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Mazzotti MC, Teti G, Giorgetti A, Carano F, Pelletti G, Pascali JP, Falconi M, Pelotti S, Fais P. Insights in opiates toxicity: impairment of human vascular mesenchymal stromal cells. Int J Legal Med 2023:10.1007/s00414-023-02961-y. [PMID: 36786894 PMCID: PMC10247844 DOI: 10.1007/s00414-023-02961-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/31/2023] [Indexed: 02/15/2023]
Abstract
The most common pulmonary findings in opiate-related fatalities are congestion and oedema, as well as acute and/or chronic alveolar haemorrhage, the cause of which is thought to be a damage to the capillary endothelium related to ischemia. Human vascular mesenchymal stromal cells (vMSCs) play a fundamental role in tissue regeneration and repair after endothelial cell injury, and they express opioid receptors. The aim of this study was to assess the effect of in vitro morphine exposure on the physiological activity and maintenance of human vMSCs. vMSCs were obtained from abdominal aorta fragments collected during surgery repair and were exposed to incremental doses (0.1 mM, 0.4 mM, 0.8 mM and 1 mM) of morphine sulphate for 7 days. The effect was investigated through cell viability assessment, proliferation assay, reactive oxygen species (ROS) detection assay, senescence-associated β-galactosidase assay, senescent-related markers (p21WAF1/CIP1 and p16INK4) and the apoptosis-related marker caspase 3. Moreover, an ultrastructural analysis by transmission electron microscopy and in vitro vascular differentiation were evaluated. Results showed a decrease of the cellular metabolic activity, a pro-oxidant and pro-senescence effect, an increase in intracellular ROS and the activation of the apoptosis signalling, as well as ultrastructural modifications and impairment of vascular differentiation after morphine treatment of vMSC. Although confirmation studies are required on real fatal opiate intoxications, the approach based on morphological and immunofluorescence methodologies may have a high potential also as a useful tool or as a complementary method in forensic pathology. The application of these techniques in the future may lead to the identification of new markers and morphological parameters useful as complementary investigations for drug-related deaths.
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Affiliation(s)
- Maria Carla Mazzotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Gabriella Teti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy.
| | - Francesco Carano
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Guido Pelletti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Jennifer Paola Pascali
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Via Giustiniani, 2, 35127, Padua, Italy
| | - Mirella Falconi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Paolo Fais
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
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Bråbäck M, Brantefors A, Franck J, Brådvik L, Isendahl P, Nilsson S, Troberg K, Håkansson A. Substance Use, Hospitalizations, and Co-Occurring Disorders among Patients Transferred from a Needle Exchange Program to Opioid Maintenance Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020697. [PMID: 35055519 PMCID: PMC8775654 DOI: 10.3390/ijerph19020697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/28/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
Opioid use disorders (OUD) is a relapsing condition with high mortality. Opioid maintenance treatment (OMT) reduces heroin use, and overall morbidity and mortality. The prevalence of psychiatric and substance use disorders, potential baseline predictors for psychiatric hospitalization, and psychiatric diagnoses at follow-up were investigated and may give hints about possible preventative strategies. The medical records for 71 patients were reviewed 36 months following referral to OMT from a needle exchange program (NEP). Their psychiatric diagnoses and hospitalizations were identified. Their baseline characteristics were assessed for potential differences between hospitalized versus non-hospitalized patients and between patients with and without psychiatric diagnoses in a longitudinal observational study without controls. A regression analysis was performed to identify predictors for hospitalization when controlling for OMT status. Sixty-five percent of the patients were hospitalized at least once with a psychiatric diagnosis. Substance-related reasons were prevalent, and detoxification occurred among 59% of patients, with sedative- hypnotics (benzodiazepines, zopiclone, zolpidem, and pregabalin) being the substance used by 52% of patients. Baseline use of these drugs and/or buprenorphine predicted for hospitalization when controlling for OMT status. During the follow-up period, 72% of patients met the criteria for a psychiatric diagnosis other than OUD. The prevalence of non-substance use disorders overlapping with SUD was 41%, and that overlapping with anxiety disorder was 27% of all participants. Increased attention to psychiatric co-occurring disorders in the treatment of OUD is required and the importance of addressing sedative-hypnotics use when initiating OMT is highlighted.
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Affiliation(s)
- Martin Bråbäck
- Department of Clinical Sciences Lund, Faculty of Medicine, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden; (M.B.); (A.B.); (L.B.); (K.T.); (A.H.)
- Addiction Center Malmö, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden;
| | - Anna Brantefors
- Department of Clinical Sciences Lund, Faculty of Medicine, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden; (M.B.); (A.B.); (L.B.); (K.T.); (A.H.)
- Addiction Center Malmö, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden;
| | - Johan Franck
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, SE171 77 Solna, Sweden;
| | - Louise Brådvik
- Department of Clinical Sciences Lund, Faculty of Medicine, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden; (M.B.); (A.B.); (L.B.); (K.T.); (A.H.)
- Correspondence: ; Tel.: +46-46-7332410
| | - Pernilla Isendahl
- Department of Infectious Diseases, University Hospital Skåne, SE205 02 Malmö, Sweden;
| | - Suzan Nilsson
- Addiction Center Malmö, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden;
| | - Katja Troberg
- Department of Clinical Sciences Lund, Faculty of Medicine, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden; (M.B.); (A.B.); (L.B.); (K.T.); (A.H.)
- Addiction Center Malmö, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden;
| | - Anders Håkansson
- Department of Clinical Sciences Lund, Faculty of Medicine, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden; (M.B.); (A.B.); (L.B.); (K.T.); (A.H.)
- Addiction Center Malmö, Division of Psychiatry, Lund University, SE222 41 Lund, Sweden;
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Mintz CM, Presnall NJ, Xu KY, Hartz SM, Sahrmann JM, Bierut LJ, Grucza RA. An examination between treatment type and treatment retention in persons with opioid and co-occurring alcohol use disorders. Drug Alcohol Depend 2021; 226:108886. [PMID: 34245997 PMCID: PMC8370094 DOI: 10.1016/j.drugalcdep.2021.108886] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Persons with opioid use disorder (OUD) and co-occurring alcohol use disorder (AUD) are understudied. We identified whether co-occurring AUD was associated with OUD treatment type, compared associations between treatment type and six-month treatment retention and determined whether co-occurring AUD moderated these relationships. METHODS We used an observational cohort study design to analyze insurance claims data from 2011 to 2016 from persons aged 12-64 with an opioid abuse or opioid dependence diagnosis and OUD treatment claim. Our unit of analysis was the treatment episode; we used logistic regression for analyses. RESULTS Of 211,047 treatment episodes analyzed, 14 % had co-occurring alcohol abuse or dependence diagnoses. Among persons with opioid dependence, persons with co-occurring alcohol dependence were 25 % less likely to receive medication treatment relative to those without AUD. Further, alcohol dependence was associated with decreased likelihood of treatment with buprenorphine (AOR 0.47, 95 % CI 0.44-0.49) or methadone (AOR 0.31, 95 % CI 0.28-0.35) and increased likelihood of treatment with extended-release (AOR 1.36, 95 % CI 1.21-1.54) or oral (AOR 1.73, 95 % CI 1.57-1.90) naltrexone relative to psychosocial treatment. Buprenorphine and methadone were associated with highest retention prevalence regardless of OUD or AUD severity. Co-occurring alcohol abuse or dependence did not meaningfully change retention prevalence associated with buprenorphine or methadone. Co-occurring AUD was not associated with improved retention among persons receiving either formulation of naltrexone. CONCLUSIONS Buprenorphine and methadone are associated with relatively high likelihood of treatment retention among persons opioid and alcohol dependence, but are disproportionately under-prescribed.
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Affiliation(s)
- Carrie M Mintz
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8134, St. Louis, MO, 63110, United States.
| | - Ned J Presnall
- Department of Social Work, Washington University, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, United States of America
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8134, St. Louis, MO, 63110, United States of America
| | - Sarah M Hartz
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8134, St. Louis, MO, 63110, United States of America
| | - John M Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, 4990 Children’s Place, St. Louis, MO, 63110, United States of America
| | - Laura J Bierut
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8134, St. Louis, MO, 63110, United States of America
| | - Richard A Grucza
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, 1008 South Spring, SLUCare Academic Pavilion, 3rd Floor, St. Louis, MO, 63110, United States of America
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Armoon B, SoleimanvandiAzar N, Rostami M, Higgs P, Bayani A, Bayat AH, Mohammadi R, Ahounbar E, Fattah Moghaddam L. Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis. J Addict Dis 2021; 40:114-125. [PMID: 34286664 DOI: 10.1080/10550887.2021.1950262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.
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Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Neda SoleimanvandiAzar
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami
- Department of Counseling, Faculty of Humanities and Social Sciences, University of Kurdistan, Kurdistan, Iran
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Azadeh Bayani
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Amir-Hossein Bayat
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Elahe Ahounbar
- Substance Abuse and Dependence Research Center, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Noroozi M, Higgs P, Bayani A, Armoon B, Astaneh AN, Moghaddam LF, Askari M. Non -fatal overdose among people who inject drugs in Tehran, Iran. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:80. [PMID: 33054806 PMCID: PMC7559998 DOI: 10.1186/s13011-020-00323-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND With increasing frequencies of non-fatal overdose in people who inject drugs (PWID), it is essential to improve our knowledge about associated risk factors for overdose to inform overdose prevention and assistance programs. The aim of present study was to determine the prevalence of non-fatal overdose and the associated risk factors among PWID in Tehran, Iran. METHODS Snowball sampling was used to collect data from 465 participants in Tehran using a cross-sectional survey. Consenting participants who reported drug injecting in the past month and were able to speak and comprehend Farsi enough to respond to survey questions were interviewed. The endpoint of interest was non-fatal overdose in the previous 6 months, or answering "Yes" to the question: "In the last six months, have you ever overdosed by accident? (at least once)". We used STATA v. 14 for this analysis. Statistical significance was defined as p < 0.05 for all analyses. RESULTS Of 465 PWIDs who participated in this study, all were male, and about half had less than a high school education. The prevalence of self-reported non-fatal overdose in the past 6 months was 38% (CI95%: 34, 43%). Our findings indicate that characteristics and behaviors that were associated with an increased risk of experiencing an overdose in the past 6 months were drug use initiation under 22 years (AOR =2.2, P < 0.05), using methamphetamine (AOR =2.8, P < 0.05), and using multiple drugs at the same time (AOR =2.1, P < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing an overdose in the past 6 months. The odds of experiencing a non-fatal overdose among PWIDs who regularly attended NSP were 0.6 times less than for those who did not attend regularly (OR = 0.6,95% CI: 0.2-0.9). CONCLUSION Methamphetamine and alcohol use were the most significant association for non-fatal overdose among PWIDs. Our results indicate that intervention and prevention initiatives seeking to reduce overdoses among PWIDs should not only be focused on the primary drug used but also the use of alcohol and poly-drug use.
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Affiliation(s)
- Mehdi Noroozi
- Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Azadeh Bayani
- Student Research Committee, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahram Armoon
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran.
| | - Ali Nazeri Astaneh
- Department of Psychiatry, University of Social Welfare and Rehabilitation Science, Tehran, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Nicolakis J, Gmeiner G, Reiter C, Seltenhammer MH. Aspiration in lethal drug abuse-a consequence of opioid intoxication. Int J Legal Med 2020; 134:2121-2132. [PMID: 32929594 PMCID: PMC7578170 DOI: 10.1007/s00414-020-02412-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/27/2020] [Indexed: 12/12/2022]
Abstract
AIMS The primary objective of this study was to investigate whether the fatalities of opioid abuse are not only related to respiratory depression but also as a result of other side effects such as emesis, delayed gastric emptying, a reduction of the cough reflex, and impaired consciousness leading to the aspiration of gastric contents, a finding regularly observed in drug-related deaths. DESIGN A retrospective exploratory study analyzing heroin/morphine/methadone-related deaths submitted to court-ordered autopsy. SETTING Center for Forensic Medicine, Medical University of Vienna, Austria (2010-2015). PARTICIPANTS Two hundred thirty-four autopsy cases were included in the study: morphine (n = 200), heroin (n = 11), and methadone (n = 23) intoxication. FINDINGS Analyses revealed that 41.88% of all deceased showed aspiration of gastric contents with equal gender distribution (p = 0.59). Aspiration was more frequent in younger deceased (χ2 = 8.7936; p = 0.012) and in deceased with higher body mass index (BMI) (χ2 = 6.2441; p = 0.044). Blood opioid concentration was lower in deceased with signs of aspiration than in non-aspirators (p = 0.013). Toxicological evaluation revealed a high degree of concomitant substance abuse (91%)-benzodiazepines (61.6%) and/or alcohol (21.8%). CONCLUSIONS There are lower opioid concentrations in deceased with signs of aspiration, a fact which strongly points to aspiration as alternative cause of death in opioid-related fatalities. Furthermore, this study highlights the common abuse of slow-release oral morphine in Vienna and discusses alternative medications in substitution programs (buprenorphine/naloxone or tamper-resistant slow-release oral morphine preparations), as they might reduce intravenous abuse and opioid-related deaths.
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Affiliation(s)
- Johannes Nicolakis
- Center for Forensic Medicine, Medical University of Vienna, Sensengasse 2, A-1090, Vienna, Austria
| | - Günter Gmeiner
- Seibersdorf Laboratories, Campus Seibersdorf, A-2444, Seibersdorf, Austria
| | - Christian Reiter
- Center for Forensic Medicine, Medical University of Vienna, Sensengasse 2, A-1090, Vienna, Austria
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Deyessa N, Senbete B, Abdo A, Mundia BM. Population estimation and harm reduction among people who inject drugs in Addis Ababa, Ethiopia. Harm Reduct J 2020; 17:61. [PMID: 32894153 PMCID: PMC7487880 DOI: 10.1186/s12954-020-00407-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 08/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background Injecting drug use is known to contribute significantly to the spread of the HIV epidemic in many parts of the developing world. Due to the hidden nature and stigma of the problem, it is difficult to study using routine surveys. Therefore, this study aims to estimate the number of people who inject drugs in Addis Ababa, Ethiopia, and to describe the epidemiological and social situation related to HIV among people who inject drugs. Methods The study used rapid assessment methods, followed by combined methods of estimating populations, using nomination and multiplier methods. The combined methods used two datasets: the first includes the proportion of people who use services within a year as a multiplier, and the second, a count of the list of people with a problem who used the specific service within a year as a benchmark. The rapid assessment incorporated different qualitative tools to elicit information related to injectable drugs, using existing data sources, in-depth interviews, and focus group discussions. Results The study estimated a total of 4068; with 95% CI (3196, 5207) people who inject drugs (PWIDs) in Addis Ababa. The study found people who inject drugs were young in age, male, with a lower educational status, unmarried, and living in small clerical business. People who inject drugs and participated in the study were more likely to use additional substances like alcohol, khat, and cannabis. The most common form of injectable drug used was heroin, and most of the people who inject drugs reported sharing syringes and needles. A high proportion of study subjects also disclosed having positive test results for HIV, hepatitis B, and C. Conclusion The population size of people who inject drugs in Addis Ababa is high. Lack of service in harm reduction in the city has made PWIDs vulnerable and at higher risk for HIV/AIDs and hepatitis B and C. Therefore, responsible bodies must start implementing the essential harm reduction strategies given by the World Health Organization.
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Affiliation(s)
- Negussie Deyessa
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, P.O. Box 3253, Addis Ababa, Ethiopia.
| | - Bekele Senbete
- Organization for Social Services, Health, and Development, Addis Ababa, Ethiopia
| | - Aman Abdo
- Organization for Social Services, Health, and Development, Addis Ababa, Ethiopia
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Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden. BMC Psychiatry 2020; 20:49. [PMID: 32028921 PMCID: PMC7006080 DOI: 10.1186/s12888-020-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. METHODS Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. DISCUSSION Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. TRIAL REGISTRATION Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.
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Affiliation(s)
- Katja Troberg
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden. .,Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden. .,Malmö Addiction Centre, Clinical Research Unit, Södra Förstadsg. 35, Plan 4, S-205 02, Malmö, Sweden.
| | - Pernilla Isendahl
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden ,Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.426217.40000 0004 0624 3273Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden
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Connery HS, Taghian N, Kim J, Griffin M, Rockett IR, Weiss RD, McHugh RK. Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder. Drug Alcohol Depend 2019; 205:107612. [PMID: 31627077 PMCID: PMC6929689 DOI: 10.1016/j.drugalcdep.2019.107612] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization. METHODS Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die). RESULTS Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood. CONCLUSIONS Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.
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Affiliation(s)
- Hilary S. Connery
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA,Harvard Medical School, Departments of Psychiatry/Psychology, 25 Shattuck Street, Boston, MA 02115, USA
| | - Nadine Taghian
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
| | - Jungjin Kim
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; Partners Health Care Addiction Psychiatry Fellowship Training Program, 115 Mill Street, Belmont, MA 02478, USA.
| | - Margaret Griffin
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; Harvard Medical School, Departments of Psychiatry/Psychology, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Ian R.H. Rockett
- West Virginia University, Department of Epidemiology, One Waterfront Place, Morgantown, WV 26506-6009, USA,University of Rochester Medical Center, Department of Psychiatry, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Roger D. Weiss
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA,Harvard Medical School, Departments of Psychiatry/Psychology, 25 Shattuck Street, Boston, MA 02115, USA
| | - R. Kathryn McHugh
- McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA,Harvard Medical School, Departments of Psychiatry/Psychology, 25 Shattuck Street, Boston, MA 02115, USA
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10
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Bennett AS, Watford JA, Elliott L, Wolfson-Stofko B, Guarino H. Military veterans' overdose risk behavior: Demographic and biopsychosocial influences. Addict Behav 2019; 99:106036. [PMID: 31494452 DOI: 10.1016/j.addbeh.2019.106036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND U.S. military veterans face many biopsychosocial (BPS) challenges post-service that may elevate risk for opioid-related overdose including physical pain, mental health concerns and social stressors. Some veterans use opioids to manage pain and cope with social readjustment. This study assessed associations between BPS factors and recent engagement in overdose risk behavior in a community sample of post-9/11 veterans who used opioids in New York City. METHODS Participants (n = 218) were recruited through convenience sampling and completed a baseline assessment including a validated Opioid Risk Behavior Scale (ORBS) that measured past-30-day engagement in 22 opioid-related overdose risk behaviors. Analyses examined associations between ORBS scores and hypothesized demographic, biological/physical, psychological and social predictors. Incident rate ratios estimated the expected relative difference in ORBS score associated with each predictor. RESULTS Participants reported an average of 4.72 overdose risk behaviors in the past 30 days. Significant independent predictors of higher ORBS score, after adjustment for demographics and current prescription medications, were past-30-day: depression symptoms; unsheltered or living in a homeless shelter (vs. private housing); history of mental health treatment; experiencing stressful life events; average pain severity; and pain interference. CONCLUSION Veterans face myriad BPS challenges and, while drug-related overdose risks are well understood, findings suggest that other factors-including mental health, pain and stressful life events-may also be associated with overdose risk among opioid-using veterans. The larger challenges veterans face should be considered in the context of BPS forms of pain management when tailoring and delivering overdose prevention interventions.
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11
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Saini R, Rao R, Parmar A, Mishra AK, Ambekar A, Agrawal A, Dhingra N. Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study. Drug Alcohol Rev 2019; 39:93-97. [PMID: 31769134 DOI: 10.1111/dar.13016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India. DESIGN AND METHODS Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed. RESULTS The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose. DISCUSSION AND CONCLUSION The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.
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Affiliation(s)
- Romil Saini
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Rao
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Arpit Parmar
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani K Mishra
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Ambekar
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Agrawal
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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12
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Njoroge LW, Al-Kindi SG, Koromia GA, ElAmm CA, Oliveira GH. Changes in the Association of Rising Infective Endocarditis With Mortality in People Who Inject Drugs. JAMA Cardiol 2019; 3:779-780. [PMID: 29926083 DOI: 10.1001/jamacardio.2018.1602] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Linda W Njoroge
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine,Case Western Reserve University, Cleveland, Ohio
| | - Sadeer G Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine,Case Western Reserve University, Cleveland, Ohio
| | | | - Chantal A ElAmm
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine,Case Western Reserve University, Cleveland, Ohio
| | - Guilherme H Oliveira
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine,Case Western Reserve University, Cleveland, Ohio
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13
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Klimas J, Gorfinkel L, Giacomuzzi SM, Ruckes C, Socías ME, Fairbairn N, Wood E. Slow release oral morphine versus methadone for the treatment of opioid use disorder. BMJ Open 2019; 9:e025799. [PMID: 30944135 PMCID: PMC6500187 DOI: 10.1136/bmjopen-2018-025799] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD). DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Three electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials. RESULTS Among 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use. CONCLUSIONS Meta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.
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Affiliation(s)
- Jan Klimas
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | - Christian Ruckes
- University Medical Center Mainz, Interdisciplinary Center Clinical Trials, Mainz, Germany
| | | | - Nadia Fairbairn
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Evan Wood
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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14
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Ivers JH, Zgaga L, O’Donoghue-Hynes B, Heary A, Gallwey B, Barry J. Five-year standardised mortality ratios in a cohort of homeless people in Dublin. BMJ Open 2019; 9:e023010. [PMID: 30782692 PMCID: PMC6352814 DOI: 10.1136/bmjopen-2018-023010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/09/2018] [Accepted: 09/18/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To calculate standardised mortality ratios (SMRs) for a cohort of homeless people in the Dublin region over a 5-year period and to examine leading causes of death. SETTING Homeless services reporting deaths from homeless persons in their care across the Dublin Homeless Region. METHODS Death data among people who experience homelessness was acquired from the Dublin Region Homeless Executive (2011-2015) and validated from both death certificates and records from the Dublin Coroner's Office. PARTICIPANTS Two hundred and nine deaths were recorded; of these 201 were verified (n=156 males, 77.6%). Deaths that could not be verified by certificate or coroners record were excluded from the study. RESULTS SMRs were 3-10 times higher in homeless men and 6-10 times higher in homeless women compared with the general population. Drug and alcohol-related deaths were the leading cause of death, accounting for 38.4% of deaths in homeless individuals. These were followed by circulatory (20%) and respiratory causes (13%). CONCLUSION Mortality rates among homeless persons are exceptionally high. Services and programmes, particularly housing and those targeting overdose and alcoholism, are urgently needed to prevent premature mortality in this vulnerable population.
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Affiliation(s)
- Jo-Hanna Ivers
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Lina Zgaga
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | | | - Aisling Heary
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Brian Gallwey
- Research, Dublin Regional Homeless Executive, Dublin, Ireland
| | - Joe Barry
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
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15
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Behar E, Chang JS, Countess K, Matheson T, Santos GM, Coffin P. Perceived Causes of Personal versus Witnessed Overdoses among People who Inject Opioids. Subst Use Misuse 2019; 54:1929-1937. [PMID: 31070106 PMCID: PMC7185847 DOI: 10.1080/10826084.2019.1609988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Studies show that people who inject drugs (PWID) underestimate their overdose risk. We sought to explore this phenomenon by comparing how PWID perceive causes of personal overdoses compared to witnessed overdoses. Methods: We analyzed 40 interviews from participants enrolled in a randomized-controlled behavioral intervention to reduce overdose among at-risk PWID in San Francisco from 2014 to 2016. Subjects were current illicit opioid injectors with opioid use disorder, had received take-home naloxone, and had overdosed within five years. Interviews were audio-recorded and transcribed verbatim. Using thematic content analysis, three analysts coded the interviews and measured interrater reliability. The analysts developed a codebook of a priori and inductively generated codes, and applied it to all interviews. Coding discrepancies were discussed. Results: We used two theoretical frameworks - actor observer bias (AOB) and intragroup stigma - to analyze participants' descriptions of personal and witnessed overdoses. AOB suggests individuals may assign responsibility of their actions to external factors, while assigning responsibility for others' actions to internal mechanisms. Intragroup stigma describes the process whereby people perpetuate stigma within their own group. Related to these concepts, two principal themes were used to describe personal overdose: (1) drug volatility and (2) ascribing blame to others, and witnessed overdoses: (1) greed and (2) inexperience/foolishness. Conclusion/Importance: The differences in perceived causes of personal versus witnessed overdose align with AOB and intragroup stigma. Understanding how these theories shape overdose experiences may improve behavioral interventions by introducing peer based supports and encouraging PWIDs to employ evidence-based safety precautions when using opioids.
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Affiliation(s)
- Emily Behar
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
| | | | - Kennedy Countess
- San Francisco Department of Public Health , San Francisco , California , USA
| | - Tim Matheson
- San Francisco Department of Public Health , San Francisco , California , USA
| | - Glenn-Milo Santos
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
| | - Phillip Coffin
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
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16
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Ji H, Liu G, Xu X, Liu H, Xu L, Hu H, Chen Y, Hong Q, Wang Q, Shen W, Li L, Xie X, Zhou W, Duan S. Hypermethylation of the κ1 opioid receptor promoter in Chinese heroin and methamphetamine addicts. Exp Ther Med 2018; 16:2392-2398. [PMID: 30210591 PMCID: PMC6122531 DOI: 10.3892/etm.2018.6514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 04/11/2017] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Huihui Ji
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Guili Liu
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Xuting Xu
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Huifen Liu
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Lei Xu
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Haochang Hu
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Yingmin Chen
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Qinxiao Hong
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Qinwen Wang
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Wenwen Shen
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Longhui Li
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Xiaohu Xie
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Wenhua Zhou
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, Ningbo, Zhejiang 315010, P.R. China
| | - Shiwei Duan
- Medical Genetics Center, School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
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17
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Mars SG, Ondocsin J, Ciccarone D. Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency. Harm Reduct J 2018; 15:26. [PMID: 29769132 PMCID: PMC5956544 DOI: 10.1186/s12954-018-0232-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 04/29/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Sarah G Mars
- Heroin in Transition Study, Department of Family and Community Medicine, UCSF, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA. .,Department of Family and Community Medicine, University of California, San Francisco, CA, USA.
| | - Jeff Ondocsin
- Heroin in Transition Study, Department of Family and Community Medicine, UCSF, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA
| | - Daniel Ciccarone
- Heroin in Transition Study, Department of Family and Community Medicine, UCSF, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA.,Department of Family and Community Medicine, University of California, San Francisco, CA, USA
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18
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Tavitian-Exley I, Boily MC, Heimer R, Uusküla A, Levina O, Maheu-Giroux M. Polydrug Use and Heterogeneity in HIV Risk Among People Who Inject Drugs in Estonia and Russia: A Latent Class Analysis. AIDS Behav 2018; 22:1329-1340. [PMID: 28699018 PMCID: PMC5878835 DOI: 10.1007/s10461-017-1836-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Non-medical drug injection is a major risk factor for HIV infection in Russia and Estonia. Multiple drug use (polydrug) has further been associated with increased harms. We compared HIV, injecting and sexual risk associated with polydrug use among people who injected drugs (PWID) in 2012–2013 in Kohtla-Järve (Estonia, n = 591) and St Petersburg (Russia, n = 811). Using latent class analysis, we identified five (poly)drug classes, the largest consisting of single-drug injectors among whom an opioid was the sole drug injected (56% of PWID). The four remaining polydrug classes included polydrug-polyroute injectors who injected and used opiates and stimulants (9%), opiate-stimulant poly-injectors who injected amphetamine-type-stimulants with a primary opiate (7%) and opiate-opioid poly-injectors who injected opioids and opiates (16%). Non-injection stimulant co-users were injectors who also used non-injection stimulants (12%). In multivariable multinomial regressions, all four polydrug classes were associated with greater injection risks than single-drug injection, while opiate-stimulant and opiate-opioid poly-injection were also associated with having multiple sex partners. Riskier behaviours among polydrug-injectors suggest increased potential for transmission of blood-borne and sexually-transmitted infections. In addition to needles/syringes provision, services tailored to PWID drug and risk profiles, could consider drug-appropriate treatment and sexual risk reduction strategies to curb HIV transmission.
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Affiliation(s)
- Isabel Tavitian-Exley
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk place, London, W21PG, UK.
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk place, London, W21PG, UK.
| | - Robert Heimer
- Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
| | - Anneli Uusküla
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Olga Levina
- NGO Stellit, St Petersburg, Russian Federation
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
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19
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Meacham MC, Strathdee SA, Rangel G, Armenta RF, Gaines TL, Garfein RS. Prevalence and Correlates of Heroin-Methamphetamine Co-Injection Among Persons Who Inject Drugs in San Diego, California, and Tijuana, Baja California, Mexico. J Stud Alcohol Drugs 2017; 77:774-81. [PMID: 27588536 DOI: 10.15288/jsad.2016.77.774] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although persons who inject drugs (PWID) in the western United States-Mexico border region are known to inject both heroin and methamphetamine, little is known about the prevalence and risks associated with co-injection of this depressant-stimulant combination (also known as "goofball" and "Mexican speedball"). METHOD Baseline data from parallel cohort studies of PWID conducted concurrently in San Diego, CA, and Tijuana, Mexico, were used to estimate the prevalence and identify correlates of heroin-methamphetamine co-injection. PWID older than 18 years of age who reported injecting illicit drugs in the past month (N = 1,311; 32.7% female) were recruited in San Diego (n = 576) and Tijuana (n = 735) and completed interviewer-administered questionnaires. Bivariate and multivariable logistic regression analyses were used to identify correlates of heroin-meth-amphetamine co-injection. RESULTS The prevalence of co-injection in the past 6 months was 39.9% overall and was higher in Tijuana (55.8%) than in San Diego (19.8%). In multivariable analyses adjusting for study cohort, distributive syringe sharing, purchasing syringes prefilled with drugs, finding it hard to get new syringes, reporting great or urgent need for treatment, and younger age were independently associated with co-injection. Past-6-month overdose was significantly associated with higher odds of co-injection in San Diego than in Tijuana. CONCLUSIONS These findings indicate that heroin-methamphetamine co-injection is more common in Tijuana than in San Diego, yet this practice was only associated with overdose in San Diego. Heroin-methamphetamine coinjection was also independently associated with HIV-associated injection risk behaviors. Overdose-prevention interventions should address co-injection of depressants and stimulants.
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Affiliation(s)
- Meredith C Meacham
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California.,Graduate School of Public Health, San Diego State University, San Diego, California.,Department of Psychiatry, University of California San Francisco, San Francisco, California
| | - Steffanie A Strathdee
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Gudelia Rangel
- U.S.-Mexico Border Health Commission, Mexico Section, Tijuana, Baja California, Mexico
| | - Richard F Armenta
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California.,Graduate School of Public Health, San Diego State University, San Diego, California.,Division of Epidemiology, Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
| | - Tommi L Gaines
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Richard S Garfein
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California
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20
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Jones JD, Campbell A, Metz VE, Comer SD. No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone. Addict Behav 2017; 71:104-106. [PMID: 28325710 DOI: 10.1016/j.addbeh.2017.03.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/16/2017] [Accepted: 03/08/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Some fear that distribution of naloxone to persons at risk of experiencing an opioid overdose may reduce the perceived negative consequences of drug use, leading to riskier patterns of use. This study assessed whether participation in naloxone/overdose training altered drug use frequency, quantity or severity among heroin users in and out of treatment. METHODS Clinical interviews were performed assessing patterns of heroin and other drug use prior to, and at multiple timepoints after overdose education and naloxone training. This study compared baseline drug use to that at 1 and 3months post training. RESULTS Both current heroin users (n=61) and former users in agonist maintenance (n=69) typically showed decreases in heroin and polydrug use at both 1 and 3months after training. The Addiction Severity Index drug composite score also decreased at follow up. CONCLUSIONS This analysis found no evidence of compensatory drug use following naloxone/overdose training among two groups of heroin users. These findings support the acceptance and expansion of naloxone distribution to at-risk populations and may assist in allaying concerns about the potential for unintended negative consequences on drug use.
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21
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Abstract
Drug-related overdoses are now the leading injury-related death in the USA, and many of these deaths are associated with illicit opioids and prescription opiate pain medication. This study uses multiple sources of data to examine accidental opioid overdoses across 6 years, 2010 through 2015, in Marion County, IN, an urban jurisdiction in the USA. The primary sources of data are toxicology reports from the county coroner, which reveal that during this period, the most commonly detected opioid substance was heroin. During the study period, 918 deaths involved an opiod, and there were significant increases in accidental overdose deaths involving both heroin and fentanyl. In order to disentangle the nature and source of opioid overdose deaths, we also examine data from Indiana's prescription drug monitoring program and the law enforcement forensic services agency. Results suggest that there have been decreases in the number of opiate prescriptions dispensed and increases in law enforcement detection of both heroin and fentanyl. Consistent with recent literature, we suggest that increased regulation of prescription opiates reduced the likelihood of overdoses from these substances, but might have also had an iatrogenic effect of increasing deaths from heroin and fentanyl. We discuss several policy implications and recommendations for Indiana.
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Affiliation(s)
- Bradley Ray
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Kenna Quinet
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Timothy Dickinson
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Dennis P. Watson
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Alfarena Ballew
- Marion County (Indiana) Coroner’s Office, Indianapolis, IN USA
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Davis JM, Suleta K, Corsi KF, Booth RE. A Hazard Analysis of Risk Factors of Mortality in Individuals Who Inject Drugs in Denver CO. AIDS Behav 2017; 21:1044-1053. [PMID: 28063072 DOI: 10.1007/s10461-016-1660-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite multiple risk factors for mortality among People Who Inject Drugs (PWID), more research is warranted that examines sub-populations within PWID. Mortality data from PWID participating in longitudinal HIV prevention research in Denver were obtained from The Colorado Department of Public Health and Environment. Risk factors for both all-cause and acute-toxicity related mortality were analyzed using Cox proportional hazards regression. Two-thousand seven individuals were interviewed at baseline. Eighty-six individuals died during the time frame of the study, 58 of which were due to acute-toxicity. Disabled (HR = 3.3, p < 0.001), gay/lesbian-identified (HR = 2.6, p = 0.03), white race/ethnicity (HR = 2.4, p = 0.003), and use of a shared cooker (HR = 2.1, p = 0.01) were important adjusted risk factors. These suggest that drug and HIV interventions should utilize techniques that can address the needs of marginalized populations in addition to HIV drug risk behaviors.
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Affiliation(s)
- Jonathan M Davis
- Project Safe, Department of Psychiatry, School of Medicine, University of Colorado Denver, 1557 Ogden Street, Denver, CO, 80218, USA.
| | - Katie Suleta
- Project Safe, Department of Psychiatry, School of Medicine, University of Colorado Denver, 1557 Ogden Street, Denver, CO, 80218, USA
| | - Karen F Corsi
- Project Safe, Department of Psychiatry, School of Medicine, University of Colorado Denver, 1557 Ogden Street, Denver, CO, 80218, USA
| | - Robert E Booth
- Project Safe, Department of Psychiatry, School of Medicine, University of Colorado Denver, 1557 Ogden Street, Denver, CO, 80218, USA
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Dahlman D, Abrahamsson T, Kral AH, Hakansson A. Nonmedical Use of Antihistaminergic Anxiolytics and Other Prescription Drugs among Persons with Opioid Dependence. JOURNAL OF ADDICTION 2016; 2016:9298571. [PMID: 28097037 PMCID: PMC5206437 DOI: 10.1155/2016/9298571] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/27/2016] [Indexed: 11/25/2022]
Abstract
Background. Nonmedical prescription drug use (NMPDU) is an increasing problem, insufficiently studied among people in opioid maintenance treatment (OMT). This study investigates the prevalence of and factors associated with NMPDU for drug classes insufficiently described in opioid-dependent populations, including antihistaminergic anxiolytics and central stimulants. Methods. Study participants were recruited at two OMT clinics in Malmo, Sweden, between October 2014 and December 2015 (N = 73) and interviewed about their use, motivations for use, and acquisition and administration of prescription drugs. Results. The majority of the sample reported lifetime NMPDU: 60% for benzodiazepine-like hypnotics (z-drugs), 21% for pregabalin, 19% for stimulants, and 12%-15% for antihistaminergic anxiolytics. Lower age was associated with nonmedical benzodiazepine use (Adjusted Odds Ratio = 0.89; 95% Confidence Interval = 0.82-0.97). Illicit acquisition was reported by 61% of people using z-drugs, 46% of people using pregabalin, and 38% of people using prescription stimulants, but only by 6-10% of people using antihistaminergic anxiolytics. Conclusions. The substantial nonmedical use of pregabalin, z-drugs, and prescription stimulants found in this study suggests that clinicians should prescribe these drugs with great caution. Nonmedical use of antihistaminergic anxiolytics does not seem to be a clinical issue among people in OMT in a Swedish setting, but we propose future studies to monitor their use.
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Affiliation(s)
- Disa Dahlman
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden
- Malmo Addiction Centre, Malmo, Sweden
| | - Tove Abrahamsson
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden
- Malmo Addiction Centre, Malmo, Sweden
| | - Alex H. Kral
- Behavioral and Urban Health Program, RTI International, San Francisco, CA, USA
| | - Anders Hakansson
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden
- Malmo Addiction Centre, Malmo, Sweden
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24
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Fairbairn NS, Walley AY, Cheng DM, Quinn E, Bridden C, Chaisson C, Blokhina E, Lioznov D, Krupitsky E, Raj A, Samet JH. Mortality in HIV-Infected Alcohol and Drug Users in St. Petersburg, Russia. PLoS One 2016; 11:e0166539. [PMID: 27898683 PMCID: PMC5127495 DOI: 10.1371/journal.pone.0166539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 10/31/2016] [Indexed: 11/18/2022] Open
Abstract
In Russia, up to half of premature deaths are attributed to hazardous drinking. The respective roles of alcohol and drug use in premature death among people with HIV in Russia have not been described. Criminalization and stigmatization of substance use in Russia may also contribute to mortality. We explored whether alcohol, drug use and risk environment factors are associated with short-term mortality in HIV-infected Russians who use substances. Secondary analyses were conducted using prospective data collected at baseline, 6 and 12-months from HIV-infected people who use substances recruited between 2007-2010 from addiction and HIV care settings in a single urban setting of St. Petersburg, Russia. We used Cox proportional hazards models to explore associations between 30-day alcohol hazardous drinking, injection drug use, polysubstance use and environmental risk exposures (i.e. past incarceration, police involvement, selling sex, and HIV stigma) with mortality. Among 700 participants, 59% were male and the mean age was 30 years. There were 40 deaths after a median follow-up of 12 months (crude mortality rate 5.9 per 100 person-years). In adjusted analyses, 30-day NIAAA hazardous drinking was significantly associated with mortality compared to no drinking [adjusted Hazard Ratio (aHR) 2.60, 95% Confidence Interval (CI): 1.24-5.44] but moderate drinking was not (aHR 0.95, 95% CI: 0.35-2.59). No other factors were significantly associated with mortality. The high rates of short-term mortality and the strong association with hazardous drinking suggest a need to integrate evidence-based alcohol interventions into treatment strategies for HIV-infected Russians.
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Affiliation(s)
- Nadia S. Fairbairn
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander Y. Walley
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Emily Quinn
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Carly Bridden
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Christine Chaisson
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Elena Blokhina
- First Pavlov State Medical University, St. Petersburg, Russian Federation
| | - Dmitry Lioznov
- First Pavlov State Medical University, St. Petersburg, Russian Federation
- North-West Regional AIDS Center, St. Petersburg, Russian Federation
| | - Evgeny Krupitsky
- First Pavlov State Medical University, St. Petersburg, Russian Federation
- Bekhterev Research Psychoneurological Institute, St. Petersburg, Russian Federation
| | - Anita Raj
- Division of Global Public Health, University of California San Diego School of Medicine, La Jolla, California, United States of America
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, United States of America
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Fairbairn N, Hayashi K, Milloy MJ, Nolan S, Nguyen P, Wood E, Kerr T. Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs. Alcohol Clin Exp Res 2016; 40:2394-2400. [PMID: 27638501 DOI: 10.1111/acer.13216] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 08/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID. METHODS Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use. RESULTS Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05). CONCLUSIONS A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.
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Affiliation(s)
- Nadia Fairbairn
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kanna Hayashi
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Nguyen
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada. .,Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain. Med Care 2016; 54:435-41. [PMID: 26807540 DOI: 10.1097/mlr.0000000000000505] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily. OBJECTIVE To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level. METHODS In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records. RESULTS The average prescribed opioid dosage was higher (P<0.001) for cases (mean=98.1 MEM, SD=112.7; median=60, interquartile range, 30-120), than controls (mean=47.7 MEM, SD=65.2; median=25, interquartile range, 15-45). In a ROC analysis, dosage was a moderately good "predictor" of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls. CONCLUSIONS A clear cut-point in opioid dosage to distinguish between overdose cases and controls was not found. However, lowering the recommended dosage threshold below the 100 MEM used in many recent guidelines would affect proportionately few patients not at risk for overdose while potentially benefitting many of those at risk for overdose.
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27
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Correlates of Nine-Month Retention following Interim Buprenorphine-Naloxone Treatment in Opioid Dependence: A Pilot Study. JOURNAL OF ADDICTION 2016; 2016:6487217. [PMID: 26904355 PMCID: PMC4745813 DOI: 10.1155/2016/6487217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/20/2015] [Accepted: 12/21/2015] [Indexed: 11/17/2022]
Abstract
Interim medication-only treatment has been suggested for the initiation of opioid maintenance treatment (OMT) in opioid-dependent subjects, but this rarely has been studied using buprenorphine instead of methadone. Following a pilot trial assessing interim buprenorphine-naloxone treatment in order to facilitate transfer into OMT, we here aimed to study retention, and potential correlates of retention, in full-scale treatment. Thirty-six patients successfully referred from a waiting list through an interim treatment phase were followed for nine months in OMT. Baseline characteristics, as well as urine analyses during the interim phase and during full-scale OMT, were studied as potential correlates of retention. The nine-month retention in OMT was 83 percent (n = 30). While interim-phase urine samples positive for benzodiazepines did not significantly predict dropout from full-scale OMT (p = 0.09), urine samples positive for benzodiazepines within full-scale OMT were significantly associated with dropout (p < 0.01), in contrast to other substances and baseline characteristics. Retention remained high through nine months in this pilot study sample of patients referred through buprenorphine-naloxone interim treatment, but use of benzodiazepines is problematic, and the present data suggest that it may be associated with treatment dropout.
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28
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Bauer LK, Brody JK, León C, Baggett TP. Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review. J Health Care Poor Underserved 2016; 27:846-59. [PMID: 27180712 PMCID: PMC4911892 DOI: 10.1353/hpu.2016.0075] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Leah K. Bauer
- Department of Psychiatry, Mid Coast Hospital, Brunswick, ME, Tufts University School of Medicine, Boston, MA
| | - Jennifer K. Brody
- Boston Health Care for the Homeless Program, Boston, MA Brigham and Women’s Hospital, Boston, MA
| | - Casey León
- Boston Health Care for the Homeless Program, Boston, MA
| | - Travis P. Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, Harvard Medical School, Boston, MA, Boston Health Care for the Homeless Program, Boston, MA
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29
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DeVido J, Connery H, Hill KP. Sleep-disordered breathing in patients with opioid use disorders in long-term maintenance on buprenorphine-naloxone: A case series. J Opioid Manag 2015; 11:363-6. [PMID: 26312963 DOI: 10.5055/jom.2015.0285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rates of opioid overdose deaths are increasing in the United States, leading to intensified efforts to provide medication-assisted treatments for opioid use disorders. It is not clear what effect opioid agonist treatments (ie, the µ-opioid receptor full agonist methadone and the partial agonist buprenorphine) may have on respiratory function. However, sleep-disordered breathing has been documented in methadone maintenance pharmacotherapy, and there is emerging evidence for similar sleep-disordered breathing in buprenorphine and buprenorphine-naloxone maintenance treatment. OBJECTIVE To provide further clinical evidence of sleep-disordered breathing emerging in the context of buprenorphine-naloxone maintenance pharmacotherapy. METHODS The authors report two additional cases of sleep-disordered breathing that developed in patients with severe opioid use disorders, treated successfully as outpatients with buprenorphine-naloxone maintenance. Both patients provided written consent for their clinical information to be included in this case report, and elements of their identities have been masked to provide confidentiality. RESULTS Two adult female patients, who were stable in buprenorphine-naloxone maintenance treatment developed daytime sleepiness, were referred for evaluation and found to have sleep-disordered breathing. One patient's daytime sleepiness improved with reduction in both buprenorphine-naloxone and other sedating medications as well as initiation of a constant positive airway pressure (CPAP) device. However, the other patient could not tolerate decreases in buprenorphine-naloxone and/or CPAP initiation and her daytime sleepiness persisted. CONCLUSION Buprenorphine-naloxone maintenance treatment can be associated with sleep-disordered breathing. It can be difficult to differentiate the cause(s) of sleep-disordered breathing among the effects of buprenorphine-naloxone treatment itself, co-occurring conditions, such as obesity and cigarette smoking or other medications, or some combination thereof. Regardless of etiology, sleep-disordered breathing and its consequences present unique challenges to the patient in recovery from an opioid use disorder and therefore warrants careful evaluation and management.
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Affiliation(s)
- Jeffrey DeVido
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, University of California, San Francisco, San Francisco, California
| | - Hilary Connery
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Kevin P Hill
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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30
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Okolie C, Evans BA, John A, Moore C, Russell D, Snooks H. Community-based interventions to prevent fatal overdose from illegal drugs: a systematic review protocol. BMJ Open 2015; 5:e008981. [PMID: 26534734 PMCID: PMC4636603 DOI: 10.1136/bmjopen-2015-008981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION 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. METHODS AND ANALYSIS 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. ETHICS AND DISSEMINATION 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. TRIAL REGISTRATION NUMBER PROSPERO CRD42015017833.
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Affiliation(s)
| | | | - Ann John
- College of Medicine, Swansea University, Swansea, UK
| | - Chris Moore
- Welsh Ambulance Services NHS Trust, Blackweir Ambulance Station, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
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31
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Jolley CJ, Bell J, Rafferty GF, Moxham J, Strang J. Understanding Heroin Overdose: A Study of the Acute Respiratory Depressant Effects of Injected Pharmaceutical Heroin. PLoS One 2015; 10:e0140995. [PMID: 26495843 PMCID: PMC4619694 DOI: 10.1371/journal.pone.0140995] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/02/2015] [Indexed: 11/18/2022] Open
Abstract
Opioids are respiratory depressants and heroin/opioid overdose is a major contributor to the excess mortality of heroin addicts. The individual and situational variability of respiratory depression caused by intravenous heroin is poorly understood. This study used advanced respiratory monitoring to follow the time course and severity of acute opioid-induced respiratory depression. 10 patients (9/10 with chronic airflow obstruction) undergoing supervised injectable opioid treatment for heroin addiction received their usual prescribed dose of injectable opioid (diamorphine or methadone) (IOT), and their usual prescribed dose of oral opioid (methadone or sustained release oral morphine) after 30 minutes. The main outcome measures were pulse oximetry (SpO2%), end-tidal CO2% (ETCO2%) and neural respiratory drive (NRD) (quantified using parasternal intercostal muscle electromyography). Significant respiratory depression was defined as absence of inspiratory airflow >10s, SpO2% < 90% for >10s and ETCO2% per breath >6.5%. Increases in ETCO2% indicated significant respiratory depression following IOT in 8/10 patients at 30 minutes. In contrast, SpO2% indicated significant respiratory depression in only 4/10 patients, with small absolute changes in SpO2% at 30 minutes. A decline in NRD from baseline to 30 minutes post IOT was also observed, but was not statistically significant. Baseline NRD and opioid-induced drop in SpO2% were inversely related. We conclude that significant acute respiratory depression is commonly induced by opioid drugs prescribed to treat opioid addiction. Hypoventilation is reliably detected by capnography, but not by SpO2% alone. Chronic suppression of NRD in the presence of underlying lung disease may be a risk factor for acute opioid-induced respiratory depression.
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Affiliation(s)
- Caroline J. Jolley
- Division of Asthma, Allergy and Lung Biology, Faculty of Life Sciences and Medicine, King’s College London, King’s Health Partners, Denmark Hill, London, United Kingdom
| | - James Bell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, King’s Health Partners, Denmark Hill, London, United Kingdom
- Addictions Services, South London & Maudsley NHS Foundation Trust, King’s Health Partners, Denmark Hill, London, United Kingdom
| | - Gerrard F. Rafferty
- Division of Asthma, Allergy and Lung Biology, Faculty of Life Sciences and Medicine, King’s College London, King’s Health Partners, Denmark Hill, London, United Kingdom
| | - John Moxham
- Division of Asthma, Allergy and Lung Biology, Faculty of Life Sciences and Medicine, King’s College London, King’s Health Partners, Denmark Hill, London, United Kingdom
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, King’s Health Partners, Denmark Hill, London, United Kingdom
- Addictions Services, South London & Maudsley NHS Foundation Trust, King’s Health Partners, Denmark Hill, London, United Kingdom
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Mars SG, Fessel JN, Bourgois P, Montero F, Karandinos G, Ciccarone D. Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States. Soc Sci Med 2015; 140:44-53. [PMID: 26202771 PMCID: PMC4587985 DOI: 10.1016/j.socscimed.2015.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, MU337E Box 0900, 500 Parnassus Avenue, San Francisco, CA 94143-0900, USA.
| | - Jason N Fessel
- Department of Anthropology, History and Social Medicine, University of California, San Francisco, 3333 California Street, Suite 485, San Francisco, CA 94143-0850, USA.
| | - Philippe Bourgois
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - Fernando Montero
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - George Karandinos
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - Daniel Ciccarone
- Department of Family and Community Medicine, 500 Parnassus Avenue, MUE3, San Francisco, CA 94143, USA.
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Lubana SS, Genin DI, Singh N, De La Cruz A. Asystolic Cardiac Arrest of Unknown Duration in Profound Hypothermia and Polysubstance Overdose: A Case Report of Complete Recovery. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:353-6. [PMID: 26054008 PMCID: PMC4464095 DOI: 10.12659/ajcr.893880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Opioid addiction and overdose is a serious problem worldwide. Fatal overdoses from opioids are responsible for numerous deaths and are increasing, especially if taken in combination with other psychoactive substances. Combined with environmental exposure, opioid overdose can cause profound hypothermia. Opioid abuse and other drugs of abuse impair thermoregulation, leading to severe hypothermia. Both drug overdose and severe hypothermia can cause cardiac arrest. CASE REPORT We report a case of 20-year-old man with history of polysubstance abuse presenting with severe hypothermia and asystole of unknown duration with return of spontaneous circulation (ROSC) achieved after 28 minutes of cardiopulmonary resuscitation (CPR). Urine toxicology was positive for cocaine, heroin, and benzodiazepine, along with positive blood alcohol level. The patient was rewarmed using non-invasive techniques. Hospital course was complicated by acute renal failure (ARF), severe rhabdomyolysis, severe hyperkalemia, ST-elevation myocardial infarction (STEMI), shock liver, coagulopathy, and aspiration pneumonia. CONCLUSIONS Survival with full cardiovascular and neurologic recovery after a cardiac arrest caused by drug overdose in the setting of severe hypothermia is still possible, even if the cardiac arrest is of unknown or prolonged duration. Patients with severe hypothermia experiencing cardiac arrest/hemodynamic instability can be rewarmed using non-invasive methods and may not necessarily need invasive rewarming techniques.
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Affiliation(s)
- Sandeep Singh Lubana
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, USA
| | - Dennis Iilya Genin
- Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, USA
| | - Navdeep Singh
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, USA
| | - Angel De La Cruz
- Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, USA
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Origer A, Le Bihan E, Baumann M. A social gradient in fatal opioids and cocaine related overdoses? PLoS One 2015; 10:e0125568. [PMID: 25938451 PMCID: PMC4418844 DOI: 10.1371/journal.pone.0125568] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 03/25/2015] [Indexed: 11/28/2022] Open
Abstract
Background 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. Methods 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. Results 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). Conclusions 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.
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Affiliation(s)
- Alain Origer
- Drug Coordination Office, Ministry of Health, Luxembourg, Luxembourg; Research Unit INSIDE, Institute Health & Behaviour, University of Luxembourg, Walferdange, Luxembourg
| | - Etienne Le Bihan
- Research Unit INSIDE, Institute Health & Behaviour, University of Luxembourg, Walferdange, Luxembourg
| | - Michèle Baumann
- Research Unit INSIDE, Institute Health & Behaviour, University of Luxembourg, Walferdange, Luxembourg
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Soyka M. Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment. Eur Addict Res 2015; 21:78-87. [PMID: 25413371 DOI: 10.1159/000363232] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Maintenance therapy with methadone or buprenorphine is an established and first-line treatment for opioid dependence. Clinical studies indicate that about a third of patients in opioid maintenance therapy show increased alcohol consumption and alcohol use disorders. Comorbid alcohol use disorders have been identified as a risk factor for clinical outcome and can cause poor physical and mental health, including liver disorders, noncompliance, social deterioration and increased mortality risk. The effects of opioid maintenance therapy on alcohol consumption are controversial and no clear pattern has emerged. Most studies have not found a change in alcohol use after initiation of maintenance therapy. Methadone and buprenorphine appear to carry little risk of liver toxicity, but further research on this topic is required. Recent data indicate that brief intervention strategies may help reduce alcohol intake, but the existing evidence is still limited. This review discusses further clinical implications of alcohol use disorders in opioid dependence.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany; Private Hospital Meiringen, Willigen, Meiringen, Switzerland
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Frank D, Mateu-Gelabert P, Guarino H, Bennett A, Wendel T, Jessell L, Teper A. High risk and little knowledge: overdose experiences and knowledge among young adult nonmedical prescription opioid users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:84-91. [PMID: 25151334 PMCID: PMC4277710 DOI: 10.1016/j.drugpo.2014.07.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/04/2014] [Accepted: 07/22/2014] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- David Frank
- The Graduate Center, City University of New York, Dept. of Sociology, 365 Fifth Avenue, Room 6112.04, New York, NY 10016, United States; National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States.
| | - Pedro Mateu-Gelabert
- National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States
| | - Honoria Guarino
- National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States
| | - Alex Bennett
- National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States
| | - Travis Wendel
- St. Ann's Corner of Harm Reduction, 886 Westchester Avenue, Bronx, NY 10459, United States
| | - Lauren Jessell
- National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States
| | - Anastasia Teper
- National Development and Research Institutes, Inc., 71 W. 23rd Street, 4th Floor, New York, NY 10010, United States.
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Espelt A, Barrio G, Álamo-Junquera D, Bravo MJ, Sarasa-Renedo A, Vallejo F, Molist G, Brugal MT. Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users. Eur Addict Res 2015; 21:300-6. [PMID: 26022713 DOI: 10.1159/000377626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 02/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of the study was to estimate the lethality of opioid overdose among young heroin users. METHODS A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models. RESULTS The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5). CONCLUSIONS Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.
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Affiliation(s)
- Albert Espelt
- Agx00E8;ncia de Salut Px00FA;blica de Barcelona, Barcelona, Spain
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Moore C, Lloyd G, Oretti R, Russell I, Snooks H. Paramedic-supplied 'Take Home' Naloxone: protocol for cluster randomised feasibility study. BMJ Open 2014; 4:e004712. [PMID: 24650810 PMCID: PMC3963087 DOI: 10.1136/bmjopen-2013-004712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION 'Take Home' Naloxone (THN) kits for use by peers in the event of an opioid overdose may reduce further overdose and deaths, but distribution through Drugs Services may not reach those at highest risk. Attendance by paramedics at emergency calls for patients who have suffered an overdose presents an opportunity to distribute THN kits. In this feasibility study we will assess the acceptability of this intervention, and gather data to inform definitive trial planning. METHODS AND ANALYSIS Cluster randomised trial with staggered allocation of paramedics (clusters) to groups. We will invite paramedics in an urban area of south Wales, UK to take part. We will randomly allocate those that accept to training sessions during the first 4 months of the trial. Patients attended by paramedics who have been trained and issued THN kits will fall into the intervention group. Patients attended by paramedics following usual practice (until they receive their training and THN kits) will fall into the control group. We will gather data about processes and outcomes of care: numbers of patients eligible for intervention, offered and accepted THN, attended emergency department, suffered further overdose, died within 3 months and about follow-up rates: numbers of patients consented, completed (postal or telephone) questionnaire. We will gather qualitative data about acceptability to patients and paramedics through interviews and focus groups. ETHICS AND DISSEMINATION Ethical approval for this study was granted on 7 December 2011, by South East Wales Research Ethics Committee, Panel C. Results of this study will be reported through peer-reviewed scientific journals, conference presentations and internal organisational report. We will also seek to report our findings through local and national substance misuse networks and publications. TRIAL REGISTRATION NUMBER ISRCTN98216498.
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Affiliation(s)
- Chris Moore
- Medical and Clinical Services Directorate, Welsh Ambulance Services NHS Trust, Blackweir Ambulance Station, Cardiff, UK
| | - Gregory Lloyd
- Operational Services, Welsh Ambulance Services NHS Trust, Blackweir Ambulance Station, Cardiff, UK
| | - Rossana Oretti
- Cardiff Addictions Unit, Cardiff & Vale University Health Board, Cardiff Royal Infirmary, Cardiff, UK
| | - Ian Russell
- West Wales Organisation for Rigorous Trials in Health (WWORTH), Institute of Life Science, College of Medicine, Singleton Park, Swansea, UK
| | - Helen Snooks
- Thematic Research Network for Emergency, Unscheduled and Trauma care (TRUST), Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, UK
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Maurer U, Kager C, Fellinger C, Loader D, Pollesböck A, Spitzer B, Jarisch R. Risk of anaphylaxis in opioid dependent persons: effects of heroin versus substitution substance. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2014; 9:12. [PMID: 24576327 PMCID: PMC3942621 DOI: 10.1186/1747-597x-9-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/21/2014] [Indexed: 02/06/2023]
Abstract
Background Across Europe, illicit drug-related mortality has not declined despite ever increasing prevention measures. The cause of these deaths has traditionally been associated with overdose. Previous findings have revealed the appearance of non-lethal opioid concentrations, leading us to investigate a further cause of death. The symptoms of heroin intoxication with asphyxia and/or cardiovascular involvement resemble anaphylaxis, and therefore it has been speculated that such deaths might be caused by an allergic reaction. The study´s aims were to investigate levels of allergic mediators in long-term injecting drug users (IDU) compared to healthy controls and to determine if oral opioid substitution therapy (OST) resulted in similar allergic symptoms to those reported by IDU after intravenous (IV) heroin use. Methods We quantified the concentrations of histamine, diamine oxidase (DAO), tryptase and lipoprotein-associated phospholipase A2 (LpPLA2) at baseline and 1 h after administration of Substitol®retard (482 ± 220 mg) in 56 patients at a withdrawal centre (Austria) and compared them with healthy controls (n = 103). Questionnaires and face-to-face interviews were used to assess allergic symptoms and side effects in IDU. Descriptive statistical analyses of quantitative data were performed by using SPSS. Results Baseline histamine, tryptase and LpPLA2 were significantly elevated in IDU compared to the healthy control group, while DAO decreased. Blood levels showed no significant change after oral substitution uptake. Self-reported allergic symptoms and side effects after IV heroin use were reported in 55 cases (98.2%), minimal symptoms were documented after OST (12.5%, 7/56). Conclusions This study revealed that baseline histamine concentrations were elevated in chronic IDU, although only relatively small changes in tryptase plasma levels occurred. After IV heroin application the reported allergic symptoms were mostly mild and did not lead to clinically relevant side effects. The substitution substance was clearly better tolerated than IV administered heroin. Elevated levels of allergic mediators such as histamine in IDUs may place them at greater risk of severe or fatal anaphylaxis when exposed to heroin; however, this requires further investigation.
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Affiliation(s)
- Ute Maurer
- Department: Health, Biomedical Science, University of Applied Sciences Wiener Neustadt, Johannes Gutenberg-Strasse 3, 2700 Wiener Neustadt, Austria.
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Havinga P, van der Velden C, de Gee A, van der Poel A. Differences in sociodemographic, drug use and health characteristics between never, former and current injecting, problematic hard-drug users in the Netherlands. Harm Reduct J 2014; 11:6. [PMID: 24524263 PMCID: PMC3926265 DOI: 10.1186/1477-7517-11-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 01/30/2014] [Indexed: 01/15/2023] Open
Abstract
Background Injecting drug users are at increased risk for harmful effects compared to non-injecting drug users. Some studies have focused on differences in characteristics between these two groups (e.g., housing, overall health). However, no study has investigated the specific Dutch situation which in the last years has seen a decrease in homelessness among problematic hard-drug users and an increasing focus on physical health in low-threshold addiction care. The purpose of this study was to determine differences in sociodemographic, drug use and health characteristics between never-injecting (NIDUs), former-injecting (FIDUs) and current-injecting drug users (IDUs) and describe injecting practices. Methods A total of 202 problematic hard-drug users (NIDU = 64; FIDU = 76; IDU = 62) were recruited from 22 low-threshold care facilities, including drug consumption rooms, methadone maintenance treatment, heroin-assisted therapy, day shelter and/or night shelter, supported housing and day activity centres. Data were collected on-site through structured face-to-face interviews. Results Results indicate that IDUs represented a separate group of problematic hard-drug users, with distinct sociodemographic and drug use characteristics. Overall, IDUs appeared to be the group with least favourable characteristics (unstable housing/homelessness, illegal activities, polydrug use) and NIDUs appeared to have the most favourable characteristics (stable housing, help with debts, less polydrug use). The FIDU group lies somewhere in between. The three groups did not differ significantly in terms of health. Regarding injecting practices, results showed that majority of IDUs had injected drugs for over 10 years and IDUs injected heroin, cocaine, amphetamine and/or methadone in the past 6 months. Sharing syringes was not common. A quarter reported public injecting. Conclusions Unstable housing and homelessness are related to (former) injecting drug use, and stable housing is related to never-injecting drug use. Our study suggests that the number of ‘new’ IDUs is low. However, public injecting among IDUs is not uncommon and is associated with unstable housing. This emphasizes the potential of housing projects as a component of harm reduction measures. Therefore, prevention of (risks associated with) injecting drug use and supported housing programmes for problematic hard-drug users deserve the continuous attention of policymakers and professionals in low-threshold addiction care.
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Affiliation(s)
| | | | | | - Agnes van der Poel
- Network of Infectious Diseases and Harm Reduction, Trimbos Institute, P,O, Box 725, Utrecht 3500, AS, The Netherlands.
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Waal H, Gossop M. Making sense of differing overdose mortality: contributions to improved understanding of European patterns. Eur Addict Res 2014; 20:8-15. [PMID: 23921286 DOI: 10.1159/000346781] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 12/30/2012] [Indexed: 11/19/2022]
Abstract
The European Monitoring Centre for Drugs and Drug Addiction, EMCDDA, publishes statistics for overdose deaths giving a European mean number, and ranking nations in a national 'league table' for overdose deaths. The interpretation of differing national levels of mortality is more problematic and more complex than is usually recognised. Different systems are used to compile mortality data and this causes problems for cross-national comparisons. Addiction behaviour can only be properly understood within its specific social and environmental ecology. Risk factors for overdose, such as the type of drug consumed, and the route of administration, are known to differ across countries. This paper describes problems associated with ranking and suggests how mortality data might be used in high-level countries aiming at reduction in the number of overdose deaths.
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Affiliation(s)
- Helge Waal
- Centre for Addiction Research (SERAF), University of Oslo, Oslo, Norway
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Origer A, Lopes da Costa S, Baumann M. Opiate- and cocaine-related fatal overdoses in Luxembourg from 1985 to 2011: a study on gender differences. Eur Addict Res 2014; 20:87-93. [PMID: 24192492 DOI: 10.1159/000355170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 08/20/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM We analysed gender differences in national fatal overdose (FOD) cases related to opiates and cocaine use between 1985 and 2011 (n = 340). METHODS Cross-examination of national data from law enforcement and drug use surveillance sources and of forensic evidence. Bivariate and logistic regression analysis of male/female differences according to sociodemographics, forensic evidence and drug use trajectories. RESULTS The burden of deaths caused by FOD on the general national mortality was higher for men (PMR/100=0.55) compared with women (PMR/100=0.34). Compared with their male peers, women were younger at the time of death (t=3.274; p=0.001) and showed shorter drug use careers (t=2.228; p=0.028). Heroin use was recorded more frequently in first drug offences of female victims (AOR=6.59; 95% CI 2.97-14.63) and according to forensic evidence, psychotropic prescription drugs were detected to a higher degree in females (AOR=2.019; 95% CI 1.065-3.827). CONCLUSION The time window between the onset of illicit drug use and its fatal outcome revealed to be shorter for women versus men included in our study. Early intervention in female drug users, routine involvement of first-line healthcare providers and increased attention to use of poly- and psychotropic prescription drugs might contribute to prevent premature drug-related death and reduce gender differences.
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Affiliation(s)
- Alain Origer
- Drug Coordination Office, Ministry of Health, Luxembourg, Luxembourg
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Strang J, Bird SM, Parmar MKB. Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. J Urban Health 2013; 90:983-96. [PMID: 23633090 PMCID: PMC3795186 DOI: 10.1007/s11524-013-9803-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.
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Affiliation(s)
- John Strang
- King's College London, National Addiction Centre (Institute of Psychiatry and The Maudsley), London, SE5 8AF, UK,
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Cerovečki V, Tiljak H, Ožvačić Adžić Z, Križmarić M, Pregelj P, Kastelic A. Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia. Croat Med J 2013; 54:42-8. [PMID: 23444245 PMCID: PMC3583393 DOI: 10.3325/cmj.2013.54.42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To determine the risk factors for fatal outcome in patients with opioid dependence treated with methadone at the primary care level. METHODS A group of 287 patients with opioid dependence was monitored prospectively from 1995 to 2007. At the beginning of the study, we collected the data on patient baseline characteristics, treatment characteristics, and living environment. At the annual check-up, we collected the data on daily methadone dose, method of methadone therapy administration, and family physician's assessment of the patient's drug use status. RESULTS Out of 287 patients, 8% died. Logistic regression analysis showed that the predictors of fatal outcome were continuation of drug use during previous therapeutic attempts (odds ratio [OR], 19.402; 95% confidence interval [CI], 1.659-226.873), maintenance therapy as the planned treatment modality (OR, 3.738; 95% CI, 1.045-13.370), living in an unstable relationship (OR, 9.275; 95% CI, 2.207-38.984), and loss of continuity of care (OR, 12.643; 95% CI, 3.001-53.253). CONCLUSION The patients presenting these risk factors require special attention. It is important for family physicians to insist on compliance with the treatment protocol and intervene when they lose contact with the patient to prevent the fatal outcome.
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Affiliation(s)
- Venija Cerovečki
- Department for Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
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Field CA, Klimas J, Barry J, Bury G, Keenan E, Smyth BP, Cullen W. Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment. BMC FAMILY PRACTICE 2013; 14:98. [PMID: 23849081 PMCID: PMC3720559 DOI: 10.1186/1471-2296-14-98] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 07/10/2013] [Indexed: 11/30/2022]
Abstract
Background Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care. Methods This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer. Results We identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment. Conclusions Problem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored.
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Affiliation(s)
- Catherine Anne Field
- UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dolphins Barn, Dublin 8, Ireland
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Klimas J, Cullen W, Field CA. Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice. Ir J Med Sci 2013; 183:89-101. [PMID: 23820987 DOI: 10.1007/s11845-013-0982-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 06/21/2013] [Indexed: 08/26/2023]
Abstract
BACKGROUND Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. AIMS This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population. METHODS The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified 'Delphi-facilitated' consensus among the group members. RESULTS The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence. CONCLUSIONS Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.
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Affiliation(s)
- J Klimas
- Graduate Entry Medical School, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland,
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Llorente J, Withey S, Rivero G, Cunningham M, Cooke A, Saxena K, McPherson J, Oldfield S, Dewey WL, Bailey CP, Kelly E, Henderson G. Ethanol reversal of cellular tolerance to morphine in rat locus coeruleus neurons. Mol Pharmacol 2013; 84:252-60. [PMID: 23716621 DOI: 10.1124/mol.113.085936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Consumption of ethanol is a considerable risk factor for death in heroin overdose. We sought to determine whether a mildly intoxicating concentration of ethanol could alter morphine tolerance at the cellular level. In rat locus coeruleus (LC) neurons, tolerance to morphine was reversed by acute exposure of the brain slice to ethanol (20 mM). Tolerance to the opioid peptide [d-Ala(2),N-MePhe(4),Gly-ol]-enkephalin was not reversed by ethanol. Previous studies in LC neurons have revealed a role for protein kinase C (PKC)α in μ-opioid receptor (MOPr) desensitization by morphine and in the induction and maintenance of morphine tolerance, but we have been unable to demonstrate that 20 mM ethanol produces significant inhibition of PKCα. The ability of ethanol to reverse cellular tolerance to morphine in LC neurons was absent in the presence of the phosphatase inhibitor okadaic acid, indicating that dephosphorylation is involved. In human embryonic kidney 293 cells expressing the MOPr, ethanol reduced the level of MOPr phosphorylation induced by morphine. Ethanol reversal of tolerance did not appear to result from a direct effect on MOPr since acute exposure to ethanol (20 mM) did not modify the affinity of binding of morphine to the MOPr or the efficacy of morphine for G-protein activation as measured by guanosine 5'-O-(3-[(35)S]thio)triphosphate binding. Similarly, ethanol did not affect MOPr trafficking. We conclude that acute exposure to ethanol enhances the effects of morphine by reversing the processes underlying morphine cellular tolerance.
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Affiliation(s)
- Javier Llorente
- School of Physiology and Pharmacology, University of Bristol, Bristol, United Kingdom
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Liu E, Rou K, McGoogan JM, Pang L, Cao X, Wang C, Luo W, Sullivan SG, Montaner JSG, Bulterys M, Detels R, Wu Z. Factors associated with mortality of HIV-positive clients receiving methadone maintenance treatment in China. J Infect Dis 2013; 208:442-53. [PMID: 23592864 DOI: 10.1093/infdis/jit163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Little is known about mortality of opiate users attending methadone maintenance treatment (MMT) clinics. We sought to investigate mortality and its predictors among human immunodeficiency virus (HIV)-positive MMT clients. METHODS Records of 306 786 clients enrolled in China's MMT program from 24 March 2004 to 30 April 2011 were abstracted. Mortality rates were calculated for all HIV-positive antiretroviral treatment (ART)-naive and ART-experienced clients. Risk factors were examined using stratified proportional hazard ratios (HRs). RESULTS The observed mortality rate for all clients was 11.8/1000 person-years (PY, 95% confidence interval [CI], 11.5-12.1) and 57.2/1000 PY (CI, 54.9-59.4) for HIV-positive clients (n = 18 193). An increase in average methadone doses to >75 mg/day was associated with a 24% reduction in mortality (HR = 0.76, CI, .70-.82), a 48% reduction for ART-naive HIV-positive clients (HR = 0.52, CI, .42-.65), and a 47% reduction for ART-experienced HIV-positive clients (HR = 0.53, CI, .46-.62). Among ART-experienced clients, initiation of ART when the CD4(+) T-cell count was >300 cells/mm(3) (HR = 0.64, CI, .43-.94) was also associated with decreased risk of death. CONCLUSIONS We found high mortality rates among HIV-positive MMT clients, yet decreased risk of death, with earlier ART initiation and higher methadone doses. A higher daily methadone dose was associated with reduced mortality in both HIV-infected and HIV-uninfected clients, independent of ART.
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Affiliation(s)
- Enwu Liu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Hull LC, Gabra BH, Bailey CP, Henderson G, Dewey WL. Reversal of morphine analgesic tolerance by ethanol in the mouse. J Pharmacol Exp Ther 2013; 345:512-9. [PMID: 23528610 DOI: 10.1124/jpet.112.202184] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- L C Hull
- Department of Pharmacology and Toxicology, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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Silva K, Schrager SM, Kecojevic A, Lankenau SE. Factors associated with history of non-fatal overdose among young nonmedical users of prescription drugs. Drug Alcohol Depend 2013; 128:104-10. [PMID: 22974490 PMCID: PMC4184803 DOI: 10.1016/j.drugalcdep.2012.08.014] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/09/2012] [Accepted: 08/14/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The current study examines the prevalence and correlates of lifetime non-fatal overdose (OD) involving the nonmedical use of prescription opioids and tranquilizers among a sample of high-risk young adults in New York, NY and Los Angeles, CA. METHODS Data were derived from a cross-sectional study of 16-25 year old nonmedical users of prescription drugs (n=596). Unadjusted associations between OD history and socio-demographic and drug use variables were investigated in bivariate logistic regression models. Multivariate logistic regression models identified correlates of non-fatal OD. RESULTS Lifetime prevalence of non-fatal overdose involving prescription opioids and/or tranquilizers was 23.6%. Factors associated with increased risk of non-fatal overdose included lower social class while growing up (OR: 1.81, 95% CI: [1.15, 2.83], p<0.01), having ever received care at a psychiatric hospital (OR: 1.79, 95% CI: [1.12, 2.85], p<0.05), ever witnessing a family member OD on drugs (OR: 1.59, 95% CI: [1.02, 2.50], p<0.05), being prescribed tranquilizers (OR: 2.07, 95% CI: [1.29, 4.27], p<0.01), ever snorting or sniffing opioids (OR: 2.51, 95% CI: [1.48, 4.27], p<0.001), injecting tranquilizers (OR: 3.09, 95% CI: [1.61, 5.93], p<0.001), and past 90-day injection drug use (OR: 1.68, 95% CI: [1.03, 2.74], p<0.05). Participants who reported past 90-day stimulant misuse had lower odds of reporting OD compared to those who were not recent stimulant users (OR: 0.60, 95% CI: [0.38-0.96], p<0.05). CONCLUSIONS This study documents the high prevalence of experiencing non-fatal overdose among young nonmedical users of prescription drugs. Results could inform overdose prevention efforts throughout the U.S.
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Affiliation(s)
- Karol Silva
- Drexel University, School of Public Health, Department of Community Health and Prevention, 1505 Race Street, 11th Floor, Philadelphia, PA 19102, USA.
| | - Sheree M. Schrager
- Children’s Hospital Los Angeles, Division of Adolescent Medicine, 5000 Sunset Boulevard, 7th Floor, Los Angeles, CA 90027, USA
| | - Aleksandar Kecojevic
- Drexel University, School of Public Health, Department of Community Health and Prevention, 1505 Race Street, 11th Floor, Philadelphia, PA 19102, USA
| | - Stephen E. Lankenau
- Drexel University, School of Public Health, Department of Community Health and Prevention, 1505 Race Street, 11th Floor, Philadelphia, PA 19102, USA
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