Trends in Fatal Poisoning Among Drug Users in France From 2011 to 2021: An Analysis of the DRAMES Register

Importance

The DRAMES (Décès en Relation avec l'Abus de Médicaments Et de Substances) register is a database of drug-related deaths with the aim of identifying the psychoactive substances associated with and estimating the trends in these deaths. Our novel approach is based on the collection of data on all deaths for which toxicology experts have performed analyses.

Objective

To describe drug-related deaths in France and report trends over an 11-year period.

Design, Setting, and Participants

This case series used a national register to assess 4460 drug-related deaths that occurred from 2011 to 2021 in France. Data analyses were performed from January 1, 2012, to December 31, 2022.

Main Outcomes and Measures

Demographic characteristics; medical and substance abuse history; forensic autopsy findings; and toxicology reports.

Results

Among the 4460 deceased individuals (mean [SD] age, 37.8 [10.5] years), the mortality rate was highest among men (sex ratio, 4.4:1). Of the deaths involving a single or predominant drug, the legal substitution product, methadone, was the leading cause of death during the entire study period, ahead of heroin-44.7% and 35.9% for methadone vs 15.8% and 21.8% for heroin in 2011 and 2021, respectively. Between 2011 and 2021, most of the drug-related deaths shifted from licit to illicit drugs, and statistically significant variations were found for buprenorphine, cocaine, heroin, methadone, and other licit opioids. Deaths related to polydrug use increased from 23.2% in 2011 to 30.6% in 2021. In this context, opioids remained associated with most deaths, with at least 1 opioid being involved in approximately 9 of 10 cases (85.9%) in 2021. However, the main trend was the dramatic increase in drug combinations with cocaine, from less than one-third of cases in 2011 (30.8%) to more than half in 2021 (57.8%).

Conclusions and Relevance

This case series assessment of 4460 drug-related deaths found that opioids used alone or in combination were the main contributor to drug-related deaths, despite having a lower prevalence than other drugs. This finding is similar to that of other countries; however, in France licit methadone was the leading cause of opioid-related deaths (ahead of heroin) during the study period. Deaths associated with use of cannabis, new psychoactive substances, and stimulants (including amphetamine-type stimulants and cocaine, especially in combination) have increased and should be closely monitored.

The opioid epidemic: A worldwide exploratory study using the WHO pharmacovigilance database

BACKGROUND AND AIMS

The current opioid epidemic in the United States began 20 years ago and has become the leading cause of accidental deaths in the country. This crisis prompted us to explore trends in opioid abuse and dependence worldwide. We sought to identify other countries at high-risk of opioid use disorders, using the World Health Organization's (WHO) pharmacovigilance database.

METHODS

We performed a disproportionality analysis using VigiBase, the WHO Global Individual Case Safety Report (ICSR) database. Five opioids used worldwide were included: oxycodone, fentanyl, morphine, tramadol, and codeine. We extracted all ICSRs associated with the drugs of interest, considered as suspect medication and recorded up until 5 June 2021, using the narrow Standardised MedDRA Query (SMQ) for drug abuse and dependence. Countries with at least one ICSR for each of the five opioids were retained. The relationship between the use of a drug (i.e. an opioid) and the occurrence of an adverse drug reaction (i.e. drug abuse and dependence) for each country was assessed by calculating the information component (IC) and its 99.9% CI [IC₀₀₀₅ ; IC₉₉₉₅ ], using a quasi-Bayesian confidence propagation neural network (BCPNN). A hierarchical cluster analysis (Ward's method) of the IC₀₀₀₅ value for each of the five opioids was performed to identify subgroups of countries with similar reported risks of opioid abuse and dependence.

RESULTS

Among 21 countries, the optimal number of clusters was calculated to be four, each with a Jaccard index >0.5 (0.95, 0.78, 0.65 and 0.75, respectively). Six countries with the highest signals of drug abuse and dependence were identified in cluster 1, with significant CIs for the five opioids of interest (IC₀₀₀₅  > 0), ranging from 0.9 to 5.8 for the lower endpoint.

CONCLUSIONS

There appear to be four distinct clusters of countries with similar opioid abuse and dependence profiles. The group with the highest reported risk for the opioids oxycodone, fentanyl, morphine, tramadol and codeine includes Australia, Canada, France, Germans, the United Kingdom and the United States.

[Thirty years of nefopam abuse in France]

AIM OF THE STUDY

The use of nefopam is constantly increasing in France. The objectives of this study were to quantify the intensity of the drug dependence signal, to identify the populations at risk and the risk factors of dependence.

METHODS

All serious and non-serious cases of misuse, abuse, drug dependence, overdose and withdrawal syndrome reported to the French Addictovigilance Network since 1988 were reviewed. An analysis of nefopam reimbursement data from the French national EGB (échantillon généraliste des bénéficiaires) database for the period 2006-2017 was also performed.

RESULTS

The drug dependence profile of nefopam is close to that of a psychostimulant. Our literature review and the analysis of spontaneous reports confirm the risk of abuse and dependence of nefopam. In addition to a frequent psychiatric history (depression, psychosis, anxiety), nearly half of the patients also present addictive disorders, including more than one-third with opioid-dependence. In almost half of the 120 reported cases, the main adverse reaction was dependence and the frequency of serious effects was greater than 40%. In nearly 70% of the reported cases, the use was associated with chronic pain, which might explain the prolonged use. Moreover, the analysis of data on the reimbursement of nefopam in the general population showed that one French person out of two, having a prescription for nefopam, presented chronic pain. However, nefopam is only indicated in the treatment of acute painful conditions. Although it does not seem to be associated with a greater risk of abuse or dependence, taking the drug orally is another very frequent off-label use that needs to be regulated.

CONCLUSION

In France, the prescription of nefopam outside of its marketing authorization is regrettable, because it contributes to the development of abuse and drug dependence.

[Improve the benefit/risk balance of methadone by respecting its pharmacological specificities]

Recent data on methadone from 2008 to 2017 by the French addictovigilance network warms on the increase of methadone use, its diversion, its increase of overdose risk factors (opioids associated, occasional use) and deaths. Whereas methadone is an essential drug for opioid addiction, its use remains complex because of its pharmacology leading to increase the awareness of health professionals.

Carbon monoxide poisoning monitoring network: a five-year experience of household poisonings in two French regions

BACKGROUND

In France, the epidemiological situation of acute carbon monoxide (CO) poisoning is only partially known. The purpose of this study was to assess the epidemiological situation of household poisonings in two French regions where a regional toxicovigilance network was active.

METHODS

During five years, we studied, by means of a standardized data collection form, cases of acute CO poisoning admitted to regional hospitals and notified by hospital physicians.

RESULTS

From 1997 to 2001, 1,458 people were involved in 489 places. Household poisonings represented the first circumstance of CO poisoning with 811 people involved in 293 places. So, analysis was performed only for household poisonings. The mean age was 33.3 years. Twenty patients died (2.6%), 16 patients were in coma (2.1%), and 11 patients had an initial isolated loss of consciousness (14.4%). Responsible appliances in household poisonings were identified in 84% of places. The appliances most often involved were vented heating systems (46.4%), mobile heaters (13.2%), and thermal motors (8.7%). In 63% of the 293 places, investigation showed that poisoning occurred because of a faulty installation. Vented gas heaters and mobile heaters were responsible for half of the severe household CO poisonings.

CONCLUSION

In the countries of Rhône-Alpes and Auvergne, most of household CO poisonings are no longer caused by waterheaters but by gas heating systems. Poisonings caused by mobile heaters more frequently led to coma and death and thermal motors played a large part in moderate poisonings. These recently emerging trends justify the efforts focused on ongoing monitoring and the introduction of preventive measures.