Heroin-related deaths in New South Wales, Australia, 1992-1996

The metabolic clock of ketamine abuse in rats by a machine learning model

Ketamine has recently become an anesthetic drug used in human and veterinary clinical medicine for illicit abuse worldwide, but the detection of illicit abuse and inference of time intervals following ketamine abuse are challenging issues in forensic toxicological investigations. Here, we developed methods to estimate time intervals since ketamine use is based on significant metabolite changes in rat serum over time after a single intraperitoneal injection of ketamine, and global metabolomics was quantified by ultra-performance liquid chromatography-quadrupole-time-of-flight mass spectrometry (UPLC-Q-TOF-MS). Thirty-five rats were treated with saline (control) or ketamine at 3 doses (30, 60, and 90 mg/kg), and the serum was collected at 21 time points (0 h to 29 d). Time-dependent rather than dose-dependent features were observed. Thirty-nine potential biomarkers were identified, including ketamine and its metabolites, lipids, serotonin and other molecules, which were used for building a random forest model to estimate time intervals up to 29 days after ketamine treatment. The accuracy of the model was 85.37% in the cross-validation set and 58.33% in the validation set. This study provides further understanding of the time-dependent changes in metabolites induced by ketamine abuse.

A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times

BACKGROUND AND AIMS

Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation.

DESIGN

Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System.

SETTING

This study was conducted Australia-wide.

CASES

There were 610 cases of fatal heroin-related drug toxicity.

MEASUREMENTS

Information was collected on characteristics, manner of death, toxicology and autopsy results.

FINDINGS

The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood.

CONCLUSIONS

The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.

Heroin use and neuropsychological impairments: comparison of intravenous and inhalational use

BACKGROUND AND OBJECTIVES

Injection and inhalational heroin use are associated with different levels of brain exposure to heroin and its metabolites and differences in the severity of dependence, which might lead to differential impacts on neuropsychological functions. We examined the difference and the magnitude of difference in the neuropsychological functions between inhalational and injection heroin-dependent subjects and also compared them with healthy controls.

METHODS

The study sample comprised three groups: 73 subjects with injection heroin dependence, 74 with inhalational heroin dependence, and 75 healthy controls (HC). We excluded patients with HIV, head injury, epilepsy, and severe mental illness. Neuropsychological assessments were done by Standard Progressive Matrices, Wisconsin Card Sorting Test (WCST), Iowa Gambling Task, Trail-Making Tests A and B (TMT), and Verbal and Visual Memory 1 and 2 Backtests (NBT). We estimated independent effects of the groups on various neuropsychological test parameters, adjusted for age and duration of dependence.

RESULTS

In the WCST, the inhalational heroin-dependent group took more trials to complete the first category and had higher scores in the failure to maintain set than controls. The intravenous group had higher total errors than controls in verbal working memory tests and Visual Working Memory 2 Backtest. This group scored higher commission errors in the Verbal 2 Backtest than the controls. The two groups of heroin users differed in failure to maintain set and Verbal Working Memory 2 Backtests. The effect sizes of the group differences were modest.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Either route of heroin use is associated with cognitive impairments; inhalational and injection use involve different cognitive domains.

Prevalence and correlates of using opioids alone among individuals in a residential treatment program in Michigan: implications for overdose mortality prevention

BACKGROUND

Avoiding use of opioids while alone reduces overdose fatality risk; however, drug use-related stigma may be a barrier to consistently using opioids in the presence of others.

METHODS

We described the frequency of using opioids while alone among 241 people reporting daily heroin use or non-prescribed use of opioid analgesic medications (OAMs) in the month before attending a substance use disorder treatment program in the Midwestern USA. We investigated drug use-related stigma as a correlate of using opioids while alone frequently (very often vs. less frequently or never) and examined overdose risk behaviors associated with using opioids while alone frequently, adjusted for sociodemographic and clinical characteristics.

RESULTS

The sample was a median age of 30 years, 34% female, 79% white, and nearly all (91%) had experienced an overdose. Approximately 63% had used OAMs and 70% used heroin while alone very often in the month before treatment. High levels of anticipated stigma were associated with using either opioid while alone very often (adjusted PR: 1.20, 95% CI: 1.04-1.38). Drinking alcohol and taking sedatives within two hours of OAMs very often (vs. less often or never) and using OAMs in a new setting very often (vs. less often or never) were associated with using OAMs while alone very often. Taking sedatives within two hours of using heroin and using heroin in a new setting very often (vs. less often or never) were associated with using heroin while alone very often.

CONCLUSION

Anticipated stigma, polysubstance use, and use in a new setting were associated with using opioids while alone. These findings highlight a need for enhanced overdose harm reduction options, such as overdose detection services that can initiate an overdose response if needed. Addressing stigmatizing behaviors in communities may reduce anticipated stigma and support engagement and trust in these services.

Frequency and recency of non-medical opioid use and death due to overdose or suicide among individuals assessed for risky substance use: A national registry study in Sweden

Sweden and many other countries have experienced increases in suicide and accidental overdose deaths. An analysis examined the associations between recency of non-medical opioid misuse and frequency of use of non-medical opioids with death due to either suicide or accidental overdose within a sample of 15,000 Swedish adults who completed an Addiction Severity Index (ASI) assessment for risky substance use or a substance use disorder.

METHODS AND MATERIALS

Suicide (n = 136) and death due to overdose (n = 405) were identified in the official Cause of Death Registry from the Swedish National Board of Health and Welfare. Control variables included demographic characteristics and risks associated with either overdose or suicide. Cox regression analyses controlled for variables statistically significantly at the bivariate level.

RESULTS

At the multivariable level: a) a higher (modified) ASI Composite Score for mental health; b) history of suicide attempt; c) having used non-medical opioids for 1-2 times per week for at least a year; d) history of injection drug use; and, e) early onset of drug use, were all significantly and positively associated with death due to suicide. At the multivariable level: a) a higher the revised ASI Composite Score for mental health; b) recency of use of non-medical opioids; c) frequency of non-medical opioid use; d) being a male; and e) being of ages 18-24 years compared to ages 43-51 years were all positively and significantly associated with death due to accidental overdose.

CONCLUSION

These findings underscore the need to integrate mental health and substance use disorder treatment and provide suicide and overdose prevention interventions for individuals with an opioid use disorder. Recency and frequency of non-medical opioids were only associated with death due to overdose and not suicide. However, other drug use related variables (using opioids 1-2 times per week for at least a year, early onset of drug use and drug injection) were significantly associated with death due to suicide.

Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care

BACKGROUND

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.

METHODS

The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.

RESULTS

PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.

CONCLUSION

Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Prevalence of high-risk drug use and coverage of opioid substitution treatment and needle and syringe programs in Lithuania in 2015-2016: A multi-method estimation study

BACKGROUND AND OBJECTIVES

In Lithuania, injecting heroin and other illicit opioids has dominated high-risk drug use since about 2000. More recently, patients have reported a high-risk use of amphetamines. Newly diagnosed HIV cases among people who inject drugs peaked in 2002 and 2009 and drug-related deaths have been on the increase. Yet research has reported a limited number of available harm-reduction programs. This study aimed to estimate the size of high-risk drug using populations in Lithuania and to apply these estimates in assessing the coverage of opioid substitution treatment (OST) and needle and syringe programs (NSP).

METHODS

We used indirect prevalence estimation methods (HIV and Mortality Multiplier, Capture-Recapture, Truncated Poisson and the Multivariate Indicator Method) to obtain annual prevalence estimates of the population of high-risk opioid users (HROU) and of people who inject drugs (PWID) in Lithuania in 2015/2016. We computed the coverage of OST (the annual percentage of HROU in these programs) and NSP (the number of provided syringes per PWID per year), using the prevalence estimates and the data from drug services.

RESULTS

There were between 4854 and 12,444 HROU and between 8371 and 10,474 PWID in Lithuania in 2015/2016. In addition, we obtained a preliminary estimate of 4742-7000 high-risk amphetamine users. This constitutes around 2.5-6.5 HROU and 4.4-5.3 PWID per 1000 inhabitants aged 15-64. On average, 9.9-25.5% of HROUs were in OST and an average PWID in Lithuania obtained 19-29 syringes via NSPs during the study period.

CONCLUSIONS

While the current prevalence of high-risk drug use in Lithuania is comparable to other European countries and for PWID, it is above the average; and the coverage of OST and NSP services in this population is markedly lower than in most countries of the European Union and warrants further investment.

Regional, national and international datasets: How they improve our understanding of the acute harms associated with prescription medicine misuse

Prescription medicine misuse is a significant problem in many areas of the world. Understanding the acute and chronic harms related to misuse of prescription medicines allows healthcare professionals, drug addiction treatment services and legislative authorities to determine what interventions may be beneficial to reduce these harms and protect individuals and society. However, it is difficult to obtain systematic data on the harms associated with prescription medicine misuse because of how patient visits to clinics and hospitals are recorded and coded in regional or national databases. In this review, we discuss how regional, national and international sources of information can help develop a greater understanding of the prevalence and pattern of acute harms related to prescription medicine misuse using data from ambulance attendances, emergency department presentations and poisons information services.

Mass Spectrometric Imaging of the Brain Demonstrates the Regional Displacement of 6-Monoacetylmorphine by Naloxone

Overdose is the main cause of mortality among heroin users. Many of these overdose-induced deaths can be prevented through the timely administration of naloxone (NLX), a nonselective mu (μ)-, kappa (κ)-, and delta (δ)-opioid receptor antagonist. NLX competitively inhibits opioid-overdose-induced respiratory depression without eliciting any narcotic effect itself. The aim of this study was to investigate the antagonistic action of NLX by comparing its distribution to that of 6-monacetylmorphine (6-MAM), heroin's major metabolite, in a rodent model using mass spectrometric imaging (MSI) in combination with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Male Sprague-Dawley rats (n = 5) received heroin (10 mg kg^-1) intraperitoneally, NLX (10 mg kg^-1) intranasally, and NLX injected intranasally 5 min after heroin administration. The animals were sacrificed 15 min after dose and brain tissues were harvested. The MSI image analysis showed a region-specific distribution of 6-MAM in the brain regions including the corpus callosum, hippocampal formation, cerebral cortex, corticospinal tracts, caudate putamen, thalamus, globus pallidus, hypothalamus, and basal forebrain regions of the brain. The antagonist had a similar biodistribution throughout the brain in both groups of animals that received NLX or NLX after heroin administration. The MSI analysis demonstrated that the intensity of 6-MAM in these brain regions was reduced following NLX treatment. The decrease in 6-MAM intensity was caused by its displacement by the antagonist and its binding to these receptors in these specific brain regions, consequently enhancing the opioid elimination. These findings will contribute to the evaluation of other narcotic antagonists that might be considered for use in the treatment of drug overdose via MSI.

Opioid overdose detection using smartphones

Early detection and rapid intervention can prevent death from opioid overdose. At high doses, opioids (particularly fentanyl) can cause rapid cessation of breathing (apnea), hypoxemic/hypercarbic respiratory failure, and death, the physiologic sequence by which people commonly succumb from unintentional opioid overdose. We present algorithms that run on smartphones and unobtrusively detect opioid overdose events and their precursors. Our proof-of- concept contactless system converts the phone into a short-range active sonar using frequency shifts to identify respiratory depression, apnea, and gross motor movements associated with acute opioid toxicity. We develop algorithms and perform testing in two environments: (i) an approved supervised injection facility (SIF), where people self-inject illicit opioids, and (ii) the operating room (OR), where we simulate rapid, opioid-induced overdose events using routine induction of general anesthesia. In the SIF (n = 209), our system identified postinjection, opioid-induced central apnea with 96% sensitivity and 98% specificity and identified respiratory depression with 87% sensitivity and 89% specificity. These two key events commonly precede fatal opioid overdose. In the OR, our algorithm identified 19 of 20 simulated overdose events. Given the reliable reversibility of acute opioid toxicity, smartphone-enabled overdose detection coupled with the ability to alert naloxone-equipped friends and family or emergency medical services (EMS) could hold potential as a low-barrier, harm reduction intervention.

Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances

Background

Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths.

Methods

The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson’s chi-square test, Fisher’s exact test and the Mann-Whitney U test to analyse group differences.

Results

A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death.

Conclusions

The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.

Factors associated with help seeking by community responders trained in overdose prevention and naloxone administration in Massachusetts

BACKGROUND

Community overdose responders do not always seek help from emergency services when administering naloxone. We aimed to identify responder, overdose event, and community characteristics associated with help seeking from emergency services during overdoses reported by Massachusetts Overdose Education and Naloxone Distribution (OEND) enrollees, and to assess trends in help seeking over time.

METHODS

We analyzed overdose reports submitted between 2007 and 2017 to the Massachusetts Department of Public Health. We used logistic regression, stratified by responder drug use status, to assess associations of characteristics with help seeking during an overdose.

RESULTS

From January 2007 through December 2017, there were 69,870 OEND enrollees. 5,588 enrollees reported 10,246 overdoses. Help seeking was more likely among responders who did not use drugs. Among responders who did not use drugs, help seeking was more likely when: the responder was older or female, the victim was a stranger or client, and when naloxone did not work. Among responders who used drugs, help seeking was more likely when: the responder was female or had not previously reported responding to an overdose, the victim was a stranger or client or did not use fentanyl, naloxone took a longer time to work, and when the overdose was public or occurred more recently. The percentage of overdoses where help seeking occurred reached a maximum in 2016 at 50%.

CONCLUSIONS

Help seeking by OEND enrollees was significantly associated with several responder, victim, and event characteristics. Targeted interventions to promote help seeking are warranted, particularly as the lethality of opioid supplies rises.

Post-overdose interventions triggered by calling 911: Centering the perspectives of people who use drugs (PWUDs)

BACKGROUND

Opioid overdose deaths have increased exponentially in the United States. Bystander response to opioid overdose ideally involves administering naloxone, providing rescue breathing, and calling 911 to summon emergency medical assistance. Recently in the US, public health and public safety agencies have begun seeking to use 911 calls as a method to identify and deliver post-overdose interventions to opioid overdose patients. Little is known about the opinions of PWUDs about the barriers, benefits, or potential harms of post-overdose interventions linked to the 911 system. We sought to understand the perspectives of PWUDs about a method for using 911 data to identify opioid overdose cases and trigger a post-overdose intervention.

METHODS AND FINDINGS

We conducted three focus groups with 11 PWUDs in 2018. Results are organized into 4 categories: willingness to call 911 (benefits and risks of calling), thoughts about a technique to identify opioid overdoses in 911 data (benefits and concerns), thoughts about the proposed post-overdose intervention (benefits and concerns), and recommendations for developing an ideal post-overdose intervention. For most participants, calling 911 was synonymous with "calling the police" and law enforcement-related fears were pervasive, limiting willingness to engage with the 911 system. The technique to identify opioid overdoses and the proposed post-overdose intervention were identified as potentially lifesaving, but the benefits were balanced by concerns related to law enforcement involvement, intervention timing, and risks to privacy/reputation. Nearly universally, participants wished for a way to summon emergency medical assistance without triggering a law enforcement response.

CONCLUSIONS

The fact that the 911 system in the US inextricably links emergency medical assistance with law enforcement response inherently problematizes calling 911 for PWUDs, and has implications for surveillance and intervention. It is imperative to center the perspectives of PWUDs when designing and implementing interventions that rely on the 911 system for activation.

Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia

AIM

Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.

METHODS

The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.

RESULTS AND DISCUSSION

There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.

CONCLUSION

This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Concurrent Use of Benzodiazepine by Heroin Users-What Are the Prevalence and the Risks Associated with This Pattern of Use?

INTRODUCTION

Polydrug use involving heroin and benzodiazepines is common. The potential risk of additive pharmacological effects may be associated with poorer outcomes in patients who use benzodiazepines together with heroin. The aim of this study was to determine the clinical picture of patients presenting to the emergency department following acute drug toxicity involving heroin and benzodiazepines.

METHODS

Exposure information, clinical data and outcome of acute drug toxicity presentations were collected between 1 October 2013 and 30 September 2014 as part of the European Drug Emergencies Network (Euro-DEN) project. The database was interrogated to identify patients who had taken heroin with or without benzodiazepine(s).

RESULTS

A total of 1345 presentations involving acute heroin toxicity were identified: 492 had used one or more non-heroin/benzodiazepine drug and were not further considered in this study; 662 were lone heroin users and 191 had co-used heroin with one or more benzodiazepines. Co-users were more likely than lone heroin users to have reduced respiratory rate at presentation 12.7 ± 4.9 vs 13.6 ± 4.4 (p = 0.02) and require admission to hospital 18.3 vs 9.8% (p < 0.01). There were no differences in critical care admission rates 3.1 vs 3.9% (p = 0.83) or length of stay 4 h 59 min vs 5 h 32 min (p = 0.23). The 3 most common benzodiazepines were clonazepam, diazepam, and alprazolam. No differences were observed for clinical features between the three benzodiazepines.

CONCLUSION

This study shows that co-use of heroin and benzodiazepines is common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.

Hypermethylation of the κ1 opioid receptor promoter in Chinese heroin and methamphetamine addicts

Heroin and methamphetamine (METH) addiction continues to be a major social, economic and therapeutic problem worldwide. The opioid pathway may mediate the effects of addictive drugs. However, the potential correlation between the κ1 opioid receptor (OPRK1) and drug addiction has not yet been characterized. The aim of the present study was to investigate the potential association between methylation of the OPRK1 promoter and substance abuse. Bisulfite pyrosequencing technology was used to determine the levels of OPRK1 promoter methylation in 60 drug abusers (30 heroin and 30 METH addicts) and 52 controls, observed to exhibit no significant differences in age or gender. The results indicated that levels of OPRK1 promoter methylation were significantly higher in drug addicts when compared with controls (P=2.43×10⁻⁴). Significant correlations between OPRK1 promoter methylation and the length and frequency of drug use were also observed in male heroin addicts (length: r=0.661, P=0.007; frequency: r=−0.684, P=0.005). In addition, a luciferase reporter gene assay indicated that the OPRK1 promoter fragment was able to regulate gene expression (fold change between two groups >32.12, P≤0.0001). In conclusion, results of the present study indicate that methylation of the OPRK1 promoter contributes to the pathophysiology of drug addiction.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Illegal Drug-Attributable Mortality and Potential Years of Life Lost in Canada 2002: Implications for Prevention and Policy

The article estimates the deaths and years of life lost due to use of illegal drugs in Canada in the year 2002. In 2002, for Canada, 1,695 deaths were attributable to illegal drug use, 0.8% of all deaths: 1,183 of men (1.0%) and 512 in women (0.5%). Main causes of illegal drug use-attributable death were drug overdose, suicide, and hepatitis C. In 2002 in total, 62,110 years of life were lost prematurely, 42,306 years among men and 19,805 years among women. Illegal drug use constitutes a major contributor to the burden of mortality in Canada. A mixture of prevention and harm reduction measures is proposed to reduce the burden of mortality associated with drug use.

Suicide Risk in Young Men and Women After Substance Intoxication

This study investigates suicide and overdoses in 1,119 consecutive patients (64% women), 15 to 34 years of age, presenting at the emergency department after self-poisoning from1994 to 2000 and followed regarding death to 2006. Regression and Kaplan-Meier survival analyses were performed for suicide and other causes of death. The patients had about a 60 times higher risk (SMR = 61.95) of death due to suicide and 26 times higher (SMR = 26.47) for all-cause mortality. Men had a nearly 2 times higher risk for suicide than women and half of the suicides occurred during the first 2 years after admission. Poisoning was the most common suicide method and early prevention of self-poisoning is crucial to reducing future deaths.

Prevalence and characteristics of opioid-related deaths involving alcohol in Ontario, Canada

BACKGROUND

While it is well known that patients receiving opioids should refrain from alcohol consumption, little is known about the involvement of alcohol in opioid-related deaths.

METHODS

We conducted a population-based analysis of opioid-related deaths in Ontario with and without alcohol involvement between 1993 and 2013, and reported rates overall and stratified by manner of death. We compared the characteristics of individuals who died of an opioid overdose based on the presence or absence of alcohol involvement.

RESULTS

The rate of opioid-related deaths increased 288% from 11.9 per million (95% confidence interval (CI) 9.8-13.9 per million) in 1993-46.2 per million (95% CI 42.6-49.8 per million) in 2013. The rate of opioid-related deaths without alcohol involvement increased 388% from 7.4 per million to 36.1 per million, while deaths involving alcohol increased by 125% from 4.5 per million to 10.1 per million. Therefore, although the annual number of opioid-related deaths involving alcohol rose, the proportion of opioid-related deaths involving alcohol declined from 37.8% in 1993-21.9% by 2013. Generally, opioid-related deaths involving alcohol were less likely to involve other central nervous system depressants, and more likely to occur among men and those with a history of alcohol use disorder.

CONCLUSIONS

Although the relative contribution of alcohol in opioid-related deaths has declined, 1 in 5 fatal opioid overdoses still involved alcohol in 2013. Our findings highlight the ongoing need for targeted messaging around risks of opioids alone, and in combination with alcohol and other CNS depressants.

Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone

BACKGROUND

Illicit opioid use is associated with high rates of fatal and non-fatal opioid overdose. This study aims to compare rates of fatal and serious but non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone, and to identify risk factors for fatal opioid overdose.

METHODS

Opioid dependent patients treated with methadone (n=3515), buprenorphine (n=3250) or implant naltrexone (n=1461) in Western Australia for the first time between 2001 and 2010, were matched against state mortality and hospital data. Rates of fatal and non-fatal serious opioid overdoses were calculated and compared for the three treatments. Risk factors associated with fatal opioid overdose were examined using multivariate cox proportional hazard models.

RESULTS

No significant difference was observed between the three groups in terms of crude rates of fatal or non-fatal opioid overdoses. During the first 28days of treatment, rates of non-fatal opioid overdose were high in all three groups, as were fatal opioid overdoses in patients treated with methadone. However, no fatal opioid overdoses were observed in buprenorphine or naltrexone patients during this period. Following the first 28 days, buprenorphine was shown to be protective, particularly in terms of non-fatal opioid overdoses. After the cessation of treatment, rates of fatal and non-fatal opioid overdoses were similar between the groups, with the exception of lower rates of non-fatal opioid overdose in the naltrexone treated patients compared with the methadone treated patients. After the commencement of treatment, gender, and hospitalisations with a diagnosis of opioid poisoning, cardiovascular or mental health problems were significant predictors of subsequent fatal opioid overdose.

CONCLUSIONS

Rates of fatal and non-fatal opioid overdose were not significantly different in patients treated with methadone, buprenorphine or implant naltrexone. Gender and prior cause-specific hospitalisations can be used to identify patients at a high risk of fatal opioid overdose.

Development of a proto-typology of opiate overdose onset

BACKGROUND AND AIMS

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.

METHODS

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.

FINDINGS

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.

CONCLUSIONS

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.

Heroin overdose

BACKGROUND AND AIMS

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.

METHODS

Papers considered landmarks were selected from 1972, 1977, 1983, 1984 and 1999.

RESULTS

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.

CONCLUSIONS

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.

Post-prison Mortality: Unnatural Death Among People Released from Victorian Prisons Between January 1990 and December 1999

The extent and nature of unnatural death among people who were released from Victorian prisons between January 1990 and December 1999 were examined. A total of 820 men and women released during that period were identified as having died unnatural deaths while not imprisoned prior to July 2000. The rate of unnatural deaths among Victorian ex-prisoners was double the 1996/1997 Victorian rate of deaths in prison custody.The unnatural death rate of ex-prisoners was 10 times that found in the general Victorian population. Risk of unnatural death was greatest during the weeks immediately following release and greater among those who had previous imprisonments. Over half of the unnatural deaths were heroin-related deaths. Ex-prisoner heroin-related deaths accounted for at least 25% of all the Victorian heroin-related deaths.

The toxicology of heroin-related death: estimating survival times

BACKGROUND AND AIMS

The feasibility of intervention in heroin overdose is of clinical importance. The presence of 6-monoacetyl morphine (6MAM) in the blood is suggestive of survival times of less than 20-30 minutes following heroin administration. The study aimed to determine the proportions of cases in which 6MAM was present, and compare concentrations of secondary metabolites and circumstances of death by 6MAM status.

DESIGN

Analysis of cases of heroin-related death presenting to the Department of Forensic Medicine Sydney, 1 January 2013-12 December 2014.

SETTING

Sydney, Australia.

CASES

A total of 145 cases. The mean age was 40.5 years and 81% were male.

MEASUREMENTS

Concentrations of 6MAM, free morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Circumstances of death included bronchopneumonia, apparent sudden collapse, location and other central nervous system (CNS) depressants.

FINDINGS

6MAM was detected in 43% [confidence interval (CI) = 35-51%] of cases. The median free morphine concentration of 6MAM-positive cases was more than twice that of cases without 6MAM (0.26 versus 0.12 mg/l). 6MAM-positive cases also had lower concentrations of the other major heroin metabolites: M3G (0.05 versus 0.29 mg/l), M6G (0.02 versus 0.05 mg/l) with correspondingly lower M3G/morphine (0.54 versus 2.71) and M6G/morphine (0.05 versus 0.50) ratios. Significant independent correlates of 6MAM were a higher free morphine concentration [odds ratio (OR) = 1.7], a lower M6G/free morphine ratio (OR = 0.5) and signs of apparent collapse (OR = 6.7).

CONCLUSIONS

In heroin-related deaths in Sydney, Australia during 2013 and 2014, 6- monoacetyl morphine was present in the blood in less than half of cases, suggesting that a minority of cases had survival times after overdose of less than 20-30 minutes. The toxicology of heroin metabolites and the circumstances of death were consistent with 6- monoacetyl morphine as a proxy for a more rapid death.

Suicide Risk of Heroin Dependent Subjects in Lebanon

The aim is to determine the frequency of suicidal behavior and associated factors among heroin dependent inpatients. 61 heroin dependent inpatients (vs. 61 controls) were assessed on their pattern of substance use, impulsivity, depression and suicidal behavior. 37.7 % of patients had a personal history of suicidal attempt (SA), 14.8 % had current suicidal ideation. SA was associated to younger age at first substance use and to higher rates of depression and impulsivity. IV heroin overdose was the most frequent mode of SA (47.8 %). Long duration, multiple drug use, and family history of suicide were associated with higher risk of suicide among lebanese patients.

Risk factors for unnatural death: Fatal accidental intoxication, undetermined intent and suicide: Register follow-up in a criminal justice population with substance use problems

BACKGROUND

Risk factors for suicide and fatal accidental intoxication are extensively studied, while risk factors for intoxications/injuries of undetermined intent are less well known. The latter have shown an overlap with suicides, but also with fatal accidental intoxications. The objective was to analyze potential differences and similarities in the patterns of risk factors for accidental intoxications, injuries/intoxications with undetermined intent, and suicides, respectively.

METHODS

A follow-up register study was conducted, using data from ASI interviews with clients in the criminal justice system in Sweden (n=6744), followed in the National Causes of Death Register. A set of risk factors from the ASI interview were tested in bivariate analysis with the respective cause of death, yielding significant risk factors further analyzed in three Cox regression models.

RESULTS

In Cox regression analyses, death from fatal accidental intoxication was associated with male gender (HR 4.09), use of heroin (HR 2.86), and use of cannabis (HR 1.94), and death from intoxication/injury of undetermined intent was associated with use of heroin (HR 3.48), binge drinking of alcohol (HR 2.46) and previous psychiatric hospitalization (HR 2.41), while negatively associated with depression (HR 0.33). Death from suicide was associated with previous suicide attempts (HR 2.78) and use of sedatives (HR 2.17).

CONCLUSIONS

In this population of criminal justice clients with reported substance use problems, fatal injuries/intoxications with undetermined intent - like fatal accidental intoxications - appear to be associated with substance use variables, and cannot readily be assumed to represent the same background factors as suicide.

Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?

BACKGROUND

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.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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.

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

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.

Double trouble: Psychiatric comorbidity and opioid addiction-all-cause and cause-specific mortality

BACKGROUND

Opioid misusers have recognized high mortality but the influence of psychiatric comorbidity in excess cause-specific mortality is unclear.

METHODS

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. Standard mortality ratios were calculated to compare mortality risk with the general population. Cox and competing risk regression models were used to investigate the effect of psychiatric comorbidity and psychological health on all-cause and cause-specific mortality (respectively) in OUD patients.

RESULTS

Of 4837 OUD patients, 176 had died. Mortality rates were substantially higher than the general population (SMR 4.23; 95%CI 3.63-4.90). Among those with OUD, comorbid personality disorder (PD) and comorbid alcohol use disorder (AUD) was associated with increased all-cause mortality in all models, including the fully adjusted model, controlling for socio-demographic factors, severity of drug use, risk behaviours and physical health (HR2.15, 95%CI 1.17-3.95; HR2.28, 95%CI 1.54-3.36). AUD was associated with increased risk of fatal overdose (HR2.57, 95%CI 1.26-5.26) and hepatic-related deaths (HR7.26, 95%CI 2.79-18.86). Individuals with OUD and comorbid PD had almost four times greater risk of liver related deaths compared to those without PD (HR3.76, 95%CI 1.21-11.74). Comorbid severe mental illness and poor psychological health were not associated with increased mortality.

CONCLUSIONS

This study highlights the importance of assessment for PD and AUD in OUD patients in order to identify individuals at substantially elevated mortality risk to enable a more personalized approach to their medical care.

Mortality Risk Among Heroin Abusers: Clients and Non-clients of Public Treatment Centers for Drug Addiction

In Europe, the prevalence of problematic heroin consumption is declining but, in spite of the constant rise in the number of treated patients, many of them do not turn to a public treatment center (PTC) for their drug addiction. The aim of this study is to study the mortality risk separately for heroin abusers PTC clients and non-PTC clients (i.e., those never treated at a PTC).

METHODS

Cohort study on 959 subjects resident in the metropolitan area of Bologna who went to a health service (i.e., hospital, emergency unit) or to a PTC following problems due to heroin abuse for the first time between 01/01/2004 and 31/12/2009. Standardized mortality ratios (SMRs) were calculated, and regression analysis using the Poisson method was used.

RESULTS

Elevated and statistically significant SMRs were found in both genders, irrespective of the contact facility, being higher for PTC clients. Among non-PTC clients 28% of deaths overall were from AIDS or infectious diseases (6% PTC clients), 17% from opiate overdose (6% PTC clients) and 14% from violent causes (6% PTC clients). Multivariate analysis showed a higher mortality risk for patients who used both heroin and cocaine and for concomitant abuse of benzodiazepines.

CONCLUSIONS

The characteristics of patients never before treated for addiction prompts a reflection on the presence of a hidden group of patients who are hard to reach, who have a high mortality risk and who turn to health care treatment facilities only in the event of an emergency.

Would legalizing illicit opioids reduce overdose fatalities? Implications from a natural experiment

Overdose is the leading cause of premature mortality among heroin users. We examine whether the provision of regulated and quality-controlled heroin to users in specified doses would reduce heroin overdose rates. We also address this in the context of the epidemic of prescription opioid use and deaths seen in recent years in the United States and internationally. We explore the extent to which any change in legal access to heroin would affect overdose rates, and note that this depends upon the validity of the two main assumptions that variations in illicit drug purity and/or the presence of drug contaminants are major causes of overdose. Toxicological and demographic data from studies of heroin overdose deaths do not support these assumptions. The surge in the use of pharmaceutical opioids provides an example of the legal delivery of opioids of known dosage and free of contaminants, where overdose deaths can be examined to test these assumptions. Rates of fatal opioid overdose have escalated, with increased rates of prescribing of pharmaceutical opioids. On the basis of the experience with prescription opioids, unregulated legal heroin access would not reduce overdose rates.

Law enforcement attitudes toward overdose prevention and response

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.

Unintentional opioid overdose deaths in New York City, 2005-2010: a place-based approach to reduce risk

BACKGROUND

Drug poisoning is the leading cause of death from injuries in the United States. In New York City (NYC), unintentional drug poisoning death is the third leading cause of premature death, and opioids are the most commonly occurring class of drugs. Opioid overdose prevention efforts aim to decrease the number of people at risk for overdose and to decrease fatality rates among those using opioids by improving overdose response. These strategies can be enhanced with a comprehensive understanding of the settings in which overdoses occur.

METHODS

A cross-sectional analysis of unintentional opioid poisoning deaths in NYC from 2005 to 2010 (n=2649). Bivariate and multivariate analyses were performed to identify factors associated with settings of fatal opioid overdose.

RESULTS

Three-quarters of the sample overdosed in a home; one-tenth in an institution, and the remaining in a public indoor setting, the outdoors or another non-home setting. Factors associated with overdosing at home include female gender, college degree, residence in the borough of Staten Island, and combined use of opioid analgesics and benzodiazepines. Factors associated with overdosing outside of the home include ages 35-64, residence in Manhattan, and use of heroin.

CONCLUSION

The sample represents a near census of unintentional opioid overdose deaths in NYC during the study period, and allows for the identification of demographic and drug-using patterns by setting of overdose. Because most opioid overdoses occur inside the home, opioid overdose response programs can most efficiently address the epidemic by both reducing the risk of overdose in the home and targeting those who may be in the home at the time of an overdose for overdose response training. Approaches include minimizing risk of misuse and diversion through safe storage and safe disposal programs, physician education on prescribing of opioid analgesics and benzodiazepines, prescription of take-home naloxone, and Good Samaritan laws.

Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006)

BACKGROUND

During the summer of 2005, multiple cities in the United States began to report outbreaks of fentanyl-associated fatalities among illicit drug users. The objectives of this study were to (1) determine if an outbreak of fentanyl-associated fatalities occurred in mid-2005 to mid-2006 and (2) to examine trends and compare features of fentanyl-contaminated heroin-associated fatalities (FHFs) with non-fentanyl, heroin-associated fatalities (NFHFs) among illicit drug users.

METHODS

Baseline prevalence of fentanyl- and heroin-associated deaths was estimated from January to May 2005 based on recorded cause of death (determined by the medical examiner (ME)) using the Wayne County, MI, USA toxicology database. The database was then queried for both FHFs and NFHFs between July 1, 2005 and May 12, 2006. A FHF was defined as having fentanyl or norfentanyl (metabolite) detected in any postmortem biological sample and either (1) detection of heroin or its metabolite (6-acetylmorphine) and/or cocaine or its metabolite (benzoylecgonine) in a postmortem biological specimen or (2) confirmation of fentanyl abuse as the cause of death by the ME or a medical history available sufficient enough to exclude prescription fentanyl or other therapeutic opioid use. A NFHF was defined as detection of heroin, 6-acetylmorphine (heroin metabolite) or morphine in any postmortem biological specimen, heroin overdose listed as the cause of death by the ME, and absence of fentanyl detection on postmortem laboratory testing. Information was systematically collected, trended for each group and then compared between the two groups with regard to demographic, exposure, autopsy, and toxicology data. Logistic regression was performed using SAS v 9.1 examining the effects of age, gender, and marital status with fentanyl group status.

RESULTS

Monthly prevalence of fentanyl-associated fatalities among illicit drug users increased from an average of two in early 2005 to a peak of 24 in May, 2006. In total, 101 FHFs and 90 NFHFs were analyzed. The median age of decedents was 46 and 45 years for the fentanyl and non-fentanyl groups, respectively. Fentanyl-contaminated heroin-associated fatalities (FHFs) were more likely to be female (p = 0.003). Women aged over 44 years (OR = 4.67;95 % CI = 1.29-16.96) and divorced/widowed women (OR = 14.18;95 % CI = 1.59-127.01) were more likely to be FHFs when compared to women aged less than 44 years and single, respectively. A significant interaction occurred between gender and age, and gender and marital status. Most FHFs had central (heart) blood samples available for fentanyl testing (n = 96; 95 %): fentanyl was detected in most (n = 91; 95 %). Of these, close to half had no detectable heroin (or 6-acetylmorphine) concentrations (n = 37; 40.7 %). About half of these samples had detectable cocaine concentrations (n = 20; 54 %). Median fentanyl concentration in central blood samples was 0.02 μg/ml (n = 91, range <0.002-0.051 μg/ml) and 0.02 μg/ml (n = 32, range <0.004-0.069 μg/ml) in peripheral blood samples. The geometric mean of the ratio of central to peripheral values was 2.10 (median C/P = 1.75). At autopsy, pulmonary edema was the most frequently encountered finding for both groups (77 %).

CONCLUSION

Illicit drugs may contain undeclared ingredients that may increase the likelihood of fatality in users. Gender differences in fentanyl-related mortality may be modified by age and/or marital status. These findings may help inform public health and prevention activities if fatalities associated with fentanyl-contaminated illicit drugs reoccur.

Buprenorphine and medication management in a community corrections population: a pilot study

AIMS

This project sought to demonstrate the feasibility and acceptability of providing on-site buprenorphine treatment to individuals under community corrections supervision.

METHODS

Seventeen women and 13 men were enrolled on-site over a 2-week period at a community corrections location. Study participants received open-label study medication dispensed weekly over 12 weeks, weekly medication management therapy, and returned for a 1-month follow-up.

RESULTS

Participants were predominantly female (56%) and white (90%) with an average age of 31.7 ± 7.4 years. More than half (53%) had hepatitis C virus infection and 75.9% reported intravenous use of opioids in the 30 days before treatment. Rates of illicit substance use was high, as 37.9% of urines were positive for benzodiazepines, 31.7% were positive for cocaine, and 13.7% were positive for alcohol across the time in the study. Although rates of positive urines for opiate use and sex with multiple partners did not change during treatment, rates of injection drug use significantly decreased during treatment. Overall, 86.7% of participants were retained through the 1-month follow-up with low rates of adverse events.

CONCLUSIONS

Acceptability and feasibility of this approach were demonstrated by the ability to enroll and randomize the target sample of participants over 2 weeks with high retention and low rates of adverse events through 1-month follow-up. This pilot study demonstrated that this population could be successfully engaged in treatment and show reductions in risky behaviors. However, more intensive interventions may be needed to reduce opiate use to reach this vulnerable population at their point of contact with the criminal justice system.

Reversal of morphine analgesic tolerance by ethanol in the mouse

The chronic use of opioids in humans, accompanied by the development of tolerance, is a dangerous phenomenon in its own right. However, chronic opioid use is often made more dangerous by the coconsumption of other substances. It has been observed that the blood level of opioids in postmortem analyses of addicts, who consumed ethanol along with the opioid, was much less than that observed in individuals who died from opioids alone. This relationship between ethanol and opioids led us to investigate the hypothesis that ethanol alters tolerance to opioids. In the present study, we report that ethanol significantly and dose-dependently reduced the antinociceptive tolerance produced by morphine and the cross-tolerance between [D-Ala2,N-Me-Phe4,Gly5-ol]-enkephalin (DAMGO) and morphine in the mouse tail-flick test. The reversal of morphine tolerance was partially blocked by both the gamma receptor blocker bicuculline and by the γ-aminobutyric acid (GABA)(B) receptor blocker phaclofen and the administration of both inhibitors completely reversed the effects of ethanol on morphine tolerance. Diazepam, like ethanol, decreased morphine tolerance. However, this inhibition was reversed by the GABA(A) antagonist bicuculline but not by the GABA(B) antagonist phaclofen. These findings have important implications for individuals who abuse opioids and ethanol as well as suggest a mechanism to reduce the amount of opioid needed in chronic pain treatment.

Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009

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.

Premature deaths after discharge from methadone maintenance: a replication

OBJECTIVE

: Examine rate and causes of death among patients discharged from methadone maintenance, relate them to reasons for discharge, and discuss treatment implications.

METHOD

: Naturalistic study of deaths and causes of death among 636 opioid-dependent veterans treated with methadone maintenance between January 1, 2000 and August 31, 2002.

RESULTS

: Among 456 patients who remained on methadone, 31 (6.8%) died (1 overdose, 1 accident, 13 liver problems, 16 other medical). Among 180 discharged patients, 34 (18.8%) died. Reasons for discharge and causes of death were: continuing drug use (N = 52), 11 deaths (4 overdoses, 4 liver problems, 3 other medical); other disciplinary problems (N = 31), 8 deaths (2 suicides, 2 overdoses, 3 other medical, 1 unknown); other reasons (N = 97), 15 deaths (2 suicides, 1 overdose, 1 accident, 7 liver problems, 3 other medical, 1 unknown). Deaths were significantly less (P < 0.05) among patients who remained on methadone than in each category of those discharged. Follow-up interviews of 99 of 146 discharged patients showed problems in drug use, medical, employment, and psychiatric areas, and that only 21% were in treatment.

CONCLUSIONS

: These findings are consistent with a previous study from the same program, and also from other studies, showing that participating in methadone maintenance reduces mortality. Considered in light of the increased mortality among patients discharged for continuing drug use or behavioral problems, these data suggest that premature mortality can be reduced by keeping patients in treatment and/or taking steps to ensure that discharged patients are promptly enrolled in another program.

Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice

BACKGROUND

Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients.

METHOD

Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies.

CONCLUSION

Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.

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

Background

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.

Methods

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.

Results

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.

Conclusions

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.