deaths and factors associated with lower survival. Cumulative incidence function (CIF) estimates given years wrestled was obtained using a competing risks model for cause of death. Results The mortality for all wrestlers over the 26-year study period was.007 deaths/total person-years or 708 per 100,000 per year, and 16% of deaths occurred below age 50 years. Among wrestlers, the leading cause of deaths based on CIF was cardiovascular-related (38%). For cardiovascular-related deaths, drug overdose-related deaths and cancer deaths, wrestler mortality rates were respectively 15.1, 122.7 and 6.4 times greater than those of males in the general population. Survival estimates from hazard models indicated that BMI is significantly associated with the hazard of death from total time wrestling (p<0.0001). Conclusion Professional wrestlers are more likely to die prematurely from cardiovascular disease compared to the general population and morbidly obese wrestlers are especially at risk. Results from this study may be useful for professional wrestlers, as well as wellness policy and medical care implementation. PMID:25372569

Radiological-Pathological Correlations Following Blast-Related Traumatic Brain Injury in the Whole Human Brain Using ex Vivo Diffusion Tensor Imaging

DTIC Science & Technology

2014-01-01

were as follows: Blast TBI: Suicide drug overdose – blast years prior Ruptured aneurysm – blast years prior intraventricular hemorrhage...drug overdose Suicide blunt trauma - fall Cancer Cardiac Arrest Tissue fixation was highly variable because cases were obtained from 4 different...blast years prior Civilian Blast DOA Non-blast TBI: MVA – DOA MVA – DOS Suicide – NFL – GSW to chest Cardiac Arrest – NFL Controls: Suicide

Sickle Cell Tests

MedlinePlus

... Autoantibodies Digoxin Direct Antiglobulin Test Direct LDL Cholesterol Drug Abuse Testing EGFR Mutation Testing Electrolytes Emergency and Overdose Drug Testing Epstein-Barr Virus (EBV) Antibody Tests Erythrocyte ...

Epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge in Japan: An exploratory descriptive study using a nationwide claims database.

PubMed

Okumura, Yasuyuki; Sakata, Nobuo; Takahashi, Kunihiko; Nishi, Daisuke; Tachimori, Hisateru

2017-08-01

Little is known about the nationwide epidemiology of the annual rate, causative substance, and clinical course of overdose-related admission. We aimed to describe the epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge to home. We assessed all cases of admission due to overdose (21,663 episodes) in Japan from October 2012 through September 2013 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. The annual rate of overdose admission was 17.0 per 100,000 population. Women exhibited two peaks in admission rates at 19-34 years (40.9 per 100,000) and ≥75 years (27.8 per 100,000). Men exhibited one peak in the admission rate at ≥75 years (23.7 per 100,000). Within 90 days prior to overdose, ≥60% and ≥9% of patients aged 19-49 years received a prescription for benzodiazepines and barbiturates, respectively. In addition, 59% of patients aged ≥75 years received a prescription for benzodiazepines prior to overdose, 47% had a history of congestive heart failure, and 24% had a diagnosis of poisoning by cardiovascular drugs. The proportion of patients with recent psychiatric treatments decreased with age (65.1% in those aged 35-49 years and 13.9% in those aged ≥75 years). The findings emphasize the need for overdose prevention programs that focus on psychiatric patients aged 19-49 years who are prescribed benzodiazepines or barbiturates and on non-psychiatric patients aged ≥75 years who are prescribed benzodiazepines or digitalis. Copyright © 2017 The Authors. Production and hosting by Elsevier B.V. All rights reserved.

Misuse of Novel Synthetic Opioids: A Deadly New Trend

PubMed Central

Prekupec, Matthew P.; Mansky, Peter A.; Baumann, Michael H.

2017-01-01

Novel synthetic opioids (NSOs) include various analogs of fentanyl and newly emerging non-fentanyl compounds. Together with illicitly manufactured fentanyl (IMF), these drugs have caused a recent spike in overdose deaths, whereas deaths from prescription opioids have stabilized. NSOs are used as stand-alone products, as adulterants in heroin, or as constituents of counterfeit prescription medications. During 2015 alone, there were 9580 deaths from synthetic opioids other than methadone. Most of these fatalities were associated with IMF rather than diverted pharmaceutical fentanyl. In opioid overdose cases, where the presence of fentanyl analogs was examined, analogs were implicated in 17% of fatalities. Recent data from law enforcement sources show increasing confiscation of acetylfentanyl, butyrylfentanyl, and furanylfentanyl, in addition to non-fentanyl compounds such as U-47700. Since 2013, deaths from NSOs in the United States were 52 for acetylfentanyl, 40 for butyrylfentanyl, 128 for furanylfentanyl, and 46 for U-47700. All of these substances induce a classic opioid toxidrome, which can be reversed with the competitive antagonist naloxone. However, due to the putative high potency of NSOs and their growing prevalence, it is recommended to forgo the 0.4 mg initial dose of naloxone and start with 2 mg. Because NSOs offer enormous profit potential, and there is strong demand for their use, these drugs are being trafficked by organized crime. NSOs present major challenges for medical professionals, law enforcement agencies, and policymakers. Resources must be distributed equitably to enhance harm reduction though public education, medication-assisted therapies, and improved access to naloxone. PMID:28590391

[Tiagabine overdose--report of two cases].

PubMed

Wiśniewski, Marek; Sein Anand, Jacek; Chodorowski, Zygmunt; Kosińska-Tomczyk, Henryka

2007-01-01

Tiagabine is a derivative of nipecotinic acid used in the therapy of partial seizures, partial seizures with secondary generalization, stress disorder, psychosis and cocaine dependence. The pharmacologic effect of the drug is achieved by inhibition of reuptake of gamma aminobutyric acid (GABA) into glial cells and neurons, without permanent increase in whole brain GABA concentration. Symptoms of acute tiagabine overdose include seizures, coma, respiratory depression ' and less often dystonias, involuntary movements, somnolence, agitation, tachycardia and increase or decrease of blood pressure. Two cases of acute tiagabine overdose have been described in the paper presenting with partial and generalized seizures which were managed with benzodiazepines. The onset of symptoms of acute tiagabine overdose is rapid with resolution within first 24 hours from exposure. Acute tiagabine poisoning may present with a wide variety of neurological symptoms. Administration of benzodiazepines may improve the outcome of overdose.

HIV infection and risk of overdose: a systematic review and meta-analysis.

PubMed

Green, Traci C; McGowan, Samuel K; Yokell, Michael A; Pouget, Enrique R; Rich, Josiah D

2012-02-20

Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for people who inject drugs. People with HIV are often exposed to opioid medications during their HIV care experience; others may continue to use illicit opioids despite their disease status. In either situation, there may be a heightened risk for nonfatal or fatal overdose. The potential mechanisms for this elevated risk remain controversial. We systematically reviewed the literature on the HIV-overdose association, meta-analyzed results, and investigated sources of heterogeneity, including study characteristics related to hypothesize biological, behavioral, and structural mechanisms of the association. Forty-six studies were reviewed, 24 of which measured HIV status serologically and provided data quantifying an association. Meta-analysis results showed that HIV seropositivity was associated with an increased risk of overdose mortality (pooled risk ratio 1.74, 95% confidence interval 1.45, 2.09), although the effect was heterogeneous (Q = 80.3, P < 0.01, I(2) = 71%). The wide variability in study designs and aims limited our ability to detect potentially important sources of heterogeneity. Causal mechanisms considered in the literature focused primarily on biological and behavioral factors, although evidence suggests structural or environmental factors may help explain the greater risk of overdose among HIV-infected drug users. Gaps in the literature for future research and prevention efforts as well as recommendations that follow from these findings are discussed.

Drug abuse first aid

MedlinePlus

... use of these drugs is a form of drug abuse. Medicines that are for treating a health problem ... about local resources. Alternative Names Overdose from drugs; Drug abuse first aid References Myck MB. Hallucinogens and drugs ...

Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series

PubMed Central

Vignesh, C.; Kumar, Madhan; Venkataraman, Ramesh; Rajagopal, Senthilkumar; Ramakrishnan, Nagarajan; Abraham, Babu K.

2018-01-01

Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried. Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy. We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy. Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support. Despite the occurrence of device-associated complications, the outcome was good and all patients survived. VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose. PMID:29531453

Self-identification of nonpharmaceutical fentanyl exposure following heroin overdose.

PubMed

Griswold, Matthew K; Chai, Peter R; Krotulski, Alex J; Friscia, Melissa; Chapman, Brittany; Boyer, Edward W; Logan, Barry K; Babu, Kavita M

2018-01-01

To compare user self-identification of nonpharmaceutical fentanyl exposure with confirmatory urine drug testing in emergency department (ED) patients presenting after heroin overdose. This was a cross-sectional study of adult ED patients who presented after a heroin overdose requiring naloxone administration. Participants provided verbal consent after which they were asked a series of questions regarding their knowledge, attitudes and beliefs toward heroin and nonpharmaceutical fentanyl. Participants also provided urine samples, which were analyzed using liquid chromatography coupled to quadrupole time-of-flight mass spectrometry to identify the presence of fentanyl, heroin metabolites, other clandestine opioids, common pharmaceuticals and drugs of abuse. Thirty participants were enrolled in the study period. Ten participants (33%) had never required naloxone for an overdose in the past, 20 participants (67%) reported recent abstinence, and 12 participants (40%) reported concomitant cocaine use. Naloxone was detected in all urine drug screens. Heroin or its metabolites were detected in almost all samples (93.3%), as were fentanyl (96.7%) and its metabolite, norfentanyl (93.3%). Acetylfentanyl was identified in nine samples (30%) while U-47700 was present in two samples (6.7%). Sixteen participants self-identified fentanyl in their heroin (sensitivity 55%); participants were inconsistent in their qualitative ability to identify fentanyl in heroin. Heroin users presenting to the ED after heroin overdose requiring naloxone are unable to accurately identify the presence of nonpharmaceutical fentanyl in heroin. Additionally, cutting edge drug testing methodologies identified fentanyl exposures in 96.7% of our patients, as well as unexpected clandestine opioids (like acetylfentanyl and U-47700).

Repetition of intentional drug overdose: a population-based study.

PubMed

Finkelstein, Yaron; Macdonald, Erin M; Hollands, Simon; Sivilotti, Marco L A; Hutson, Janine R; Mamdani, Muhammad M; Koren, Gideon; Juurlink, David N

2016-08-01

Intentional overdose is a leading method of self-harm and suicide, and repeat attempts strongly predict eventual death by suicide. To determine the risk of recurrence after a first intentional overdose. Secondary objectives included characterization of the temporal course and potential predictors of repeat overdose, a strong risk factor for death from suicide. Population-based cohort study. Ontario, Canada, from 1 April 2002 to 31 March 2013. All Ontario residents presenting to an emergency department after a first intentional overdose. The incidence and timing of recurrent overdose. We followed 81,675 patients discharged from hospital after a first intentional overdose. Overall, 13,903 (17.0%) returned with a repeat overdose after a median interval of 288 (inter-quartile range: 62 to 834) days. Of these, 4493 (5.5%) had multiple repeat episodes. Factors associated with repeat self-poisoning included psychiatric care in the preceding year (adjusted hazard ratio [aHR] 1.55; 95% confidence interval [CI] 1.50 to 1.61), alcohol dependence (aHR 1.41; 95% CI 1.35 to 1.46) and documented depression (aHR 1.39; 95% CI 1.34 to 1.44). Female sex, rural residence, lower socioeconomic status, ingestion of psychoactive drugs and younger age were also weakly associated with repeat overdose. Hospital presentation for repetition of intentional overdose is common, with recurrent episodes often far removed from the first. While several factors predict overdose repetition, none is particularly strong. Secondary prevention initiatives should be implemented for all individuals who present to the emergency department and survive intentional overdose.

Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates.

PubMed

Dowell, Deborah; Zhang, Kun; Noonan, Rita K; Hockenberry, Jason M

2016-10-01

To address the opioid overdose epidemic in the United States, states have implemented policies to reduce inappropriate opioid prescribing. These policies could affect the coincident heroin overdose epidemic by either driving the substitution of heroin for opioids or reducing simultaneous use of both substances. We used IMS Health's National Prescription Audit and government mortality data to examine the effect of these policies on opioid prescribing and on prescription opioid and heroin overdose death rates in the United States during 2006-13. The analysis revealed that combined implementation of mandated provider review of state-run prescription drug monitoring program data and pain clinic laws reduced opioid amounts prescribed by 8 percent and prescription opioid overdose death rates by 12 percent. We also observed relatively large but statistically insignificant reductions in heroin overdose death rates after implementation of these policies. This combination of policies was effective, but broader approaches to address these coincident epidemics are needed. Project HOPE—The People-to-People Health Foundation, Inc.

Prescription opioid misuse in the United States and the United Kingdom: cautionary lessons.

PubMed

Weisberg, Daniel F; Becker, William C; Fiellin, David A; Stannard, Cathy

2014-11-01

In the United States, opioid analgesics have increasingly been prescribed in the treatment of chronic pain, and this trend has accompanied increasing rates of misuse and overdose. Lawmakers have responded with myriad policies to curb the growing epidemic of opioid misuse, and a global alarm has been sounded among countries wishing to avoid this path. In the United Kingdom, a similar trend of increasing opioid consumption, albeit at lower levels, has been observed without an increase in reported misuse or drug-related deaths. The comparison between these two countries in opioid prescribing and opioid overdose mortality underscores important features of prescribing, culture, and health systems that may be permissive or protective in the development of a public health crisis. As access to opioid medications increases around the world, it becomes vitally important to understand the forces impacting opioid use and misuse. Trends in benzodiazepine and methadone use in the UK as well as structural elements of the National Health Service may serve to buffer opioid-related harms in the face of increasing prescriptions. In addition, the availability and price of heroin, as well as the ease of access to opioid agonist treatment in the UK may limit the growth of the illicit market for prescription opioids. The comparison between the US and the UK in opioid consumption and overdose rates should serve as a call to action for UK physicians and policymakers. Basic, proactive steps in the form of surveillance - of overdoses, marketing practices, prescribers, and patients - and education programs may help avert a public health crisis as opioid prescriptions increase. Copyright © 2014 Elsevier B.V. All rights reserved.

Buprenorphine physician supply: Relationship with state-level prescription opioid mortality.

PubMed

Knudsen, Hannah K; Havens, Jennifer R; Lofwall, Michelle R; Studts, Jamie L; Walsh, Sharon L

2017-04-01

Buprenorphine is an effective treatment for opioid use disorder but the supply of buprenorphine physicians is currently inadequate to address the nation's prescription opioid crisis. Perception of need due to rising opioid overdose rates is one possible reason for physicians to adopt buprenorphine. This study examined associations between rates of growth in buprenorphine physicians and prescription opioid overdose mortality rates in US states. The total buprenorphine physician supply and number of physicians approved to treat 100 patients (per 100,000 population) were measured from June 2013 to January 2016. States were divided into two groups: those with rates of prescription opioid overdose mortality in 2013 at or above the median (>5.5 deaths per 100,000 population) and those with rates below the median. State-level growth curves were estimated using mixed-effects regression to compare rates of growth between high and low overdose states. The total supply and the supply of 100-patient buprenorphine physicians grew significantly (total supply from 7.7 to 9.9 per 100,000 population, p<0.001; 100-patient supply from 2.2 to 3.4 per 100,000 population, p<0.001). Rates of growth were significantly greater in high overdose states when compared to low overdose states (total supply b=0.033, p<0.01; 100-patient b=0.022, p<0.01). The magnitude of the US prescription opioid crisis, as measured by the rate of prescription opioid overdose mortality, is associated with growth in the number of buprenorphine physicians. Because this observational design cannot establish causality, further research is needed to elucidate the factors influencing physicians' decisions to begin prescribing buprenorphine. Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.

Nurse practitioner LEADERSHIP in face of OPIOID CRISIS.

PubMed

Denhartog, Lauren

2017-01-01

Opioid misuse has been a growing problem in Alberta and throughout Canada and the U.S. in recent years. According to Alberta Health, the number of fentanyl-related overdose deaths in Alberta rose from six in 2011 to over 300 in 2016. This alarming increase in substance abuse is a national health crisis.

Use of Naloxone by Emergency Medical Services During Opioid Drug Overdose Resuscitation Efforts

PubMed Central

Sumner, Steven Allan; Mercado-Crespo, Melissa C.; Spelke, M. Bridget; Paulozzi, Leonard; Sugerman, David E.; Hillis, Susan D.; Stanley, Christina

2015-01-01

Naloxone administration is an important component of resuscitation attempts by emergency medical services (EMS) for opioid drug overdoses. However, EMS providers must first recognize the possibility of opioid overdose in clinical encounters. As part of a public health response to an outbreak of opioid overdoses in Rhode Island, we examined missed opportunities for naloxone administration and factors potentially influencing EMS providers’ decision to administer naloxone. We reviewed medical examiner files on all individuals who died of an opioid-related drug overdose in Rhode Island from January 1, 2012 through March 31, 2014, underwent attempted resuscitation by EMS providers, and had records available to assess for naloxone administration. We evaluated whether these individuals received naloxone as part of their resuscitation efforts and compared patient and scene characteristics of those who received naloxone to those who did not receive naloxone via chi-square, t-test, and logistic regression analyses. One hundred and twenty-four individuals who underwent attempted EMS resuscitation died due to opioid overdose. Naloxone was administered during EMS resuscitation attempts in 82 (66.1%) of cases. Females were nearly three-fold as likely not to receive naloxone as males (OR 2.9; 95% CI 1.2–7.0; p-value 0.02). Additionally, patients without signs of potential drug abuse also had a greater than three-fold odds of not receiving nalox-one (OR 3.3; 95% CI 1.2–9.2; p-value 0.02). Older individuals, particularly those over age 50, were more likely not to receive naloxone than victims younger than age 30 (OR 4.8; 95% CI 1.3–17.4; p-value 0.02). Women, older individuals, and those patients without clear signs of illicit drug abuse, were less likely to receive naloxone in EMS resuscitation attempts. Heightened clinical suspicion for opioid overdose is important given the recent increase in overdoses among patients due to prescription opioids. PMID:26383533

Substance use and risk of death in young offenders: a prospective data linkage study.

PubMed

Kinner, Stuart A; Degenhardt, Louisa; Coffey, Carolyn; Hearps, Stephen; Spittal, Matthew; Sawyer, Susan M; Patton, George C

2015-01-01

Young offenders are at increased risk of preventable death after release from custody, but risk factors for death in this population are poorly understood. Despite their poor health profiles, no studies have examined mortality outcomes in young people who have served community-based orders. The aims of this study were to describe the causes and identify risk factors for death in a cohort of young offenders in Victoria, Australia. We interviewed young people serving a custodial (n = 273) or community-based order (n = 242) in Victoria, Australia in 2002-2003. Measures included demographics and family history, offence history, experience of victimisation, mental illness, self-harm and substance use. Deaths up to 31 December 2011 were identified through a probabilistic linkage with the National Death Index. The all-cause crude mortality rate was 4.2 (95% confidence interval 2.7-6.8) per 1000 person years and was not significantly different for those who had served custodial and community-based orders. Most deaths were due to drug overdose, traffic accidents or suicide. Adjusting for age, sex and order type, risk factors for death from the baseline interview included weekly use of opioids, sleeping pills or painkillers, polydrug use and injecting drug use. Young people who have served community-based and custodial orders are at an increased risk of preventable death. Those engaging in risky substance use, particularly injecting drug use and use of multiple central nervous system depressants, are at greatest risk. There is an urgent need to develop and rigorously evaluate preventive interventions. © 2014 Australasian Professional Society on Alcohol and other Drugs.

Fully Automated Anesthesia, Analgesia and Fluid Management

ClinicalTrials.gov

2017-01-03

General Anesthetic Drug Overdose; Adverse Effect of Intravenous Anesthetics, Sequela; Complication of Anesthesia; Drug Delivery System Malfunction; Hemodynamic Instability; Underdosing of Other General Anesthetics

Risk Factors for Opioid-Use Disorder and Overdose.

PubMed

Webster, Lynn R

2017-11-01

Opioid analgesics are recognized as a legitimate medical therapy for selected patients with severe chronic pain that does not respond to other therapies. However, opioids are associated with risks for patients and society that include misuse, abuse, diversion, addiction, and overdose deaths. Therapeutic success depends on proper candidate selection, assessment before administering opioid therapy, and close monitoring throughout the course of treatment. Risk assessment and prevention include knowledge of patient factors that may contribute to misuse, abuse, addiction, suicide, and respiratory depression. Risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. Suicides are probably undercounted or frequently misclassified in reports of opioid-related poisoning deaths. Greater understanding and better assessment are needed of the risk associated with suicide risk in patients with pain. Clinical tools and an evolving evidence base are available to assist clinicians with identifying patients whose risk factors put them at risk for adverse outcomes with opioids.

Unintentional overdose and suicide among substance users: a review of overlap and risk factors.

PubMed

Bohnert, Amy S B; Roeder, Kathryn; Ilgen, Mark A

2010-08-01

Substance use is a risk factor for suicide, suicide attempts, and fatal and non-fatal overdose, but to date, little has been done to integrate the research on suicidal behavior and overdose among substance users. This study reviews the literature on suicide and overdose among substance users with the goal of illuminating the similarities and differences between these two events. A structured review resulted in 15 articles (describing 14 unique studies) published between 1990 and 2010 that examined both overdose and suicide in samples of substance users. There is some evidence that substance users who attempt suicide are more likely to report an overdose and vice versa. This relationship may be partially explained by the fact that overdose is a common method of suicide. The results of the literature review also indicate that substance users with a history of both events may represent a group with particularly poor psychological and social functioning and severe drug-related problems. Further research is needed to understand the overlap of, and differences between, suicide and accidental overdose among individuals who misuse substances, particularly individuals who primarily use substances other than heroin. An improved understanding of the interrelationships between suicide and unintentional overdose among individuals who use alcohol or drugs is necessary to guide the development of effective prevention and intervention approaches. Published by Elsevier Ireland Ltd.

Characteristics of overdose and non-overdose suicide attempts in a multi-ethnic Asian society.

PubMed

Mak, Kwok Kei; Ho, Cyrus S H; Zhang, Melvyn W B; Day, Jeffrey R; Ho, Roger C M

2013-10-01

Overdosing is an accessible method adopted by people attempting suicide in city settings. This study aimed to compare the trends and characteristics of people attempting suicide by drug overdose and by other methods in Singapore. This study examined the medical records of 628 patients who were admitted to a university hospital in Singapore, between January 2004 and December 2006. Patients were classified as overdose and non-overdose persons attempting suicide for comparisons of demographic and suicidal characteristics. Logistic regression was used to determine the odds ratios of various factors associated with self-perceived lethality of the suicide attempt. Patterns of monthly and weekly variations in the frequencies of suicide attempts were also analyzed. The percentages of Chinese people was higher in the non-overdose group (71.5% vs. 62.9%), while the percentages of Malay and Indian people were higher in the overdose group (31.6% vs. 18.5%). The female gender (OR=0.36, p=0.04) and admission of suicide intention (OR=7.11, p<0.001) were significantly associated with higher perceived lethality of the suicide method in the non-overdose group. Suicide attempts occurred more frequently between May and November, and on Tuesdays. Gender and ethnic differences between overdose and non-overdose people attempting suicide were found. Temporal variations of suicidal cases were also noted. Copyright © 2013 Elsevier B.V. All rights reserved.

Clinical behavior of Japanese community pharmacists for preventing prescription drug overdose.

PubMed

Shimane, Takuya; Matsumoto, Toshihiko; Wada, Kiyoshi

2015-04-01

Prescription drug abuse, including benzodiazepines, is a growing health problem in Japan. This study examined the community pharmacist's clinical behavior regarding patients who overdose on prescribed drugs, and explored the possibility of overdose prevention by community pharmacists. We surveyed all registered community pharmacies with dispensing functions (n = 1867) in the Saitama Pharmaceutical Association. An anonymous self-administered questionnaire was mailed to each pharmacy. Respondents were asked about clinical behavior such as medication counseling and referral to the prescriber if prescription drug overdose was identified. Among respondents, 26% of community pharmacists reported clinical experience of working with patients who overdosed on prescribed drugs in the previous year. Half of respondents evaluated their practice such as medication counseling and referral to the prescriber as 'good'. On multivariate analysis, a 'poor' self-evaluation of referral to the prescriber was significantly associated with the following perceptions: 'insufficient confidence in communication with prescribers' (odds ratio [OR], 2.7; 95% confidence interval [95%CI]: 1.4-5.3), and 'to avoid trouble with prescribers' (OR, 1.7; 95%CI: 1.0-2.7). Japanese community pharmacists could prevent prescription drug abuse in their practice, but the pharmacists who have insufficient confidence in communication with prescribers and who are afraid of trouble with a prescriber, reported poor self-evaluation for referral to the prescribers. All prescribers should understand the importance of referral by community pharmacists, to assist community pharmacists in playing a critical role in prevention of prescription drug abuse. © 2014 The Authors. Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology.

[Recent life events preceding suicide attempt by drug overdose].

PubMed

Kubiak, Małgorzata; Musikowska, Barbara; Sein Anand, Jacek

2013-01-01

Recent stressful life events (ASLE) are considered to be one of the factors precipitating suicidal behavior. They precede a suicide attempt in most cases and according to research occur more often during the month or week before the suicide attempt. Interpersonal events are most common. The article presents an analysis of ASLE timing and incidence of events from specific categories during the month preceding suicide attempt by drug overdose. 124 patients admitted to the hospital because of suicidal intoxication were included in the study. Data regarding ASLE were collected with the use of a structured interview. Majority of patients attempting suicide by drug overdose experience a stressful event during the month prior to the suicide attempt. Nearly 4 out of 10 study subjects experience a stressful event on the day of the attempt or on the preceding day. Most common events that occur during the month prior to the attempt and immediately before the attempt are interpersonal events and most of them are related to relationships with spouses or partners.

Anticholinergics: Effects on Thermoregulation and Performance in Rats

DTIC Science & Technology

1991-01-01

organizations. REFERENCES I. Aarbakkc, J., Miura. G. A., Brown, N. D., Gray. R. R., Gordon. drug overdose . New York. Plenum Press, 1977:817-825. R. K... overdose . Br. J. Clin. Pract. 39:400-401; 1985. In. Jenden, D. J., ed. Cholinergic. mechanisms in the treatment of 4. Blumensohn. R., Razom. G.. Shalev

The Psychological and Social Characteristics of Asian Adolescent Overdose.

ERIC Educational Resources Information Center

Kingsbury, Stephen

1994-01-01

Compared social and psychological features of Asian (n=13) and Caucasian (n=37) adolescents who had taken drug overdoses. Found that Asians were more socially isolated than Caucasians and that, despite Asians having low suicidal intent, they had higher rates of depression, hopelessness, long premeditation time, and previous overdose. (Author/NB)

No association between HIV status and risk of non-fatal overdose among people who inject drugs in Vancouver, Canada

PubMed Central

Escudero, Daniel J; Marshall, Brandon DL; Kerr, Thomas; Hayashi, Kanna; Feng, Cindy; Guillemi, Silvia A; Hogg, Robert S; Montaner, Julio; Wood, Evan; Milloy, M-J

2016-01-01

Background The evidence to date on whether HIV infection increases the risk of accidental drug overdose among people who inject drugs (PWID) is equivocal. Thus, we sought to estimate the effect of HIV infection on risk of non-fatal overdose among two parallel cohorts of HIV-positive and –negative PWID. Methods Data were collected from a prospective cohort of PWID in Vancouver, Canada between 2006 and 2013. During biannual follow-up assessments, non-fatal overdose within the previous 6 months was assessed. Bivariable and multivariable generalized mixed-effects regression models were used to determine the unadjusted and adjusted associations between HIV status, plasma HIV-1 RNA viral load, and likelihood of non-fatal overdose. Results A total of 1,760 eligible participants (67% male, median age = 42, and 42% HIV-positive at baseline) were included. Among 15,070 unique observations, 649 (4.3%) included a report of a non-fatal overdose within the previous 6 months (4.4% among seropositive and 4.3% among seronegative individuals). We did not observe a difference in the likelihood of overdose by HIV serostatus in crude (odds ratio [OR]: 1.05, p=0.853) analyses or analyses adjusted for known overdose risk factors (adjusted OR [AOR]: 1.19, p=0.474). In a secondary analysis, among HIV-positive PWID, we did not observe an association between having a detectable viral load and overdose (AOR: 1.03, p=0.862). Conclusions Despite the evidence that HIV infection is a risk factor for fatal overdose, we found no evidence for a relationship between HIV disease and non-fatal overdose. However, overdose remains high among PWID, indicating the need for ongoing policy addressing this problem, and research into understanding modifiable risk factors that predict non-fatal overdose. PMID:27082262

Self-identification of nonpharmaceutical fentanyl exposure following heroin overdose

PubMed Central

Griswold, Matthew K.; Chai, Peter R.; Krotulski, Alex J.; Friscia, Melissa; Chapman, Brittany; Boyer, Edward W.; Logan, Barry K.; Babu, Kavita M.

2018-01-01

Objective To compare user self-identification of nonpharmaceutical fentanyl exposure with confirmatory urine drug testing in emergency department (ED) patients presenting after heroin overdose. Methods This was a cross-sectional study of adult ED patients who presented after a heroin overdose requiring naloxone administration. Participants provided verbal consent after which they were asked a series of questions regarding their knowledge, attitudes and beliefs toward heroin and non-pharmaceutical fentanyl. Participants also provided urine samples, which were analyzed using liquid chromatography coupled to quadrupole time-of-flight mass spectrometry to identify the presence of fentanyl, heroin metabolites, other clandestine opioids, common pharmaceuticals and drugs of abuse. Results Thirty participants were enrolled in the study period. Ten participants (33%) had never required naloxone for an overdose in the past, 20 participants (67%) reported recent abstinence, and 12 participants (40%) reported concomitant cocaine use. Naloxone was detected in all urine drug screens. Heroin or its metabolites were detected in almost all samples (93.3%), as were fentanyl (96.7%) and its metabolite, norfentanyl (93.3%). Acetylfentanyl was identified in nine samples (30%) while U-47700 was present in two samples (6.7%). Sixteen participants self-identified fentanyl in their heroin (sensitivity 55%); participants were inconsistent in their qualitative ability to identify fentanyl in heroin. Conclusions Heroin users presenting to the ED after heroin overdose requiring naloxone are unable to accurately identify the presence of nonpharmaceutical fentanyl in heroin. Additionally, cutting edge drug testing methodologies identified fentanyl exposures in 96.7% of our patients, as well as unexpected clandestine opioids (like acetylfentanyl and U-47700). PMID:28681615

Comparison of Bile Acids and Acetaminophen Protein Adducts in Children and Adolescents with Acetaminophen Toxicity.

PubMed

James, Laura; Yan, Ke; Pence, Lisa; Simpson, Pippa; Bhattacharyya, Sudeepa; Gill, Pritmohinder; Letzig, Lynda; Kearns, Gregory; Beger, Richard

2015-01-01

Metabolomics approaches have enabled the study of new mechanisms of liver injury in experimental models of drug toxicity. Disruption of bile acid homeostasis is a known mechanism of drug induced liver injury. The relationship of individual bile acids to indicators of oxidative drug metabolism (acetaminophen protein adducts) and liver injury was examined in children with acetaminophen overdose, hospitalized children with low dose exposure to acetaminophen, and children with no recent exposure to acetaminophen. Nine bile acids were quantified through targeted metabolomic analysis in the serum samples of the three groups. Bile acids were compared to serum levels of acetaminophen protein adducts and alanine aminotransferase. Glycodeoxycholic acid, taurodeoxycholic acid, and glycochenodeoxycholic acid were significantly increased in children with acetaminophen overdose compared to healthy controls. Among patients with acetaminophen overdose, bile acids were higher in subjects with acetaminophen protein adduct values > 1.0 nmol/mL and modest correlations were noted for three bile acids and acetaminophen protein adducts as follows: taurodeoxycholic acid (R=0.604; p<0.001), glycodeoxycholic acid (R=0.581; p<0.001), and glycochenodeoxycholic acid (R=0.571; p<0.001). Variability in bile acids was greater among hospitalized children receiving low doses of acetaminophen than in healthy children with no recent acetaminophen exposure. Compared to bile acids, acetaminophen protein adducts more accurately discriminated among children with acetaminophen overdose, children with low dose exposure to acetaminophen, and healthy control subjects. In children with acetaminophen overdose, elevations of conjugated bile acids were associated with specific indicators of acetaminophen metabolism and non-specific indicators of liver injury.

Suicide attempts and overdoses among adults entering addictions treatment: comparing correlates in a U.S. National Study.

PubMed

Bohnert, Amy S B; Roeder, Kathryn M; Ilgen, Mark A

2011-12-01

Suicide attempts and non-fatal overdoses are both associated with substance use. The aim of the present study was to examine correlates of suicide attempts and non-fatal overdoses simultaneously among individuals seeking addictions treatment. A large U.S. national sample of individuals entering addictions treatment participated in a cross-sectional survey (n=5892). Multinomial logistic regression modeling tested the adjusted associations of violence, injection drug use, specific substances, and depressive symptoms with a four-category outcome variable based on prior histories of suicide attempt and non-fatal overdose (neither, suicide attempt only, overdose only, both), adjusting for demographic and treatment characteristics. Sexual and physical victimization was associated with suicide attempts with or without overdoses (ORs 1.25-2.84), while perpetrating violence was associated with having experienced either or both outcomes (ORs 1.25-1.56). Depressive symptoms had a stronger association with suicide attempts (OR=3.05) than overdoses (OR=1.29). Injection drug use was associated with overdoses with or without suicide attempts (ORs 2.65-3.22). Individuals seeking treatment for marijuana use were less likely have overdosed or attempted suicide (ORs 0.39-0.67), while individuals seeking treatment for heroin use were more likely to have overdosed (OR=1.46). Seeking treatment for use of more than one substance was associated with overdose and overdose and suicide attempt (ORs 1.58-2.51), but not suicide attempt alone. The present findings indicate that suicide and overdose are connected yet distinct problems. Individuals who have had a history of both may be a group with particularly poor psychological functioning as well as more severe drug-related problems. Published by Elsevier Ireland Ltd.

[Mechanisms of opioid-induced overdose: experimental approach to clinical concerns].

PubMed

Baud, F-J

2009-09-01

The widely used term "overdose" denotes a toxic effect: opioid-induced intoxication and a mechanism: the poisoning results only from an overdose. Surprisingly, our understanding of the pathophysiology of this deadly complication is limited. In drug users, we attempted to: (1) improve knowledge of drug-induced respiratory effects; (2) clarify the mechanisms of drug interactions; (3) identify factors of variability and vulnerability. A prospective study of opioid overdoses confirmed that poisonings involving buprenorphine do exist. However, the mechanisms of buprenorphine poisoning are more complex than only an overdose, particularly the severity is less than that induced by heroin. In contrast, methadone overdose is life-threatening. Experimental studies addressed several clinical questions and also showed limited discrepancies. At pharmacological doses, opioids decrease the ventilatory response to CO(2). However, this effect does not account for the morbimortality of opioid poisonings. The mechanisms of opioid-induced morbimortality are different. Buprenorphine at doses near its median lethal dose did not induce acute respiratory failure as defined by a decrease in the partial pressure of oxygen in arterial blood (PaO(2)). In contrast, the combination of buprenorphine with flunitrazepam results in a decrease in PaO(2). This harmful interaction does not exist with other benzodiazepines in the rat, except for very high doses of nordazepam. The interaction results from a pharmacokinetic process. In contrast, methadone causes a dose-dependent decrease in PaO(2,) even significant before hypercapnia. We are assessing the relationships between on one hand alterations of ventilatory pattern and of arterial blood gas and on the other hand the different types of opiate receptors in the rats.

Overdose beliefs and management practices among ethnic Vietnamese heroin users in Sydney, Australia

PubMed Central

Maher, Lisa; Ho, Hien T

2009-01-01

Background Ethnic Vietnamese injecting drug users (IDUs) in Australia draw on a range of beliefs and etiologic models, sometimes simultaneously, in order to make sense of health and illness. These include understandings of illness as the result of internal imbalances and Western concepts of disease causation including germ/pollution theory. Methods Observational fieldwork and in-depth interviews were conducted between 2001 and 2006 in neighbourhoods characterised by high proportions of Asian background IDUs and street-based drug markets. Eligibility criteria for the study were: 1) ethnic Vietnamese cultural background; 2) aged 16 years and over and; 3) injected drugs in the last 6 months. Results Participants commonly attempted to treat heroin overdose by withdrawing blood (rút máu) from the body. Central to this practice are cultural beliefs about the role and function of blood in the body and its relationship to illness and health. Participants' beliefs in blood were strongly influenced by understandings of blood expressed in traditional Chinese and Vietnamese medicine. Many participants perceived Western drugs, particularly heroin, as "hot" and "strong". In overdose situations, it was commonly believed that an excessive amount of drugs (particularly heroin) entered the bloodstream and traveled to the heart, making the heart work too hard. Withdrawing blood was understood to reduce the amount of drugs in the body which in turn reduced the effects of drugs on the blood and the heart. Conclusion The explanatory model of overdose employed by ethnic Vietnamese IDUs privileges traditional beliefs about the circulatory, rather than the respiratory, system. This paper explores participants' beliefs about blood, the effects of drugs on blood and the causes of heroin overdose in order to document the explanatory model of overdose used by ethnic Vietnamese IDUs. Implications for overdose prevention, treatment and management are identified and discussed. PMID:19397811

Heroin and Methamphetamine Injection: An Emerging Drug Use Pattern.

PubMed

Al-Tayyib, Alia; Koester, Stephen; Langegger, Sig; Raville, Lisa

2017-07-03

We sought to describe an emerging drug use pattern characterized by injection of both methamphetamine and heroin. We examined differences in drug injection patterns by demographics, injection behaviors, HIV and HCV status, and overdose. Persons who inject drugs (PWID) were recruited as part of the National HIV Behavioral Surveillance (NHBS) system in Denver, Colorado. We used chi-square statistics to assess differences between those who reported only heroin injection, only methamphetamine injection, and combined heroin and methamphetamine injection. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios to describe the association between drug injection pattern and reported nonfatal overdose in 2015. We also examined changes in the drug reported as most frequently injected across previous NHBS cycles from 2005, 2009, and 2012. Of 592 participants who completed the survey in 2015, 173 (29.2%) reported only injecting heroin, 123 (20.8%) reported only injecting methamphetamine, and 296 (50.0%) reported injecting both drugs during the past 12 months. Injecting both heroin and methamphetamine was associated with a 2.8 (95% confidence interval: 1.7, 4.5) fold increase in reported overdose in the past 12 months compared with only injecting heroin. The proportion of those reporting methamphetamine as the most frequently injected drug increased from 2.1% in 2005 to 29.6% in 2015 (p < 0.001). The rapid increase in methamphetamine injection, and the emergence of combining methamphetamine with heroin, may have serious public health implications.

Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy.

PubMed

Sehgal, Nalini; Colson, James; Smith, Howard S

2013-11-01

Chronic non-cancer pain (CNCP) is a disabling chronic condition with a high prevalence rate around the world. Opioids are routinely prescribed for treatment of chronic pain (CP). In the past two decades there has been a massive increase in the number of opioid prescriptions, prescribed daily opioid doses and overall opioid availability. Many more patients with CNCP receive high doses of long-acting opioids on a long-term basis. Yet CP and related disability rates remain high, and majority of the patients with CNCP are dissatisfied with their treatments. Intersecting with the upward trajectory in opioid use are the increasing trends in opioid related adverse effects, especially prescription drug abuse, addiction and overdose deaths. This complex situation raises questions on the relevance of opioid therapy in the treatment of CNCP. This article reviews current evidence on opioid effectiveness, the benefits and harms of long-term therapy in CNCP.

21 CFR 332.30 - Labeling of antiflatulent drug products.

Code of Federal Regulations, 2012 CFR

2012-04-01

... section 502 of the Federal Food, Drug, and Cosmetic Act (the act) relating to misbranding and the... accidental overdose, seek professional assistance or contact a poison control center immediately.” The...

21 CFR 332.30 - Labeling of antiflatulent drug products.

Code of Federal Regulations, 2013 CFR

2013-04-01

... section 502 of the Federal Food, Drug, and Cosmetic Act (the act) relating to misbranding and the... accidental overdose, seek professional assistance or contact a poison control center immediately.” The...

Over-the-counter analgesics: a toxicology perspective.

PubMed

Jones, Alison

2002-01-01

The decision to use any analgesic is a balance of benefit and risk. In the case of analgesics, it is important to balance the therapeutic benefit against both the risk in therapeutic use and the risk (and ease of treatment) in overdose. Paracetamol in therapeutic dose carries little risk of adverse events. Less than 0.1% of the estimated 30 million paracetamol users in the United Kingdom attend hospital with a paracetamol overdose each year, and approximately 200 people die, most of whom presented late or did not receive antidote, N-acetylcysteine, within 12 hours. Nonsteriodal anti-inflammatory drugs (NSAIDs) have greater adverse effects in therapeutic use than paracetamol but also have a lower incidence of severe features or death in overdose. There is no antidote available for NSAID poisoning. Aspirin carries both significant adverse effects in therapeutic dose and a substantial risk in overdose, for which there is no antidote. Its risk-benefit profile is probably the poorest of all analgesics currently available over-the-counter (OTC); this is reflected in current trends both in analgesic use and overdose figures. Although a number of options to reduce deaths from poisoning by OTC analgesics have been considered, few are practical, and all must take account of the public health benefits provided by these drugs. A perspective should be retained that the vast majority of the population in Australia, the United States, the United Kingdom, and Denmark derive therapeutic benefit from OTC analgesics and do not take them in overdose. The majority of those who do take overdoses come to little or no harm. Management of serious poisoning by paracetamol, aspirin, or NSAIDs remains a medical challenge.

Dextromethorphan abuse in Thai adolescents: A report of two cases and review of literature.

PubMed

Manaboriboon, Boonying; Chomchai, Chulathida

2005-11-01

Dextromethorphan is an opiod-derived, easily available cough remedy that, when used in large quantities, can have stimulatory effects which mimic that of amphetamine and other psychedelic drugs. Due to its easy availability, dextromethorphan is gaining widespread popularity as a recreational drug among Thai youths. Symptoms of overdose are directly related to its pharmacodynamic and pharmacokinetic properties. Dextromethorphan is metabolized by cytochrome p450 2D6, an isoenzyme that exhibit polymorphism in Asians. The drug is also a serotonin-reuptake inhibitor and has significant interactions with other drugs that exert their effects through the serotonin pathway such as the amphetamines, cocaine, and Lysergic Acid (LSD). We report here two cases of dextromethorphan overdose that presented to the Pediatric Toxicology Service at Siriraj Hospital, Bangkok, Thailand. Both cases presented with hyper-agitation, confusion, with signs of sympathomimetic overdose. Both patients were treated with supportive care and fully recovered within 24 hours without sequalae. Although the acute toxicity of dextromethorphan is abated within 24 hours, its pharmacological properties still render it a dangerous drug to use alone or in combination with other drugs.

Development and evaluation of a multidisciplinary controlled substances committee within a patient-centered medical home.

PubMed

Gernant, Stephanie A; Bastien, Rachel; Lai, Andrea

2015-01-01

To present the development of a multidisciplinary controlled substances committee and describe its effectiveness in relation to prescribers' acceptance of committee recommendations, the number of premature deaths associated with controlled substances, and prescribers' need for education on controlled substances. A patient-centered medical home and accountable care organization in Maine that serves more than 60,000 patients across a large rural area, 70% of whom are classified as lower income. A multidisciplinary group of prescribers and PharmD residents created a committee to influence organizational culture regarding controlled substances. The Controlled Substances Initiative Committee (CSIC) updated institutional policies, developed provider education, and made personalized patient recommendations to prescribers. The primary outcome was average change in daily morphine equivalent dose (MED) in patients for whom CSIC recommended a dose reduction to the patient's prescriber. Secondary outcomes included the proportion of patients who died of a known overdose or suspected drug-related death during 2012-2013 or 2013-2014. In addition, prescriber beliefs about controlled substances were measured via a needs assessment. The average daily MED for patients whom CSIC recommended dose reduction was lower after 3 months compared with at baseline (175.5 ± 344.3 mg vs. 292.7 ± 466.5 mg; P <0.05). The proportion of patients who died of a known overdose did not differ between 2012-2013 and 2013-2014 (11.8% vs. 11.1%; P = 1.00). However, a greater number of patients had a suspected drug-related death during 2013-2014 compared with during 2012-2013 (0% vs. 27.3%; P = 0.05). A multidisciplinary controlled substances committee may improve patient safety and outcomes by offering prescriber support and helping alter prescribing culture.

Propoxyphene overdose

MedlinePlus

... of this medicine. The US Food and Drug Administration (FDA) took this drug off the market in ... Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ed. Philadelphia, PA: Elsevier ...

Drug use in business bathrooms: An exploratory study of manager encounters in New York City

PubMed Central

Wolfson-Stofko, Brett; Bennett, Alex S.; Elliott, Luther; Curtis, Ric

2017-01-01

Background Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses. Methods A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches. Results More than half of managers interviewed (58%, n = 50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance. Conclusion The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks. PMID:27768996

Evaluation of poly-drug use in methadone-related fatalities using segmental hair analysis.

PubMed

Nielsen, Marie Katrine Klose; Johansen, Sys Stybe; Linnet, Kristian

2015-03-01

In Denmark, fatal poisoning among drug addicts is often related to methadone. The primary mechanism contributing to fatal methadone overdose is respiratory depression. Concurrent use of other central nervous system (CNS) depressants is suggested to heighten the potential for fatal methadone toxicity. Reduced tolerance due to a short-time abstinence period is also proposed to determine a risk for fatal overdose. The primary aims of this study were to investigate if concurrent use of CNS depressants or reduced tolerance were significant risk factors in methadone-related fatalities using segmental hair analysis. The study included 99 methadone-related fatalities collected in Denmark from 2008 to 2011, where both blood and hair were available. The cases were divided into three subgroups based on the cause of death; methadone poisoning (N=64), poly-drug poisoning (N=28) or methadone poisoning combined with fatal diseases (N=7). No significant differences between methadone concentrations in the subgroups were obtained in both blood and hair. The methadone blood concentrations were highly variable (0.015-5.3, median: 0.52mg/kg) and mainly within the concentration range detected in living methadone users. In hair, methadone was detected in 97 fatalities with concentrations ranging from 0.061 to 211ng/mg (median: 11ng/mg). In the remaining two cases, methadone was detected in blood but absent in hair specimens, suggesting that these two subjects were methadone-naive users. Extensive poly-drug use was observed in all three subgroups, both recently and within the last months prior to death. Especially, concurrent use of multiple benzodiazepines was prevalent among the deceased followed by the abuse of morphine, codeine, amphetamine, cannabis, cocaine and ethanol. By including quantitative segmental hair analysis, additional information on poly-drug use was obtained. Especially, 6-acetylmorphine was detected more frequently in hair specimens, indicating that regular abuse of heroin was common among the deceased. In conclusion, continuous exposure of methadone provide by segmental hair analysis suggested that reduced tolerance of methadone was not a critical factor among methadone-related fatalities. In contrast, a high abundance of co-ingested CNS depressants suggested that adverse effects from drug-drug interactions were more important risk factors for fatal outcome in these deaths. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Comparative drug dose and drug combinations in patients that present to hospital due to self-poisoning.

PubMed

Armstrong, Thomas M; Davies, Matthew S; Kitching, Gary; Waring, W Stephen

2012-11-01

Self-poisoning is a common reason for acute presentation to hospital. Commonly involved drugs have been reported, but few data exist concerning the different combinations of agents or comparative doses ingested. The present study sought to better characterise the typical patterns of drug overdose that may present via the emergency department. Consecutive adults ≥16 years of age that presented to York Hospital owing to self-poisoning were studied for 2010-2011 inclusive. The primary outcome measure was reported dose, expressed as a multiple of the defined daily dose (DDD) to allow comparison between different agents. There were 1024 patients, including 622 women (60.7%), and median age was 32 years (range, 16 to 92 years). Overdose in men was associated with a higher overall quantity of drugs: arithmetic mean of 20 DDD multiples (95% CI, 15-26) versus 13 (11-15), p = 0.001. Overdose involved a single agent only in 538 patients (52.5%). The mean paracetamol dose was 4.0 (95% CI, 3.7-4.3) DDD multiples; the doses of antidepressants (19.4, 17.0-21.7, p < 0.0001) and benzodiazepines (18.0, 12.8-23.2, p < 0.0001) were comparatively higher. The types of agents involved in self-poisoning and common combinations of agents are characterised. Psychotropic medications were ingested in comparatively larger quantities than analgesic agents and had worse clinical outcome. Further work is required to understand the factors that determine the quantity of drug ingested in patients at risk of drug overdose so as to minimise the risk of significant toxicity. © 2012 The Authors Basic & Clinical Pharmacology & Toxicology © 2012 Nordic Pharmacological Society.

Drumming: An Innovative Alternative for Drug Addicted Individuals

ERIC Educational Resources Information Center

Hill, John C.; Hains, Bryan; Ricketts, Kristina

2017-01-01

Drug abuse has been a persistent problem within the United States. Among the nation, Kentucky ranks third in drug overdose and drug mortality rates, with numbers quadrupling from 1999 to 2010. Recent statistics indicate drug offenders account or a significant portion of individuals within the criminal justice system, directly affecting the…

[Self-reported substance abuse related emergencies: frequency and nature].

PubMed

Schäfer, G; Smoltczyk, H; Dengler, W; Buchkremer, G

2000-04-01

The aim of this study was to estimate the frequency and nature of self-reported and drug-related emergencies. 47 patients of a ward for opiate detoxification were interviewed about their experiences with drug-related emergencies. Typical categories had to be found like overdoses, seizures, accidents and suicide attempts respectively. 68% had own experience with drug-related emergency. A majority suffered opiate overdose with different extensions as unconsciousness or breath-depression. Alcohol and polydrug use was associated with overdose. Drug-related accidents were only reported by men. Half the number of drug-related emergencies were treated in hospital. Most emergencies occurred alone either in a home environment or outside. Harm reduction interventions like observed user rooms should be established. Furthermore other strategies to reduce the number of emergencies as sharing naloxon or resuscitation programs in wards for detoxification could also be an effective method to prevent near fatal or fatal overdoses in dependent subjects.

Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States.

PubMed

Mars, Sarah G; Fessel, Jason N; Bourgois, Philippe; Montero, Fernando; Karandinos, George; Ciccarone, Daniel

2015-09-01

Heroin overdose, more accurately termed 'heroin-related overdose' due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black 'tar' heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007-12) and of users in San Francisco (1994-2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study. Copyright © 2015 Elsevier Ltd. All rights reserved.

Re-branding cannabis: the next generation of chronic pain medicine?

PubMed

Carter, Gregory T; Javaher, Simone P; Nguyen, Michael Hv; Garret, Sharon; Carlini, Beatriz H

2015-01-01

The field of pain medicine is at a crossroads given the epidemic of addiction and overdose deaths from prescription opioids. Cannabis and its active ingredients, cannabinoids, are a much safer therapeutic option. Despite being slowed by legal restrictions and stigma, research continues to show that when used appropriately, cannabis is safe and effective for many forms of chronic pain and other conditions, and has no overdose levels. Current literature indicates many chronic pain patients could be treated with cannabis alone or with lower doses of opioids. To make progress, cannabis needs to be re-branded as a legitimate medicine and rescheduled to a more pharmacologically justifiable class of compounds. This paper discusses the data supporting re-branding and rescheduling of cannabis.

Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'.

PubMed

Ciccarone, Daniel; Ondocsin, Jeff; Mars, Sarah G

2017-08-01

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use. A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin. (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports. Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations. Copyright © 2017 Elsevier B.V. All rights reserved.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study.

PubMed

Hawton, K; Simkin, S; Deeks, J J; O'Connor, S; Keen, A; Altman, D G; Philo, G; Bulstrode, C

1999-04-10

To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning. Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods. 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data. 4403 self poisoning patients; questionnaires completed for 1047. Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers. Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%). Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Predicting risk in patients with acetaminophen overdose

PubMed Central

James, Laura P.; Gill, Prit; Simpson, Pippa

2014-01-01

Acetaminophen (APAP) overdose is a very common cause of drug overdose and acute liver failure in the US and Europe. Mechanism-based biomarkers of APAP toxicity have the potential to improve the clinical management of patients with large dose ingestions of APAP. The current approach to the management of APAP toxicity is limited by imprecise and time-constrained risk assessments and late-stage markers of liver injury. A recent study of “low-risk” APAP overdose patients who all received treatment with N-acetylcysteine, found that cell-death biomarkers were more sensitive than alanine aminotransferase (ALT) and APAP concentrations in predicting the development of acute liver injury. The data suggest a potential role for new biomarkers to identify “low risk” patients following APAP overdose. However, a practical and ethical consideration that complicates predictive biomarker research in this area is the clinical need to deliver antidote treatment within 10 hours of APAP overdose. The treatment effect and time-dependent nature of N-acetylcysteine treatment must be considered in future “predictive” toxicology studies of APAP-induced liver injury. PMID:23984999

21 CFR 332.30 - Labeling of antiflatulent drug products.

Code of Federal Regulations, 2010 CFR

2010-04-01

... section 502 of the Federal Food, Drug, and Cosmetic Act (the act) relating to misbranding and the... accidental overdose, seek professional assistance or contact a poison control center immediately.” The...

21 CFR 332.30 - Labeling of antiflatulent drug products.

Code of Federal Regulations, 2011 CFR

2011-04-01

... section 502 of the Federal Food, Drug, and Cosmetic Act (the act) relating to misbranding and the... accidental overdose, seek professional assistance or contact a poison control center immediately.” The...

21 CFR 332.30 - Labeling of antiflatulent drug products.

Code of Federal Regulations, 2014 CFR

2014-04-01

... section 502 of the Federal Food, Drug, and Cosmetic Act (the act) relating to misbranding and the... accidental overdose, seek professional assistance or contact a poison control center immediately.” The...

Efficacy of Adenine in the Treatment of Leukopenia and Neutropenia Associated with an Overdose of Antipsychotics or Discontinuation of Lithium Carbonate Administration: Three Case Studies.

PubMed

Tomita, Takashi; Goto, Hidekazu; Sumiya, Kenji; Yoshida, Tadashi; Tanaka, Katsuya; Kohda, Yukinao

2016-11-30

Because adenine is effective for managing cases of radiation-induced and drug-induced leukopenia, it may be effective in cases of antipsychotic-induced leukopenia and neutropenia. Here, we report our experience with patients with leukopenia and neutropenia caused by an antipsychotic overdose or discontinuation of lithium carbonate, in whom adenine administration ameliorated the white blood cell and neutrophil counts. The progress of patients suggests that adenine is effective in cases of leukopenia and neutropenia associated with lithium carbonate discontinuation and an antipsychotic overdose.

Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study

PubMed Central

2014-01-01

Background One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. Methods To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. Results Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). Conclusion Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them. PMID:24684801

Liver transplant associated with paracetamol overdose: results from the seven-country SALT study.

PubMed

Gulmez, Sinem Ezgi; Larrey, Dominique; Pageaux, Georges-Philippe; Bernuau, Jacques; Bissoli, Franco; Horsmans, Yves; Thorburn, Douglas; McCormick, P Aiden; Stricker, Bruno; Toussi, Massoud; Lignot-Maleyran, Séverine; Micon, Sophie; Hamoud, Fatima; Lassalle, Régis; Jové, Jérémy; Blin, Patrick; Moore, Nicholas

2015-09-01

Acute drug overdose, especially with paracetamol, may cause acute liver failure leading to registration for transplantation (ALFT). Population statistics and between-country differences for ALFT related to overdose have been poorly described. The aim of the present study was to evaluate overdose ALFT in the multi-country Study of Acute Liver Transplantation (SALT). All adult overdose-related ALFT, with or without suicidal intent, in France, Greece, Ireland, Italy, the Netherlands, Portugal and the UK between 2005 and 2007 were identified from liver transplant registries and hospital records. These were compared with whole-country and per capita use of paracetamol. Six hundred cases of ALFT were identified in 52 of 57 eligible transplant centres, of which 114 involved overdose (72 intentional, 10 non-intentional, 32 uncertain). Overdose represented 20% of all-cause ALFT: Ireland 52%, UK 28%, France 18%, the Netherlands 8%, and Italy 1%. Overdose ALFT were mostly females (61%), mean age 33.6 ± 10.9 years. A total of 111 (97%) of the overdoses involved paracetamol. Event rates ranged from one ALFT for 20.7 tons of paracetamol in Ireland, to one for 1074 tons in Italy and one case in 60 million inhabitants over 3 years in Italy to one case in 286 000 inhabitants per year in Ireland. Per-country event rates for non-overdose ALFT exposed to paracetamol were between 2.5 and 4.0 per million treatment-years sold. Paracetamol overdose was found to represent one-sixth of all-cause ALFT. There was a 50-fold difference in Europe in the rates of paracetamol overdose ALFT, and a 200-fold difference per million inhabitants. © 2015 The British Pharmacological Society.

Silicone septum leakage at the origin of a drug overdose in a patient implanted with an intrathecal pump.

PubMed

Perruchoud, Christophe; Bovy, Michèle; Rutschmann, Blaise; Durrer, Anne; Buchser, Eric

2013-01-01

Intrathecal (IT) pump failures usually result in decreased drug administration and symptom reoccurrence with or without withdrawal syndrome. We report a case of a leaking silicone septum associated to a systemic drug overdose. An 84-year-old patient treated with IT clonidine for chronic back pain presented with a state of confusion, visual hallucinations, and hypertension two hours after an unremarkable pump (SynchroMed EL, Medtronic, Minneapolis, MN, USA) refill. The reservoir was emptied and 14 mL (8.4 mg of clonidine) was found to be missing (difference between retrieved and expected volumes). The pump was refilled and a check on the next day showed again a loss of 3.5 mL. A malfunction was suspected and the pump was replaced (SynchroMed II, Medtronic). The inspection of the external surface of the pump revealed severe damage to the silicone septum with multiple gouges due to needle scarring. A fluid leak also was clearly seen through the septum. The signs and symptoms presented by this patient are consistent with clonidine overdose that resulted from a combination of a possible accidental pocket fill and a definite septum leak into the subcutaneous tissue. The damage to the silicone could be due to the loss of the nontraumatic properties of the Huber needles that are rubbed against the metallic case in attempting to locate the injection port during refill procedures. This observation is the first description of a silicone septum damage contributing to a pump dysfunction and drug overdose despite the use of appropriate needles for refilling. © 2012 International Neuromodulation Society.

Risk of fentanyl-involved overdose among those with past year incarceration: Findings from a recent outbreak in 2014 and 2015.

PubMed

Brinkley-Rubinstein, Lauren; Macmadu, Alexandria; Marshall, Brandon D L; Heise, Andrew; Ranapurwala, Shabbar I; Rich, Josiah D; Green, Traci C

2018-04-01

Overdose is the leading cause of unintentional injury-related death. Rhode Island (RI) has the highest rate of illicit drug use nationally and the 5th highest overdose mortality rate. RI has experienced an outbreak of fentanyl-related overdoses. In incarcerated populations, risk of overdose is greatly elevated. However, little is known about fentanyl-related overdose post-release. In the current analyses, we identify changes in fentanyl-related fatal overdose among those who died in 2014 and 2015 who were incarcerated in the year before death. We linked data from the RI Office of the Medical Examiner with records from the RI Department of Corrections. We calculated risk ratios and 95% confidence intervals using log-binomial regression to compare risk of fentanyl-involved overdose death. We also compared median time to death since release, median sentence length, and median number of incarcerations in 2014 and 2015. Results indicate that the risk of dying of a fentanyl-related overdose increased (RR: 1.99 (95% CI: 1.11-3.57, p = 0.014)) from 2014 to 2015 among those with past year incarceration. This study is one of the first to describe fentanyl-related fatal overdose among those with past year incarceration. In 2015 the median sentence was longer among those with a fentanyl-related overdose death and the median time from release to death among all who had past year incarceration extended past 90 days. Access to medications for addiction treatment, overdose education, and naloxone should be available during community re-entry and extended beyond the early post-release period. Copyright © 2018. Published by Elsevier B.V.

Liver transplant associated with paracetamol overdose: results from the seven-country SALT study

PubMed Central

Gulmez, Sinem Ezgi; Larrey, Dominique; Pageaux, Georges-Philippe; Bernuau, Jacques; Bissoli, Franco; Horsmans, Yves; Thorburn, Douglas; McCormick, P Aiden; Stricker, Bruno; Toussi, Massoud; Lignot-Maleyran, Séverine; Micon, Sophie; Hamoud, Fatima; Lassalle, Régis; Jové, Jérémy; Blin, Patrick; Moore, Nicholas

2015-01-01

Aims Acute drug overdose, especially with paracetamol, may cause acute liver failure leading to registration for transplantation (ALFT). Population statistics and between-country differences for ALFT related to overdose have been poorly described. The aim of the present study was to evaluate overdose ALFT in the multi-country Study of Acute Liver Transplantation (SALT). Methods All adult overdose-related ALFT, with or without suicidal intent, in France, Greece, Ireland, Italy, the Netherlands, Portugal and the UK between 2005 and 2007 were identified from liver transplant registries and hospital records. These were compared with whole-country and per capita use of paracetamol. Results Six hundred cases of ALFT were identified in 52 of 57 eligible transplant centres, of which 114 involved overdose (72 intentional, 10 non-intentional, 32 uncertain). Overdose represented 20% of all-cause ALFT: Ireland 52%, UK 28%, France 18%, the Netherlands 8%, and Italy 1%. Overdose ALFT were mostly females (61%), mean age 33.6 ± 10.9 years. A total of 111 (97%) of the overdoses involved paracetamol. Event rates ranged from one ALFT for 20.7 tons of paracetamol in Ireland, to one for 1074 tons in Italy and one case in 60 million inhabitants over 3 years in Italy to one case in 286 000 inhabitants per year in Ireland. Per-country event rates for non-overdose ALFT exposed to paracetamol were between 2.5 and 4.0 per million treatment-years sold. Conclusions Paracetamol overdose was found to represent one-sixth of all-cause ALFT. There was a 50-fold difference in Europe in the rates of paracetamol overdose ALFT, and a 200-fold difference per million inhabitants. PMID:26017643

Implementing an overdose education and naloxone distribution program in a health system.

PubMed

Devries, Jennifer; Rafie, Sally; Polston, Gregory

To design and implement a health system-wide program increasing provision of take-home naloxone in patients at risk for opioid overdose, with the downstream aim of reducing fatalities. The program includes health care professional education and guidelines, development, and dissemination of patient education materials, electronic health record changes to promote naloxone prescriptions, and availability of naloxone in pharmacies. Academic health system, San Diego, California. University of California, San Diego Health (UCSDH), offers both inpatient and outpatient primary care and specialty services with 563 beds spanning 2 hospitals and 6 pharmacies. UCSDH is part of the University of California health system, and it serves as the county's safety net hospital. In January 2016, a multisite academic health system initiated a system-wide overdose education and naloxone distribution program to prevent opioid overdose and opioid overdose-related deaths. An interdisciplinary, interdepartmental team came together to develop and implement the program. To strengthen institutional support, naloxone prescribing guidelines were developed and approved for the health system. Education on naloxone for physicians, pharmacists, and nurses was provided through departmental trainings, bulletins, and e-mail notifications. Alerts in the electronic health record and preset naloxone orders facilitated co-prescribing of naloxone with opioid prescriptions. Electronic health record reports captured naloxone prescriptions ordered. Summary reports on the electronic health record measured naloxone reminder alerts and response rates. Since the start of the program, the health system has trained 252 physicians, pharmacists, and nurses in overdose education and take-home naloxone. There has been an increase in the number of prescriptions for naloxone from a baseline of 4.5 per month to an average of 46 per month during the 3 months following full implementation of the program including implementation of electronic health record alerts. Initiating and implementing an overdose education and naloxone distribution program is feasible in an academic health system. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England.

PubMed

Marsden, John; Stillwell, Garry; Jones, Hayley; Cooper, Alisha; Eastwood, Brian; Farrell, Michael; Lowden, Tim; Maddalena, Nino; Metcalfe, Chris; Shaw, Jenny; Hickman, Matthew

2017-08-01

People with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk. Prospective observational cohort study using prison health care, national community drug misuse treatment and deaths registers. Recruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning. Adult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n = 15 141 in the risk set). At release, participants were classified as OST exposed (n = 8645) or OST unexposed (n = 6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose. Primary outcome: all-cause mortality (ACM) in the first 4 weeks. drug-related poisoning (DRP) deaths in the first 4 weeks; ACM and DRP mortality after 4 weeks to 1 year; admission to community drug misuse treatment in the first 4 weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake. During the first 4 weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR) = 0.25; 95% confidence interval (CI) = 0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR = 0.15; 95% CI = 0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI = 2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR = 0.25; 95% CI = 0.09-0.64 and HR = 0.15; 95% CI = 0.04-0.52, respectively). In an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release. © 2017 Society for the Study of Addiction.

Kratom, an Emerging Drug of Abuse: A Case Report of Overdose and Management of Withdrawal.

PubMed

Diep, Jack; Chin, David Tian; Gupta, Somdatta; Syed, Faraz; Xiong, Ming; Cheng, Jianguo

2017-10-26

Kratom is an herb indigenous to Southeast Asia with psychoactive opioid compounds, often used as a treatment for chronic pain or opiate withdrawal symptoms. It is legally and readily available via Internet sales and has been identified as an emerging drug of abuse in the United States. Kratom use has been associated with psychosis, seizures, and even death. At lower doses, kratom acts as a stimulant, while at higher doses, it produces analgesia and euphoria. Here, we describe the successful management of kratom overdose and withdrawal in a young man with negative toxicology screens.

Kratom, an Emerging Drug of Abuse: A Case Report of Overdose and Management of Withdrawal.

PubMed

Diep, Jack; Chin, David Tian; Gupta, Somdatta; Syed, Faraz; Xiong, Ming; Cheng, Jianguo

2018-04-15

Kratom is an herb indigenous to Southeast Asia with psychoactive opioid compounds, often used as a treatment for chronic pain or opiate withdrawal symptoms. It is legally and readily available via Internet sales and has been identified as an emerging drug of abuse in the United States. Kratom use has been associated with psychosis, seizures, and even death. At lower doses, kratom acts as a stimulant, while at higher doses, it produces analgesia and euphoria. Here, we describe the successful management of kratom overdose and withdrawal in a young man with negative toxicology screens.

Drug use in business bathrooms: An exploratory study of manager encounters in New York City.

PubMed

Wolfson-Stofko, Brett; Bennett, Alex S; Elliott, Luther; Curtis, Ric

2017-01-01

Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses. A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches. More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance. The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks. Copyright © 2016 Elsevier B.V. All rights reserved.

Urine and oral fluid drug testing in support of pain management.

PubMed

Kwong, Tai C; Magnani, Barbarajean; Moore, Christine

2017-09-01

In recent years, the abuse of opioid drugs has resulted in greater prevalence of addiction, overdose, and deaths attributable to opioid abuse. The epidemic of opioid abuse has prompted professional and government agencies to issue practice guidelines for prescribing opioids to manage chronic pain. An important tool available to providers is the drug test for use in the initial assessment of patients for possible opioid therapy, subsequent monitoring of compliance, and documentation of suspected aberrant drug behaviors. This review discusses the issues that most affect the clinical utility of drug testing in chronic pain management with opioid therapy. It focuses on the two most commonly used specimen matrices in drug testing: urine and oral fluid. The advantages and disadvantages of urine and oral fluid in the entire testing process, from specimen collection and analytical methodologies to result interpretation are reviewed. The analytical sensitivity and specificity limitations of immunoassays used for testing are examined in detail to draw attention to how these shortcomings can affect result interpretation and influence clinical decision-making in pain management. The need for specific identification and quantitative measurement of the drugs and metabolites present to investigate suspected aberrant drug behavior or unexpected positive results is analyzed. Also presented are recent developments in optimization of test menus and testing strategies, such as the modification of the standard screen and reflexed-confirmation testing model by eliminating some of the initial immunoassay-based tests and proceeding directly to definitive testing by mass spectrometry assays.

Transdermal fentanyl in deliberate overdose in pediatrics.

PubMed

Lyttle, Mark D; Verma, Sapna; Isaac, Rhian

2012-05-01

The use of the fentanyl skin patch to provide pain relief in chronic pain conditions and oncology in adult practice has been common for several years, and an increase in use is now being seen in pediatric practice. Its use in drug misuse and suicide has also increased in recent years. We present the case of an adolescent who deliberately overdosed using fentanyl skin patches and describe the implications for management. This report serves to remind clinicians to consider this method of drug administration in children who display signs of opioid toxicity, where overdose may be subsequent to its use in therapy, recreation, or deliberate self-harm.

Non-fatal overdose among adult prisoners with a history of injecting drug use in two Australian states.

PubMed

Moore, Elizabeth; Winter, Rebecca; Indig, Devon; Greenberg, David; Kinner, Stuart A

2013-11-01

Recently released prisoners are at markedly increased risk of death and drug-related causes predominate. Non-fatal overdose (NFOD) is considerably more common than fatal overdose, but has received relatively little research attention and most studies of NFOD in this population have suffered from small samples of unknown representativeness. This study aimed to estimate the prevalence and correlates of lifetime NFOD among prisoners in NSW and Queensland. Cross-sectional surveys of adult prisoners in two Australian states: New South Wales (n=972) and Queensland (n=1316). Use of similar measures and methods in the two states made direct comparison of findings possible. In both NSW and Queensland, 23% of participants reported a lifetime history of NFOD and prisoners with a history of injecting drug use were significantly more likely to report lifetime NFOD. The lifetime prevalence of NFOD among prisoners with a history of injecting drug use was significantly higher in NSW than in Queensland (44% vs. 35%; p<0.01). Independent correlates of lifetime NFOD were similar across the two states and included ever attempting suicide, ever injecting heroin, and ever injecting opioids. The risk of NFOD among prisoners with a history of injecting drug use is high. An understanding of the risk factors for NFOD in this population can inform targeted, evidence-based interventions to reduce this risk. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

NAGD regimen for the coma of drug-related overdose.

PubMed

Rappolt, R T; Gay, G R; Decker, W J; Inaba, D S

1980-07-01

A specific arousal therapy with NAGD (Naloxone, Activated Charcoal, Glucagon, Doxapram) is outlined for victims of drug overdose in comatose and semi-comatose states. Several direct benefits accrue if early awakening or lightening of such patients is safely accomplished. There are: 1) elimination of need for prolonged intubation or tracheostomy; 2) patient's ability to tell which drug(s) were taken; 3) excessively frantic and vigorous supportive treatment is obviated; and 4) the overall hospital stay is shortened. The NAGD regimen has been found to effectively, safely, and predictably reverse coma. Therapy consists of: naloxone 0.8 mg to 1.6 mg intravenously; large-bore orogastric tube instillation of 100 gm to 120 gm activated charcoal slurry; glucagon 1 mg to 2 mg intravenously; and, in selected cases, doxapram 1 mg/kg to 2 mg/kg intravenously.

Profit-driven drug testing.

PubMed

Collen, Mark

2012-01-01

Random drug testing of people being treated for chronic pain has become more common. Physicians may drug test patients on opioid therapy as a result of concerns over prosecution, drug misuse, addiction, and overdose. However, profit motive has remained unexplored. This article suggests profits also drive physician drug-testing behavior and evidence is offered, including an exploration of Medicare reimbursement incentives and kickbacks for drug testing.

Associations between injection risk and community disadvantage among suburban injection drug users in southwestern Connecticut, USA.

PubMed

Heimer, Robert; Barbour, Russell; Palacios, Wilson R; Nichols, Lisa G; Grau, Lauretta E

2014-03-01

Increases in drug abuse, injection, and opioid overdoses in suburban communities led us to study injectors residing in suburban communities in southwestern Connecticut, US. We sought to understand the influence of residence on risk and injection-associated diseases. Injectors were recruited by respondent-driven sampling and interviewed about sociodemographics, somatic and mental health, injection risk, and interactions with healthcare, harm reduction, substance abuse treatment, and criminal justice systems. HIV, hepatitis B and C (HBV and HCV) serological testing was also conducted. Our sample was consistent in geographic distribution and age to the general population and to the patterns of heroin-associated overdose deaths in the suburban towns. High rates of interaction with drug abuse treatment and criminal justice systems contrasted with scant use of harm reduction services. The only factors associated with both dependent variables-residence in less disadvantaged census tracts and more injection risk-were younger age and injecting in one's own residence. This contrasts with the common association among urban injectors of injection-associated risk behaviors and residence in disadvantaged communities. Poor social support and moderate/severe depression were associated with risky injection practices (but not residence in specific classes of census tracts), suggesting that a region-wide dual diagnosis approach to the expansion of harm reduction services could be effective at reducing the negative consequences of injection drug use.

Willingness to use drug checking within future supervised injection services among people who inject drugs in a mid-sized Canadian city.

PubMed

Kennedy, Mary Clare; Scheim, Ayden; Rachlis, Beth; Mitra, Sanjana; Bardwell, Geoff; Rourke, Sean; Kerr, Thomas

2018-04-01

Esclating epidemics of fatal overdose are affecting communities across Canada. In many instances, the unanticipated presence of powerful opioids, such as fentanyl, in street drugs is a contributing factor. Drug checking offered within supervised injection services (SIS) is being considered as a potential measure for reducing overdose and related harms. We therefore sought to characterize the willingness of people who inject drugs (PWID) to use drug checking within SIS. Data were derived from a cross-sectional survey examining the feasibility of SIS in London, Canada, a mid-sized city. Multivariable logistic regression was used to examine factors associated with willingness to frequently (always or usually) use drug checking at SIS. Between March and April 2016, 180 PWID were included in the present study, including 68 (38%) women. In total, 78 (43%) reported that they would frequently check their drugs at SIS if this service were available. In multivariable analyses, female gender (Adjusted Odds Ratio [AOR] = 2.31; 95% confidence interval [CI]: (1.20-4.46), homelessness (AOR = 2.36; 95% CI: 1.14-4.86), and drug dealing (AOR = 2.16; 95% CI: 1.07-4.33) were positively associated with willingness to frequently check drugs at SIS. These findings highlight the potential of drug checking as a complement to other services offered within SIS, particularly given that subpopulations of PWID at heightened risk of overdose were more likely to report willingness to frequently use this service. However, further research is needed to determine the possible health impacts of offering drug checking at SIS. Copyright © 2018 Elsevier B.V. All rights reserved.

The US Opioid Crisis: Current Federal and State Legal Issues.

PubMed

Soelberg, Cobin D; Brown, Raeford E; Du Vivier, Derick; Meyer, John E; Ramachandran, Banu K

2017-11-01

The United States is in the midst of a devastating opioid misuse epidemic leading to over 33,000 deaths per year from both prescription and illegal opioids. Roughly half of these deaths are attributable to prescription opioids. Federal and state governments have only recently begun to grasp the magnitude of this public health crisis. In 2016, the Centers for Disease Control and Prevention released their Guidelines for Prescribing Opioids for Chronic Pain. While not comprehensive in scope, these guidelines attempt to control and regulate opioid prescribing. Other federal agencies involved with the federal regulatory effort include the Food and Drug Administration (FDA), the Drug Enforcement Agency (DEA), and the Department of Justice. Each federal agency has a unique role in helping to stem the burgeoning opioid misuse epidemic. The DEA, working with the Department of Justice, has enforcement power to prosecute pill mills and physicians for illegal prescribing. The DEA could also implement use of prescription drug monitoring programs (PDMPs), currently administered at the state level, and use of electronic prescribing for schedule II and III medications. The FDA has authority to approve new and safer formulations of immediate- and long-acting opioid medications. More importantly, the FDA can also ask pharmaceutical companies to cease manufacturing a drug. Additionally, state agencies play a critical role in reducing overdose deaths, protecting the public safety, and promoting the medically appropriate treatment of pain. One of the states' primary roles is the regulation of practice of medicine and the insurance industry within their borders. Utilizing this authority, states can both educate physicians about the dangers of opioids and make physician licensure dependent on registering and using PDMPs when prescribing controlled substances. Almost every state has implemented a PDMP to some degree; however, in addition to mandating their use, increased interstate sharing of prescription information would greatly improve PDMPs' effectiveness. Further, states have the flexibility to promote innovative interventions to reduce harm such as legislation allowing naloxone access without a prescription. While relatively new, these types of laws have allowed first responders, patients, and families access to a lifesaving drug. Finally, states are at the forefront of litigation against pharmaceutical manufacturers. This approach is described as analogous to the initial steps in fighting tobacco companies. In addition to fighting for dollars to support drug treatment programs and education efforts, states are pursuing these lawsuits as a means of holding pharmaceutical companies accountable for misleading marketing of a dangerous product.

Implications of Drug Testing Cheerleaders

ERIC Educational Resources Information Center

Trachsler, Tracy A.; Birren, Genevieve

2016-01-01

With the untimely death of a University of Louisville cheerleader due to an accidental drug overdose in the summer of 2014, the athletic department representatives took steps to prevent future incidents by adding cheerleaders to the randomized drug testing protocols conducted at the university for the student-athletes involved in National…

Toxicology screen

MedlinePlus

... Analgesics - screen; Antidepressants - screen; Narcotics - screen; Phenothiazines - screen; Drug abuse screen; Blood alcohol test ... poisoning) Complicated alcohol abstinence (delirium tremens) Delirium ... Fetal alcohol syndrome Intentional overdose Seizures Stroke ...

Substances used in completed suicide by overdose in Toronto: an observational study of coroner's data.

PubMed

Sinyor, Mark; Howlett, Andrew; Cheung, Amy H; Schaffer, Ayal

2012-03-01

To identify the substances used by people who die from suicide by overdose in Toronto and to determine the correlates of specific categories of substances used. Coroner's records for all cases of suicide by overdose in Toronto, Ontario, during a 10-year period (1998 to 2007) were examined. Data collected included demographic data, all substances detected, and those determined by the coroner to have caused death. Logistic regression analyses were used to examine demographic and clinical factors associated with suicide by different drug types. There were 397 documented suicides by overdose (mean age 49.1 years, 50% female). Most substances detected were psychotropic prescription medications (n = 245), followed by other prescription medications (n = 143) and over-the-counter (OTC) medications (n = 83). More than one-half of all suicides by overdose were determined to have only one specific substance as the cause of death (n = 206). In suicides where only one class of substance was present in lethal amounts, OTC medication (n = 48), opioid analgesics (n = 44), and tricyclic antidepressants (n = 44) were most common. Suicides by overdose involved the use of different classes of substances, including psychotropic prescription medication, other prescription medications, as well as OTC medications. Physicians and pharmacists should be aware of commonly used prescription and OTC medications in overdose and exercise increased vigilance in prescribing or dispensing them to at-risk patients.

Drugs and other chemicals involved in fatal poisoning in England and Wales during 2000 – 2011.

PubMed

Handley, S A; Flanagan, R J

2014-01-01

Fatal poisoning data can reveal trends in the poisons encountered, which can help guide prescribing practices and product safety and other legislation, and more recently has helped to monitor the use of emerging drugs of abuse ( ‘ legal highs ’ ). We searched Mortality Statistics – Injury and poisoning, Series DH4 (2000 – 2005), Mortality Statistics – Deaths registered in England and Wales, Series DR (2006 – 2011), and the Office for National Statistics drug poisoning database for information on fatal poisoning during 2000 – 2011. We also searched the Pubmed database for ‘ fatal ’ and ‘ poisoning ’ and ‘ England ’ and ‘ Wales ’ : this search yielded seven papers that gave relevant information on deaths reported during 2000 – 2011 that were not superseded by later publications. DEATHS FROM POISONING: The annual number of deaths from poisoning fell from 2000 (3092) to 2010 (2749), before increasing to 3341 in 2011. This increase was due in part to a change in the ICD coding relating to alcohol poisoning, suggesting that such deaths had been under-recorded previously. Although fatalities from dextropropoxyphene declined (287 in 2004 and 18 in 2011) following the withdrawal of co-proxamol (paracetamol [acetaminophen] and dextropropoxyphene [propoxyphene] mixture) during 2005 – 2007, deaths involving codeine and most notably tramadol (836 deaths during 2000 – 2011) increased. Deaths from paracetamol poisoning either alone, or with alcohol reached 89 in 2011, the lowest annual figure since 1974. However, in reality there has been no marked downward trend since 1999 despite reductions in pack size, continued publicity as to the dangers of paracetamol overdose, and improved liver failure treatment, including transplantation. The annual number of deaths from antidepressants remained relatively stable (median: 397, range: 335 – 469). Although the number of deaths from dosulepin [dothiepin] decreased (186 in 2000 and 49 in 2011), the number of deaths involving selective serotonin reuptake inhibitors increased (50 in 2000 and 127 in 2011). Although annual numbers of deaths involving diamorphine/morphine (88% unintentional) declined, deaths involving methadone (89% unintentional) increased and the total annual number of deaths from these drugs showed little change (2000: 1061, 2011: 995). Deaths involving amfetamine/metamfetamine remained relatively constant at about 50 annually, and whilst cocaine-related deaths fell by 48% during 2008 – 2011, and deaths involving MDMA and related compounds fell by 69% over this same period, deaths involving ‘ legal highs ’ , notably γ -hydroxybutrate/ γ -butyrolactone and ketamine, increased. Alterations in the availability of paracetamol and of prescription drugs such as dextropropoxyphene and dosulepin have not been accompanied by decreases in the number of deaths from poisoning. Despite intense media and other interest, the annual number of deaths (250 – 300) involving ‘ recreational ’ drugs remains small in relation to the 1000 or so deaths a year from diamorphine and/or methadone.

Fatal and Non-Fatal Overdose After Narcology Hospital Discharge Among Russians Living with HIV/Aids who Inject Drugs‡

PubMed Central

Walley, Alexander Y; Cheng, Debbie M; Quinn, Emily K.; Blokhina, Elena; Gnatienko, Natalia; Chaisson, Christine E.; Krupitsky, Evgeny; Coffin, Philip O; Samet, Jeffrey H

2016-01-01

Objectives Among Russians living with HIV/AIDS who inject drugs, we examined the incidence of fatal and non-fatal overdoses following discharge from a narcology hospital and the associations with more advanced HIV infection. Design Prospective cohort study of data collected at baseline, 3 and 6 months from HIV-infected patients with a history of injection drug use who were not treated with anti-retroviral therapy. Participants were recruited between 2012-14 from a narcology (addiction) hospital in St. Petersburg, Russia. Methods Fatal overdose was determined based on contact reports to study staff in the year after discharge. Non-fatal overdose was self-reported at the 3- and 6-month assessments. The main independent variable for HIV severity was CD4 cell count at the baseline interview (<200 cells/mm3 ≥ 200 cells/mm3). Secondary analyses assessed time since HIV diagnosis and treated with anti-retroviral treatment (ART) prior to enrollment as independent variables. We fit Cox proportional hazards models to assess whether HIV severity is associated with either fatal or non-fatal overdose. Results Among 349 narcology patients, 18 participants died from overdose within one year after discharge (8.7%, 95%CI 3.4-14.2 by Kaplan-Meier); an estimated 51% [95% CI 34-68%] reported at least one non-fatal overdose within 6 months of discharge. HIV severity, time since HIV diagnosis and ever ART were not significantly associated with either fatal or non-fatal overdose events. Conclusion Fatal and non-fatal overdose are common among Russians living with HIV/AIDS who inject drugs after narcology hospital discharge. Overdose prevention interventions are urgently warranted among Russian narcology patients with HIV infection. PMID:27907848

Fentanyl patches: preventable overdose.

PubMed

2010-02-01

Fentanyl is a potent opioid analgesic marketed for the treatment of stable intense chronic pain, particularly in the form of a transdermal patch. These delivery devices carry the same risk of adverse effects and drug interactions as conventional formulations of opioids. The patches carry an added risk of fentanyl overdose because they contain very high doses, both before and after use. High-risk situations for overdose were identified by examining the results of pharmacovigilance studies and medication error prevention programmes, as well as an observational study, case reports, and a French legal action. The main situations exposing patients to a risk of overdose are: confusion between two dose strengths, forgetting to remove the patch; accidental transfer of the patch to another person, application of more than one patch, cutting the patches, self-medication, and ingestion. Increased skin temperature facilitates fentanyl absorption and thus increases the risk of overdose; high-risk situations include fever, electric blankets, and intense physical exercise. In practice, the precautions for treatment and patch disposal must be followed exactly if this delivery system is to serve as a valid alternative to morphine for selected patients with stable intense chronic pain.

Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks.

PubMed

Calvo, Michele; MacFarlane, Jessica; Zaccaro, Heather; Curtis, Matthew; Cabán, María; Favaro, Jamie; Passannante, Marian R; Frost, Taeko

2017-09-01

Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services. The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants. The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20). Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people. Copyright © 2017. Published by Elsevier B.V.

N-acetylcysteine-induced headache in hospitalized patients with acute acetaminophen overdose.

PubMed

Zyoud, Sa'ed H; Awang, Rahmat; Sulaiman, Syed Azhar Syed; Al-Jabi, Samah W

2011-06-01

Intravenous N-acetylcysteine (IV-NAC) is usually regarded as a safe antidote to acetaminophen overdose. However, during infusion of the loading dose, adverse drug reactions such as a headache may occur. The objectives of this study were to investigate the prevalence of headache in patients presenting to hospital after acetaminophen overdose and to determine which clinical findings are most predictive of headache among these patients. This is a retrospective cohort study of hospital admissions for acute acetaminophen overdose that was conducted over a period of 4 years from January 1, 2005 to December 31, 2008. Demographic data, clinical characteristics, and predictors of headache were analyzed. spss 15 was used for data analysis. Two-hundred and fifty-five patients were studied; their mean age was 23.1 ± 1.6; 83.9% of them were women and 14.9% had a headache during hospitalization. Headache among patients was significantly associated with IV-NAC administration (P = 0.001), intentional ingestion of drug (P = 0.04), acetaminophen concentration above 'possible toxicity' treatment line (P = 0.04), a high acetaminophen concentration (P = 0.04), and a long hospital stay (P = 0.03). Multiple logistic regression showed a significant risk factor for headache in patients administered IV-NAC (P = 0.04). We recorded a high frequency of headache in patients with acute acetaminophen overdose in our geographical area. This study suggests that among those patients, the use of IV-NAC is associated with an increased risk of headache. © 2010 The Authors Fundamental and Clinical Pharmacology © 2010 Société Française de Pharmacologie et de Thérapeutique.

Associations of Adverse Clinical Course and Ingested Substances among Patients with Deliberate Drug Poisoning: A Cohort Study from an Intensive Care Unit in Japan.

PubMed

Ichikura, Kanako; Okumura, Yasuyuki; Takeuchi, Takashi

2016-01-01

Some patients with deliberate drug poisoning subsequently have an adverse clinical course. The present study aimed to examine whether the type of drugs ingested and psychiatric diagnoses were related to an adverse clinical course. We conducted a cohort study of patients with deliberate drug poisoning admitted to the intensive care unit of a university hospital located in Tokyo, Japan, between September 2006 and June 2013. Intensive care unit (ICU) stay of ≥4 days was used as a primary outcome measure, while the incidence of aspiration pneumonitis was used as a secondary outcome measure. Ingested substances and psychiatric diagnoses were used as explanatory variables. Of the 676 patients with deliberate drug poisoning, 88% had a history of psychiatric treatment and 82% had ingested psychotropic drugs. Chlorpromazine-promethazine-phenobarbital combination drug (Vegetamin®) ranked fifth among the most frequently ingested substances in cases of deliberate drug poisoning and had the highest incidence of prolonged ICU stay (20%) and aspiration pneumonitis (29%). The top three major classes consisted of benzodiazepines (79%), new-generation antidepressants (25%), and barbiturates/non-barbiturates (23%). Barbiturate overdose was independently associated with increased odds of both prolonged ICU stay (8% vs. 17%; odds ratio [OR], 2.97; 95% confidence interval [CI], 1.60-5.55) and aspiration pneumonitis (8% vs. 24%; OR, 3.83; 95% CI, 2.18-6.79) relative to those associated with overdose of only other sedative-hypnotics (i.e., benzodiazepines). These results suggest that judicious prescribing of barbiturates by psychiatrists could reduce the risk of an adverse clinical course when a patient attempts an overdose.

Clinical Effects of Synthetic Cannabinoid Receptor Agonists Compared with Marijuana in Emergency Department Patients with Acute Drug Overdose.

PubMed

Zaurova, Milana; Hoffman, Robert S; Vlahov, David; Manini, Alex F

2016-12-01

Synthetic cannabinoid receptor agonists (SCRAs) are heterogeneous compounds originally intended as probes of the endogenous cannabinoid system or as potential therapeutic agents. We assessed the clinical toxicity associated with recent SCRA use in a large cohort of drug overdose patients. This subgroup analysis of a large (n = 3739) drug overdose cohort study involved consecutive ED patients at two urban teaching hospitals collected between 2009 and 2013. Clinical characteristics of patients with the exposure to SCRAs (SRCA subgroup) were compared with those from patients who smoked traditional cannabinoids (marijuana subgroup). Data included demographics, exposure details, vital signs, mental status, and basic chemistries gathered as part of routine clinical care. Study outcomes included altered mental status and cardiotoxicity. Eighty-seven patients reported exposure to any cannabinoid, of whom 17 reported SCRAs (17 cases, 70 controls, mean age 38.9 years, 77 % males, 31 % Hispanic). There were no significant differences between SRCA and marijuana with respect to demographics (age, gender, and race/ethnicity), exposure history (suicidality, misuse, and intent), vital signs, or serum chemistries. Mental status varied between SRCA and marijuana, with agitation significantly more likely in SCRA subgroup (OR = 3.8, CI = 1.2-11.9). Cardiotoxicity was more pronounced in the SCRA subgroup with dysrhythmia significantly more likely (OR = 9.2, CI = 1.0-108). In the first clinical study comparing the adverse effects of SCRA overdose vs. marijuana controls in an ED population, we found that SCRA overdoses had significantly pronounced neurotoxicity and cardiotoxicity compared with marijuana.

Decision support in addiction: The development of an e-health tool to assess and prevent risk of fatal overdose. The ORION Project.

PubMed

Baldacchino, A; Crocamo, C; Humphris, G; Neufeind, J; Frisher, M; Scherbaum, N; Carrà, G

2016-09-01

The application of e-health technology to the field of substance use disorders is at a relatively early stage, and methodological quality is still variable. Few have explored the extent of utilization of communication technology in exploring risk perception by patients enrolled in substance abuse services. The Overdose RIsk InfOrmatioN (ORION) project is a European Commission funded programme, aimed to develop and pilot an e-health psycho-educational tool to provide information to drug using individuals about the risks of suffering a drug overdose. In this article, we report on phase 1 (risk estimation), phase 2 (design), and phase 3 (feasibility) of the ORION project. The development of ORION e-health tool underlined the importance of an evidence-based intervention aimed in obtaining reliable evaluation of risk. The ORION tool supported a decision making process aimed at influencing the substance users' self-efficacy and the degree to which the substance users' understand risk factors. Therefore, its innovative power consisted in translating risks combination into a clear estimation for the user who will then appear more likely to be interested in his/her risk perception. Exploratory field testing and validation confirmed the next stage of evaluation, namely, collection of routine patient samples in study clinics. The associations between risk perception of overdose, engagement with the ORION tool and willingness to alter overdose risk factors, in a clinical setting across various EU member states will further confirm the ORION tool's generalisability and effectiveness. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Care versus convenience: Examining paracetamol overdose in New Zealand and harm reduction strategies through sale and supply.

PubMed

Freeman, Nadia; Quigley, Paul

2015-10-30

To examine statistics on paracetamol overdose in New Zealand and investigate options to reduce paracetamol overdose rates, through supply reduction strategies. Data was gathered from the Ministry of Health's National Minimum Dataset and Wellington Hospital Emergency Department attendances. Twenty articles on supply reduction strategies were sourced through article database searches. A survey on paracetamol availability from online pharmacies within New Zealand was conducted by searching for New Zealand online pharmacies through Google. A five-year audit of data (2007-2012) from the Wellington Hospital Emergency Department revealed that paracetamol was the most common medication used for overdose (23%). National data on aminophenol derivatives accounted for 22.4% of poisonings in New Zealand's public hospitals. An online search found that 25 out of 27 online pharmacies sold packets containing 50 grams of paracetamol. However, the literature supported restricting packets to the minimum threshold for an acute exposure (10 g). Paracetamol poisoning is the most common form of drug overdose in many developed countries. Tightening restrictions on the quantity of paracetamol sold per packet, in all outlets in New Zealand, may be an effective strategy to reduce overdose rates. This includes online pharmacies where large quantities of paracetamol per packet are available for sale.

[Acetaminophen: Knowledge, use and overdose risk in urban patients consulting their general practitioner. A prospective, descriptive and transversal study].

PubMed

Cipolat, Lauriane; Loeb, Ouriel; Latarche, Clotilde; Pape, Elise; Gillet, Pierre; Petitpain, Nadine

2017-09-01

Acetaminophen is the most involved active substance in both unintentional and intentional drug poisoning. However, its availability outside community pharmacies is being debated in France. We made, via a self-administered questionnaire, a prospective assessment of knowledge, use and acetaminophen overdose risk in patients consulting their general practitioner, in the Metz Métropole urban area, between May 2015 and February 2016. We estimated the prevalence of potential unintentional overdosage by capture-recapture method. Among 819 responding patients, only 17.9 % had a sufficient knowledge and 20.3 % were at risk for potential unintentional overdose. The risk was higher for patients aged over 55 years or belonging to socioprofessional categories of laborers and inactive. A good knowledge score was a protective factor for overdose risk (P<0.0001). The liver toxicity of acetaminophen was particularly unknown. The prevalence of potential unintentional acetaminophen overdose was estimated at 1 to2 % of the population. Proposing acetaminophen outside of pharmacies cannot be recommended in France in such conditions. Information campaigns are needed to limit the risk of unintentional overdose and its consequences on liver toxicity. Copyright © 2017 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.

A Primer on Heroin and Fentanyl.

PubMed

Worley, Julie

2017-06-01

Heroin and fentanyl use have reached epidemic proportions in the United States and are now blamed for the majority of drug-related overdose deaths. Both drugs are produced primarily in South America and Asia and enter the United States illegally. One result of smoking or injecting heroin or fentanyl is the development of a substance use disorder (SUD), which causes changes in brain chemistry and function. These changes result in negative behaviors and an inability to stop use. Yet, treatments are available and recovery is possible. Nurses have the potential to impact the heroin and fentanyl epidemic through developing therapeutic relationships with patients who are at risk or already have a SUD. Strategies for effective communication include maintaining a supportive, nonjudgmental attitude and incorporating motivational interviewing. All patients should be screened for opioid use and referred for treatment if indicated. It is important for nurses to be knowledgeable about heroin and fentanyl and available treatments. [Journal of Psychosocial Nursing and Mental Health Services, 55(6), 16-20.]. Copyright 2017, SLACK Incorporated.

Clinical Effects and Lethal and Forensic Aspects of Propofol*

PubMed Central

Levy, Richard J.

2010-01-01

Propofol is a potent intravenous anesthetic agent that rapidly induces sedation and unconsciousness. The potential for propofol dependency, recreational use and abuse has only recently been recognized and several cases of accidental overdose and suicide have emerged. In addition, the first documented case of murder using propofol was reported a few months ago and a high profile case of suspected homicide with propofol is currently under investigation. A number of analytical methods have been employed to detect and quantify propofol concentrations in biological specimens. The reported propofol related deaths and post-mortem blood and tissue levels are reviewed. Importantly, limitations of propofol detection are discussed and future considerations are presented. Because propofol has the potential for diversion with lethal consequences, the forensic scientist must have a basic understanding of its clinical indications and uses, pharmacologic properties, and detection methods. In addition, medical institutions should develop systems to prevent and detect diversion of this potential drug of abuse. PMID:20950316

Alcohol and other drug problems in Australia: the urgent need for nurse education.

PubMed

de Crespigny, C

1996-07-01

The economic, social and health costs associated with alcohol and other drug use, including medicines, impact on the Australian community profoundly. Many Australians use alcohol and other drugs (AODs) on a regular basis and a significant number experience problems at some time. There are about 25,000 drug-related deaths annually, the majority of which are related to alcohol and tobacco use. Many young people die or are injured as a direct result of alcohol intoxication, accidental overdose and related problems, and significant numbers of elderly people are hospitalised, permanently incapacitated or suffer avoidable trauma through adverse drug reactions and side-effects of medications. It is estimated that at least 25 per cent of acute hospital beds hold patients with alcohol-related problems directly associated with the medical diagnosis, and there are comparable numbers of people needing social and other forms of assistance at some time. Despite the preventative nature of many AOD problems and the call for harm reduction, timely intervention and support for the thousands of Australians attending hospitals, community health and mental health services, nurses are yet to effectively assist the community in preventing and responding to the range of AOD problems. Nursing policy, guidelines and clinical expertise are required to assist the community in addressing this issue. Undergraduate, postgraduate and continuing education have a vital role to play in providing the profession with the knowledge, skills and research base to meet this challenge.

Fentanyl novel derivative-related deaths.

PubMed

Giorgetti, Arianna; Centola, Carmela; Giorgetti, Raffaele

2017-05-01

Fentanyl (FEN) is a potent, synthetic narcotic used as an anaesthetic and a pain reliever, but also illegally manufactured. For diversion purpose, it is being steadily modified to produce new analogous compounds and derivatives (FENS), categorised as novel psychoactive substances. While potential FEN abuse is already known, even in the absence of a clear lethal dosage, there is still a shortage of data on its derivatives. A literature review of FENS-related deaths was performed, to better understand potential damage and future perspectives of FEN congeners. Epidemiological data, pathological findings, administration routes, average concentrations and lethal doses, toxicological issues, trends in misuses, comparison among FENS, and possible explanation for FENS abuse are reviewed and discussed in depth. This study provides a medical-legal and toxicological assessment of this phenomenon in order to understand the role of illegal fentanyl and its congeners in deaths from FENS overdose. Copyright © 2017 John Wiley & Sons, Ltd.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

PubMed Central

Hawton, Keith; Simkin, Sue; Deeks, Jonathan J; O’Connor, Susan; Keen, Allison; Altman, Douglas G; Philo, Greg; Bulstrode, Christopher

1999-01-01

Objectives To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning. Design Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods. Setting 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data. Subjects 4403 self poisoning patients; questionnaires completed for 1047. Main outcome measures Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers. Results Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode—20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%). Conclusions Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour. Key messagesThis study found that portrayal of self poisoning in a popular television drama was associated with a short lived increase in presentation of self poisoning patients to general hospitalsChoice of substance taken in overdose was also influenced by the broadcastExtreme caution should be exercised about portraying suicidal behaviour on television, and especially about giving details of the method usedThe potential role of television in preventing suicidal behaviour requires investigation PMID:10195966

Clinical parameters that predict the need for medium or intensive care admission in intentional drug overdose patients: A retrospective cohort study.

PubMed

van den Oever, Huub L A; van Dam, Mirja; van 't Riet, Esther; Jansman, Frank G A

2017-02-01

Many patients with intentional drug overdose (IDO) are admitted to a medium (MC) or intensive care unit (IC) without ever requiring MC/IC related interventions. The objective of this study was to develop a decision tool, using parameters readily available in the emergency room (ER) for patients with an IDO, to identify patients requiring admission to a monitoring unit. Retrospective cohort study among cases of IDO with drugs having potentially acute effects on neurological, circulatory or ventilatory function, admitted to the MC/IC unit between 2007 and 2013. A decision tool was developed, using 6 criteria, representing intubation, breathing, oxygenation, cardiac conduction, blood pressure, and consciousness. Cases were labeled as 'high acuity' if one or more criteria were present. Among 255 cases of IDO that met the inclusion criteria, 197 were identified as "high acuity". Only 70 of 255 cases underwent one or more MC/IC related interventions, of which 67 were identified as 'high acuity by the decision tool (sensitivity 95.7%). In a population of patients with intentional drug overdose with agents having potentially acute effect on vital functions, 95.7% of MC/IC interventions could be predicted by clinical assessment, supplemented with electrocardiogram and blood gas analysis, in the ER. Copyright © 2016 Elsevier Inc. All rights reserved.

A physiologically based pharmacokinetic (PBPK) model for predicting the efficacy of drug overdose treatment with liposomes in man.

PubMed

Howell, Brett A; Chauhan, Anuj

2010-08-01

Physiologically based pharmacokinetic (PBPK) models were developed for design and optimization of liposome therapy for treatment of overdoses of tricyclic antidepressants and local anesthetics. In vitro drug-binding data for pegylated, anionic liposomes and published mechanistic equations for partition coefficients were used to develop the models. The models were proven reliable through comparisons to intravenous data. The liposomes were predicted to be highly effective at treating amitriptyline overdoses, with reductions in the area under the concentration versus time curves (AUC) of 64% for the heart and brain. Peak heart and brain drug concentrations were predicted to drop by 20%. Bupivacaine AUC and peak concentration reductions were lower at 15.4% and 17.3%, respectively, for the heart and brain. The predicted pharmacokinetic profiles following liposome administration agreed well with data from clinical studies where protein fragments were administered to patients for overdose treatment. Published data on local cardiac function were used to relate the predicted concentrations in the body to local pharmacodynamic effects in the heart. While the results offer encouragement for future liposome therapies geared toward overdose, it is imperative to point out that animal experiments and phase I clinical trials are the next steps to ensuring the efficacy of the treatment. (c) 2010 Wiley-Liss, Inc. and the American Pharmacists Association

Quinine intoxications reported to the Scottish Poisons Information Bureau 1997–2002: a continuing problem

PubMed Central

Langford, N J; Good, A M; Laing, W J; Bateman, D N

2003-01-01

Quinine is widely prescribed in the UK for night cramps. Its potential toxicity in overdose is well known. We have reviewed the Scottish experience of enquiries regarding quinine overdose to the poisons information service responsible for Scotland over a 6-year period. Between 1997 and 2002 there were 96 reports of suspected quinine toxicity from Scotland (population 5.2 million), 19 of which were in children. The largest quantities of drug ingested were in patients between the ages of 11 and 30. In comparison with older studies the pattern of quinine poisoning does not appear to have changed in the UK over 20 years, despite recognition that it is a toxic agent in overdose, and particularly in children. PMID:14651733

Confronting Death From Drug Self-Intoxication (DDSI): Prevention Through a Better Definition

PubMed Central

Smith, Gordon S.; Caine, Eric D.; Kapusta, Nestor D.; Hanzlick, Randy L.; Larkin, G. Luke; Naylor, Charles P. E.; Nolte, Kurt B.; Miller, Ted R.; Putnam, Sandra L.; De Leo, Diego; Kleinig, John; Stack, Steven; Todd, Knox H.; Fraser, David W.

2014-01-01

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities. PMID:25320874

Intentional Drug Overdose Involving Pregabalin and Gabapentin: Findings from the National Self-Harm Registry Ireland, 2007-2015.

PubMed

Daly, Caroline; Griffin, Eve; Ashcroft, Darren M; Webb, Roger T; Perry, Ivan J; Arensman, Ella

2018-04-01

Intentional drug overdose (IDO) is a significant public health problem. Concerns about the misuse of gabapentinoids, i.e. pregabalin and gabapentin, including their consumption in IDO have grown in recent years. This paper examines the trends in the prevalence of gabapentinoids taken in IDO, the profile of individuals taking them, and associated overdose characteristics. Presentations to emergency departments involving IDO, recorded by the National Self-Harm Registry Ireland between 1 January 2007 and 31 December 2015 were examined. Data items included patient demographics, drug names, total tablet quantity consumed and alcohol involvement. Gabapentinoids were involved in 2115 (2.9%) of the 72,391 IDOs recorded. Presentations involving a gabapentinoid increased proportionally from 0.5% in 2007 to 5.5% in 2015. The majority of IDOs involving a gabapentinoid were made by females (59.9%), with over one-third (37.2%) involving alcohol. Compared with IDOs involving other drugs, presentations with a gabapentinoid were made by persons who were older (median 37 vs. 32 years) and involved a significantly greater median quantity of tablets (30 vs. 21, p ≤ 0.001), with over one-quarter (27.4%) of these involving the ingestion of 50 tablets or more. Admission to hospital was significantly more common following IDOs with a gabapentinoid compared with those without (49.4% vs. 41.4%, p ≤ 0.001). This study identified the increasing use of gabapentinoids in IDO, describing the profile and overdose characteristics of presentations. It is important for clinicians to exercise vigilance while prescribing gabapentinoids, including being aware of other medications that their patients may have access to. Our findings support the need for routine monitoring for signs of misuse among those prescribed gabapentinoids.

Screening of Potential Small Volume Resuscitation Products Using a Severe Hemorrhage Sedated Swine Model

DTIC Science & Technology

2012-03-30

as though uncomfortable (CNS adverse overdose reaction seen in hu- mans), with body movements such as extension of the limbs. One animal had...would account for the dra- matic results noted in the present experiments. VPA is a drug that has been accidentally or in- tentionally overdosed many...a large proportion of the VPA is free, exacerbating its effects. Normal half life is 7-15 hrs [34] but can be extended by overdose . Serum

Sex Differences and the Effects of Stress on Subsequent Opioid Consumption in Adult Rats Following Adolescent Nicotine Exposure: A Psychopharmacologic Examination of the Gateway Hypothesis

DTIC Science & Technology

1997-07-18

sign of fentanyl addiction is death by drug overdose (David Hester, personal communication, 1996). The addiction and abuse liability offentanyl is high...rats, not exposed to stress, died of apparent fentanyl overdose . These two rats also had been exposed to 12 mg nicotinelkglday and died despite lower...nicotinelkglday) during adolescence was related to increased, subsequent fentanyl self-administration in non-stressed male rats. Exposure to immobilization stress

Alberta's provincial take-home naloxone program: A multi-sectoral and multi-jurisdictional response to overdose.

PubMed

Freeman, Lisa K; Bourque, Stacey; Etches, Nick; Goodison, Karin; O'Gorman, Claire; Rittenbach, Kay; Sikora, Christopher A; Yarema, Mark

2017-11-09

Alberta is a prairie province located in western Canada, with a population of approximately 4.3 million. In 2016, 363 Albertans died from apparent drug overdoses related to fentanyl, an opioid 50-100 times more toxic than morphine. This surpassed the number of deaths from motor vehicle collisions and homicides combined. Naloxone is a safe, effective, opioid antagonist that may quickly reverse an opioid overdose. In July 2015, a committee of community-based harm reduction programs in Alberta implemented a geographically restricted take-home naloxone (THN) program. The successes and limitations of this program demonstrated the need for an expanded, multi-sectoral, multi-jurisdictional response. The provincial health authority, Alberta Health Services (AHS), used previously established incident command system processes to coordinate implementation of a provincial THN program. Alberta's provincial THN program was implemented on December 23, 2015. This collaborative program resulted in a coordinated response across jurisdictional levels with wide geographical reach. Between December 2015 and December 2016, 953 locations, including many community pharmacies, registered to dispense THN kits, 9572 kits were distributed, and 472 reversals were reported. The provincial supply of THN kits more than tripled from 3000 to 10 000. Alberta was uniquely poised to deliver a large, province-wide, multi-sectoral and multi-jurisdictional THN program as part of a comprehensive response to increasing opioid-related morbidity and mortality. The speed at which AHS was able to roll out the program was made possible by work done previously and the willingness of multiple jurisdictions to work together to build on and expand the program.

Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States

PubMed Central

Mars, Sarah G.; Fessel, Jason N.; Bourgois, Philippe; Montero, Fernando; Karandinos, George; Ciccarone, Daniel

2015-01-01

Heroin overdose, more accurately termed ‘heroin-related overdose’ due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black ‘tar’ heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007–12) and of users in San Francisco (1994–2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study. PMID:26202771

Re-racialization of Addiction and the Redistribution of Blame in the White Opioid Epidemic.

PubMed

Mendoza, Sonia; Rivera, Allyssa Stephanie; Hansen, Helena Bjerring

2018-04-27

New York City has the largest number of opioid dependent people of U.S. cities, and within New York, Whites have the highest rate of prescription opioid and heroin overdose deaths. The rise of opioid abuse among Whites has resulted in popular narratives of victimization by prescribers, framing of addiction as a biological disease, and the promise of pharmaceutical treatments that differ from the criminalizing narratives that have historically described urban Latino and black narcotic use. Through an analysis of popular media press and interviews with opioid prescribers and community pharmacists in Staten Island-the epicenter of opioid overdose in New York City and the most suburban and white of its boroughs-we found that narratives of white opioid users disrupted notions of the addict as "other," producing alternative logics of blame that focus on prescribers and the encroachment of dealers from outside of white neighborhoods. © 2018 by the American Anthropological Association.

Developing Core Competencies for the Prevention and Management of Prescription Drug Misuse: A Medical Education Collaboration in Massachusetts.

PubMed

Antman, Karen H; Berman, Harris A; Flotte, Terence R; Flier, Jeffrey; Dimitri, Dennis M; Bharel, Monica

2016-10-01

Drug overdose has become the leading cause of injury death in the United States. More than half of those deaths involve prescription drugs, specifically opioids. A key component of addressing this national epidemic is improving prescriber practices.A review of the curricula at the four medical schools in Massachusetts revealed that, although they taught components of addiction medicine, no uniform standard existed to ensure that all students were taught prevention and management strategies for prescription drug misuse. To fill this gap, the governor and the secretary of health and human services invited the deans of the state's four medical schools to convene to develop a common educational strategy for teaching safe and effective opioid-prescribing practices. With leadership from the Department of Public Health and Massachusetts Medical Society, the deans formed the Medical Education Working Group in 2015. This group reviewed the relevant literature and current standards for treating substance use disorders and defined 10 core competencies for the prevention and management of prescription drug misuse.The medical schools have incorporated these competencies into their curricula and have committed to assessing students' competence in these areas. The members of the Medical Education Working Group have agreed to continue to work together on key next steps, including connecting these competencies to those for residents, equipping interprofessional teams to address prescription drug misuse, and developing materials in pain management and opioid misuse for practicing physicians. This first-in-the-nation partnership has yielded cross-institutional competencies that aim to address a public health emergency in real time.

Characteristics of alprazolam-related deaths compiled by a centralized state medical examiner.

PubMed

Shah, Neel A; Abate, Marie A; Smith, Michael J; Kaplan, James A; Kraner, James C; Clay, David J

2012-11-01

Unintentional drug poisoning deaths represent a major health concern, particularly in rural areas. Although alprazolam is frequently detected in drug-related deaths, characterization of its involvement is limited. Our objective was to compare the characteristics of alprazolam-related deaths with nonalprazolam deaths in a predominantly rural state. A comprehensive forensic drug database (FDD) was developed in 2005 to compile demographic, toxicology, and co-morbidity information from all West Virginia (WV) drug-related deaths. All FDD data from 2005 to mid-November 2007 were analyzed. Alprazolam contributed to 204 (17.0%) of the 1,199 drug-related deaths and was identified in 7.2% of the 363 deaths occurring during 2005 and in 27.5% of the 422 deaths entered in the database during 2007. At least one other drug, predominantly an opioid, was identified in 97.5% of the alprazolam cases, with concurrent benzodiazepines also found. Compared to nonalprazolam deaths, alprazolam decedents were significantly more likely to be obese and to have preexisting cardiovascular disease, but were less likely to have documented substance abuse. An alprazolam prescription existed in 52.5% of the alprazolam deaths, with 77.6% having a prescription for all drugs identified. Alprazolam was a contributing cause of death in a substantial and increasing number of drug-related deaths. Prescriptions for alprazolam and the other drugs detected were often present in these cases. Controlled substance monitoring programs should be routinely used as one mechanism to help prevent potential drug misuse/abuse. Our findings provide a baseline for ongoing alprazolam-related death surveillance. Copyright © American Academy of Addiction Psychiatry.

Overdose

MedlinePlus

... PA: Elsevier Saunders; 2014:chap 147. Little M. Toxicology emergencies. In: Cameron P, Jelinek G, Kelly A- ... chap 29. Pincus MR, Bluth MH, Abraham NZ. Toxicology and therapeutic drug monitoring. In: McPherson RA, Pincus ...

NCHS Data on Drug-poisoning Deaths

MedlinePlus

... NCHS Materials NCHS NCHS Data on Drug-poisoning Deaths Format: Select One PDF [303K] Recommend on Facebook ... NCHS, National Vital Statistics System, Mortality. Drug-poisoning death rates, by state Deaths per 100,000 population ...

North Carolina's Operation Medicine Drop: Results From One of the Nation's Largest Drug Disposal Programs.

PubMed

Fleming, Eleanor; Proescholdbell, Scott; Sachdeva, Nidhi; Alexandridis, Apostolos A; Margolis, Lewis; Ransdell, Kelly

2016-01-01

In 2013, a total of 1,085 North Carolina residents died due to unintentional poisoning; 91% of these deaths were attributed to medications or drugs (over-the-counter, prescription, or illicit). Proper disposal of unused, unneeded, and/or expired medications is an essential part of preventing these unintentional deaths, as well as averting the other adverse consequences of these drugs on the environment and population health. Operation Medicine Drop is a medication take-back program coordinated by Safe Kids North Carolina, a county-level, coalition-based injury prevention organization. The Operation Medicine Drop program and event registration system were used to review and validate the number of events, the counties where the events were held, and the number of unit doses (pills) collected from March 2010 to June 2014. SAS version 9.4 was used to generate basic counts and frequencies of events and doses, and ArcGIS version 10.0 was used to create the map. From March 2010 to June 2014, Operation Medicine Drop held 1,395 events with 245 different participating law enforcement agencies in 91 counties in North Carolina, and it collected 69.6 million unit doses of medication. More than 60 local Safe Kids North Carolina community coalitions had participated as of June 2014. Every year, Operation Medicine Drop has witnessed increases in events, participating agencies, participating counties, and the number of doses collected. Operation Medicine Drop is an excellent example of a successful and ongoing collaboration to improve public health. Medication take-back programs may play an important role in preventing future overdose deaths in North Carolina. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

Trends in causes of death among persons with acquired immunodeficiency syndrome in the era of highly active antiretroviral therapy, San Francisco, 1994-1998.

PubMed

Louie, Janice K; Hsu, Ling Chin; Osmond, Dennis H; Katz, Mitchell H; Schwarcz, Sandra K

2002-10-01

To understand recent temporal trends in acquired immunodeficiency syndrome (AIDS) mortality in the era of highly active antiretroviral therapy (HAART), trends in causes of death among persons with AIDS in San Francisco who died between 1994 and 1998 were analyzed. Among 5234 deaths, the mortality rate for human immunodeficiency virus (HIV)-related or AIDS-related deaths declined after 1995 (P<.01), whereas the mortality rate for non-HIV- or non-AIDS-related deaths remained stable. The proportion of deaths of persons with AIDS associated with septicemia, non-AIDS-defining malignancy, chronic liver disease, viral hepatitis, overdose, obstructive lung disease, coronary artery disease, and pancreatitis increased (P<.05). The standardized mortality ratio was high for these causes in both pre- and post-HAART periods, except for pancreatitis, a possible complication of HAART, which demonstrated an increasing standardized mortality ratio trend after 1996. With increasing AIDS survival, prevention of chronic diseases, assessment of long-term toxicity from HAART, and surveillance for additional causes of mortality will become increasingly important.

Deodorant poisoning

MedlinePlus

... Poisoning and Drug Overdose . 4th ed. Philadelphia, PA: Elsevier Saunders; 2007:chap 100. Farmer B, Seger DL. ... Textbook of Critical Care . 7th ed. Philadelphia, PA: Elsevier; 2017:chap 153. Meehan TJ. Approach to the ...

21 CFR 862.3750 - Quinine test system.

Code of Federal Regulations, 2012 CFR

2012-04-01

... quinine, a fever-reducing and pain-relieving drug intended in the treatment of malaria, in serum and urine. Measurements obtained by this device are used in the diagnosis and treatment of quinine overdose and malaria...

Tips to Prevent Poisonings

MedlinePlus

... CDC: Prescription Drug Overdose Poison Help (Department of Health & Human Services) American Association of Poison Control Centers, Inc. ... 232-6348 Email CDC-INFO U.S. Department of Health & Human Services HHS/Open USA.gov Top

Is immunotherapy an opportunity for effective treatment of drug addiction?

PubMed

Zalewska-Kaszubska, Jadwiga

2015-11-27

Immunotherapy has a great potential of becoming a new therapeutic strategy in the treatment of addiction to psychoactive drugs. It may be used to treat addiction but also to prevent neurotoxic complications of drug overdose. In preclinical studies two immunological methods have been tested; active immunization, which relies on the administration of vaccines and passive immunization, which relies on the administration of monoclonal antibodies. Until now researchers have succeeded in developing vaccines and/or antibodies against addiction to heroin, cocaine, methamphetamine, nicotine and phencyclidine. Their effectiveness has been confirmed in preclinical studies. At present, clinical studies are being conducted for vaccines against nicotine and cocaine and also anti-methamphetamine monoclonal antibody. These preclinical and clinical studies suggest that immunotherapy may be useful in the treatment of addiction and drug overdose. However, there are a few problems to be solved. One of them is controlling the level of antibodies due to variability between subjects. But even obtaining a suitable antibody titer does not guarantee the effectiveness of the vaccine. Additionally, there is a risk of intentional or unintentional overdose. As vaccines prevent passing of drugs through the blood/brain barrier and thereby prevent their positive reinforcement, some addicted patients may erroneously seek higher doses of psychoactive substances to get "high". Consequently, vaccination should be targeted at persons who have a strong motivation to free themselves from drug dependency. It seems that immunotherapy may be an opportunity for effective treatment of drug addiction if directed to adequate candidates for treatment. For other addicts, immunotherapy may be a very important element supporting psycho- and pharmacotherapy. Copyright © 2015 Elsevier Ltd. All rights reserved.

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment.

PubMed

Drainoni, Mari-Lynn; Koppelman, Elisa A; Feldman, James A; Walley, Alexander Y; Mitchell, Patricia M; Ellison, Jacqueline; Bernstein, Edward

2016-10-18

The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation. After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework. Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training. The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.

Psychological Variables Potentially Implicated in Opioid-Related Mortality as Observed in Clinical Practice

PubMed Central

Passik, Steven D.; Lowery, Amy

2014-01-01

Opioid-related deaths in the United States have become a public health problem, with accidental and unintended overdoses being especially troubling. Screening for psychological risk factors is an important first step in safeguarding against nonadherence practices and identifying patients who may be vulnerable to the risks associated with opioid therapy. Validated screening instruments can aid in this attempt as a complementary tool to clinicians’ assessments. A structured screening is imperative as part of an assessment, as clinician judgment is not the most reliable method of identifying nonadherence. As a complement to formal screening, we present for discussion and possible future study certain psychological variables observed during years of clinical practice that may be linked to medication nonadherence and accidental overdose. These variables include catastrophizing, fear, impulsivity, attention deficit disorders, existential distress, and certain personality disorders. In our experience, chronic pain patients with dual diagnoses may become “chemical copers” as a way of coping with their negative emotion. For these patients, times of stress could lead to accidental overdose. Behavioral, cognitive-behavioral (acceptance and commitment, dialectical behavior), existential (meaning-centered, dignity), and psychotropic therapies have been effective in treating these high-risk comorbidities, while managing expectations of pain relief appears key to preventing accidental overdose. PMID:21668755

Psychological variables potentially implicated in opioid-related mortality as observed in clinical practice.

PubMed

Passik, Steven D; Lowery, Amy

2011-06-01

Opioid-related deaths in the United States have become a public health problem, with accidental and unintended overdoses being especially troubling. Screening for psychological risk factors is an important first step in safeguarding against nonadherence practices and identifying patients who may be vulnerable to the risks associated with opioid therapy. Validated screening instruments can aid in this attempt as a complementary tool to clinicians' assessments. A structured screening is imperative as part of an assessment, as clinician judgment is not the most reliable method of identifying nonadherence. As a complement to formal screening, we present for discussion and possible future study certain psychological variables observed during years of clinical practice that may be linked to medication nonadherence and accidental overdose. These variables include catastrophizing, fear, impulsivity, attention deficit disorders, existential distress, and certain personality disorders. In our experience, chronic pain patients with dual diagnoses may become "chemical copers" as a way of coping with their negative emotion. For these patients, times of stress could lead to accidental overdose. Behavioral, cognitive-behavioral (acceptance and commitment, dialectical behavior), existential (meaning-centered, dignity), and psychotropic therapies have been effective in treating these high-risk comorbidities, while managing expectations of pain relief appears key to preventing accidental overdose. Wiley Periodicals, Inc.

Transient thyrotoxicosis from thyroiditis induced by sibutramine overdose: a case report.

PubMed

Kim, S K; Lee, S M; Yoo, S S; Hahm, J R; Jung, J H; Kim, H S; Kim, S; Chung, S I; Jung, T S

2013-08-01

Sibutramine is an antiobesity drug that inhibits the reuptake of serotonin and noradrenalin in the hypothalamus. A 37-year-old Korean man presented to the emergency room for the oral intake of 280 mg of sibutramine. The patient was in thyrotoxic state. The (99m)Technetium-pertechnetate thyroid scan showed irregular uptake of radioisotope and thyroid-stimulating hormone receptor antibody and thyroperoxidase antibody were negative. Thyroid function normalized after that. The patient had transient thyrotoxicosis with thyroiditis. We report a case of thyrotoxicosis accompanied by thyroiditis resulting from the intentional overdose of sibutramine.

Comparative Resuscitation Measures for Drug Toxicities Utilizing Lipid Emulsions

DTIC Science & Technology

2015-01-13

experimental, mixed research design Methods: For each drug studied, seven swine were assigned to eight ACLS or BLS protocol resuscitation groups ...studied drug overdose. For example, with bupivacaine, seventy- one percent of the epinephrine/lipid group survived compared to 19% of all the groups ...surviving. The Epinephrine only group yielded three survivors and the Lipid emulsion only group yielded one survivor. No swine in the CPR only or

Effective Use of Naloxone by Law Enforcement in Response to Multiple Opioid Overdoses.

PubMed

Kitch, Bryan B; Portela, Roberto C

2016-01-01

Growing rates of opioid abuse and overdose throughout the nation have lead some community organizations to develop naloxone administration programs. In Pitt County North Carolina, two of our law enforcement agencies were trained in the identification of opioid overdose and use of naloxone therapy. Attributed partially to introduction of fentanyl into the illicit drug market, our community experienced a 48-hour period in which officers successfully deployed five doses of antagonist medication to four individuals. This article presents case descriptions demonstrating the feasibility and safety of law enforcement naloxone programs.

Fatal overdose due to prescription fentanyl patches in a patient with sickle cell/beta-thalassemia and acute chest syndrome: A case report and review of the literature.

PubMed

Biedrzycki, Olaf J; Bevan, David; Lucas, Sebastian

2009-06-01

Introduced into clinical practice in the 1960s, the analgesic fentanyl is 100 times more potent than morphine. Various methods of administration exist including the transdermal Duragesic patch system, widely used in chronic pain and palliative care settings. Numerous, often imaginative methods of abuse of fentanyl patches have been reported; the majority of fatal fentanyl overdose cases resulting from deliberate abuse or suicide. We describe the accidental overdose of a young black male with sickle cell/beta-thalassemia who had been using the Duragesic system for almost 2 years.At autopsy the macroscopic findings were of nonspecific opiate overdose with congested heavy lungs. Histopathological examination revealed severe sickling of red blood cells in the lungs (acute chest syndrome). Toxicological examination revealed blood and urine fentanyl levels of 40 microg/L and 400 microg/L (10 fold and 100 fold higher than therapeutic levels). The mast cell tryptase was also significantly elevated at 76 microg/L, (Normal 2-14 microg/L). We discuss the relevance of these findings with regard to the cause of death, and stress the need to consider fentanyl when confronted with nonspecific signs of opiate overdose as it is not detected in routine toxicological drug screens.

Bupropion Overdose Presenting as Status Epilepticus in an Infant.

PubMed

Rivas-Coppola, Marianna S; Patterson, Amy L; Morgan, Robin; Wheless, James W

2015-09-01

Bupropion is a monocyclic antidepressant in the aminoketone class, structurally related to amphetamines. The Food and Drug Administration withdrew this product from the market in 1986 after seizures were reported in bulimic patients. It was later reintroduced in 1989 when the incidence of seizures was shown to be dose-related in the immediate release preparation. Massive bupropion ingestion has been associated with status epilepticus and cardiogenic shock in adults. Seizures have been reported in children, but not status epilepticus. This report highlights a patient who presented with status epilepticus and developed cardiopulmonary arrest after bupropion ingestion. False-positive amphetamine diagnosis from urine drug screen on presentation was reported. We review the presentation, clinical course, diagnostic studies, and outcome of this patient. We then review the literature regarding bupropion overdose in children. Symptoms of bupropion toxicity and risk for seizures are dose-dependent and fatalities have been reported. Our patient developed status epilepticus and cardiopulmonary arrest and then progressed to have a hypoxic ischemic encephalopathy and refractory symptomatic partial seizures. Our report highlights the need to keep this medication away from children in order to prevent accidental overdose. Copyright © 2015 Elsevier Inc. All rights reserved.

San Diego State U. Defends Its Role in Federal Drug Sting

ERIC Educational Resources Information Center

Lipka, Sara

2008-01-01

When a freshman at San Diego State University (SDSU) died of a cocaine overdose last May, the campus police chief decided to pursue a full-scale investigation. In December, he summoned undercover agents from the federal Drug Enforcement Administration to pose as students and roam the campus in search of illegal drugs. According to college…

Antidiarrheal drug overdose

MedlinePlus

... OJ, Yealy DM, Meckler GD, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide . 8th ed. New York, ... RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: ...

Removal of methadone by extended dialysis using a high cut-off dialyzer: implications for the treatment of overdose and for pain management in patients undergoing light chain removal.

PubMed

Arelin, Viktor; Schmidt, Julius J; Kayser, Nathalie; Kühn-Velten, W Nikolaus; Suhling, Hendrik; Eden, Gabriele; Kielstein, Jan T

2016-06-01

The synthetic opioid methadone hydrochloride has a low molecular weight of 346 D, a high volume of distribution (4 - 7 L/kg), and is lipophilic. It is used as an analgesic and for the maintenance treatment of opiate dependence. In drug addicts, methadone is frequently involved in mixed intoxications that can lead to death. Here we present the case of a drug addict in whom a high cut-off dialysis membrane together with extended dialysis was used in the setting of suspected overdose and acute kidney injury. Although the observed dialyzer plasma clearance (31.5 mL/min) and reduction ratio (38%) were higher than previously reported for standard hemodialysis, the total amount of methadone in the spent dialysate after 1 extended dialysis session was quite low. Hence, even extended dialysis with a high cut-off membrane does not seem to offer a clinically relevant benefit in the setting of overdose for enhanced methadone removal. On the other hand, in patients undergoing high cut-off dialysis for the removal of light chains, methadone could still be used as an analgesic without an additional dose after high cut-off hemodialysis.

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

PubMed

Oliva, Elizabeth M; Bowe, Thomas; Tavakoli, Sara; Martins, Susana; Lewis, Eleanor T; Paik, Meenah; Wiechers, Ilse; Henderson, Patricia; Harvey, Michael; Avoundjian, Tigran; Medhanie, Amanuel; Trafton, Jodie A

2017-02-01

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients' estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009-9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Opioid overdose prevention training with naloxone, an adjunct to basic life support training for first-year medical students.

PubMed

Berland, Noah; Fox, Aaron; Tofighi, Babak; Hanley, Kathleen

2017-01-01

Opioid overdose deaths have reached epidemic proportions in the United States. This problem stems from both licit and illicit opioid use. Prescribing opioids, recognizing risky use, and initiating prevention, including opioid overdose prevention training (OOPT), are key roles physicians play. The American Heart Association (AHA) modified their basic life support (BLS) algorithms to consider naloxone in high-risk populations and when a pulse is appreciated; however, the AHA did not provide OOPT. The authors' intervention filled this training deficiency by teaching medical students opioid overdose resuscitation with a Train-the-Trainer model as part of mandatory BLS training. The authors introduced OOPT, following a Train-the-Trainer model, into the required basic life support (BLS) training for first-year medical students at a single medical school in a large urban area. The authors administered pre- and post-evaluations to assess the effects of the training on opioid overdose knowledge, self-reported preparedness to respond to opioid overdoses, and attitudes towards patients with substance use disorders (SUDs). In the fall 2014, 120 first-year medical students received OOPT. Seventy-three students completed both pre- and posttraining evaluations. Improvements in knowledge about and preparedness to respond to opioid overdoses were statistically significant (P < .01) and large (Cohen's D = 2.70 and Cohen's D = 2.10, respectively). There was no statistically significant change in attitudes toward patients with SUDs. The authors demonstrated the effectiveness of OOPT as an adjunct to BLS in increasing knowledge about and preparedness to respond to opioid overdoses; improving attitudes toward patients with SUDs likely requires additional intervention. The authors will characterize knowledge and preparedness durability, program sustainability, and long-term changes in attitudes in future evaluations. These results support dissemination of OOPT as a part of BLS training for all medical students, and potentially all BLS providers.

A Novel Oral Fluid Assay (LC-QTOF-MS) for the Detection of Fentanyl and Clandestine Opioids in Oral Fluid After Reported Heroin Overdose.

PubMed

Griswold, Matthew K; Chai, Peter R; Krotulski, Alex J; Friscia, Melissa; Chapman, Brittany P; Varma, Neha; Boyer, Edward W; Logan, Barry K; Babu, Kavita M

2017-12-01

The adulteration of heroin with non-pharmaceutical fentanyl and other high-potency opioids is one of the factors contributing to striking increases in overdose deaths. To fully understand the magnitude of this problem, accurate detection methods for fentanyl and other novel opioid adulterant exposures are urgently required. The objective of this work was to compare the detection of fentanyl in oral fluid and urine specimens using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) in a population of heroin users presenting to the Emergency Department after overdose. This was a prospective observational study of adult Emergency Department patients who presented after a reported heroin overdose requiring naloxone administration. Participants provided paired oral fluid and urine specimens, which were prepared, extracted, and analyzed using a dual LC-QTOF-MS workflow for the identification of traditional and emerging drugs of abuse. Analytical instrumentation included SCIEX TripleTOF® 5600+ and Waters Xevo® G2-S QTOF systems. Thirty participants (N = 30) were enrolled during the study period. Twenty-nine participants had fentanyl detected in their urine, while 27 had fentanyl identified in their oral fluid (overall agreement 93.3%, positive percent agreement 93.1%). Cohen's Kappa (k) was calculated and demonstrated moderately, significant agreement (k = 0.47; p value 0.002) in fentanyl detection between oral fluid and urine using this LC-QTOF-MS methodology. Additional novel opioids and metabolites, including norfentanyl, acetylfentanyl, and U-47700, were detected during this study. In this study of individuals presenting to the ED after reported heroin overdose, a strikingly high proportion had a detectable fentanyl exposure. Using LC-QTOF-MS, the agreement between paired oral fluid and urine testing for fentanyl detection indicates a role for oral fluid testing in surveillance for nonpharmaceutical fentanyl. Additionally, the use of LC-QTOF-MS allowed for the detection of other clandestine opioids (acetylfentanyl and U-47700) in oral fluid.

21 CFR 862.3750 - Quinine test system.

Code of Federal Regulations, 2010 CFR

2010-04-01

... quinine, a fever-reducing and pain-relieving drug intended in the treatment of malaria, in serum and urine. Measurements obtained by this device are used in the diagnosis and treatment of quinine overdose and malaria...

21 CFR 862.3750 - Quinine test system.

Code of Federal Regulations, 2011 CFR

2011-04-01

... quinine, a fever-reducing and pain-relieving drug intended in the treatment of malaria, in serum and urine. Measurements obtained by this device are used in the diagnosis and treatment of quinine overdose and malaria...

21 CFR 862.3750 - Quinine test system.

Code of Federal Regulations, 2014 CFR

2014-04-01

... quinine, a fever-reducing and pain-relieving drug intended in the treatment of malaria, in serum and urine. Measurements obtained by this device are used in the diagnosis and treatment of quinine overdose and malaria...

21 CFR 862.3750 - Quinine test system.

Code of Federal Regulations, 2013 CFR

2013-04-01

... quinine, a fever-reducing and pain-relieving drug intended in the treatment of malaria, in serum and urine. Measurements obtained by this device are used in the diagnosis and treatment of quinine overdose and malaria...

Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy.

PubMed

Bebarta, Vikhyat S; Pead, Joshua; Varney, Shawn M

2015-08-01

Metformin-associated lactic acidosis or lacticemia has been widely reported as an adverse drug effect in diabetic patients with other significant comorbidities and in acute overdose in adults. Lacticemia has been reported twice in a previously healthy pediatric population, both of which were suicide attempts and required hemodialysis. We report a case of a 17-year-old, nondiabetic, healthy adolescent girl with metformin-associated lacticemia who intentionally overdosed on metformin, had no coingestants, and was treated only with crystalloids. Furthermore, she did not require intravenous bicarbonate administration or extracorporeal removal.

A review: Fentanyl and non-pharmaceutical fentanyls.

PubMed

Suzuki, Joji; El-Haddad, Saria

2017-02-01

Fentanyl and non-pharmaceutical fentanyls (NPFs) have been responsible for numerous outbreaks of overdoses all over the United States since the 1970s. However, there has been a growing concern in recent years that NPFs are contributing to an alarming rise in the number of opioid-related overdoses. The authors conducted a narrative review of the published and grey literature on fentanyl and NPFs in PubMed, Google Scholar, and Google using the following search terms: "fentanyl", "non-pharmaceutical fentanyl", "fentanyl analogs", "fentanyl laced heroin" and "fentanyl overdose". References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion. The article reviews the emergence and misuse of fentanyl and NPFs, their clinical pharmacology, and the clinical management and prevention of fentanyl-related overdoses. Fentanyl and NPFs may be contributing to the recent rise in overdose deaths in the United States. There is an urgent need to educate clinicians, researchers, and patients about this public health threat. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017

PubMed Central

Seth, Puja; Gladden, R. Matthew; Mattson, Christine L.; Baldwin, Grant T.; Kite-Powell, Aaron; Coletta, Michael A.

2018-01-01

Introduction From 2015 to 2016, opioid overdose deaths increased 27.7%, indicating a worsening of the opioid overdose epidemic and highlighting the importance of rapid data collection, analysis, and dissemination. Methods Emergency department (ED) syndromic and hospital billing data on opioid-involved overdoses during July 2016–September 2017 were examined. Temporal trends in opioid overdoses from 52 jurisdictions in 45 states were analyzed at the regional level and by demographic characteristics. To assess trends based on urban development, data from 16 states were analyzed by state and urbanization level. Results From July 2016 through September 2017, a total of 142,557 ED visits (15.7 per 10,000 visits) from 52 jurisdictions in 45 states were suspected opioid-involved overdoses. This rate increased on average by 5.6% per quarter. Rates increased across demographic groups and all five U.S. regions, with largest increases in the Southwest, Midwest, and West (approximately 7%–11% per quarter). In 16 states, 119,198 ED visits (26.7 per 10,000 visits) were suspected opioid-involved overdoses. Ten states (Delaware, Illinois, Indiana, Maine, Missouri, Nevada, North Carolina, Ohio, Pennsylvania, and Wisconsin) experienced significant quarterly rate increases from third quarter 2016 to third quarter 2017, and in one state (Kentucky), rates decreased significantly. The highest rate increases occurred in large central metropolitan areas. Conclusions and Implications for Public Health Practice With continued increases in opioid overdoses, availability of timely data are important to inform actions taken by EDs and public health practitioners. Increases in opioid overdoses varied by region and urbanization level, indicating a need for localized responses. Educating ED physicians and staff members about appropriate services for immediate care and treatment and implementing a post-overdose protocol that includes naloxone provision and linking persons into treatment could assist EDs with preventing overdose. PMID:29518069

Drug-related death following release from prison: a brief review of the literature with recommendations for practice.

PubMed

Leach, D; Oliver, P

2011-12-01

Mortality from drug-related death is a significant contributor to the loss of life of young people in the UK. Despite attention, the high death rate from this cause continues to persist. One of the most frequently cited factors involved in drug-related death (DRD) is release from prison. This review aims to examine the published literature with a view to quantifying the risk associated with recent prison release and identifying risk factors and prevention strategies. Most deaths following release from prison are caused by overdose, usually from opioid use. The risk of death is greatest within the first week of release but, when compared with the general population, continues to be elevated for several weeks. Relative risk estimates suggest that those released from prison are up to 40 times more likely to die than similar individuals from the general population. Other than gender and an association with poor mental health, there is little in the way of robust risk factors for post-release death that could be identified from the literature. In-prison pharmacological maintenance treatment with methadone and buprenorphine has been shown to reduce the rate of heroin use, in the period immediately following release, in a small number of randomised controlled trials. It is widely recognised that continuity of care, of any form, is critical in avoiding DRDs. For problem drug users, packages of education, including information on the associated risks, treatments, and recognition of DRD after release from prison, are seen as a basic minimum requirement of the prison services. However, special protocols may be required for those drug-using prisoners who have a possibility of being released at short notice.

Phencyclidine overdose

MedlinePlus

... time between taking the drug and receiving treatment Recovery from the psychotic state may take several weeks. The person should be in a quiet, darkened room. Long-term effects may include kidney failure and seizures. Repeated PCP use may cause long- ...

Opioid Overdose Prevention: Safety Advice for Patients & Family Members

MedlinePlus

... OPIOIDS O pioids include illicit drugs such as heroin and prescription medications used to treat pain such ... prescription opioid or an illicit drug such as heroin. Also at risk is the person who takes ...

Changing epidemiology of intentional antidepressant drug overdose in Victoria, Australia.

PubMed

Wong, Anselm; Taylor, David McD; Ashby, Karen; Robinson, Jeff

2010-08-01

To determine the epidemiology of intentional antidepressant drug overdose (OD), over an extended time period, in Victoria, Australia. Retrospective epidemiological study of all cases reported to the Victorian Emergency Minimum Dataset (VEMD) January 1998 to December 2007 and calls to the Victorian Poisons Information Centre (VPIC) June 2005 to September 2008. 5467 VEMD cases were analysed. 3169 (57.9%) cases involved selective serotonin reuptake inhibitors (SSRIs) and 1149 (21%) involved tricyclic antidepressants (TCAs). Sertraline (1252, 22.9% cases) was the most common drug. During 2001, the peak year of OD, there were 8.8 OD/100 000 population in the SSRI group and 3.8 OD/100 000 population in the TCA group. Trends over the study period showed increasing SSRI and 'other' newer antidepressant prescription rates and decreases for TCA and monoamine oxidase inhibitors (MAOI). However, the risks of OD in all drug classes were similar and OD/100 000 prescriptions trended downwards for all drug classes over time. 1833 VPIC calls were analysed. Calls relating to SSRIs were the most common yet SSRI OD was associated with significantly fewer symptoms (p < 0.001) and fewer patients with Poisoning Severity Score classifications of moderate or severe (p < 0.01). Antidepressant OD patterns are changing. Antidepressant OD incidence is following prescribing trends. The risk of OD is similar for all drug classes. Absolute numbers of OD and OD/100 000 prescriptions are decreasing for all drug classes.

Causes of death and expected years of life lost among treated opioid-dependent individuals in the United States and Taiwan

PubMed Central

Chang, Kun-Chia; Wang, Jung-Der; Saxon, Andrew; Matthews, Abigail G.; Woody, George; Hser, Yih-Ing

2017-01-01

Aims This study compared the cause-specific standardized mortality ratios (SMRs) and expected years of life lost (EYLL) among opioid-dependent individuals in the United States and Taiwan. Methods Survival data came from two cohorts followed until 2014: The U.S. data were based on a randomized trial of 1,267 opioid-dependent participants enrolled between 2006 and 2009; the Taiwan data were from a study of 983 individuals that began in 2006, when opioid agonist treatment (OAT) was implemented in Taiwan. SMRs were calculated for each national cohort and compared. Kaplan-Meier estimation was performed on the survival data, then lifespans were extrapolated to 70 years (840 months) to estimate life expectancy using a semi-parametric method. EYLLs for both cohorts were estimated by subtracting their life expectancies from the age- and gender-matched referents within the general population of their respective country. Results Compared with age- and gender- matched referents, the SMRs were 3.2 for the U.S. sample and 7.8 for the Taiwan sample; the EYLLs were 7.7 and 16.4 years, respectively. Half of decedents died of unnatural causes in both cohorts; overdose deaths predominated in the U.S. and suicide in Taiwan. Conclusions Our study identified differences by country in EYLL and causes of deaths. These findings suggest that intervention strategies to reduce mortality risk by overdose (particularly in the U.S.) and suicide (particularly in Taiwan) are urgently needed in these countries. PMID:28160734

Temporal correlation between opiate seizures in East/Southeast Asia and B.C. heroin deaths: a transoceanic model of heroin death risk.

PubMed

McLean, Mark E

2003-01-01

Because heroin supply changes cannot be measured directly, their impact on populations is poorly understood. British Columbia has experienced an injection drug use epidemic since the 1980s that resulted in 2,590 illicit drug deaths from 1990-1999. Since previous work indicates heroin seizures can correlate with supply and B.C. receives heroin only from Southeast Asia, this study examined B.C. heroin deaths against opiate seizures in East/Southeast Asia. Opiate seizures in East/Southeast Asia and data from two B.C. mortality datasets containing heroin deaths were examined. The Pearson correlation coefficient for seizures against each mortality dataset was determined. Opiate seizures, all illicit drug deaths and all opiate deaths concurrently increased twice and decreased twice from 1989-1999, and all reached new peak values in 1993. Three B.C. sub-regions exhibited illicit drug deaths rate trends concurrent with the three principal datasets studied. The Pearson correlation coefficient for opiate-induced deaths against opiate seizures from 1980-1999 was R=0.915 (p<0.0001), and for illicit drug deaths against opiate seizures from 1987-1999 was R=0.896 (p<0.0001). From 1980-1999, opiate seizures in East/Southeast Asia were very strongly correlated with B.C. opiate and illicit drug deaths. The number of B.C. heroin-related deaths may be strongly linked to heroin supply. Enforcement services are not effective in preventing harm caused by heroin in B.C.; therefore, Canada should examine other methods to prevent harm. The case for harm reduction is strengthened by the ineffectiveness of enforcement and the unlikelihood of imminent eradication of heroin production in Southeast Asia.

Development of an opioid-related Overdose Risk Behavior Scale (ORBS).

PubMed

Pouget, Enrique R; Bennett, Alex S; Elliott, Luther; Wolfson-Stofko, Brett; Almeñana, Ramona; Britton, Peter C; Rosenblum, Andrew

2017-01-01

Drug overdose has emerged as the leading cause of injury-related death in the United States, driven by prescription opioid (PO) misuse, polysubstance use, and use of heroin. To better understand opioid-related overdose risks that may change over time and across populations, there is a need for a more comprehensive assessment of related risk behaviors. Drawing on existing research, formative interviews, and discussions with community and scientific advisors an opioid-related Overdose Risk Behavior Scale (ORBS) was developed. Military veterans reporting any use of heroin or POs in the past month were enrolled using venue-based and chain referral recruitment. The final scale consisted of 25 items grouped into 5 subscales eliciting the number of days in the past 30 during which the participant engaged in each behavior. Internal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectivelyInternal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectively. Data for 220 veterans were analyzed. The 5 subscales-(A) Adherence to Opioid Dosage and Therapeutic Purposes; (B) Alternative Methods of Opioid Administration; (C) Solitary Opioid Use; (D) Use of Nonprescribed Overdose-associated Drugs; and (E) Concurrent Use of POs, Other Psychoactive Drugs and Alcohol-generally showed good internal reliability (alpha range = 0.61 to 0.88), test-retest reliability (ICC range = 0.81 to 0.90), and criterion validity (r range = 0.22 to 0.66). The subscales were internally consistent with each other (alpha = 0.84). The scale mean had an ICC value of 0.99, and correlations with validators ranged from 0.44 to 0.56. These results constitute preliminary evidence for the reliability and validity of the new scale. If further validated, it could help improve overdose prevention and response research and could help improve the precision of overdose education and prevention efforts.

Illegal drug-related deaths in East Germany between 1995 and 2004.

PubMed

Zwingenberger, Sabrina; Pietsch, Jörg; Hommola, Annett; Dressler, Jan

2010-06-15

The retrospective analysis determines changes between the deaths caused by illegal drugs in East Germany between 1995 and 2004 with specific regard to the number and manner of deaths, common intoxicants, concomitant drug use, the age and gender of the victims as well as the places of death. The data was collected by the institutes of forensic medicine in the German federal states of Saxony, Thuringia, Brandenburg, Mecklenburg West-Pomerania, Saxony-Anhalt and the State Offices of Criminal Investigation of these federal states. A comparison of these two different sources of data is also made. 510 drug-related deaths occurred in East Germany between 1995 and 2004. This was equivalent to a death rate of 0.4 per 100,000 inhabitants and represented 3% of all drug-related deaths throughout Germany. The average age of the victims was 24 years and male accounted for 85% of all the fatalities. Opiates, especially heroin, caused the majority of deaths (55%). Comparison of the two sources revealed that approximately half of the drug-related deaths were accounted for by national statistics. The analysis reveals an increase of drug-related deaths in East Germany after reunification but no relevant difference between the five East German states. (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Butyrfentanyl overdose resulting in diffuse alveolar hemorrhage.

PubMed

Cole, Jon B; Dunbar, John F; McIntire, Sarah A; Regelmann, Warren E; Slusher, Tina M

2015-03-01

Butyrfentanyl is a potent short-acting opioid and a fentanyl analog with uncertain clinical effects. A review of the literature reveals no human case reports of butyrfentanyl overdose. As the use of analog and synthetic drugs continues to increase, clinicians are often faced with tremendous uncertainty when they encounter patients exposed to these synthetic drugs. We describe, to our knowledge, the first case of a butyrfentanyl overdose that resulted in clinically significant hemoptysis, acute lung injury, hypoxic respiratory failure, and diffuse alveolar hemorrhage. Complicating this case was a false-positive urine drug screen for fentanyl. Clinicians who encounter fentanyl exposures should be aware they may in fact be dealing with butyrfentanyl. As little is known of butyrfentanyl and our patient suffered a significant pulmonary hemorrhage, those who encounter butyrfentanyl exposures should monitor for hemorrhagic complications. Copyright © 2015 by the American Academy of Pediatrics.

Opioid Overdose Outbreak - West Virginia, August 2016.

PubMed

Massey, Joel; Kilkenny, Michael; Batdorf, Samantha; Sanders, Sarah K; Ellison, Debra; Halpin, John; Gladden, R Matthew; Bixler, Danae; Haddy, Loretta; Gupta, Rahul

2017-09-22

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil, † which had been used by patients who overdosed in Huntington. Results of these two investigations highlight the importance of collaboration between public health and public safety agencies to provide in-depth surveillance data from opioid overdose outbreaks that involve high-potency fentanyl analogs. These data facilitated a public health response through increased awareness of powerful opioid substances requiring multiple naloxone doses for reversal, and improved patient linkage to recovery support services and a harm reduction program from the ED after opioid overdose.

Acute fatal posthypoxic leukoencephalopathy following benzodiazepine overdose: a case report and review of the literature.

PubMed

Aljarallah, Salman; Al-Hussain, Fawaz

2015-04-30

Among the rare neurological complications of substances of abuse is the selective cerebral white matter injury (leukoencephalopathy). Of which, the syndrome of delayed post hypoxic encephalopathy (DPHL) that follows an acute drug overdose, in addition to "chasing the dragon" toxicity which results from chronic heroin vapor inhalation remain the most commonly described syndromes of toxic leukoencephalopathy. These syndromes are reported in association with opioid use. There are very few cases in the literature that described leukoencephalopathy following benzodiazepines, especially with an acute and progressive course. In this paper, we present a patient who developed an acute severe fatal leukoencephalopathy following hypoxic coma and systemic shock induced by benzodiazepine overdose. A 19-year-old male was found comatose at home and brought to hospital in a deep coma, shock, hypoxia, and acidosis. Brain magnetic resonant imaging (MRI) revealed a strikingly selective white matter injury early in the course of the disease. The patient remained in a comatose state with no signs of neurologic recovery until he died few weeks later following an increase in the brain edema and herniation. Toxic leukoencephalopathy can occur acutely following an overdose of benzodiazepine and respiratory failure. This is unlike the usual cases of toxic leukoencephalopathy where there is a period of lucidity between the overdose and the development of white matter disease. Unfortunately, this syndrome remains of an unclear pathophysiology and with no successful treatment.

Causes of death and expected years of life lost among treated opioid-dependent individuals in the United States and Taiwan.

PubMed

Chang, Kun-Chia; Wang, Jung-Der; Saxon, Andrew; Matthews, Abigail G; Woody, George; Hser, Yih-Ing

2017-05-01

This study compared the cause-specific standardized mortality ratios (SMRs) and expected years of life lost (EYLL) among opioid-dependent individuals in the United States and Taiwan. Survival data came from two cohorts followed until 2014: The U.S. data were based on a randomized trial of 1267 opioid-dependent participants enrolled between 2006 and 2009; the Taiwan data were from a study of 983 individuals that began in 2006, when opioid agonist treatment (OAT) was implemented in Taiwan. SMRs were calculated for each national cohort and compared. Kaplan-Meier estimation was performed on the survival data, then lifespans were extrapolated to 70 years (840 months) to estimate life expectancy using a semi-parametric method. EYLLs for both cohorts were estimated by subtracting their life expectancies from the age- and gender-matched referents within the general population of their respective country. Compared with age- and gender-matched referents, the SMRs were 3.2 for the U.S. sample and 7.8 for the Taiwan sample; the EYLLs were 7.7 and 16.4 years, respectively. Half of decedents died of unnatural causes in both cohorts; overdose deaths predominated in the U.S. and suicide in Taiwan. Our study identified differences by country in EYLL and causes of deaths. These findings suggest that intervention strategies to reduce mortality risk by overdose (particularly in the U.S.) and suicide (particularly in Taiwan) are urgently needed in these countries. Copyright © 2016 Elsevier B.V. All rights reserved.

State Legal Restrictions and Prescription-Opioid Use among Disabled Adults

PubMed Central

Meara, Ellen; Horwitz, Jill R.; Powell, Wilson; McClelland, Lynn; Zhou, Weiping; O’Malley, A. James; Morden, Nancy E.

2016-01-01

BACKGROUND In response to rising rates of opioid abuse and overdose, U.S. states enacted laws to restrict the prescribing and dispensing of controlled substances. The effect of these laws on opioid use is unclear. METHODS We tested associations between prescription-opioid receipt and state controlled-substances laws. Using Medicare administrative data for fee-for-service disabled beneficiaries 21 to 64 years of age who were alive throughout the calendar year (8.7 million person-years from 2006 through 2012) and an original data set of laws (e.g., prescription-drug monitoring programs), we examined the annual prevalence of beneficiaries with four or more opioid prescribers, prescriptions yielding a daily morphine-equivalent dose (MED) of more than 120 mg, and treatment for nonfatal prescription-opioid overdose. We estimated how opioid outcomes varied according to eight types of laws. RESULTS From 2006 through 2012, states added 81 controlled-substance laws. Opioid receipt and potentially hazardous prescription patterns were common. In 2012 alone, 47% of beneficiaries filled opioid prescriptions (25% in one to three calendar quarters and 22% in every calendar quarter); 8% had four or more opioid prescribers; 5% had prescriptions yielding a daily MED of more than 120 mg in any calendar quarter; and 0.3% were treated for a nonfatal prescription-opioid overdose. We observed no significant associations between opioid outcomes and specific types of laws or the number of types enacted. For example, the percentage of beneficiaries with a prescription yielding a daily MED of more than 120 mg did not decline after adoption of a prescription-drug monitoring program (0.27 percentage points; 95% confidence interval, −0.05 to 0.59). CONCLUSIONS Adoption of controlled-substance laws was not associated with reductions in potentially hazardous use of opioids or overdose among disabled Medicare beneficiaries, a population particularly at risk. PMID:27332619

Immunopharmacotherapeutic Manifolds and Modulation of Cocaine Overdose

PubMed Central

Treweek, Jennifer B.; Roberts, Amanda J.; Janda, Kim D.

2011-01-01

Cocaine achieves its psychostimulant, reinforcing properties through selectively blocking dopamine transporters, and this neurobiological mechanism impedes the use of classical receptor-antagonist pharmacotherapies to outcompete cocaine at CNS sites. Passive immunization with monoclonal antibodies (mAb) specific for cocaine circumvents this problem as drug is sequestered in the periphery prior to entry into the brain. To optimize an immunopharmacotherapeutic strategy for reversing severe cocaine toxicity, the therapeutic properties of mAb GNC92H2 IgG were compared to those of its engineered formats in a mouse overdose model. Whereas the extended half-life of an IgG justifies its application to the prophylactic treatment of addiction, the rapid, thorough biodistribution of mAb-based fragments, including F(ab')2, Fab and scFv, may correlate to accelerated scavenging of cocaine and reversal of toxicity. To test this hypothesis, mice were administered the anti-cocaine IgG (180 mg/kg, i.v.) or GNC92H2-based agent after receiving an LD50 cocaine dose (93 mg/kg, i.p.), and the timeline of overdose symptoms was recorded. All formats lowered the rate of lethality despite the >100-fold molar excess of drug to antibody binding capacity. However, only F(ab')2-92H2 and Fab-92H2 significantly attenuated the progression of premorbid behaviors, and Fab-92H2 prevented seizure generation in a percentage of mice. The calculation of serum half-life of each format demonstrated that the pharmacokinetic profile of Fab-92H2 (elimination half-life, t1/2 ∼ 100 minutes) best approximated that of cocaine. These results not only confirm the importance of highly specific and tight drug binding by the mAb, but also highlight the benefit of aligning the pharmacokinetic and pharmacodynamic properties of the immunopharmacotherapeutic with the targeted drug. PMID:21356233

The Half RR Rule: A Poor Rule of Thumb and Not a Risk Assessment Tool for QT Interval Prolongation.

PubMed

Berling, Ingrid; Isbister, Geoffrey K

2015-10-01

Measuring the QT interval on an electrocardiogram (ECG) is integral to risk assessment of Torsade de Pointes (TdP). This study aimed to investigate the accuracy of the 1/2 RR rule as a risk assessment tool for drug-induced TdP, comparing it to the QT nomogram, Bazett's corrected QT (QTcB), and Fridericia's corrected QT (QTcF). The authors calculated sensitivity and specificity of the 1/2 RR rule using a published data set of 129 cases of drug-induced TdP and 316 controls (noncardiotoxic overdoses), compared to the QT nomogram, QTcB > 500 msec and QTcF > 500 msec. To further determine the value of the 1/2 RR rule, its observed positive, and negative agreement were calculated when compared to the QT nomogram for determining an abnormal QT in eight samples of different drugs in overdose. The sensitivity and specificity of the 1/2 RR rule were 88% (95% confidence interval [CI] = 80% to 93%) and 53% (95% CI = 47% to 58%), respectively, compared to the QT nomogram (sensitivity = 97%, 95% CI = 92% to 99%; specificity = 99%, 95% CI = 97% to 100%). It was also less sensitive than QTcB > 500 msec and had a lower specificity than QTcB > 500 msec and QTcF > 500 msec. In drug overdose patients, the 1/2 RR rule had poor observed agreement averaging 41%, which was mainly due to poor positive agreement, except for amisulpride where there was good agreement. The 1/2 RR rule was not as sensitive as the QT nomogram or QTcB > 500 msec for drug-induced TdP. It had poor positive agreement in almost all overdose patients, resulting in over half of patients receiving unnecessary cardiac monitoring and repeat ECGs. © 2015 by the Society for Academic Emergency Medicine.

Action, Not Rhetoric, Needed to Reverse the Opioid Overdose Epidemic.

PubMed

Davis, Corey; Green, Traci; Beletsky, Leo

2017-03-01

Despite shifts in rhetoric and some positive movement, Americans with the disease of addiction are still often stigmatized, criminalized, and denied access to evidencebased care. Dramatically reducing the number of lives unnecessarily lost to overdose requires an evidence-based, equity-focused, well-funded, and coordinated response. We present in this brief article evidence-based and promising practices for improving and refocusing the response to this simmering public health crisis. Topics covered include improving clinical decision-making, improving access to non-judgmental evidence-based treatment, investing in comprehensive public health approaches to problematic drug use, and changing the way law enforcement actors interact with people who use drugs.

Survival After Cardiac Arrest: ECMO Rescue Therapy After Amlodipine and Metoprolol Overdose.

PubMed

Maskell, Kevin F; Ferguson, Nikki Miller; Bain, Jesse; Wills, Brandon K

2017-04-01

Extracorporeal membrane oxygenation (ECMO) use in poisoned patients is increasing, but is rare post cardiac arrest. We report a case of ECMO use with complete recovery in a patient who arrested twice after a cardiotoxicant overdose. A 17-year-old male presented after an unknown overdose. He rapidly became hypotensive and bradycardic and received aggressive supportive care without improvement. He was transferred to our institution and suffered a cardiac arrest shortly after arrival. Six minutes of advanced cardiac life support resulted in return of spontaneous circulation. High-dose insulin, lipid emulsion, and ECMO were initiated. While awaiting ECMO deployment, he again became pulseless. Compressions resumed, and after 30 min, ROSC was achieved, and he was cannulated for veno-arterial ECMO. Within 48 h, he was decannulated, and then weaned off epinephrine 2 days later. Upon extubation, he was neurologically intact. Amlodipine and metoprolol were later confirmed in serum. Adolescent poisoned patients represent an ideal population for ECMO due to lack of comorbidities. As experience with ECMO in overdose increases, additional research is needed to determine appropriate indications and timing for its use. ECMO is an option for patients poisoned with a cardiotoxicant drug, even following witnessed cardiac arrest.

Safety becomes danger: dilemmas of drug-use in public space.

PubMed

Dovey, K; Fitzgerald, J; Choi, Y

2001-12-01

This paper provides a socio-spatial analysis of injecting drug-use in public space. It focuses on one urban district in Melbourne, Australia, which has become strongly identified with heroin sale and use in public space. Selling activities are camouflaged within a diverse street life while injecting sites are dispersed through a broad diversity of laneways, car parks and toilets. These injecting zones occupy liminal places which slide between categories of private and public, and which mediate complex and paradoxical relations between safety and danger. Those who inject in public space are caught in a dilemma--needing both privacy and exposure in the event of an overdose, safety from police becomes danger from an overdose. This empirical work, based on interview and spatial analysis, is presented as a basis for theorizing the socio-spatial construction of heroin use and for assessing the prospects for safe injecting.

The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013.

PubMed

Florence, Curtis S; Zhou, Chao; Luo, Feijun; Xu, Likang

2016-10-01

It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information to evaluate the cost effectiveness of their choices. To estimate the economic burden of prescription opioid overdose, abuse, and dependence from a societal perspective. Incidence of fatal prescription opioid overdose from the National Vital Statistics System, prevalence of abuse and dependence from the National Survey of Drug Use and Health. Fatal data are for the US population, nonfatal data are a nationally representative sample of the US civilian noninstitutionalized population ages 12 and older. Cost data are from various sources including health care claims data from the Truven Health MarketScan Research Databases, and cost of fatal cases from the WISQARS (Web-based Injury Statistics Query and Reporting System) cost module. Criminal justice costs were derived from the Justice Expenditure and Employment Extracts published by the Department of Justice. Estimates of lost productivity were based on a previously published study. Calendar year 2013. Monetized burden of fatal overdose and abuse and dependence of prescription opioids. The total economic burden is estimated to be $78.5 billion. Over one third of this amount is due to increased health care and substance abuse treatment costs ($28.9 billion). Approximately one quarter of the cost is borne by the public sector in health care, substance abuse treatment, and criminal justice costs. These estimates can assist decision makers in understanding the magnitude of adverse health outcomes associated with prescription opioid use such as overdose, abuse, and dependence.

Cognitive impairment in patients clinically recovered from central nervous system depressant drug overdose.

PubMed

Dassanayake, Tharaka L; Michie, Patricia T; Jones, Alison; Carter, Gregory; Mallard, Trevor; Whyte, Ian

2012-08-01

Central nervous system depressant drugs (CNS-Ds) are known to impair cognitive functions. Overdose of these drugs is common, and most of the hospital-treated patients are discharged within 24 to 48 hours. No previous studies have examined whether they have residual impairment at the time of discharge. Our aim was to evaluate whether patients with CNS-D overdose are impaired in cognitive domains important in daily activities at that time. We compared visuomotor skills (Trail-Making Test A and Choice Reaction Time), executive functions (viz attentional set-shifting: Trail-Making Test B; and planning: Stockings of Cambridge Task from the Cambridge Neuropsychological Test Automated Battery), working memory (Letter-Number Sequencing), and impulsivity and decision making (Cambridge Neuropsychological Test Automated Battery Information Sampling) in 107 patients with CNS-D overdose (benzodiazepines, opioids, or antipsychotics) with a control group of 68 with non-CNS-D overdose (acetaminophen, selective serotonin reuptake inhibitors, and serotonin noradrenaline reuptake inhibitors) on discharge from hospital. Outcome measures were adjusted for demographic and clinical covariates in multivariate regression models. Compared with the controls, patients in the CNS-D group were significantly impaired in all domains: they had prolonged Trail-Making completion times and reaction times, poorer working memory and planning and were more impulsive in decision making. Their Stockings of Cambridge Task performance was comparable to that of the control group for simple problems but worsened with increasing task complexity. The results show that patients with CNS-D overdose could be impaired in multiple cognitive domains underlying everyday functioning even at the time they are deemed medically fit to be discharged. Such impairments could adversely affect social and professional lives of this relatively young population during the immediate postdischarge period.

Predictors of participant engagement and naloxone utilization in a community-based naloxone distribution program.

PubMed

Rowe, Christopher; Santos, Glenn-Milo; Vittinghoff, Eric; Wheeler, Eliza; Davidson, Peter; Coffin, Philip O

2015-08-01

To describe characteristics of participants and overdose reversals associated with a community-based naloxone distribution program and identify predictors of obtaining naloxone refills and using naloxone for overdose reversal. Bivariate statistical tests were used to compare characteristics of participants who obtained refills and reported overdose reversals versus those who did not. We fitted multiple logistic regression models to identify predictors of refills and reversals; zero-inflated multiple Poisson regression models were used to identify predictors of number of refills and reversals. San Francisco, California, USA. Naloxone program participants registered and reversals reported from 2010 to 2013. Baseline characteristics of participants and reported characteristics of reversals. A total of 2500 participants were registered and 702 reversals were reported from 2010 to 2013. Participants who had witnessed an overdose [adjusted odds ratio (AOR)=2.02, 95% confidence interval (CI)= 1.53-2.66; AOR = 2.73, 95% CI = 1.73-4.30] or used heroin (AOR = 1.85, 95% CI =  1.44-2.37; AOR = 2.19, 95% CI = 1.54-3.13) or methamphetamine (AOR=1.71, 95% CI=1.37-2.15; AOR=1.61, 95% CI=1.18-2.19) had higher odds of obtaining a refill and reporting a reversal, respectively. African American (AOR = 0.63, 95% CI = 0.45-0.88) and Latino (AOR = 0.65, 95% CI =  0.43-1.00) participants had lower odds of obtaining a naloxone refill, whereas Latino participants who obtained at least one refill reported a higher number of refills [incidence rate ratio (IRR) = 1.33 (1.05-1.69)]. Community naloxone distribution programs are capable of reaching sizeable populations of high-risk individuals and facilitating large numbers of overdose reversals. Community members most likely to engage with a naloxone program and use naloxone to reverse an overdose are active drug users. © 2015 Society for the Study of Addiction.

Management of opioid addiction with buprenorphine: French history and current management.

PubMed

Poloméni, Pierre; Schwan, Raymund

2014-01-01

The way in which opioid addiction is managed in France is unique, as it is based on the prescription of buprenorphine by general practitioners and is dispensed by retail pharmacies. This policy has had a direct, positive impact on the number of deaths caused by heroin overdose, which was reduced by four-fifths between 1994 and 2002. In addition, certain associated comorbidities, such as infection with the human immunodeficiency virus, have also been reduced; the incidence of acquired immune deficiency syndrome in intravenous drug users fell from 25% in the mid-1990s to 6% in 2010. Since the implementation of this French model of opioid management, major scientific progress has been made, leading to a better understanding of the pathophysiologic mechanisms of addiction and of the management modalities required for its treatment. However, despite notable advances in scientific knowledge and in the implementation of devices, opioid addiction remains a major public health care issue in France, with 275,000-360,000 "problem drug users" being reported in 2011. The situation is still particularly worrying due to psychoactive substance use and misuse of opioid substitution treatments. Since 2003, there has been a persistent increase in the number of deaths and comorbidities related to opioid addiction, principally hepatitis C virus infection, which affects up to 40% of intravenous drug users. In France, the direct involvement of general practitioners in the management of opioid addiction is indisputable. Nevertheless, management could be optimized through better understanding of the pathophysiologic mechanisms of the disease, better knowledge of the pharmacology of opioid substitution treatments, and clear definition of short-, medium- and long-term treatment objectives. Data related to the management of opioid addiction by general practitioners in France have been published in 2005. Since then, the context has changed, other drugs were launched on the market such as generics of buprenorphine, methadone capsule, and Suboxone. Thus, an update seems necessary. This paper provides a description of opioid addiction management objectives and treatment modalities for general practitioners, based on currently available knowledge.

Out-of-hospital mortality among patients receiving methadone for noncancer pain.

PubMed

Ray, Wayne A; Chung, Cecilia P; Murray, Katherine T; Cooper, William O; Hall, Kathi; Stein, C Michael

2015-03-01

Growing methadone use in pain management has raised concerns regarding its safety relative to other long-acting opioids. Methadone hydrochloride may increase the risk for lethal respiratory depression related to accidental overdose and life-threatening ventricular arrhythmias. To compare the risk of out-of-hospital death in patients receiving methadone for noncancer pain with that in comparable patients receiving sustained-release (SR) morphine sulfate. A retrospective cohort study was conducted using Tennessee Medicaid records from 1997 through 2009. The cohort included patients receiving morphine SR or methadone who were aged 30 to 74 years, did not have cancer or another life-threatening illness, and were not in a hospital or nursing home. At cohort entry, 32 742 and 6014 patients had filled a prescription for morphine SR or methadone, respectively. The patients' median age was 48 years, 57.9% were female, and comparable proportions had received cardiovascular, psychotropic, and other musculoskeletal medications. Nearly 90% of the patients received the opioid for back pain or other musculoskeletal pain. The median doses prescribed for morphine SR and methadone were 90 mg/d and 40 mg/d, respectively. The primary study end point was out-of-hospital mortality, given that opioid-related deaths typically occur outside the hospital. There were 477 deaths during 28 699 person-years of follow-up (ie, 166 deaths per 10 000 person-years). After control for study covariates, patients receiving methadone had a 46% increased risk of death during the follow-up period, with an adjusted hazard ratio (HR) of 1.46 (95% CI, 1.17-1.83; P < .001), resulting in 72 (95% CI, 27-130) excess deaths per 10 000 person-years of follow-up. Methadone doses of 20 mg/d or less, the lowest dose quartile, were associated with an increased risk of death (HR, 1.59; 95% CI, 1.01-2.51, P = .046) relative to a comparable dose of morphine SR (<60 mg/d). The increased risk of death observed for patients receiving methadone in this retrospective cohort study, even for low doses, supports recommendations that it should not be a drug of first choice for noncancer pain.

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

PubMed

Brennan, Penny L; Del Re, Aaron C; Henderson, Patricia T; Trafton, Jodie A

2016-12-01

This study provides an example of how healthcare system-wide progress in implementation of opioid-therapy guideline recommendations can be longitudinally assessed and then related to subsequent opioid-prescribed patient health and safety outcomes. Using longitudinal linear mixed effects analyses, we determined that in the Department of Veterans Affairs (VA) healthcare system (n = 141 facilities), over the 4-year interval from 2010 to 2013, a key opioid therapy guideline recommendation, urine drug screening (UDS), increased from 29 to 42 %, with an average within-facility increase rate of 4.5 % per year. Higher levels of UDS implementation from 2010 to 2013 were associated with lower risk of suicide and drug overdose events among VA opioid-prescribed patients in 2013, even after adjusting for patients' 2012 demographic characteristics and medical and mental health comorbidities. Findings suggest that VA clinicians and healthcare policymakers have been responsive to the 2010 VA/Department of Defense (DOD) UDS treatment guideline recommendation, resulting in improved patient safety for VA opioid-prescribed patients.

Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000.

PubMed

Fischer, Benedikt; Murphy, Yoko; Rudzinski, Katherine; MacPherson, Donald

2016-01-01

By the year 2000, Canada faced high levels of illicit drug use and related harms. Simultaneously, a fundamental tension had raisen between continuing a mainly repression-based versus shifting to a more health-oriented drug policy approach. Despite a wealth of new data and numerous individual studies that have emerged since then, no comprehensive review of key indicators and developments of illicit drug use/harm epidemiology, interventions and law/policy exist; this paper seeks to fill this gap. We searched and reviewed journal publications, as well as key reports, government publications, surveys, etc. reporting on data and information since 2000. Relevant data were selected and extracted for review inclusion, and subsequently grouped and narratively summarized in major topical sub-theme categories. Cannabis use has remained the principal form of illicit drug use; prescription opioid misuse has arisen as a new and extensive phenomenon. While new drug-related blood-borne-virus transmissions declined, overdose deaths increased in recent years. Acceptance and proliferation of - mainly local/community-based - health measures (e.g., needle exchange, crack paraphernalia or naloxone distribution) aiming at high-risk drug users has evolved, though reach and access limitations have persisted; Vancouver's 'supervised injection site' has attracted continued attention yet remains un-replicated elsewhere in Canada. While opioid maintenance treatment utilization increased, access to treatment for key (e.g., infectious disease, psychiatric) co-morbidities among drug users remained limited. Law enforcement continued to principally focus on cannabis and specifically cannabis users. 'Drug treatment courts' were introduced but have shown limited effectiveness; several attempts cannabis control law reform have failed, except for the recent establishment of 'medical cannabis' access provisions. While recent federal governments introduced several law and policy measures reinforcing a repression approach to illicit drug use, lower-level jurisdictions (e.g., provincial/municipal levels) and non-governmental organizations increasingly promoted social- and health-oriented intervention frameworks and interventions, therefore creating an increasingly bifurcated - and inherently contradictory - drug policy landscape and reality in Canada. Copyright © 2015 Elsevier B.V. All rights reserved.

The Portapotty Experiment: Neoliberal approaches to the intertwined epidemics of opioid-related overdose and HIV/HCV, and why we need cultural anthropologists in the South Bronx.

PubMed

Wolfson-Stofko, Brett; Curtis, Ric; Fuentes, Faustino; Manchess, Ed; Del Rio-Cumba, Alexis; Bennett, Alex S

2016-12-01

The following report from the field focuses on the authors' collective efforts to operate an ad hoc safer injection facility (SIF) out of portapotties (portable toilets) in an area of the South Bronx that has consistently experienced some of the highest overdose morbidity and mortality rates in New York City over the past decade (New York City Department of Health and Mental Hygiene, 2011, 2015, 2016). Safer injection facilities (also known as supervised injection facilities, drug consumption rooms, etc.) operating outside the US provide a legal, hygienic, and supervised environment for individuals to use drugs in order to minimize the likelihood of fatal overdose and the spread of blood-borne infections while reducing public injection. In the US, the operation of SIFs is federally prohibited by the federal "Crack House" statute though federal, state, and local elected officials can sanction their operation to various degrees (Beletsky, Davis, Anderson, & Burris, 2008). The activists, researchers, undergraduate students and peers from syringe exchange programs who came together to operate the portapotties discovered that they were, in many ways, emblematic of neoliberal solutions to disease prevention: primarily focused on auditing individual risk behaviors and virtually blind to the wider social context that shapes those lives. That social context - the culture of drug injection - was and is out in the open for all of us to see. Going forward, the cultural anthropologist's toolbox will be opened up and used by large groups of undergraduate students to better understand the culture of drug use and how it is changing.

Drug-poisoning Deaths Involving Opioid Analgesics: United States, 1999-2011.

PubMed

Chen, Li Hui; Hedegaard, Holly; Warner, Margaret

2014-09-01

Data from the National Vital Statistics System, Mortality File. The age-adjusted rate for opioid-analgesic poisoning deaths nearly quadrupled from 1.4 per 100,000 in 1999 to 5.4 per 100,000 in 2011. Although the opioid-analgesic poisoning death rates increased each year from 1999 through 2011, the rate of increase has slowed since 2006. Natural and semisynthetic opioid analgesics, such as hydrocodone, morphine, and oxycodone, were involved in 11,693 drug-poisoning deaths in 2011, up from 2,749 deaths in 1999. Benzodiazepines were involved in 31% of the opioid-analgesic poisoning deaths in 2011, up from 13% of the opioid-analgesic poisoning deaths in 1999. During the past decade, adults aged 55-64 and non-Hispanic white persons experienced the greatest increase in the rates of opioid-analgesic poisoning deaths. Poisoning is the leading cause of injury death in the United States (1). Drugs-both illicit and pharmaceutical-are the major cause of poisoning deaths, accounting for 90% of poisoning deaths in 2011. Misuse or abuse of prescription drugs, including opioid-analgesic pain relievers, is responsible for much of the recent increase in drug-poisoning deaths (2). This report highlights trends in drug-poisoning deaths involving opioid analgesics (referred to as opioid-analgesic poisoning deaths) and updates previous Data Briefs on this topic. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

[Responsibility due to medication errors in France: a study based on SHAM insurance data].

PubMed

Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P

2015-03-01

The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Increases in self-reported fentanyl use among a population entering drug treatment: The need for systematic surveillance of illicitly manufactured opioids.

PubMed

Cicero, Theodore J; Ellis, Matthew S; Kasper, Zachary A

2017-08-01

Recent reports indicate a sharp increase in fentanyl-related overdose deaths across the United States, much of which is likely related to the introduction of cheap, illicitly manufactured fentanyl derivatives. In this study, we sought to estimate the magnitude of illicit fentanyl use from 2012 to 2016 using a national opioid abuse surveillance system. The study program surveyed 10,900 individuals entering substance abuse treatment for opioid use disorder, with participants asked to endorse past month 'use to get high' of fentanyl drugs, stratified by identifiable (i.e., branded) fentanyl formulations or a 'type unknown' drug alleged to contain fentanyl. Total past-month fentanyl-use rose modestly from 2012 to 2016. While use of known fentanyl products remained relatively stable (mean=10.9%; P=0.25), endorsements of 'unknown' fentanyl products nearly doubled from 9% in 2013 to 15.1% by 2016 (P<0.001). Data show no discernable indication that this increase is diminishing or stabilizing. This first attempt to assess the prevalence of illicit fentanyl use shows that recent increases in fentanyl use seem to be due almost entirely to 'unknown' fentanyl presumed to be illicitly manufactured. Given that it is difficult to assess the extent to which fentanyl may have been substituted for another drug (i.e., oxycodone, alprazolam, etc.) or was used as a heroin admixture, our data likely represent an underestimation of the full magnitude of illicit fentanyl abuse. As such, this growing public health problem requires immediate attention and more systematic efforts to identify and track its abuse. Copyright © 2017. Published by Elsevier B.V.

Recovering from Opioid Overdose: Resources for Overdose Survivors & Family Members

MedlinePlus

... Opioid Overdose Prevention TOOLKIT: Recovering From Opioid Overdose – Resources for Overdose Survivors & Family Members TABLE OF CONTENTS ... From Opioid Overdose Recovering from Opioid Overdose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Resources for Overdose Survivors and Family Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Finding ...

A human recombinant monoclonal antibody to cocaine: Preparation, characterization and behavioral studies

PubMed Central

Eubanks, Lisa M.; Ellis, Beverly A.; Cai, Xiaoqing; Schlosburg, Joel E.; Janda, Kim D.

2014-01-01

Cocaine abuse remains prevalent worldwide and continues to be a major health concern; nonetheless, there is no effective therapy. Immunopharmacothery has emerged as a promising treatment strategy by which anti-cocaine antibodies bind to the drug blunting its effects. Previous passive immunization studies using our human monoclonal antibody, GNCgzk, resulted in protection against cocaine overdose and acute toxicity. To further realize the clinical potential of this antibody, a recombinant IgG form of the antibody has been produced in mammalian cells. This antibody displayed a high binding affinity for cocaine (low nanomolar) in line with the superior attributes of the GNCgzk antibody and reduced cocaine-induced ataxia in a cocaine overdose model. PMID:25205191

Accidental drug deaths in Fulton County, Georgia, 2002: characteristics, case management and certification issues.

PubMed

Graham, Jason K; Hanzlick, Randy

2008-09-01

Historically, the duty of the medical examiner in assigning cause and manner of death in drug-related death cases has been fraught with controversial challenges. The lack of standardization in certifying drug-related deaths may involve differences among practicing forensic pathologists in their approach to such cases. The central objectives of the present study include characterization of current drug death patterns and the variability among medical examiners with respect to autopsy performance and death certification practices in one county medical examiner's office. Death certificates, scene information/investigative reports, autopsy reports, and toxicological laboratory results for each of the 100 cases of drug-related death occurring in 2002 in Fulton County, Georgia were reviewed. Comparison of overall autopsy rates and autopsy rates in drug-related death cases for each medical examiner individually and for the group collectively was performed. In examining cocaine-related deaths (most common), statistical analysis was performed for comparison of drug concentrations (cocaine and benzoylecgonine) between deaths certified as cocaine toxicity (poisoning) versus cocaine-complicating disease or causing an adverse event such as cerebral hemorrhage. Causes of accidental drug deaths included cocaine 40%, mixed drug intoxication 37%, opioids 10%, ethanol 7%, and prescription medication (nonopioid) 5%. Overall total autopsy rates in 2002 for each of the 6 independent medical examiners ranged from 51% to 69% (mean 64%), whereas autopsy rates in drug-related death ranged from 55% to 91% (mean 81%). In review of the subset of 40 cocaine-related deaths, 25% were certified as cocaine toxicity (poisoning), with the remaining 75% certified as cocaine-complicating disease or causing and adverse event. Autopsy rates in cocaine-related deaths were as follows: cocaine toxicity 80%, cocaine-complicating disease 77.3%, and cocaine causing adverse event 62.5%. Thirty-eight percent of cocaine-related deaths were considered to be of "low suspicion" for drug involvement at the time the death was reported to the medical examiner with the remaining 62% being of "high suspicion". Autopsy rates were somewhat lower in the low suspicion group (67%) versus the high suspicion group (72%). Comparison of drug levels between cocaine-related death certification groups was performed. No statistically significant difference was shown in drug levels (cocaine, P > 0.3; benzoylecgonine, P > 0.2) between deaths certified as cocaine toxicity versus those certified as cocaine-complicating disease or causing adverse event. In Fulton County, accidental drug deaths in 2002 most often involved cocaine either alone or in combination with opiates and/or alcohol. Cocaine, opiates, or both were involved in greater than three-fourths (77%) of all drug-related deaths. The majority of all decedents were black (57%) and male (76%) with an average age of 42.2 years. Cocaine and ethanol were more frequently detected in black decedents, whereas opiates and polydrug abuse were more common in white decedents throughout the period studied. Preliminary investigation showed a high index of suspicion for the specific drug involved in virtually all opiate and alcohol cases, and in 62% of cocaine-related cases. Overall, the 100 accidental drug deaths in 2002 accounted for 7.5% of all deaths investigated and certified by the Fulton County Medical Examiner's Office. Our study provides further evidence to support the lack of correlation between serum drug levels and the mechanism of drug toxicity in cocaine-related deaths. No statistically significant differences were shown in parent cocaine or benzoylecgonine concentrations between those cases certified as toxicities or poisonings versus those cases certified as aggravating underlying disease or causing an adverse event. In addition, 62% of the cocaine-related death cases were considered initially to be of high suspicion for drug-related death, thus emphasizing the strong importance of scene information/investigative reports in evaluating drug-death cases and in formulating plans of action to handle each individual case. Among the drug-death cases handled by 6 staff medical examiners at the Fulton County Medical Examiner's Office, variation existed in autopsy performance and death certification practices. These issues are discussed in the context of the National Association of Medical Examiners' (NAME) Position Paper on Cocaine, NAME Forensic Autopsy Performance Standards, and other relevant literature. Most variations relate to completeness of the cause-of-death statement (whether or not comorbid conditions are included) rather than classification of manner of death within the office. However, specific wording in the cause of death may have significant ramifications regarding drug-related mortality statistics processed by the vital statistics system, with possible under-representation of drug-related deaths in single-cause mortality data.

Tobacco-, Alcohol-, and Drug-Attributable Deaths and Their Contribution to Mortality Disparities in a Cohort of Homeless Adults in Boston

PubMed Central

Chang, Yuchiao; Singer, Daniel E.; Porneala, Bianca C.; Gaeta, Jessie M.; O’Connell, James J.; Rigotti, Nancy A.

2015-01-01

Objectives. We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults. Methods. We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences. Results. Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults. Conclusions. In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality. PMID:25521869

Detection of Acetaminophen-Protein Adducts in Decedents with Suspected Opioid-Acetaminophen Combination Product Overdose.

PubMed

Thomas, Karen C; Wilkins, Diana G; Curry, Steven C; Grey, Todd C; Andrenyak, David M; McGill, Lawrence D; Rollins, Douglas E

2016-09-01

Acetaminophen overdose is a leading cause of drug-induced liver failure in the United States. Acetaminophen-protein adducts have been suggested as a biomarker of hepatotoxicity. The purpose of this study was to determine whether protein-derived acetaminophen-protein adducts are quantifiable in postmortem samples. Heart blood, femoral blood, and liver tissue were collected at autopsy from 22 decedents suspected of opioid-acetaminophen overdose. Samples were assayed for protein-derived acetaminophen-protein adducts, acetaminophen, and selected opioids found in combination products containing acetaminophen. Protein-derived APAP-CYS was detected in 17 of 22 decedents and was measurable in blood that was not degraded or hemolyzed. Heart blood concentrations ranged from 11 ng/mL (0.1 μM) to 7817 ng/mL (28.9 μM). Protein-derived acetaminophen-protein adducts were detectable in liver tissue for 20 of 22 decedents. Liver histology was also performed for all decedents, and no evidence of centrilobular hepatic necrosis was observed. © 2016 American Academy of Forensic Sciences.

Postmortem Toxicology Findings of Acetyl Fentanyl, Fentanyl, and Morphine in Heroin Fatalities in Tampa, Florida

PubMed Central

Pearson, Julia; Poklis, Justin; Poklis, Alphonse; Wolf, Carl; Mainland, Mary; Hair, Laura; Devers, Kelly; Chrostowski, Leszek; Arbefeville, Elise; Merves, Michele

2017-01-01

In the last two years, an epidemic of 40 fatal heroin overdose cases has occurred in the Tampa area of Florida. Of these cases, 14 involved fentanyl and acetyl fentanyl. Victim demographics, case histories, toxicology findings, and causes and manners of death for all 40 deaths are presented. In 26 deaths in which acetyl fentanyl or fentanyl were not involved, free and total peripheral blood morphine concentrations were consistent with fatal heroin intoxications, averaging 0.16 mg/L and 0.35 mg/L, respectively. In the heroin cases with fentanyl present (n=7), the average free morphine concentration was 0.040 mg/L, the average total morphine concentration was 0.080 mg/L, and the average fentanyl concentration was 0.012 mg/L. In the cases with heroin, fentanyl, and acetyl fentanyl (n=3), the average free morphine concentration was 0.010 mg/L, the average total morphine concentration was 0.030 mg/L, the average fentanyl concentration was 0.018 mg/L, and the average acetyl fentanyl concentration was 0.008 mg/L. In the cases involving only acetyl fentanyl (without heroin or fentanyl, n=4), the average acetyl fentanyl concentration was 0.47 mg/L and the average acetyl norfentanyl concentration was 0.053 mg/L. The presented cases, with associated drug concentrations, case histories, demographics, and causes and manners of death may help provide assistance with the interpretation of the postmortem findings. Based on case circumstances, autopsy results, and toxicology results, it is evident that fentanyl and/or acetyl fentanyl, when present, contributed to the cause of death. PMID:29034049

Efficacy and safety of a modified-live cyprinid herpesvirus 3 vaccine in koi (Cyprinus carpio koi) for prevention of koi herpesvirus disease.

PubMed

Weber, E P Scott; Malm, Kirsten V; Yun, Susan C; Campbell, Lori A; Kass, Philip H; Marty, Gary D; Salonius, Kira; Dishon, Arnon

2014-10-01

To investigate safety and efficacy of a cyprinid herpesvirus type 3 (CyHV3) modified-live virus vaccine for the prevention of koi herpesvirus disease (KHVd). 420 healthy koi (Cyprinus carpio koi). Fish were vaccinated with a 1× dose or 10× overdose of CyHV3 modified-live virus vaccine or a placebo through bath exposure in tanks at 22°C. Horizontal transmission of vaccine virus was evaluated by commingling unvaccinated and vaccinated fish. Efficacy was evaluated by challenge exposure of vaccinated and naïve fish to a wild-type virus. Fish that died were submitted for quantitative PCR assay for CyHV3 and histologic evaluation. The CyHV3 vaccine was safe and efficacious, even at a 10× overdose. Vaccine-associated mortality rate was inversely associated with body weight, with a cumulative mortality rate of 9.4% (18/192) in fish weighing ≤ 87 g and no deaths in fish weighing > 87 g (0/48). Horizontal transfer of vaccine virus from vaccinates to naïve fish was negligible. For efficacy, the vaccine provided a significant reduction in mortality rate after challenge exposure to a wild-type virus, with a prevented fraction of 0.83 versus the placebo control fish. KHVd is highly contagious and commonly leads to deaths in 80% to 100% of exposed fish, representing a major threat to koi and common carp populations throughout the world. The CyHV3 modified-live virus vaccine had a favorable safety profile and was an effective vaccine for the control of KHVd in koi weighing > 87 g.

Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013.

PubMed

Jones, Christopher M; Lurie, Peter G; Compton, Wilson M

2016-04-01

Distribution of naloxone, traditionally through community-based naloxone programs, is a component of a comprehensive strategy to address the epidemic of prescription opioid and heroin overdose deaths in the United States. Recently, there has been increased focus on naloxone prescription in the outpatient setting, particularly through retail pharmacies, yet data on this practice are sparse. We found an 1170% increase in naloxone dispensing from US retail pharmacies between the fourth quarter of 2013 and the second quarter of 2015. These findings suggest that prescribing naloxone in the outpatient setting complements traditional community-based naloxone programs.

Calculating expected years of life lost for assessing local ethnic disparities in causes of premature death.

PubMed

Aragón, Tomás J; Lichtensztajn, Daphne Y; Katcher, Brian S; Reiter, Randy; Katz, Mitchell H

2008-04-10

A core function of local health departments is to conduct health assessments. The analysis of death certificates provides information on diseases, conditions, and injuries that are likely to cause death - an important outcome indicator of population health. The expected years of life lost (YLL) measure is a valid, stand-alone measure for identifying and ranking the underlying causes of premature death. The purpose of this study was to rank the leading causes of premature death among San Francisco residents, and to share detailed methods so that these analyses can be used in other local health jurisdictions. Using death registry data and population estimates for San Francisco deaths in 2003-2004, we calculated the number of deaths, YLL, and age-standardized YLL rates (ASYRs). The results were stratified by sex, ethnicity, and underlying cause of death. The YLL values were used to rank the leading causes of premature death for men and women, and by ethnicity. In the years 2003-2004, 6312 men died (73,627 years of life lost), and 5726 women died (51,194 years of life lost). The ASYR for men was 65% higher compared to the ASYR for women (8971.1 vs. 5438.6 per 100,000 persons per year). The leading causes of premature deaths are those with the largest average YLLs and are largely preventable. Among men, these were HIV/AIDS, suicide, drug overdose, homicide, and alcohol use disorder; and among women, these were lung cancer, breast cancer, hypertensive heart disease, colon cancer, and diabetes mellitus. A large health disparity exists between African Americans and other ethnic groups: African American age-adjusted overall and cause-specific YLL rates were higher, especially for homicide among men. Except for homicide among Latino men, Latinos and Asians have comparable or lower YLL rates among the leading causes of death compared to whites. Local death registry data can be used to measure, rank, and monitor the leading causes of premature death, and to measure and monitor ethnic health disparities.

Pattern of poisoning in the elderly: an experience from Tehran.

PubMed

Karbakhsh, Mojgan; Zandi, Negar Salehian

2008-03-01

Poisoning is considered a significant health problem in the elderly. This study aimed to portray the pattern of poisoning in the elderly population of Tehran. This cross-sectional study included all patients aged 60 years and older with acute poisoning who attended the emergency department of the Loghman-Hakim hospital over a six-month period (n=299). Episodes of poisoning were more common in men (70.9%) and the majority of incidents took place in the patient's own home (84.3%). Most episodes were accidental (53.2%) followed by attempted suicide (32.4%). Opioids and opiate products accounted for 54.02% of the non-pharmaceutical substances that were involved in episodes of poisoning. Overdose with opioids and opiate products, was higher in male patients than in female patients. The most frequently involved drug groups were benzodiazepines, antidepressants, and analgesics. The most common cause of accidental poisoning was overdose by drug abusers. The Poisoning Severity Score was minor in 25.4%, moderate in 52.2%, and severe in 17.1% of patients. Asymptomatic patients accounted for 5.4% of the total. Unfortunately, 11.7% of patients died. The main agents involved in the fatal cases were opioids and opiate products. The commonest method of accidental poisoning was overdose in opioid and opiate abusers. Attempted suicide was also very common comprising about one third of all cases. The high mortality observed in this study warrants attention to the risk factors and prognostic factors of poisoning in elderly.

Syndrome surveillance of fentanyl-laced heroin outbreaks: Utilization of EMS, Medical Examiner and Poison Center databases.

PubMed

Moore, P Quincy; Weber, Joseph; Cina, Steven; Aks, Steven

2017-11-01

Describe surveillance data from three existing surveillance systems during an unexpected fentanyl outbreak in a large metropolitan area. We performed a retrospective analysis of three data sets: Chicago Fire Department EMS, Cook County Medical Examiner, and Illinois Poison Center. Each included data from January 1, 2015 through December 31, 2015. EMS data included all EMS responses in Chicago, Illinois, for suspected opioid overdose in which naloxone was administered and EMS personnel documented other criteria indicative of opioid overdose. Medical Examiner data included all deaths in Cook County, Illinois, related to heroin, fentanyl or both. Illinois Poison Center data included all calls in Chicago, Illinois, related to fentanyl, heroin, and other prescription opioids. Descriptive statistics using Microsoft Excel® were used to analyze the data and create figures. We identified a spike in opioid-related EMS responses during an 11-day period from September 30-October 10, 2015. Medical Examiner data showed an increase in both fentanyl and mixed fentanyl/heroin related deaths during the months of September and October, 2015 (375% and 550% above the median, respectively.) Illinois Poison Center data showed no significant increase in heroin, fentanyl, or other opioid-related calls during September and October 2015. Our data suggests that EMS data is an effective real-time surveillance mechanism for changes in the rate of opioid overdoses. Medical Examiner's data was found to be valuable for confirmation of EMS surveillance data and identification of specific intoxicants. Poison Center data did not correlate with EMS or Medical Examiner data. Copyright © 2017 Elsevier Inc. All rights reserved.

Drug-related celebrity deaths: A cross-sectional study.

PubMed

Just, Johannes M; Bleckwenn, Markus; Schnakenberg, Rieke; Skatulla, Philipp; Weckbecker, Klaus

2016-12-09

Celebrities are at risk for premature mortality as well as drug-related death. Despite being a vulnerable patient group, celebrities influence people's health behaviours through biological, psychological and social processes. Therefore, celebrity endorsement of the topic could be one way to challenge the current "opioid endemic". Our aim was to better understand the factors surrounding drug-related celebrity deaths by investigating the incidence as well as substances used between 1970 and 2015 using a cross-sectional study design. We searched public databases for drug-related celebrity deaths between 1970 and 2015. They were categorized for sex, profession, age at death, year of death and substances involved. The main outcome measures are descriptive values including number of drug deaths per year and substances involved. Secondary outcome measures are analytical questions to examine whether and which factors influence age at death and year of death (e.g. type of substance use disorder). We identified 220 celebrities who died a drug-related death with a clear indication of involved substances between 1970 and 2015. The average age at death was 38.6 years; 75% were male. Most celebrities died between the age of 25 and 40. The number of drug-related deaths increased in the 21st century, with a significant increase in the use of prescription opioids. Deaths involving prescription opioids and heroin were associated with a significantly lower mean age at death compared to deaths where these substances were not involved. Compared to the 20th century, the total number of celebrities who died from a drug-related death in the 21st century increased, possibly due to an increased involvement of prescription opioids. Negative effects on individual health decisions of celebrity's followers could be the result.

Severe Hypertension and Bradycardia Secondary to Midodrine Overdose.

PubMed

Wong, L Y; Wong, A; Robertson, T; Burns, K; Roberts, M; Isbister, G K

2017-03-01

The objective of this case is to describe the pharmacokinetics and toxicity of midodrine in overdose. A 20 year old female ingested up to 350 mg midodrine while recovering in hospital from another overdose. She developed vomiting and severe hypertension (blood pressure [BP], 210/100 mmHg). Remarkable findings included a heart rate with a range of 43-60 beats/min, spontaneous respirations (20 breaths/min), and oxygen saturations of >95 % on FiO2 25 %, and a GS of 8. She was admitted to intensive care and had a normal non-contrast CT brain. She was treated with a glyceryl trinitrate patch (5 mg) and observed for 36 h with subsequent BP reduction to 124/81 mmHg and improved in conscious state. Midodrine and desglymidodrine concentrations were measured with liquid chromatography tandem mass spectrometry and were detected with 2-h post-ingestion at concentrations of 158.4 and 169.7 ng/mL, respectively. The parent drug concentrations rapidly decreased with an elimination of half-life of 1.6 h, and the metabolite initially increased and then decreased. The peak in blood pressure appeared to coincide with peak metabolite concentrations. Midodrine in overdose can potentially cause severe hypertension and reflex bradycardia but given its short half-life treatment with vasodilator agents and supportive care is sufficient.

Suicide due to cyclizine overdose.

PubMed

Arnestad, Marianne; Eldor, Kari Beate Boye; Stray-Pedersen, Arne; Bachs, Liliana; Karinen, Ritva

2014-03-01

Cyclizine is an antihistamine with sedative effect used to treat motion sickness. A few studies have reported on cyclizine abuse among teenagers, and cyclizine abuse has been reported among opioid dependants receiving methadone, with the combination having been reported to produce strong psychoactive effects. Few reports exist on the possible toxic effects of cyclizine, and it is regarded as a safe drug most often sold as a non-prescription/over-the-counter drug. Very few cases of fatalities resulting from cyclizine overdose can be found in the literature. We present a case where a 22-year-old female was found unconscious and intoxication with drugs and alcohol was suspected. Whole blood from the femoral vein, urine and stomach content were collected during autopsy and screened for drugs of abuse and medicinal drugs. GC-MS screening of the stomach contents revealed presence of cyclizine and meclozine. Cyclizine and meclozine concentrations in blood were determined using a UPLC-MS-MS method. Quantification of femoral blood revealed a high concentration of cyclizine (16 mg/L), a low concentration of meclozine (0.2 mg/L) and ethanol 0.16 g/dL. No other medicinal drugs or drugs of abuse were detected. We report on a case of suicide where cyclizine was found to be the principal drug and question the safety of this drug.

Mechanistic Biomarkers in Acetaminophen-induced Hepatotoxicity and Acute Liver Failure: From Preclinical Models to Patients

PubMed Central

McGill, Mitchell R.; Jaeschke, Hartmut

2015-01-01

SUMMARY Introduction Drug hepatotoxicity is a major clinical issue. Acetaminophen (APAP) overdose is especially common. Serum biomarkers used to follow patient progress reflect either liver injury or function, but focus on biomarkers that can provide insight into the basic mechanisms of hepatotoxicity is increasing and enabling us to translate mechanisms of toxicity from animal models to humans. Areas covered We review recent advances in mechanistic serum biomarker research in drug hepatotoxicity. Specifically, biomarkers for reactive drug intermdiates, mitochondrial dysfunction, nuclear DNA damage, mode of cell death and inflammation are discussed, as well as microRNAs. Emphasis is placed on APAP-induced liver injury. Expert Opinion Several serum biomarkers of reactive drug intermediates, mitochondrial damage, nuclear DNA damage, apoptosis and necrosis, and inflammation have been described. These studies have provided evidence that mitochondrial damage is critical in APAP hepatotoxicity in humans, while apoptosis has only a minor role, and inflammation is important for recovery and regeneration after APAP overdose. Additionally, mechanistic serum biomarkers have been shown to predict outcome as well as, or better than, some clinical scores. In the future, such biomarkers will help determine the need for liver transplantation and, with improved understanding of the human pathophysiology, identify novel therapeutic targets. PMID:24836926

The effects of rurality on substance use disorder diagnosis: A multiple-groups latent class analysis.

PubMed

Brooks, Billy; McBee, Matthew; Pack, Robert; Alamian, Arsham

2017-05-01

Rates of accidental overdose mortality from substance use disorder (SUD) have risen dramatically in the United States since 1990. Between 1999 and 2004 alone rates increased 62% nationwide, with rural overdose mortality increasing at a rate 3 times that seen in urban populations. Cultural differences between rural and urban populations (e.g., educational attainment, unemployment rates, social characteristics, etc.) affect the nature of SUD, leading to disparate risk of overdose across these communities. Multiple-groups latent class analysis with covariates was applied to data from the 2011 and 2012 National Survey on Drug Use and Health (n=12.140) to examine potential differences in latent classifications of SUD between rural and urban adult (aged 18years and older) populations. Nine drug categories were used to identify latent classes of SUD defined by probability of diagnosis within these categories. Once the class structures were established for rural and urban samples, posterior membership probabilities were entered into a multinomial regression analysis of socio-demographic predictors' association with the likelihood of SUD latent class membership. Latent class structures differed across the sub-groups, with the rural sample fitting a 3-class structure (Bootstrap Likelihood Ratio Test P value=0.03) and the urban fitting a 6-class model (Bootstrap Likelihood Ratio Test P value<0.0001). Overall the rural class structure exhibited less diversity in class structure and lower prevalence of SUD in multiple drug categories (e.g. cocaine, hallucinogens, and stimulants). This result supports the hypothesis that different underlying elements exist in the two populations that affect SUD patterns, and thus can inform the development of surveillance instruments, clinical services, and prevention programming tailored to specific communities. Copyright © 2017 Elsevier Ltd. All rights reserved.

A case of Fanconi syndrome due to a deferasirox overdose and a trial of plasmapheresis.

PubMed

Shah, L; Powell, J L; Zaritsky, J J

2017-10-01

Deferasirox has nephrotoxic effects in the context of chronic therapy. This case report illustrates proximal tubular dysfunction (Fanconi syndrome) due to an acute deferasirox overdose. In response, we trialled plasmapheresis to eliminate the drug. Deferasirox levels were obtained in the context of three rounds of plasmapheresis. Given the half-life model of decay, we concluded that plasmapheresis may not have been successful. The patient ultimately recovered normal tubular function after 2 months. This report is the first to describe acute deferasirox-induced nephrotoxicity, and the application of plasmapheresis that, ultimately, did not change the typical time to recovery. © 2017 John Wiley & Sons Ltd.

Pyrilamine-induced prolonged QT interval in adolescent with drug overdose.

PubMed

Paudel, Govinda; Syed, Muhammad; Kalantre, Sarika; Sharma, Jayendra

2011-10-01

The widespread availability of antihistamines in many over-the-counter preparations can lead to significant hazard to the public because of their possible link to potential ventricular arrhythmias secondary to prolongation of QT interval. The effect can be further compounded by the use of other commonly used medications such as macrolides, antifungal agents, antipsychotics, and other antihistamine-containing preparations. The effect of antihistamines on QT interval is not a class effect but is unique to certain medications. Pyrilamine, a first-generation antihistaminic agent, is considered safe as there are no reports regarding its cardiac toxicity available in literature. We report a case of an adolescent with prolonged QT interval after an overdose of pyrilamine.

One-year follow up after admission to an emergency department for drug overdose in Japan.

PubMed

Ando, Shuntaro; Matsumoto, Toshihiko; Kanata, Sho; Hojo, Aya; Yasugi, Daisuke; Eto, Nobuaki; Kawanishi, Chiaki; Asukai, Nozomu; Kasai, Kiyoto

2013-09-01

The aim of the study was to investigate the incidence of and risk factors for repetition of suicidal behavior within a year after admission for drug overdose in Japan. Patients admitted to the emergency department of a general public hospital in Tokyo for drug overdose of prescribed medicine and/or over-the-counter drugs between March 2008 and February 2009 were followed up after 1 year. Demographic characteristics, previous suicide attempts, and mental health state were examined by self-report questionnaire and interview at recovery from the initial attempt. Information about suicidal behavior during the follow-up period was obtained from the outpatient psychiatrists by postal questionnaire 1 year after discharge. Of 190 patients admitted to the emergency department, 132 patients answered the questionnaire and had the interview. Information about thefollow-up period for 66 patients was obtained. Of the 66 patients, 28 patients attempted suicide again and two patients committed suicide during the 1-year follow-up period. Psychiatric diagnosis of personality disorder and denial of suicidal intent at the time of recovery were associated with increased risk for another suicide attempt. Lethality levels of suicidal behaviors before and after admission were associated with each other. The rate of fatal and non-fatal suicide attempt within a year after admission for self-poisoning was substantial. Psychiatric diagnosis of personality disorder was a risk factor for repetition of suicide attempt. Clinicians should pay attention to the means of previous suicide attempts even though the patient denies suicidal intent at recovery. © 2013 The Authors. Psychiatry and Clinical Neurosciences © 2013 Japanese Society of Psychiatry and Neurology.

The Portapotty Experiment: Neoliberal approaches to the intertwined epidemics of opioid-related overdose and HIV/HCV, and why we need cultural anthropologists in the South Bronx

PubMed Central

Wolfson-Stofko, Brett; Curtis, Ric; Fuentes, Faustino; Manchess, Ed; Del Rio-Cumba, Alexis; Bennett, Alex S.

2016-01-01

The following report from the field focuses on the authors’ collective efforts to operate an ad hoc safer injection facility (SIF) out of portapotties (portable toilets) in an area of the South Bronx that has consistently experienced some of the highest overdose morbidity and mortality rates in New York City over the past decade (New York City Department of Health and Mental Hygiene, 2011, 2015, 2016). Safer injection facilities (also known as supervised injection facilities, drug consumption rooms, etc.) operating outside the US provide a legal, hygienic, and supervised environment for individuals to use drugs in order to minimize the likelihood of fatal overdose and the spread of blood-borne infections while reducing public injection. In the US, the operation of SIFs is federally prohibited by the federal “Crack House” statute though federal, state, and local elected officials can sanction their operation to various degrees (Beletsky, Davis, Anderson, & Burris, 2008). The activists, researchers, undergraduate students and peers from syringe exchange programs who came together to operate the portapotties discovered that they were, in many ways, emblematic of neoliberal solutions to disease prevention: primarily focused on auditing individual risk behaviors and virtually blind to the wider social context that shapes those lives. That social context — the culture of drug injection — was and is out in the open for all of us to see. Going forward, the cultural anthropologist’s toolbox will be opened up and used by large groups of undergraduate students to better understand the culture of drug use and how it is changing. PMID:27917016

Activity spaces among injection drug users in San Francisco.

PubMed

Martinez, Alexis N; Lorvick, Jennifer; Kral, Alex H

2014-05-01

Representations of activity spaces, defined as the local areas within which people move or travel in the course of their daily activities, are unexplored among injection drug users (IDUs). The purpose of this paper is to use an activity space framework to study place and drug user health. Data for this analysis is from an epidemiological study of street-recruited IDUs in San Francisco (N=1084). Study participants reported geographic intersections of where they most often slept at night, hung out during the day, and used drugs during a 6 month time period. We used GIS software to construct and map activity space routes of street-based network paths between these intersections. We further identified if syringe exchange program (SEP) locations intersected with, participant activity space routes. We used logistic regression to estimate associations between activity space variables and HIV serostatus, syringe sharing, and non-fatal overdose, after adjusting for individual and Census tract covariates. Mean activity space distance for all participants was 1.5miles. 9.6% of participants had a SEP located along their activity space. An increase in activity space distance was associated with a decrease in odds of being HIV positive. An increase in residential transience, or the number of different locations slept in by participants in a 6 month time period, was associated with higher odds of syringe sharing. Activity space distance was not independently associated with overdose or syringe sharing. Research that locates individuals in places of perceived importance is needed to inform placement and accessibility of HIV and overdose prevention programs. More attention needs to be given to the logistics of collecting sensitive geospatial data from vulnerable populations as well as how to maximize the use of GIS software for visualizing and understanding how IDUs interact with their environment. Copyright © 2013. Published by Elsevier B.V.

TRPM2 channels mediate acetaminophen-induced liver damage

PubMed Central

Kheradpezhouh, Ehsan; Ma, Linlin; Morphett, Arthur; Barritt, Greg J.; Rychkov, Grigori Y.

2014-01-01

Acetaminophen (paracetamol) is the most frequently used analgesic and antipyretic drug available over the counter. At the same time, acetaminophen overdose is the most common cause of acute liver failure and the leading cause of chronic liver damage requiring liver transplantation in developed countries. Acetaminophen overdose causes a multitude of interrelated biochemical reactions in hepatocytes including the formation of reactive oxygen species, deregulation of Ca2+ homeostasis, covalent modification and oxidation of proteins, lipid peroxidation, and DNA fragmentation. Although an increase in intracellular Ca2+ concentration in hepatocytes is a known consequence of acetaminophen overdose, its importance in acetaminophen-induced liver toxicity is not well understood, primarily due to lack of knowledge about the source of the Ca2+ rise. Here we report that the channel responsible for Ca2+ entry in hepatocytes in acetaminophen overdose is the Transient Receptor Potential Melanostatine 2 (TRPM2) cation channel. We show by whole-cell patch clamping that treatment of hepatocytes with acetaminophen results in activation of a cation current similar to that activated by H2O2 or the intracellular application of ADP ribose. siRNA-mediated knockdown of TRPM2 in hepatocytes inhibits activation of the current by either acetaminophen or H2O2. In TRPM2 knockout mice, acetaminophen-induced liver damage, assessed by the blood concentration of liver enzymes and liver histology, is significantly diminished compared with wild-type mice. The presented data strongly suggest that TRPM2 channels are essential in the mechanism of acetaminophen-induced hepatocellular death. PMID:24569808

The Suicide of Marigold Perry.

ERIC Educational Resources Information Center

Berman, Alan L., Ed.

1992-01-01

Presents case study of 50-year-old widow with history of emotional disturbance who committed suicide by a drug overdose 10 days after discharge from inpatient treatment for psychotic illness. Following case presentation are commentaries from John Maltsberger, MD (McLean Hospital, Belmont, Massachusetts) and Wayne Fenton, MD (Chestnut Lodge…

Multiple episodes of aspirin overdose in an individual patient: a case report.

PubMed

Ghosh, Debasish; Williams, Kenneth M; Graham, Garry G; Nair, Priya; Buscher, Hergen; Day, Richard O

2014-11-19

Aspirin overdose, though now infrequently encountered, nevertheless continues to contribute to significant morbidity and mortality. The patient described in this case report intentionally ingested overdoses of aspirin on repeated occasions. The case provided an unusual and possibly one-of-a-kind opportunity to focus on the variability in the time course of plasma salicylate concentrations with current treatment modalities of aspirin overdose in an individual patient. A 75-year-old Caucasian man who weighed 45 kg and had an extensive history of various drug overdoses and stage 3 chronic kidney disease presented to a tertiary university hospital on three occasions within 2 months after successive overdoses of aspirin. During his third admission, he overdosed with aspirin, while on the ward recovering from the previous aspirin overdose. The overdoses were categorized as "potentially lethal" on two occasions and as "serious" in the other two, based on the alleged dose of aspirin ingested (over 500 mg/kg in the first two overdoses, and 320 mg/kg and 498 mg/kg in the other two, respectively). However, as assessed by the observed salicylate concentrations, the ingestions would more appropriately have been categorized as being of "moderate" severity for the first and second overdose and "mild" severity for each of the others. This categorization was more consistent with the clinical severity of his admissions. A single dose of activated charcoal was administered only after the second overdose. On each occasion, he was given intravenous fluid with the aim of achieving euvolemia. Urinary alkalization was not attempted during the first admission, which was associated with the longest apparent elimination half-life of salicylate (30 hours). A plasma potassium concentration of approximately 4 mmol/L appeared to be needed for adequate urinary alkalization. In a patient with impaired renal function, intravenous fluid and urinary alkalization are the mainstays of treatment of aspirin overdose. Correction of hypokalemia is recommended. Repeated doses of charcoal may be a worthwhile intervention when there is no risk of aspiration. Our experience in this case also revealed considerable unexplained variation in management despite the availability of guidelines. It is, therefore, important to monitor the implementation of available guidelines.

Accidental overdose of insufflated colchicine.

PubMed

Baldwin, L R; Talbert, R L; Samples, R

1990-01-01

An accidental overdose of colchicine by nasal insufflation occurred when the colchicine was mistaken for methamphetamine. Colchicine insufflation is not believed to be a common practice among drug abusers; however, its physical appearance was similar enough to methamphetamine for it to be mistaken for that drug of abuse. In this case a 29-year-old White man presented to the emergency room 3 days after he 'snorted' approximately 200mg of colchicine powder. The colchicine was used as a 'root stimulator' in gardening by the patient's brother and stored in the same cabinet as the methamphetamine. Within 24 hours of exposure the patient began experiencing gastrointestinal distress and myalgia, which eventually prompted him to seek medical attention. The clinical course included hypocalcaemia (69 mg/L--day 5), hypophosphataemia (10 mg/L--day 5) and thrombocytopenia (19 X 10(3)/mm3 - day 8), all of which are consistent with colchicine toxicity. The patient improved with supportive care and electrolyte replacement, and was discharged after an 8-day hospitalisation.

2010 drug packaging review: identifying problems to prevent errors.

PubMed

2011-06-01

Prescrire's analyses showed that the quality of drug packaging in 2010 still left much to be desired. Potentially dangerous packaging remains a significant problem: unclear labelling is source of medication errors; dosing devices for some psychotropic drugs create a risk of overdose; child-proof caps are often lacking; and too many patient information leaflets are misleading or difficult to understand. Everything that is needed for safe drug packaging is available; it is now up to regulatory agencies and drug companies to act responsibly. In the meantime, health professionals can help their patients by learning to identify the pitfalls of drug packaging and providing safe information to help prevent medication errors.

Toxicology and methods of committing suicide other than overdose.

PubMed

Coklo, Miran; Stemberga, Valter; Cuculic, Drazen; Sosa, Ivan; Bosnar, Alan

2009-11-01

Suicide represents a serious public health problem throughout the world. Toxicology plays a crucial role in the investigation of suicide. Psychoactive substances are recognized in the literature as the main suicide-generating stimuli. Ethanol is known to produce disinhibition and increased self-confidence. Other psychoactive substances can predominantly be central nervous system (CNS) stimulants or depressors. In cases of overdose as a method of suicide, the link between toxicology and the method of suicide is a matter of common sense and requires no additional explanation. On the other hand, in cases of non-overdose suicides this link is much more complex, and has not yet been extensively elucidated. We hypothesize a close relationship between toxicology and the choice of the method of committing suicide other than overdose. Negative findings may reflect either poor prescribed drug compliance in psychiatric patients, or suggest the role of other (non-toxicological) suicide-generating stimuli. On the other hand, positive findings influence the choice of the suicide method in a way that it depends on the prevalence of either stimulation or depression of the CNS, and consequent degree of behavioral aggression. Simplified, if the prevailing effect is CNS stimulation (with an increase in aggression), the method would be more drastic and more immediately fatal one, while with the CNS depression the method would be less immediately fatal and less drastic. There are only a few studies on the prevalence of psychoactive substances amongst completed suicides and even fewer studies have attempted to examine the relationship between substances used and the circumstances surrounding suicide. In evaluation of our hypothesis, we suggest thorough studies of toxicology and the choice of methods of committing suicides other than overdose. The scientific knowledge gained this way will eventually make toxicology a useful target in suicide prevention, especially amongst younger population.

Opioid Deaths in Milwaukee County, Wisconsin 2013-2017: The Primacy of Heroin and Fentanyl.

PubMed

Peterson, Brian L; Schreiber, Sara; Fumo, Nicole; Brooke Lerner, E

2018-04-23

Heroin and fentanyl are the overwhelming and increasing cause of opioid deaths in Milwaukee County, Wisconsin. We reviewed all drug and opioid deaths from 2013 to 2017 to delineate the specific opioid drugs involved and changes in their incidence. From 2013 to 2017, 980 deaths were due to opioids, rising from 184 in 2013 to 337 in 2017. In 2017, opioid deaths exceeded combined non-natural deaths from homicide and suicide. Illicit heroin and fentanyl/analogs caused 84% of opioid deaths and 80% of drug deaths, with no increase in deaths due to oral prescription drugs such as oxycodone and hydrocodone. Any approach to decreasing this dramatic increase in opioid deaths should first focus on interdicting the supply and cheap availability of these illicit opioids. Fentanyl and its analogs represent the most deadly opioids and the greatest threat to human life in our population. © 2018 American Academy of Forensic Sciences.

Expression of Enzymes that Metabolize Medications

NASA Technical Reports Server (NTRS)

Wotring, Virginia E.; Peters, C. P.

2012-01-01

Most pharmaceuticals are metabolized by the liver. Clinically-used medication doses are given with normal liver function in mind. A drug overdose can result if the liver is damaged and removing pharmaceuticals from the circulation at a rate slower than normal. Alternatively, if liver function is elevated and removing drugs from the system more quickly than usual, it would be as if too little drug had been given for effective treatment. Because of the importance of the liver in drug metabolism we want to understand the effects of spaceflight on the enzymes of the liver.

Sildenafil (Viagra) prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current.

PubMed

Geelen, P; Drolet, B; Rail, J; Bérubé, J; Daleau, P; Rousseau, G; Cardinal, R; O'Hara, G E; Turgeon, J

2000-07-18

BACKGROUND-Several cases of unexpected death have been reported with sildenafil in patients predisposed to ischemic cardiac events. Although acute episodes of ischemia could account for some of these deaths, we hypothesized that sildenafil may have unsuspected electrophysiological effects predisposing some patients to proarrhythmia. METHODS AND RESULTS-Studies were undertaken in 10 isolated guinea pig hearts that demonstrated prolongation of cardiac repolarization in a reverse use-dependent manner by sildenafil 30 mcmol/L. Action potential duration increased 15% from baseline 117+/-3 to 134+/-2 ms with sildenafil during pacing at 250 ms cycle length, whereas a 6% increase from 99+/-2 to 105+/-2 ms was seen with pacing at 150 ms cycle length. Experiments in human ether-a-go-go-related gene (HERG)-transfected HEK293 cells (n=30) demonstrated concentration-dependent block of the rapid component (I(Kr)) of the delayed rectifier potassium current: activating current was 50% decreased at 100 mcmol/L. This effect was confirmed using HERG-transfected Chinese hamster ovary (CHO) cells, which exhibit no endogenous I(K)-like current. CONCLUSIONS-Sildenafil possesses direct cardiac electrophysiological effects similar to class III antiarrhythmic drugs. These effects are observed at concentrations that may be found in conditions of impaired drug elimination such as renal or hepatic insufficiency, during coadministration of another CYP3A substrate/inhibitor, or after drug overdose and offer a new potential explanation for sudden death during sildenafil treatment.

Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties.

PubMed

Watson, Dennis P; Ray, Bradley; Robison, Lisa; Huynh, Philip; Sightes, Emily; Walker, La Shea; Brucker, Krista; Duwve, Joan

2018-04-06

To reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana. Postcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections. Few respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own. Knowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.

Societal Reaction to a Child's Death by Suicide.

ERIC Educational Resources Information Center

Rudestam, Kjell E.; Imbroll, Doreen

1983-01-01

Explored the impact of a child's suicide on the community. Adults (N=80) responded to newspaper accounts of a girl who died either from disease, an accident, a drug overdose, or hanging. The child and her family were perceived as most disturbed and her parents most blameworthy in the suicide. (JAC)

An Antidote for Acute Cocaine Toxicity

PubMed Central

Treweek, Jennifer B.; Janda, Kim D.

2012-01-01

Not only has immunopharmacotherapy grown into a field that addresses the abuse of numerous illicit substances, but also the treatment methodologies within immunopharmacotherapy have expanded from traditional active vaccination to passive immunization with anti-drug monoclonal antibodies, optimized mAb formats, and catalytic drug-degrading antibodies. Many laboratories have focused on transitioning distinct immunopharmacotherapeutics to clinical evaluation, but with respect to the indication of cocaine abuse, only the active vaccine TA-CD, which is modeled after our original cocaine hapten GNC1, has been carried through to human clinical trials.2 The successful application of murine mAb GNC92H2 to the reversal of cocaine overdose in a mouse model prompted investigations of human immunoglobulins with the clinical potential to serve as cocaine antidotes. We now report the therapeutic utility of a superior clone, human mAb GNCgzk (Kd = 0.18 nM), which offers a 10-fold improvement in cocaine binding affinity. The GNCgzk manifold was engineered for rapid cocaine clearance, and administration of the F(ab′)2 and Fab formats even after the appearance of acute behavioral signs of cocaine toxicity granted nearly complete prevention of lethality. Thus, contrary to the immunopharmacotherapeutic treatment of drug self-administration, minimal antibody doses were shown to counteract the lethality of a molar excess of circulating cocaine. Passive vaccination with drug-specific antibodies represents a viable treatment strategy for the human condition of cocaine overdose. PMID:22380623

21 CFR 369.9 - General warnings re accidental ingestion by children.

Code of Federal Regulations, 2010 CFR

2010-04-01

... by children. Section 369.20 includes under certain items, but not all medicines, the statement: “Keep this and all medicines out of children's reach. In case of overdose, get medical help or contact a... children. 369.9 Section 369.9 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN...

Review of prehospital sodium bicarbonate use for cyclic antidepressant overdose

PubMed Central

Calkins, T; Chan, T; Clark, R; Stepanski, B; Vilke, G

2003-01-01

Methods: A three year retrospective observational review of records was performed using the San Diego County Quality Assurance Network database for prehospital providers. All adult patients who were treated with NaHCO3 by paramedics for a CA overdose were included. Demographic data, presenting cardiovascular and neurological symptoms, paramedic treatments, and any changes in status were reviewed. Results: Twenty one patients were treated by paramedics with NaHCO3 for CA overdose. Seventeen patients (80%) presented with mental status changes, including 11 presenting with a GCS<8. Seven of the 21 (33%) presented with a cardiac arrhythmia expected to possibly respond to NaHCO3 treatment. Seven of the 21 (33%) were hypotensive, and five (24%) patients had reported seizure activity. Only 2 of the 21 patients (10%) treated with NaHCO3 had recorded improvements after administration of the drug, while the other 19 remained stable without any deterioration. Sixteen of 21 patients (76%) were given NaHCO3 for indications on standing order, while five patients were treated outside the standing order indications by base physician order with none of the five patients having any change in status ater treatment. Conclusions: After prehospital NaHCO3 use in patients with CA overdose, there were no complications reported, two patients improved in status and the others remained unchanged. Base hospital physician orders of NaHCO3 for indications beyond the standing orders were not associated with changes in patient status. PMID:12954700

Post-Marketing Regulation of Medicines Withdrawn from the Market Because of Drug-Attributed Deaths: An Analysis of Justification.

PubMed

Onakpoya, Igho J; Heneghan, Carl J; Aronson, Jeffrey K

2017-05-01

Several medicinal products have been withdrawn from the market because of drug-attributed deaths. However, there has been no investigation of whether such withdrawals were justified, and the extent to which confirmatory studies are used to investigate drug-adverse event relationships when deaths are reported is uncertain. We documented medicinal products withdrawn from the market because of drug-attributed deaths, identified confirmatory studies investigating the drug-adverse event relationships, examined whether withdrawals of medicinal products because of drug-attributed deaths after marketing were justified based on a mechanistic analysis, and examined the trends over time. We searched electronic and non-electronic sources to identify medicinal products that were withdrawn because of drug-attributed deaths. We used a previously published algorithm to examine whether the withdrawals of products were justified. We then searched PubMed and Google Scholar to identify studies investigating the drug-adverse event relationships, used the Oxford Centre for Evidence-Based Medicine criteria to document the levels of evidence, and assessed whether the evidence of an association was confirmed. We included 83 medicinal products. The reasons for withdrawal appeared to have been justified in 80 cases (96%). The median interval between the first reported adverse reaction that was related to the cause of death and the first reported death was 1 year (interquartile range = 1-3); products were withdrawn sooner when the interval between the first reported relevant adverse reaction and the first death was shorter. Confirmatory studies were conducted in 57 instances (69%), and there was evidence of an association in 52 cases (63%). Four products (5%) were re-introduced after initial withdrawal. Regulatory authorities have been justified in making withdrawal decisions when deaths have been attributed to medicinal products, using the precautionary principle when alternative decisions could have been made. Medicinal products are likely to be quickly withdrawn from the market when there is a short interval to the first reported deaths. The use of an algorithm such as we have used in this study could help to expedite the process of decision making.

Engagement in the Overdose RIsk InfOrmatioN (ORION) e-Health Tool for Opioid Overdose Prevention and Self-Efficacy: A Preliminary Study.

PubMed

Carrà, Giuseppe; Crocamo, Cristina; Humphris, Gerald; Tabacchi, Tommaso; Bartoli, Francesco; Neufeind, Julia; Scherbaum, Norbert; Baldacchino, Alexander

2017-12-01

Increasing awareness of, and information about, overdose risk is an appropriate approach in risk reduction. e-Health technology in substance use disorders is an opportunity to support behavioral changes related to public health concerns. The present study aimed to evaluate the short-term impact of an innovative e-health psychoeducational software, the Overdose RIsk InfOrmatioN (ORION) tool. The ORION programme provided relevant information to opioid-dependent individuals about the risk of suffering a drug overdose as a result of high risky and dysfunctional behaviors. Seven aggregate risk factors were identified through a systematic review and their outputs included in a risk estimation model. We recruited 194 opioid-dependent treatment-seeking individuals from the United Kingdom, Germany, Italy, and Denmark. All participants were given at study entry, and after their use of the software, the General Self-Efficacy (GSE) Scale. We found comparable pre- and post-ORION administration mean GSE scores (SD), 28.49 (5.50) and 28.32 (5.90), respectively (p = 0.297). However, there was an inverse correlation between the number of risk factors and reported levels of self-efficacy (p < 0.001). ORION was able to identify individuals who are most in need of reducing their modifiable risk factors with appropriate interventions. However, a one-shot e-health tool cannot influence complex domains such as self-efficacy unless this is used with other effective interventions. Nonetheless, the ORION tool is unique in its style and content of delivery, that is translating risks combination into a clear estimation, and will need further development such as (a) integration in smartphone-based e-health apps and (b) testing in other high-risk populations.

Virtually a drug scare: mephedrone and the impact of the internet on drug news transmission.

PubMed

Forsyth, Alasdair J M

2012-05-01

On the 16th April 2010 the drug mephedrone was outlawed in the UK. This followed news media reports of deaths linked to the drug. In many respects the mephedrone scare represented a familiar pattern of drug framing and legislative reaction. However, the mephedrone scare took place in the era of online news transmission. To quantify the mephedrone scare the Google Internet search-engine's Trends and News applications were monitored from when the first death was attributed to the drug until 1 year after it was banned. Web interest in buying mephedrone peaked when online news stories reported deaths from the drug. Eighteen alleged mephedrone deaths were identified from online news. The fatalities which received the most Internet traffic subsequently proved false-alarms. Online interactive media widened access to alternative explanations of these alleged mephedrone deaths. It is contended that the advent of the Internet accelerated and inflated the mephedrone scare, but also that online media allowed [web] user-generated information transmission, rather than simple dissemination by news media to audience, fostering competing discourses to stock drug scare themes as they emerged. Copyright © 2012 Elsevier B.V. All rights reserved.

The prognostic impact of psychotropic drugs in intentional drug overdose.

PubMed

Tournier, M; Grolleau, A; Cougnard, A; Verdoux, H; Molimard, M

2009-03-01

Psychotropic drugs belong to the drugs most frequently involved in intentional drug overdose (IDO). Few studies have explored their prognostic impact during hospitalisation for IDO. In order to assess which types of psychotropic drugs ingested during IDOs were associated with an increased morbidity, a cohort study included 1,974 patients consecutively hospitalised for IDO. IDOs were categorised as serious if associated with one of the following criteria: death, hospitalisation longer than 48 h, respiratory support, vasopressive drugs, cardiac massage or dialysis. Nearly all the patients ingested psychotropic medications during the IDO (88.4%), most often benzodiazepines (71.6%). Serious IDO was associated with tricyclics (OR 5.7; 95% CI 3.3-9.8), lithium (OR 4.3; 95% CI 1.6-11.6), carbamates (OR 2.7; 95% CI 1.8-4), anticonvulsants (OR 2.4: 95% CI 1.4-4.3), first-generation antipsychotics (OR 2.4; 95% CI 1.7-3.5) or selective serotonin reuptake inhibitors (SSRIs) (OR 1.6; 95% CI 1.1-2.3). Some drugs may be dangerous because of low toxic doses; hence, prescriptions of short duration may be recommended. Moreover, for safety reasons, prescribers may prefer SSRIs to tricyclics and benzodiazepines to carbamates or phenothiazines.

Trends in licit and illicit drug-related deaths in Florida from 2001 to 2012.

PubMed

Lee, Dayong; Delcher, Chris; Maldonado-Molina, Mildred M; Bazydlo, Lindsay A L; Thogmartin, Jon R; Goldberger, Bruce A

2014-12-01

Florida, the epicenter of the recent prescription drug epidemic in the United States, maintains a statewide drug mortality surveillance system. We evaluated yearly profiles, demographic characteristics, and correlation between drug trends to understand the factors influencing drug-induced mortality. All drug-related deaths reported to the Florida Medical Examiners Commission during 2001-2012 were included (n=92,596). A death was considered "drug-related" if at least one drug was identified in the decedent. Depending on its contribution to death, a drug could be listed as a causative agent or merely present, but not both. Rate of drug-caused deaths was 8.0 per 100,000 population in 2001, increasing to 17.0 in 2010 and then decreasing to 13.9 in 2012. Benzodiazepines had the highest mortality rate in 2010, although <10% were solely due these drugs. Opioid-caused mortality rate also peaked in 2010 and started to decline (-28%) in 2010-2012. The heroin-caused mortality rates were negatively correlated with opioids and benzodiazepines (ρ's ≥ -0.670; P≤0.034). Ethanol- and cocaine-mortality rates stabilized to 3.0-3.1 and 2.8-3.0 per 100,000 over 2009-2012, respectively. Amphetamines, zolpidem, and inhalants-caused deaths were on the rise with rates of ≤0.6 per 100,000. Overall declines in benzodiazepine- and opioid-caused deaths in 2011-2012 may have been related to Florida's attempts to regulate prescription drug abuse. This period, however, was also marked by a rise in heroin-caused mortality, which may reflect growing use of heroin as an alternative. Increases in amphetamines, zolpidem, and inhalants-induced mortality are an additional public health concern. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Increasing deaths involving oxycodone, Victoria, Australia, 2000-09.

PubMed

Rintoul, Angela C; Dobbin, Malcolm D H; Drummer, Olaf H; Ozanne-Smith, Joan

2011-08-01

In light of an emerging epidemic identified in the United States and Canada, to identify trends in fatal drug toxicity involving oxycodone and the demographic characteristics and indicators of socioeconomic disadvantage of the deceased. Population-based observational study in Victoria, Australia. Decedents whose death was reported to the Victorian Coroner between 2000 and 2009 and where oxycodone was detected. Association between supply of oxycodone and deaths. Demographic characteristics of decedents. Rate ratios of the rural or metropolitan location and socioeconomic indicators of disadvantage of the deceased. Supply to Victoria has increased nine-fold from 7.5 mg per capita in 2000 to 67.5 mg per capita in 2009. Detection of oxycodone in deaths reported to the Victorian Coroner has increased from 4 (0.08/100,000 population) in 2000 to 97 (1.78/100,000 population) in 2009-a 21-fold increase in deaths. Of the 320 cases described, 53.8% (172) were the result of drug toxicity. Of these, 52.3% were unintentional and 19.8% intentional self-harm; the remaining 27.9% are either still under investigation by the coroner or intent is unknown. Drug toxicity deaths were overrepresented in both rural areas and areas indexed with high levels of disadvantage. The substantial increase in the number of deaths involving oxycodone is strongly and significantly associated with the increase in supply. Most drug toxicity deaths involving oxycodone were unintentional. This newly identified trend in fatalities in Victoria supports concerns that a pattern of increasing deaths involving oxycodone is emerging globally.

[Harm reduction interventions in drug users: current situation and recommendations].

PubMed

Bosque-Prous, Marina; Brugal, María Teresa

2016-11-01

Harm reduction encompasses interventions, programmes and policies that seek to reduce the negative consequences of the consumption of both legal and illegal drugs on the individual and public health. Harm reduction looks to mitigate the harm suffered by drug users through drug use monitoring and prevention, and promotes initiatives that respect and protect the human rights of this population. The harm reduction policies that have proven effective and efficient are: opioid substitution maintenance therapy (methadone); needle and syringe exchange programmes; supervised drug consumption rooms; and overdose prevention through peer-based naloxone distribution. In order to be effective, these policies must have comprehensive coverage and be implemented in areas where the target population is prevalent. Resident-based opposition to the implementation of these policies is known as the NIMBY (Not In My Back Yard) phenomenon, which is characterised by being against the implementation of new measures in a particular place, but does not question their usefulness. Given that any NIMBY phenomenon is a complex social, cultural and political phenomenon, it is important to conduct a thorough analysis of the situation prior to implementing any of these measures. Harm reduction policies must be extended to other substances such as alcohol and tobacco, as well as to other conditions beyond infectious/contagious diseases and overdose. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

The Mysterious Death: An HPLC Lab Experiment. An Undergraduate Forensic Lab

ERIC Educational Resources Information Center

Beussman, Douglas J.

2007-01-01

A high-performance liquid chromatography (HPLC) laboratory experiment based on the separation of four prescription drugs (disopyramide, lidocaine, procainamide, and quinidine) is presented. The experiment is set within the forensic science context of the discovery of a patient's mysterious death where a drug overdose is suspected. Each lab group…

Qualitative assessment of take-home naloxone program participant and law enforcement interactions in British Columbia.

PubMed

Deonarine, Andrew; Amlani, Ashraf; Ambrose, Graham; Buxton, Jane A

2016-05-21

The British Columbia take-home naloxone (BCTHN) program has been in operation since 2012 and has resulted in the successful reversal of over 581 opioid overdoses. The study aims to explore BCTHN program participant perspectives about the program, barriers to participants contacting emergency services (calling "911") during an overdose, and perspectives of law enforcement officials on naloxone administration by police officers. Two focus groups and four individual interviews were conducted with BCTHN program participants; interviews with two law enforcement officials were also conducted. Qualitative analysis of all transcripts was performed. Positive themes about the BCTHN program from participants included easy to understand training, correcting misperceptions in the community, and positive interactions with emergency services. Potential barriers to contacting emergency services during an overdose include concerns about being arrested for outstanding warrants or for other illegal activities (such as drug possession) and confiscation of kits. Law enforcement officials noted that warrants were complex situational issues, kits would normally not be confiscated, and admitted arrests for drug possession or other activities may not serve the public good in an overdose situation. Law enforcement officials were concerned about legal liability and jurisdictional/authorization issues if naloxone administration privileges were expanded to police. Program participants and law enforcement officials expressed differing perspectives about warrants, kit confiscation, and arrests. Facilitating communication between BCTHN program participants and other stakeholders may address some of the confusion and remove potential barriers to further improving program outcomes. Naloxone administration by law enforcement would require policies to address jurisdiction/authorization and liability issues.

Risk of recurrent overdose associated with prescribing patterns of psychotropic medications after nonfatal overdose

PubMed Central

Okumura, Yasuyuki; Nishi, Daisuke

2017-01-01

Objective We aimed to estimate risk of recurrent overdose associated with psychosocial assessment by psychiatrists during hospitalization for nonfatal overdose and prescribing patterns of psychotropic medications after discharge. Methods A retrospective cohort study was conducted using a nationwide claims database in Japan. We classified patients aged 19–64 years hospitalized for nonfatal overdose between October 2012 and September 2013 into two cohorts: 1) those who had consulted a psychiatrist prior to overdose (n=6,790) and 2) those who had not (n=4,950). All patients were followed up from 90 days before overdose until 365 days after discharge. Results Overall, 15.3% of patients with recent psychiatric treatment had a recurrent overdose within 365 days, compared with 6.0% of those without psychiatric treatment. Psychosocial assessment during hospital admission had no significant effect on subsequent overdose, irrespective of treatment by psychiatrists before overdose. There was a dose–response relationship for the association of benzodiazepine prescription after overdose with subsequent overdose in either cohort, even after accounting for average daily dosage of benzodiazepines before overdose and other confounders. In patients with recent psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 27.7% for patients receiving excessive dosages of benzodiazepines, 22.0% for those receiving high dosages, 15.3% for those receiving normal dosages, and 7.6% for those receiving no benzodiazepines. In patients without psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 24.3% for patients receiving excessive dosages of benzodiazepines, 18.0% for those receiving high dosages, 9.0% for those receiving normal dosages, and 4.1% for those receiving no benzodiazepines. Conclusion Lower dose of benzodiazepines after overdose is associated with lower risk of subsequent overdose. PMID:28293108

Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?

PubMed

Burns, Glenn; DeRienz, Rebecca T; Baker, Daniel D; Casavant, Marcel; Spiller, Henry A

2016-06-01

There has been a significant spike in fentanyl-related deaths from illicit fentanyl supplied via the heroin trade. Past fentanyl access was primarily oral or dermal via prescription fentanyl patch diversion. One factor potentially driving this increase in fatalities is the change in route of administration. Rapid intravenous (IV) fentanyl can produce chest wall rigidity. We evaluated post-mortem fentanyl and norfentanyl concentrations in a recent surge of lethal fentanyl intoxications. Fentanyl related deaths from the Franklin County coroner's office from January to September 2015 were identified. Presumptive positive fentanyl results were confirmed by quantitative analysis using liquid chromatography tandem mass spectrometry (LC/MS/MS) and were able to quantify fentanyl, norfentanyl, alfentanyl, and sufentanyl. 48 fentanyl deaths were identified. Mean fentanyl concentrations were 12.5 ng/ml, (range 0.5 ng/ml to >40 ng/ml). Mean norfentanyl concentrations were 1.9 ng/ml (range none detected to 8.3 ng/ml). No appreciable concentrations of norfentanyl could be detected in 20 of 48 cases (42%) and were less than 1 ng/ml in 25 cases (52%). Elevated fentanyl concentrations did not correlate with rises in norfentanyl levels. In several cases fentanyl concentrations were strikingly high (22 ng/ml and 20 ng/ml) with no norfentanyl detected. The lack of any measurable norfentanyl in half of our cases suggests a very rapid death, consistent with acute chest rigidity. An alternate explanation could be a dose-related rapid onset of respiratory arrest. Deaths occurred with low levels of fentanyl in the therapeutic range (1-2 ng/ml) in apparent non-naïve opiate abusers. Acute chest wall rigidity is a well-recognized complication in the medical community but unknown within the drug abuse community. The average abuser of illicit opioids may be unaware of the increasing fentanyl content of their illicit opioid purchase. In summary we believe sudden onset chest wall rigidity may be a significant and previously unreported factor leading to an increased mortality, from illicit IV fentanyl use. Fentanyl and norfentanyl ratios and concentrations suggest a more rapid onset of death given the finding of fentanyl without norfentanyl in many of the fatalities. Chest wall rigidity may help explain the cause of death in these instances, in contrast to the typical opioid-related overdose deaths. Intravenous heroin users should be educated regarding this potentially fatal complication given the increasingly common substitution and combination with heroin of fentanyl.

Rhode Island Board of Medical Licensure and Discipline: Illustration of the disciplinary process as it pertains to cases involving opioid prescribing.

PubMed

McDonald, James V

Prescription-drug overuse/overdose and misuse is an important and pivotal issue to state medical boards. This is an illustration of how some cases involving overprescribing of opioids have been addressed by the Rhode Island Board of Medical Licensure and Discipline.

Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain.

PubMed

Wilder, Christine M; Miller, Shannon C; Tiffany, Elizabeth; Winhusen, Theresa; Winstanley, Erin L; Stein, Michael D

2016-01-01

Rising overdose fatalities among U.S. veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk. The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group. In the current study, 90 veterans on chronic opioid medication, for either opioid use disorder or pain management, completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose. Nearly all veterans in both groups had multiple overdose risk factors, although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 versus 8.5, p < .0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 versus 13.5, p < .01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors. Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology.

PubMed

Franklin, Gary M

2014-09-30

The Patient Safety Subcommittee requested a review of the science and policy issues regarding the rapidly emerging public health epidemic of prescription opioid-related morbidity and mortality in the United States. Over 100,000 persons have died, directly or indirectly, from prescribed opioids in the United States since policies changed in the late 1990s. In the highest-risk group (age 35-54 years), these deaths have exceeded mortality from both firearms and motor vehicle accidents. Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction. The objectives of the article are to review the following: (1) the key initiating causes of the epidemic; (2) the evidence for safety and effectiveness of opioids for chronic pain; (3) federal and state policy responses; and (4) recommendations for neurologists in practice to increase use of best practices/universal precautions most likely to improve effective and safe use of opioids and to reduce the likelihood of severe adverse and overdose events. © 2014 American Academy of Neurology.

School District Policies for Response to Death-Related Crises: Fact or Fiction?

ERIC Educational Resources Information Center

Christenberry, Nola J.; Burns, John L.

Findings of a literature review of school policies and procedures for school-based responses to death-related crises are presented in this paper. A rationale and guidelines for policy development and examples of practices for dealing with death-related incidents--such as suicide, homicide, drug overdose, and accidents--are described. Following an…

Development of a proto-typology of opiate overdose onset.

PubMed

Neale, Joanne; Bradford, Julia; Strang, John

2017-01-01

The time available to act is a crucial factor affecting the probable success of interventions to manage opiate overdose. We analyse opiate users' accounts of non-fatal overdose incidents to (i) construct a proto-typology of non-fatal opiate overdose onset and (ii) assess the implications for overdose management and prevention of fatalities. Re-analysis of a subset of data from a large qualitative study of non-fatal opiate overdose conducted from 1997 to 1999. Data were generated from semi-structured interviews undertaken with opiate users who had experienced a non-fatal overdose in the previous 24 hours. Forty-four participants (30 men; 14 women; aged 16-47 years) provided sufficient information for in-depth analysis. Data relating to 'memory of the moment of overdose', 'time to loss of consciousness' and 'subjective description of the overdose experience' were scrutinised using iterative categorization. Four types of overdose onset were identified: type A 'amnesic' (n = 8), characterized by no memory, rapid loss of consciousness and no description of the overdose experience; type B 'conscious' (n = 17), characterized by some memory, sustained consciousness and a description of the overdose in terms of feeling unwell and symptomatic; type C 'instant' (n = 14), characterized by some memory, immediate loss of consciousness and no description of the overdose experience; and type D 'enjoyable' (n = 5), characterized by some memory, rapid loss of consciousness and a description of the overdose experience as pleasant or positive. The identification of different types of overdose onset highlights the complexity of overdose events, the need for a range of interventions and the challenges faced in managing incidents and preventing fatalities. Opiate overdose victims who retain consciousness for a sustained period and recognize the negative signs and symptoms of overdosing could summon help or self-administer naloxone, thus indicating that opiate overdose training should incorporate self-management strategies. © 2016 Society for the Study of Addiction.

Anti-Xa activity in apixaban overdose: a case report.

PubMed

Barton, James; Wong, Anselm; Graudins, Andis

2016-11-01

Apixaban is a novel oral anticoagulation agent that exerts its effect through direct factor Xa inhibition. We present a case of multi-drug overdose including apixaban with associated apixaban concentrations. A 53 year-old man presented to our metropolitan hospital following a deliberate self-poisoning with 200 mg apixaban, 35 mg ramipril, 105 mg bisoprolol, 280 mg atorvastatin, 6 mg colchicine, 37.4 mg magnesium, 4 × 500 mg paracetamol/9.5 mg codeine/5 mg phenylephrine and alcohol. He developed hypotension that was treated with noradrenaline. His initial and peak apixaban concentration was 1022.6 ng/ml and was associated with only minor bleeding from his femoral central line insertion site, which improved with local compression. Vitamin K 10 mg (at 9 h post-ingestion) and Prothrombinex-VF 2000 units (at 13 h post-ingestion) were also administered without any observed effect on coagulation studies. Apixaban elimination appeared to display first-order kinetics with an elimination half-life of 7.4 h. His plasma apixaban concentration was within the therapeutic dose range 10 h post-ingestion and he recovered uneventfully. A case of apixaban overdose with associated apixaban concentrations is presented. There was rapid resolution of anticoagulation with no demonstrable benefit of currently available clotting factor replacement.

Intralipid therapy does not improve level of consciousness in overdoses with sedating drugs: a case series.

PubMed

Downes, Michael A; Calver, Leonie A; Isbister, Geoffrey K

2014-06-01

To assess the effect of intralipid emulsion therapy (ILE) in sedating drugs presenting to an urban emergency department. Following the introduction of a clinical protocol for the use of ILE a retrospective chart review was undertaken, which describes the use of ILE in treating sedating drug overdose in a facility with a tertiary referral level clinical toxicology unit. Demographic data as well as details of drug ingested, physiological parameters and disposition were extracted from the medical record. Over a 7 month period nine cases were treated with intralipid, of which two were male and the median age was 33 years (17-52 years). Endotracheal intubation was required in seven cases and of the other two, one required a nasopharyngeal airway for several hours while being observed in a critical care area. One patient was managed in the intensive care unit without intubation. The median duration of ventilation in the seven patients was 31 h (22-82 h), and median length of stay for all nine cases was 63 h (24-133 h). This study does not support any clinically significant effect of intralipid in sedating drug overdose. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

[The body packer syndrome].

PubMed

Clément, R; Fornes, P; Lecomte, D

2001-02-17

Ingestion of illicit drug packages is a well known method for transportation. These packages are prone to rupture causing overdose. The body packer syndrome may be overlooked in medical practice as illustrated by the following case report. A 19-year old male had convulsions followed by cardiac arrest during a flight. He was resuscitated in the plane, but he died a few hours after admission in intensive care unit. Chest and abdominal X-rays were considered normal. Cocaïne métabolites were found in his urine. The death was considered suspicious. X-rays performed before medicolegal autopsy showed numerous packages in his digestive tract. Thirty-six packages were found in the stomach and intestine. Two were ruptured in the stomach. The cause of death was cocaïne overdose caused by package rupture. The packages are usually visible on an standard abdomen X-ray. The drug is often wrapped in latex membranes or condoms. The air is trapped between the condoms by the nodes, forming two crescents visible on the X-ray. Surgery is preferred to laxatives when the packages are fragile with a high risk of rupture.

Understanding opioid overdose characteristics involving prescription and illicit opioids: A mixed methods analysis.

PubMed

Yarborough, Bobbi Jo H; Stumbo, Scott P; Janoff, Shannon L; Yarborough, Micah T; McCarty, Dennis; Chilcoat, Howard D; Coplan, Paul M; Green, Carla A

2016-10-01

Opioid abuse and misuse are significant public health issues. The CDC estimated 72% of pharmaceutical-related overdose deaths in the US in 2012 involved opioids. While studies of opioid overdoses have identified sociodemographic characteristics, agents used, administration routes, and medication sources associated with overdoses, we know less about the context and life circumstances of the people who experience these events. We analyzed interviews (n=87) with survivors of opioid overdoses or family members of decedents. Individuals experiencing overdoses were members of a large integrated health system. Using ICD codes for opioid overdoses and poisonings, we identified participants from five purposefully derived pools of health-plan members who had: 1) prescriptions for OxyContin(®) or single-ingredient sustained-release oxycodone, 2) oxycodone single-ingredient immediate release, 3) other long-acting opioids, 4) other short-acting opioids, or 5) no active opioid prescriptions. Individuals who experienced opioid overdoses abused and misused multiple medications/drugs; experienced dose-related miscommunications or medication-taking errors; had mental health and/or substance use conditions; reported chronic pain; or had unstable resources or family/social support. Many had combinations of these risks. Most events involved polysubstance use, often including benzodiazepines. Accidental overdoses were commonly the result of abuse or misuse, some in response to inadequately treated chronic pain or, less commonly, medication-related mistakes. Suicide attempts were frequently triggered by consecutive negative life events. To identify people at greater risk of opioid overdose, efforts should focus on screening for prescribed and illicit polysubstance use, impaired cognition, and changes in life circumstances, psychosocial risks/supports, and pain control. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

America's Opioid Epidemic: Supply and Demand Considerations.

PubMed

Clark, David J; Schumacher, Mark A

2017-11-01

America is in the midst of an opioid epidemic characterized by aggressive prescribing practices, highly prevalent opioid misuse, and rising rates of prescription and illicit opioid overdose-related deaths. Medical and lay public sentiment have become more cautious with respect to prescription opioid use in the past few years, but a comprehensive strategy to reduce our reliance on prescription opioids is lacking. Addressing this epidemic through reductions in unnecessary access to these drugs while implementing measures to reduce demand will be important components of any comprehensive solution. Key supply-side measures include avoiding overprescribing, reducing diversion, and discouraging misuse through changes in drug formulations. Important demand-side measures center around educating patients and clinicians regarding the pitfalls of opioid overuse and methods to avoid unnecessary exposure to these drugs. Anesthesiologists, by virtue of their expertise in the use of these drugs and their position in guiding opioid use around the time of surgery, have important roles to play in reducing patient exposure to opioids and providing education about appropriate use. Aside from the many immediate steps that can be taken, clinical and basic research directed at understanding the interaction between pain and opioid misuse is critical to identifying the optimal use of these powerful pain relievers in clinical practice.

What caused the recent reduction in heroin supply in Australia?

PubMed

Wodak, Alex

2008-08-01

Heroin availability and purity decreased and prices increased in Australia suddenly in early 2001. The heroin market in Australia has still not returned to the status quo ante after more than six years. Benefits of the heroin shortage, including a substantial reduction in drug overdose deaths and property crime, are generally considered to have outweighed adverse effects which included increased use of other drugs, especially stimulants, with a subsequent increase in aggression, violence and mental illness. Some commentators attributed the heroin shortage to a combination of factors, while an influential study highlighted the importance of supply control asserting that increased funding and improved effectiveness of domestic drug law enforcement produced critical heroin seizures which disrupted major syndicates, thereby producing the heroin shortage. Evidence to support a critical role for drug law enforcement in the heroin shortage is weak with some recent evidence contradicting key assertions used to support the supply control hypothesis. Although the most likely interpretation is still a combination of multiple factors, the most important factors appear to have been a substantial recent reduction in source opium cultivation and heroin production in Burma, but probably also increased heroin consumption en route through China and a switch from heroin to amphetamine production in Burma. This interpretation is consistent with the international experience of several recent decades in numerous countries where national heroin shortages have occurred rarely and generally only briefly, notwithstanding vigorous and very well resourced supply control efforts. The recent reduction in heroin supply in Australia, the most severe, longest lasting and best-documented heroin shortage in the world, cannot be confidently attributed, solely or largely, to improved domestic drug law enforcement. At best, domestic law enforcement may have made a small contribution compared to several other factors. Evaluation of supply, demand and harm reduction should be held to the same standards.

The Supply of Physicians Waivered to Prescribe Buprenorphine for Opioid Use Disorders in the United States: A State-Level Analysis.

PubMed

Knudsen, Hannah K

2015-07-01

The U.S. Food and Drug Administration's approval of buprenorphine in 2002 expanded options for treating opioid use disorder (OUD). Physicians who intend to treat OUD patients with buprenorphine must seek a waiver to prescribe it, which may contribute to state-by-state variation in the supply of waivered physicians. This study integrates data extracted from the U.S. Drug Enforcement Agency's database of waivered physicians with state-level indicators of the macro environment, health-related resources, and treatment demand. In December 2013, the average state had 8.0 waivered physicians per 100,000 residents (SD = 5.2). Large regional differences between states in the Northeast relative to states in the Midwest, South, and West were observed. The percentage of residents covered by Medicaid as well as the population-adjusted availability of opioid treatment programs and substance use disorder treatment facilities were positively associated with buprenorphine physician supply. Buprenorphine physician supply was positively correlated with states' rates of overdose deaths, suggesting that physicians may seek the waiver in response to the magnitude of the opioid problem in their state. States with greater health-related resources, particularly in terms of the supply of opioid treatment programs and substance use disorder treatment programs, had more waivered physicians in 2013. The finding regarding Medicaid coverage suggests that states implementing Medicaid expansion under health reform may experience additional growth in buprenorphine physician supply. However, large regional disparities in the supply of waivered physicians may impede access to care for many Americans with OUD.

Use of intravenous lipid emulsion to reverse central nervous system toxicity of an iatrogenic local anesthetic overdose in a patient on peritoneal dialysis.

PubMed

Lange, D Bruce; Schwartz, Daniel; DaRoza, Gerald; Gair, Robert

2012-12-01

To describe a case of severe central nervous system toxicity after an overdose of lidocaine by local infiltration in a peritoneal dialysis patient and subsequent treatment of the toxicity with lipid emulsion. A 31-year-old male received an iatrogenic overdose of 1600 mg of lidocaine 2% by infiltration during an attempt to remove and replace a peritoneal dialysis catheter. Within 10 minutes after the last lidocaine injection, the patient exhibited features of local anesthetic toxicity, which included tachycardia, hypertension, shortness of breath, dizziness, and a choking sensation that progressed to hallucinations, dysarthria, and uncoordinated, weak limb movement. Within 10 minutes after administration of a single 1.5-mg/kg intravenous bolus of 1.5 mL/kg [corrected], the patient improved dramatically. After observation overnight in a monitored care setting, the patient was discharged home with no apparent neurologic sequelae. Systemic toxicity due to regional anesthesia with local anesthetic agents such as lidocaine has been well described in the medical literature. The use of lipid emulsion as an antidote to the toxicity of local anesthetics and other lipophilic drugs has been suggested as a valuable intervention in both early, rapidly progressive toxicity, as well as toxicity that is refractory to standard treatment. Patients with advanced chronic kidney disease may be more susceptible to systemic effects of lidocaine due to decreased drug elimination. Central nervous system toxicity due to an overdose of lidocaine was quickly reversed by intravenous lipid emulsion in our patient.

Marked EEG worsening following Levetiracetam overdose: How a pharmacological issue can confound coma prognosis.

PubMed

Bouchier, Baptiste; Demarquay, Geneviève; Guérin, Claude; André-Obadia, Nathalie; Gobert, Florent

2017-01-01

Levetiracetam is an anti-epileptic drug commonly used in intensive care when seizure is suspected as a possible cause of coma. We propose to question the cofounding effect of Levetiracetam during the prognostication process in a case of anoxic coma. We report the story of a young woman presenting a comatose state following a hypoxic cardiac arrest. After a first EEG presenting an intermediate EEG pattern, a seizure suspicion led to prescribe Levetiracetam. The EEG showed then the appearance of burst suppression, which was compatible with a very severe pattern of post-anoxic coma. This aggravation was in fact related to an overdose of Levetiracetam (the only medication introduced recently) and was reversible after Levetiracetam cessation. The increased plasmatic dosages of Levetiracetam confirming this overdose could have been favoured by a moderate reduction of renal clearance, previously underestimated because of a low body-weight. This EEG dynamic was unexpected under Levetiracetam and could sign a functional instability after anoxia. Burst suppression is classically observed with high doses of anaesthetics, but is not expected after a minor anti-epileptic drug. This report proposes that Levetiracetam tolerance might not be straightforward after brain lesions and engages us to avoid confounding factors during the awakening prognostication, which is mainly based on the severity of the EEG. Hence, prognosis should not be decided on an isolated parameter, especially if the dynamic is atypical after a new prescription, even for well-known drugs. For any suspicion, the drug's dosage and replacement should be managed before any premature care's withdrawal. Copyright © 2016 Elsevier B.V. All rights reserved.

Acute acetaminophen overdose is associated with dose-dependent hypokalaemia: a prospective study of 331 patients.

PubMed

Waring, W Stephen; Stephen, Alexandra F L; Malkowska, Aleks M; Robinson, Oliver D G

2008-03-01

Hypokalaemia is a recognized complication of acute acetaminophen overdose. It is unclear whether this might be a pharmacological effect of acetaminophen, or due to association with confounding factors. The present study sought to better characterize the relationship between acetaminophen concentrations and risk of hypokalaemia. A prospective study of patients received N-acetylcysteine treatment within 15 hr of acute acetaminophen ingestion. Serum potassium concentrations were determined before and after N-acetylcysteine. Serum acetaminophen concentrations were used to indicate overall drug exposure by comparison to the Rumack-Matthew nomogram. Hypokalaemia was pre-defined by serum concentrations <3.5 mmol/l, and groups compared by Mann-Whitney tests. There were 331 patients. Median (95% confidence interval) fall in serum potassium concentration after N-acetylcysteine was 0.05 mmol/l (-0.11-0.30 mmol/l) if acetaminophen concentrations were below the 'high-risk' treatment line, 0.30 mmol/l (0.17-0.40 mmol/l) if between the 'high-risk' and 'normal' treatment lines (P = 0.0358), and 0.40 mmol/l (0.20-0.50 mmol/l) if above the 'normal' treatment line (P = 0.0136). A receiver operating characteristic showed that high acetaminophen concentrations were predictive of hypokalaemia (P = 0.0001 versus zero discriminatory line), and 4 hr acetaminophen concentration >156 mmol/l gave 81% sensitivity and 48% specificity. The risk of hypokalaemia after acute acetaminophen overdose depends on the extent of acetaminophen exposure, irrespective of N-acetylcysteine administration and independent of whether vomiting occurred. Acetaminophen appears to cause concentration-dependent hypokalaemia after overdose, and the pharmacological basis requires further consideration.

Alcohol and Other Chemicals. Adolescent Alcoholism: Recognizing, Intervening, and Treating Series No. 6.

ERIC Educational Resources Information Center

Gougelet, Robert M.; Nelson, E. Don

This document is one of seven publications contained in a series of materials for physicians on recognizing, intervening with, and treating adolescent alcoholism. The materials in this unit of study are designed to help the physician know the different classes of drugs, recognize common presenting symptoms of drug overdose, and place use and abuse…

Alcohol and Drug-Related Mortality among Enrollees in the World Trade Center Health Registry (WTCHR), 2004-12.

PubMed

Welch, Alice E; Zweig, Kimberly Caramanica; Liao, Tim; Yip, Jennifer; Davidson, Alexander; Jordan, Hannah; Brackbill, Robert; Cone, James

2018-06-13

Have World Trade Center Health Registry (WTCHR) enrollees experienced increased alcohol and drug-related mortality associated with exposures to the events of 9/11/01? Cases involving death due to alcohol or drugs between 2003 and 2012 in New York City (NYC) were obtained through a match of the Registry with NYC Vital Records. We compared ICD-10-coded deaths where alcohol and/or drug use was the underlying cause of death to deaths from all other causes. Of 1,193 deaths, 66 (5.5%) were alcohol/drug-related. Adjusted odds ratios for dying from alcohol/drug-related causes were significantly elevated for enrollees who were male, age 18-44 years, smoked at enrollment, had 9/11-related probable PTSD, were rescue/recovery workers, or sustained an injury on 9/11/01. Following a major disaster, alcohol and drug-related mortality may be increased.

Why are some people who have received overdose education and naloxone reticent to call Emergency Medical Services in the event of overdose?

PubMed

Koester, Stephen; Mueller, Shane R; Raville, Lisa; Langegger, Sig; Binswanger, Ingrid A

2017-10-01

Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law's influence by describing OEND trained PWIDs' experience reversing overdoses and their decision about calling for EMS support. Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs' self-identified health concerns were triangulated to describe and explain participants' decision to call for EMS. In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver's aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city's homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing. Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs' fear that their current legal status as well as the victim's will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs' already enmeshed in the criminal justice system, or PWID fearful of losing their housing. Copyright © 2017 Elsevier B.V. All rights reserved.

Suspected Lonely Mouse Syndrome as a Cage Effect in a Drug Safety Study.

PubMed

Ye, Xiaobu; Itzoe, MariaLisa; Sarabia-Estrada, Rachel; DeTolla, Louis; Tyler, Betty M; Guarnieri, Michael

2018-01-01

Studies have demonstrated that buprenorphine, a front line drug for veterinary analgesia, may alleviate symptoms of chronic pain. A cage side observation protocol was used to record behavioral signs in a mouse clinical trial of extended release buprenorphine. A retrospective review of the observations for signs of pain and stress revealed that mice given a fivefold overdose of buprenorphine (16.25 mg/kg) showed lethargy and facial signs associated with stress. However, similar signs were observed in the drug-free control mice as early as Day 3 of single-cage housing. This appears to be the first report of cage effects in a clinical trial for a veterinary drug.

Suspected Lonely Mouse Syndrome as a Cage Effect in a Drug Safety Study

PubMed Central

Ye, Xiaobu; Itzoe, MariaLisa; Sarabia-Estrada, Rachel; DeTolla, Louis

2018-01-01

Studies have demonstrated that buprenorphine, a front line drug for veterinary analgesia, may alleviate symptoms of chronic pain. A cage side observation protocol was used to record behavioral signs in a mouse clinical trial of extended release buprenorphine. A retrospective review of the observations for signs of pain and stress revealed that mice given a fivefold overdose of buprenorphine (16.25 mg/kg) showed lethargy and facial signs associated with stress. However, similar signs were observed in the drug-free control mice as early as Day 3 of single-cage housing. This appears to be the first report of cage effects in a clinical trial for a veterinary drug. PMID:29854826

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.

PubMed

Sordo, Luis; Barrio, Gregorio; Bravo, Maria J; Indave, B Iciar; Degenhardt, Louisa; Wiessing, Lucas; Ferri, Marica; Pastor-Barriuso, Roberto

2017-04-26

Objective  To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment. Design  Systematic review and meta-analysis. Data sources  Medline, Embase, PsycINFO, and LILACS to September 2016. Study selection  Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine. Data extraction and synthesis  Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis. Results  There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment. Conclusions  Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Anesthetic propofol overdose causes endothelial cytotoxicity in vitro and endothelial barrier dysfunction in vivo

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lin, Ming-Chung; Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan; Chen, Chia-Ling

An overdose and a prolonged treatment of propofol may cause cellular cytotoxicity in multiple organs and tissues such as brain, heart, kidney, skeletal muscle, and immune cells; however, the underlying mechanism remains undocumented, particularly in vascular endothelial cells. Our previous studies showed that the activation of glycogen synthase kinase (GSK)-3 is pro-apoptotic in phagocytes during overdose of propofol treatment. Regarding the intravascular administration of propofol, we therefore hypothesized that propofol overdose also induces endothelial cytotoxicity via GSK-3. Propofol overdose (100 μg/ml) inhibited growth in human arterial and microvascular endothelial cells. After treatment, most of the endothelial cells experienced caspase-independent necrosis-likemore » cell death. The activation of cathepsin D following lysosomal membrane permeabilization (LMP) determined necrosis-like cell death. Furthermore, propofol overdose also induced caspase-dependent apoptosis, at least in part. Caspase-3 was activated and acted downstream of mitochondrial transmembrane potential (MTP) loss; however, lysosomal cathepsins were not required for endothelial cell apoptosis. Notably, activation of GSK-3 was essential for propofol overdose-induced mitochondrial damage and apoptosis, but not necrosis-like cell death. Intraperitoneal administration of a propofol overdose in BALB/c mice caused an increase in peritoneal vascular permeability. These results demonstrate the cytotoxic effects of propofol overdose, including cathepsin D-regulated necrosis-like cell death and GSK-3-regulated mitochondrial apoptosis, on endothelial cells in vitro and the endothelial barrier dysfunction by propofol in vivo. Highlights: ► Propofol overdose causes apoptosis and necrosis in endothelial cells. ► Propofol overdose triggers lysosomal dysfunction independent of autophagy. ► Glycogen synthase kinase-3 facilitates propofol overdose-induced apoptosis. ► Propofol overdose causes an increase in peritoneal vascular permeability.« less

Substance use and homelessness among emergency department patients.

PubMed

Doran, Kelly M; Rahai, Neloufar; McCormack, Ryan P; Milian, Jacqueline; Shelley, Donna; Rotrosen, John; Gelberg, Lillian

2018-05-22

Homelessness and substance use often coexist, resulting in high morbidity. Emergency department (ED) patients have disproportionate rates of both homelessness and substance use, yet little research has examined the overlap of these issues in the ED setting. We aimed to characterize alcohol and drug use in a sample of homeless vs. non-homeless ED patients. A random sample of urban hospital ED patients were invited to complete an interview regarding housing, substance use, and other health and social factors. We compared substance use characteristics among patients who did vs. did not report current literal (streets/shelter) homelessness. Additional analyses were performed using a broader definition of homelessness in the past 12-months. Patients who were currently homeless (n = 316, 13.7%) versus non-homeless (n = 1,993, 86.3%) had higher rates of past year unhealthy alcohol use (44.4% vs. 30.5%, p < .0001), any drug use (40.8% vs. 18.8%, p < .0001), heroin use (16.7% vs. 3.8%, p < .0001), prescription opioid use (12.5% vs. 4.4%, p < .0001), and lifetime opioid overdose (15.8% vs. 3.7%, p < .0001). In multivariable analyses, current homelessness remained significantly associated with unhealthy alcohol use, AUDIT scores among unhealthy alcohol users, any drug use, heroin use, and opioid overdose; past 12-month homelessness was additionally associated with DAST-10 scores among drug users and prescription opioid use. Patients experiencing homelessness have higher rates and greater severity of alcohol and drug use than other ED patients across a range of measures. These findings have implications for planning services for patients with concurrent substance use and housing problems. Copyright © 2018 Elsevier B.V. All rights reserved.

A nationwide pharmacy chain responds to the opioid epidemic.

PubMed

Shafer, Emily; Bergeron, Nyahne; Smith-Ray, Renae; Robson, Chester; O'Koren, Rachel

To describe the 3-pronged approach taken by a large national retail pharmacy chain to address the opioid epidemic and associated overdoses. Large national retail pharmacy chain with more than 8200 stores in 50 states. Eight million customer interactions daily through in-store and digital settings. This is a company with a long history of responding to public health crises. Initiated 3 programs to respond to the opioid crisis: 1) provide safe medication disposal kiosks; 2) expand national access to naloxone; and 3) provide education on the risk and avoidance of opioid overdose. Used the RE-AIM framework to evaluate and enhance the quality, speed, and public health impact of the interventions. Not applicable. Early results are safe medication disposal kiosks in more than 43 states, naloxone-dispensing program in 33 states, and patient and support system education using the Opioid Overdose Toolkit from the Substance Abuse and Mental Health Services Administration. The availability of safe drug-disposal kiosks, naloxone dispensing at pharmacies, and patient education are key prevention initiatives to address the opioid epidemic and reduce the increasing national burden of opioid overdose. Early results are quantitatively and qualitatively promising. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Caffeine and suicide: a systematic review.

PubMed

Silva, Adriana Cardoso; de Oliveira Ribeiro, Natalia Pinho; de Mello Schier, Alexandre Rafael; Pereira, Valeska Martinho; Vilarim, Marina Machado; Pessoa, Tamires Marinho; Arias-Carrión, Oscar; Machado, Sergio; Nardi, Antonio Egidio

2014-01-01

Suicide is considered a deliberate act initiated and concluded by a person with full knowledge or expectation of a fatal result, and one of the main symptoms of depression. An individual's conscious and excessive ingestion of a damaging substance is also considered to be an attempted suicide. Despite limited knowledge of caffeine abuse, deaths from overdose of caffeine have been reported in the literature. Thus, this study aims to review the existing literature on caffeine consumption and suicide attempts and deaths, investigating the relation between caffeine consumption and suicide attempts and deaths. We found 24 studies that discuss the relationship between caffeine and suicide. The findings revealed that, despite being an addictive substance and potentially fatal in higher doses, caffeine was still a rare factor in a number of studies concerning its relation with suicide attempts and death. The majority of the research found in this study was of the case study type. Furthermore, the majority of studies focus on the assistance offered to the victim and the procedures undertaken to control the bodily damage created. The existing studies indicate the substance may act as either a direct or an indirect agent in suicide. Therefore, a better understanding of how caffeine may be linked to suicide is crucial for its prevention.

Application of human factors engineering (HFE) to the design of a naloxone auto-injector for the treatment of opioid emergencies.

PubMed

Raffa, Robert B; Taylor, Robert; Pergolizzi, Joseph V; Nalamachu, Srinivas; Edwards, Eric S; Edwards, Evan T

2017-02-01

The increased use of opioids for chronic treatment of pain and the resulting epidemic of opioid overdoses have created a major public health challenge. Parenteral naloxone has been used since the 1970's to treat opioid overdose. Recently, a novel naloxone auto-injector device (EVZIO, kaleo, Inc., Richmond, VA) was approved by the Food and Drug Administration. In this article, we review the Human Factors Engineering (HFE) process used in the development and testing of this novel naloxone auto-injector currently used in nonmedical settings for the emergency treatment of known or suspected opioid overdose. HFE methods were employed throughout the product development process for the naloxone auto-injector including formative and summative studies in order to optimize the auto-injector's user interface, mitigate use-related hazards and increase reliability during an opioid emergency use scenario. HFE was also used to optimize the product's design and user interface in order to reduce or prevent user confusion and misuse. The naloxone auto-injector went through a rigorous HFE process that included perceptual, cognitive, and physical action analysis; formative usability evaluations; use error analysis and summative design validation studies. Applying HFE resulted in the development of a product that is safe, fast, easy and predictably reliable to deliver a potentially life-saving dose of naloxone during an opioid overdose emergency. The naloxone auto-injector may be considered as a universal precaution option for at-risk patients prescribed opioids or those who are at increased risk for an opioid overdose emergency.