Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

OBJECTIVE

To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.

DESIGN

Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.

SETTING

19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006.

PARTICIPANTS

OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users.

INTERVENTION

OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.

MAIN OUTCOME MEASURES

Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.

RESULTS

Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.

CONCLUSIONS

Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.

Prescription drug overdoses: a review

PROBLEM

Overdoses involving prescription drugs in the United States have reached epidemic proportions over the past 20 years.

METHODS

This review categorizes and summarizes literature on the topic dating from the first published reports through 2011 using a traditional epidemiologic model of host, agent, and environment.

RESULTS

Host factors include male sex, middle age, non-Hispanic white race, low income, and mental health problems. Agent risk factors include use of opioid analgesics and benzodiazepines, high prescribed dosage for opioid analgesics, multiple prescriptions, and multiple prescribers. Environmental factors include rural residence and high community prescribing rates.

DISCUSSION

The epidemiology of prescription drug overdoses differs from the epidemiology of illicit drug overdoses. Incomplete understanding of prescription overdoses impedes prevention efforts.

SUMMARY

This epidemic demands additional attention from injury professionals.

Opioid overdoses in the United States

The November 2011 issue of the online bulletin CDC Vital Signs posted by the Centers for Disease Control and Prevention of the U.S. Public Health Service entitled "Prescription Painkiller Overdoses in the U.S." addressed epidemiologic aspects of drug overdose deaths in the United States due to opioids. A subsequent blog posting on the CDC Directors Blog entitled "Prescription Drug Overdose in the United States: Blog Q&A" also addresses this important issue. Statistics on overdose deaths and strategies for improvement by all stakeholders are provided.

Evaluation and referral for child maltreatment in pediatric poisoning victims

OBJECTIVE

Although the majority of poisonings in young children are due to exploratory ingestions and might be prevented through improved caregiver supervision, the circumstances that warrant evaluation for suspected maltreatment and referral to Child Protective Services (CPS) are unclear. Therefore the objective of this study was to determine the percentage and characteristics of young poisoning victims who were evaluated for child maltreatment by the hospital team (social work and/or child protection team) and/or referred to CPS.

METHODS

Retrospective study of poisoning victims<6 years old seen at an urban children's hospital from 2006 to 2008. Logistic regression was performed to evaluate the associations between the outcomes (evaluation for maltreatment by hospital team and/or referral to CPS) and predictor variables (demographics and circumstances, type and severity of poisoning).

RESULTS

Among 928 poisonings, 41% were from household products, 20% from over-the-counter drugs, 7% from prescription narcotics/sedatives, 29% from other prescription drugs, and ≤ 1% each from ethanol, illicit drugs, or other substances. Most children were asymptomatic (69%) or stable (28%); 3% were critically ill. Only 13% were evaluated by the hospital team and 4% were referred to CPS. Demographic characteristics were not associated with referral to CPS. Higher clinical severity was associated with increased referral (p<0.001). Compared to poisonings with over-the-counter drugs, referrals were more likely for poisonings with ethanol and prescription narcotics/sedatives, but not other prescription drugs or household products (p<0.001). All illicit drug poisonings and 44% of ethanol poisonings were referred. The majority of referrals to CPS were for concerns for illicit drugs, poor supervision or multiple forms of maltreatment; 6% were secondary to concerns for intentional poisoning.

CONCLUSIONS

Evaluations and referrals to CPS for maltreatment are uncommon in young poisoning victims. Referrals occurred consistently for illicit drugs but not ethanol. Although referrals were more likely for higher severity poisonings, it is unclear if the severity of poisoning is associated with the level of supervisory neglect or a marker of ongoing risk to the child. These findings suggest the need to identify risk factors for ongoing harm and the development of clinical guidelines used to determine which poisoning victims should be referred to Child Protective Services.

Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan

CONTEXT

Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use.

OBJECTIVE

To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use.

DESIGN

Retrospective cohort study involving 141,029 Iraq and Afghanistan veterans who received at least 1 non-cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010.

MAIN OUTCOME MEASURES

Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis.

RESULTS

A total of 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD.

CONCLUSION

Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.

CDC grand rounds: prescription drug overdoses - a U.S. epidemic

In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years has been driven by increased use of a class of prescription drugs called opioid analgesics. Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined. In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics. Implementing strategies that target those persons at greatest risk will require strong coordination and collaboration at the federal, state, local, and tribal levels, as well as engagement of parents, youth influencers, health-care professionals, and policy-makers.

From pesticides to medicinal drugs: time series analyses of methods of self-harm in Sri Lanka

OBJECTIVE

To explore if recent changes in methods of self-harm in Sri Lanka could explain the decline in the incidence of suicide.

METHODS

Time series analyses of suicide rates and hospitalization due to different types of poisoning were carried out.

FINDINGS

Between 1996 and 2008 the annual incidence of hospital admission resulting from poisoning by medicinal or biological substances increased exponentially, from 48.2 to 115.4 admissions per 100,000 population. Over the same period, annual admissions resulting from poisoning with pesticides decreased from 105.1 to 88.9 per 100,000. The annual incidence of suicide decreased exponentially, from a peak of 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009. Poisoning accounted for 37.4 suicides per 100,000 population in 1995 but only 11.2 suicides per 100,000 in 2009. The case fatality rate for pesticide poisoning decreased linearly, from 11.0 deaths per 100 cases admitted to hospital in 1997 to 5.1 per 100 in 2008.

CONCLUSION

Since the mid 1990s, a trend away from the misuse of pesticides (despite no reduction in pesticide availability) and towards increased use of medicinal and other substances has been seen in Sri Lanka among those seeking self-harm. These trends and a reduction in mortality among those suffering pesticide poisoning have resulted in an overall reduction in the national incidence of accomplished suicide.

Drug poisoning deaths in the United States, 1980-2008

In 2008, the number of poisoning deaths exceeded the number of motor vehicle traffic deaths and was the leading cause of injury death for the fi rst time since at least 1980. During the past three decades, the poisoning death rate nearly tripled, while the motor vehicle traffic death rate decreased by one-half. During this period, the percentage of poisoning deaths that were caused by drugs increased from about 60% to about 90%. The population groups with the highest drug poisoning death rates in 2008 were males, people aged 45–54 years, and non-Hispanic white and American Indian or Alaska Native persons. The vast majority of drug poisoning deaths are unintentional (see Appendix table). Opioid analgesics were involved in more drug poisoning deaths than other specified drugs, including heroin and cocaine. Opioid analgesics were involved in nearly 15,000 deaths in 2008, while cocaine was involved in about 5,100 deaths and heroin was involved in about 3,000 deaths (data not shown). Deaths involving opioid analgesics may involve other drugs as well, including benzodiazepines (2). In addition to an increase in the number of deaths caused by drug poisoning, increases in drug use, abuse, misuse, and nonfatal health outcomes have been observed. In the past two decades, there has been an increase in the distribution and medical use of prescription drugs, including opioid analgesics (3). From 1999 to 2008, the use of prescription medications increased (4). In 2007–2008, 48% of Americans used at least one prescription drug in the past month and 11% of Americans used five or more prescriptions in the past month. Analgesics for pain relief were among the common drugs taken by adults aged 20–59 years (4). In 2009–2010, over 5 million Americans reported using prescription pain relievers nonmedically in the past month (that is, without a doctor’s prescription or only for the experience or feeling they caused), and the majority of people using prescription pain relievers nonmedically reported getting the drugs from friends or family (5,6). From 2004 to 2008, the estimated rate of emergency department visits involving nonmedical use of opioid analgesics doubled from 49 per 100,000 to 101 per 100,000 (7). Government agencies and other organizations joined together to achieve great reductions in the number of deaths from motor vehicle crashes in the past three decades (8,9). A comprehensive approach, including improvements in the safety of vehicles; improvements in roadways; increased use of restraint systems, such as seat belts and child safety seats; reductions in speed; and also efforts to reduce driving under the influence of alcohol and drugs, contributed to the decline in motor vehicle related deaths (8,9). Using a comprehensive, multifaceted approach, it may be possible to reverse the trend in drug poisoning mortality.

Drug overdose deaths--Florida, 2003-2009

In the United States in 2007, unintentional poisonings were the second leading cause of injury death (after motor-vehicle crashes); approximately 93% of all unintentional poisoning deaths were caused by drug poisoning, also known as drug overdose. From 1990 to 2001 in Florida, the nonsuicidal poisoning death rate increased 325%. To characterize recent trends in drug overdose death rates in Florida, CDC analyzed data from the Florida Medical Examiners Commission. This report summarizes the results of that analysis, which found that, from 2003 to 2009, the number of annual deaths in which medical examiner testing showed lethal concentrations of one or more drugs increased 61.0%, from 1,804 to 2,905, and the death rate increased 47.5%, from 10.6 to 15.7 per 100,000 population. During 2003-2009, death rates increased for all substances except cocaine and heroin. The death rate for prescription drugs increased 84.2%, from 7.3 to 13.4 per 100,000 population. The greatest increase was observed in the death rate from oxycodone (264.6%), followed by alprazolam (233.8%) and methadone (79.2%). By 2009, the number of deaths involving prescription drugs was four times the number involving illicit drugs. These findings indicate the need to strengthen interventions aimed at reducing overdose deaths from prescription drugs in Florida. Medical examiner records are a timely, population-based source for data regarding overdose deaths from specific drugs. The data in this report and subsequent analyses can be used to design and measure the effectiveness of interventions.

[Drug intoxications as an indicator of social tensions and social ill-being]

Taken together statistical data illustrating the frequency of acute iatrogenic intoxication and parameters of economic development of the country testify to the importance of the problem of drug abuse confirmed by calculation of Piearson's correlation coefficients. The analysis of the rating list of pharmaceutical products known to most frequently cause intoxication indicates that a group of potentially dangerous' preparations include not only prescription drugs, such as neuroleptics, antidepressants, and soporifics, but also over-the-counter medicines. The results of the present study give evidence of the appearance of a separate nosological form in this country referred to as iatrogenic diseases. Moreover, they give reason to regard iatrogenic intoxication as a risk factor of social tensions and ill-being.

Acculturation in Hispanics and childhood poisoning: are medicines and household cleaners stored properly?

BACKGROUND

Unintentional poisonings are a major public health issue in the United States (US). With the increasing number of Hispanics in the US, childhood poisoning is a salient public health issue to address within this population. There is a paucity of research examining the relationship between acculturation in Hispanics and the safe storage of medicines and cleaners. The purpose of the study was to determine if demographic variables, such as acculturation in Hispanics, age, gender and education, were predictive of incorrectly storing medicines and household cleaners.

METHODS

We conducted a study among parents/guardians of small children at two pediatric primary care clinics in the Dallas/Fort Worth (DFW) Metropolitan area. We enrolled 201 parents to identify where they stored medicines and household cleaners, and measured acculturation with the Short Acculturation Scale for Hispanics.

RESULTS

Of Hispanic participants, 49% were categorized as less acculturated (n = 99) while 21% were more acculturated (n = 42). Less acculturated participants were over 4 times more likely to store medicines incorrectly, and participants with a high school education or less were over 3 times more likely to improperly store cleaners. With each additional child in the household, the risk for improper storage of cleaners increased by 44%.

CONCLUSION

The fact that children of less acculturated families are at greater risk for poisoning and have lower levels of education demonstrates the need for readable educational materials on this salient topic. Because social networks are integral in Hispanic culture, especially among new immigrants, poison prevention messages should be disseminated by interpersonal communications.

Increasing US mortality due to accidental poisoning: the role of the baby boom cohort

AIMS

In this study we examine whether the recent, sharp increase in mortality in the United States due to accidental poisoning since 2000 is the result of the aging of the baby boom cohort or, instead, a historical trend apparent among decedents of all ages.

DESIGN

We conducted an age-period-cohort analysis using data from the US Vital Statistics and the US Census covering the period 1968-2007.

SETTING AND PARTICIPANTS

The United States population aged 15-64 years.

MEASUREMENTS

Cause of death and demographic data as recorded on death certificates.

FINDINGS

The increase in mortality due to accidental poisoning since the year 2000 stems primarily from a historical period effect across all ages for whites, but results in large part from a rate spike in the baby boom cohort among blacks. For all demographic groups baby boomers had higher odds of death due to accidental poisoning than the cohorts that came before and after them. Historical influences acting across all ages led to an increase in accidental poisoning mortality that was almost 10-fold for whites and threefold for blacks over the study period.

CONCLUSIONS

While the recent, sharp increase in accidental poisoning mortality stems in part from the aging of the baby boom cohort, substantially more of the increase results from influences unique to recent years that have affected all age groups. These results point to the need to bolster overdose prevention programs and policies as the historical increase in accidental poisoning mortality appears to continue unabated.

Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario

OBJECTIVE

To examine whether variation in prescribing at the level of the individual physician is associated with opioid-related mortality.

DESIGN

A population-based cross-sectional analysis linking prescription data with records from the Office of the Chief Coroner.

SETTING

The province of Ontario. Participants Family physicians in Ontario and Ontarians aged 15 to 64 who were eligible for prescription drug coverage under the Ontario Public Drug Program.

MAIN OUTCOME MEASURES

Variation in family physicians' opioid prescribing and opioid-related mortality among their patients.

RESULTS

The 20% of family physicians (n = 1978) who prescribed opioids most frequently issued opioid prescriptions 55 times more often than the 20% who prescribed opioids least frequently. Family physicians in the uppermost quintile also wrote the final opioid prescription before death for 62.7% of public drug plan beneficiaries whose deaths were related to opioids. Physician characteristics associated with greater opioid prescribing were male sex (P = .003), older age (P < .001), and a greater number of years in practice (P < .001).

CONCLUSION

Opioid prescribing varies remarkably among family physicians, and opioid-related deaths are concentrated among patients treated by physicians who prescribe opioids frequently. Strategies to reduce opioid-related harm should include efforts focusing on family physicians who prescribe opioids frequently.

Small dose... big poison

BACKGROUND

It is not possible to identify all toxic substances in a single journal article. However, there are some exposures that in small doses are potentially fatal. Many of these exposures are particularly toxic to children. Using data from poison control centres, it is possible to recognise this group of exposures.

OBJECTIVE

This article provides information to assist the general practitioner to identify potential toxic substance exposures in children.

DISCUSSION

In this article the authors report the signs and symptoms of toxic exposures and identify the time of onset. Where clear recommendations on the period of observation and known fatal dose are available, these are provided. We do not discuss management or disposition, and advise readers to contact the Poison Information Service or a toxicologist for this advice.