A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia

Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?

BACKGROUND

For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected.

METHODS

Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles).

RESULTS

Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles.

CONCLUSION

There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.

Trends in reporting methadone-associated cardiac arrhythmia, 1997-2011: an analysis of registry data

BACKGROUND

Long-acting opioids are a leading cause of accidental death in the United States, and methadone is associated with greater mortality rates. Whether this increase is related to the proarrhythmic properties of methadone is unclear.

OBJECTIVE

To describe methadone-associated arrhythmia events reported in the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS).

DESIGN

Description of national adverse event registry data before and after publication of a 2002 report describing an association between methadone and arrhythmia.

SETTING

FAERS, November 1997 and June 2011.

PATIENTS

Adults with QTc prolongation or torsade de pointes and ventricular arrhythmia or cardiac arrest.

MEASUREMENTS

FAERS reports before and after the 2002 report.

RESULTS

1646 cases of ventricular arrhythmia or cardiac arrest and 379 cases of QTc prolongation or torsade de pointes were associated with methadone. Monthly reports of QTc prolongation or torsade de pointes increased from a mean of 0.3 (95% CI, 0.1 to 0.5) before the 2002 publication to a mean of 3.5 (CI, 2.5 to 4.8) after it. After 2000, methadone was the second-most common primary suspect in cases of QTc prolongation or torsade de pointes after dofetilide (a known proarrhythmic drug) and was associated with disproportionate reporting similar to that of antiarrhythmic agents known to promote torsade de pointes. Antiretroviral drugs for HIV were the most common coadministered drugs.

LIMITATION

Reports to FAERs are voluntary and selective, and incidence rates cannot be determined from spontaneously reported data.

CONCLUSION

Since 2002, reports to FAERS of methadone-associated arrhythmia have increased substantially and are disproportionately represented relative to other events with the drug. Coadministration of methadone with antiretrovirals in patients with HIV may pose particular risk.

PRIMARY FUNDING SOURCE

Colorado Clinical and Translational Sciences Institute, National Institutes of Health, and Agency for Healthcare Research and Quality.

Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users

OBJECTIVES

We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users.

METHODS

This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics.

RESULTS

The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network.

CONCLUSIONS

One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.

Polydrug abuse: a review of opioid and benzodiazepine combination use

This paper reviews studies examining the pharmacological interactions and epidemiology of the combined use of opioids and benzodiazepines (BZDs). A search of English language publications from 1970 to 2012 was conducted using PubMed and PsycINFO(®). Our search found approximately 200 articles appropriate for inclusion in this paper. While numerous reports indicate that the co-abuse of opioids and BZDs is ubiquitous around the world, the reasons for the co-abuse of these medications are not entirely clear. Though the possibility remains that opioid abusers are using BZDs therapeutically to self-medicate anxiety, mania or insomnia, the data reviewed in this paper suggest that BZD use is primarily recreational. For example, co-users report seeking BZD prescriptions for the purpose of enhancing opioid intoxication or "high," and use doses that exceed the therapeutic range. Since there are few clinical studies investigating the pharmacological interaction and abuse liability of their combined use, this hypothesis has not been extensively evaluated in clinical settings. As such, our analysis encourages further systematic investigation of BZD abuse among opioid abusers. The co-abuse of BZDs and opioids is substantial and has negative consequences for general health, overdose lethality, and treatment outcome. Physicians should address this important and underappreciated problem with more cautious prescribing practices, and increased vigilance for abusive patterns of use.

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.

Differences in poisoning mortality in the United States, 2003-2007: epidemiology of poisoning deaths classified as unintentional, suicide or homicide

INTRODUCTION

Poisoning, specifically unintentional poisoning, is a major public health problem in the United States (U.S.). Published literature that presents epidemiology of all forms of poisoning mortalities (i.e., unintentional, suicide, homicide) together is limited. This report presents data and summarizes the evidence on poisoning mortality by demographic and geographic characteristics to describe the burden of poisoning mortality and the differences among sub-populations in the U.S. for a 5-year period.

METHODS

Using mortality data from the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we presented the age-specific and age-adjusted unintentional and intentional (suicide, homicide) poisoning mortality rates by sex, age, race, and state of residence for the most recent years (2003-2007) of available data. Annual percentage changes in deaths and rates were calculated, and linear regression using natural log were used for time-trend analysis.

RESULTS

There were 121,367 (rate=8.18 per 100,000) unintentional poisoning deaths. Overall, the unintentional poisoning mortality rate increased by 46.9%, from 6.7 per 100,000 in 2003 to 9.8 per100.000 in 2007, with the highest mortality rate among those aged 40-59 (rate=15.36), males (rate=11.02) and whites (rate=8.68). New Mexico (rate=18.2) had the highest rate. Unintentional poisoning mortality rate increased significantly among both sexes, and all racial groups except blacks (p<0.05 time-related trend for rate). Among a total of 29,469 (rate=1.97) suicidal poisoning deaths, the rate increased by 9.9%, from 1.9 per 100,000 in 2003 to 2.1 per 100,000 in 2007, with the highest rate among those aged 40-59 (rate=3.92), males (rate=2.20) and whites (rate=2.24). Nevada (rate=3.9) had the highest rate. Mortality rate increased significantly among females and whites only (p<0.05 time-related trend for rate). There were 463 (rate=0.03) homicidal poisoning deaths and the rate remained the same during 2003-2007. The highest rates were among aged 0-19 (rate=0.05), males (rate=0.04) and blacks (rate=0.06).

CONCLUSION

Prevention efforts for poisoning mortalities, especially unintentional poisoning, should be developed, implemented and strengthened. Differences exist in poisoning mortality by age, sex, location, and these findings underscore the urgency of addressing this public health burden as this epidemic continues to grow in the U.S.

The prescription drug epidemic in the United States: a perfect storm

INTRODUCTION AND AIMS

Abuse of prescription analgesics in the USA is increasing. The epidemic has been driven by many factors, including marketing strategies, incorrect prescribing practices, a variety of legal and illegal drug sources, belated governmental responses and increases in the number of prescriptions written.

DESIGN AND METHODS

Data sources including surveys, emergency room visits, treatment admissions, overdose deaths, toxicology laboratory findings and journal articles were examined to identify trends.

RESULTS

The surveys and emergency department visits show use lowest among young teenagers and highest among older teenagers and young adults, with significant increases among those aged 55 and older. The length of time between initial use of an opioid other than heroin and admission to treatment is shortening. Mortality data and toxicology exhibits confirm the increases and show the variation in the prevalence of various drugs across the USA.

DISCUSSION AND CONCLUSIONS

Abuse is increasing, with varying patterns of use by high-risk groups and different geographic preferences. Prescription drug monitoring programs are being developed in each of the US states to deter 'doctor shopping'; the Food and Drug Administration has increased authority over manufacturers; and options for proper disposal of leftover medications exist. There is increased emphasis on responsible prescribing including risk assessments, prescribing agreements, treatment plans, and training for clinicians, as well as monitoring the interactions with benzodiazepines. However, unless these efforts decrease diversion, abuse and addiction, clinicians may lose the ability to use some of these opioids for effective pain management or so many barriers will be raised that pain will go undertreated or untreated.

System dynamics modeling as a potentially useful tool in analyzing mitigation strategies to reduce overdose deaths associated with pharmaceutical opioid treatment of chronic pain

OBJECTIVE

To illustrate a system-level, simulation-based approach for evaluating mitigation strategies to address the dramatic rise in abuse, addiction, and overdose deaths associated with the use of pharmaceutical opioid analgesics to treat chronic pain. SIMULATED INTERVENTIONS: Making available drug formulations with increased tamper-resistance, prescriber education programs, and programs that reduce rates of medical user-related abuse and addiction. SIMULATED OUTCOME MEASURE: Number of overdose deaths of medical users of pharmaceutical opioid analgesics, including those who abuse or have become addicted.

METHODS

A demonstration system dynamics model is developed, tested, and used to evaluate the impact of candidate mitigation strategies on the outcome measures.

RESULTS

Tamper-resistant drug products will likely reduce overdose death rates but may not reduce overall deaths if there is increased prescribing. Prescriber education would likely reduce deaths through a reduction in patient access to pharmaceutical opioid analgesics.

CONCLUSIONS

The system dynamics approach may have potential for opioid-related policy evaluation. However, metrics must be carefully selected, and trade-offs may be involved. For example, it may be difficult to limit negative outcomes associated with pharmaceutical opioids without adversely affecting chronic pain patients' access to pharmaceutical treatment. Ultimately, a combination of metrics and value judgments will be needed to properly evaluate mitigation strategies.

The source of methadone in overdose deaths in Western Virginia in 2004

OBJECTIVES

Methadone-related overdose deaths increased in the United States by 468% from 1999 to 2005. Current studies associate the nonmedical use of methadone with methadone-related deaths. This study describes medical examiner cases in rural Virginia in 2004 with methadone identified by toxicology and compares cases according to source of methadone.

METHODS

In 2004, all intentional and unintentional poisoning deaths from the Office of The Chief Medical Examiner, Western District of Virginia, were reviewed to identify cases in which methadone was a direct or contributing cause of death. The Virginia Prescription Monitoring Program was reviewed for prescription opioids in the name of these identified decedents. Decedent participation in local opioid treatment programs (OTP) was also assessed.

RESULTS

The source of methadone in the 61 methadone-related overdose deaths was mostly nonprescribed (67%), although 28% of decedents were prescribed methadone for analgesia. Only 5% of decedents were actively enrolled in an OTP. The majority of deaths were attributed to polysubstance overdose.

CONCLUSIONS

The majority of methadone overdose deaths in this study were related to illicit methadone use, rather than prescribed or OTP uses. Interventions to decrease methadone-related deaths should focus on reduction of nonprescription use of methadone.

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

BACKGROUND

The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths ("overdoses") in CT over an 11-year period.

METHODS

We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type.

RESULTS

Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities.

CONCLUSIONS

The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts.

A continuing black hole? The FDA boxed warning: an appeal to improve its clinical utility

The boxed warning is increasingly utilized by the Food and Drug Administration (FDA) as a clinical warning to prescribers of dangerous adverse drug reactions. As these warnings have expanded, we feel the utility and application of boxed warnings are becoming more nebulous. The use of drugs following issuance of a boxed warning has been variable. Droperidol sales decreased 10-fold in the year following the warning, yet there has been essentially no change in the methadone usage over a similar time period after its boxed warning. Including more information, such as estimation of incidence for the adverse drug reaction, would be more clinically useful to the prescriber. Reasonable standards using supplemental databases outside of the FDA (such as national poison center data) could be helpful in developing an integrated and balanced approach to boxed warnings.

Multiple Determinants of Specific Modes of Prescription Opioid Diversion

Numerous national surveys and surveillance programs have shown a substantial rise in the abuse of prescription opioids over the past 15 years. Accessibility of these drugs to non-patients is the result of their unlawful channeling from legal sources to the illicit marketplace (diversion). Empirical data on diversion remain absent from the literature. This paper examines abusers' sources of diverted drugs from two large studies: 1) a national sample of opioid treatment clients (N=1983), and 2) a South Florida study targeting diverse populations of opioid abusers (N=782). The most common sources of diverted medications were dealers, sharing/trading, legitimate medical practice (e.g., unknowing medical providers), illegitimate medical practice (e.g., pill mills), and theft, in that order. Sources varied by users' age, gender, ethnicity, risk-aversiveness, primary opioid of abuse, injection drug use, physical health, drug dependence, and either access to health insurance or relative financial wealth. Implications for prescription drug control policy are discussed.

Prescription drug abuse: insight into the epidemic

The emergence of clinically efficacious prescription drugs to treat pain, anxiety, and learning disorders is accompanied by the potential for nonmedical use. Prescription drug abuse has become a modern-day epidemic in the United States and is now second only to marijuana use across all age groups. This article reviews the various data collection, analysis, and reporting systems that have been developed in response to the growing concern for nonmedical prescription drug use. The terminology used to categorize prescription drugs that are abused and the various definitions for abuse, misuse, and nonmedical use are discussed. The epidemiology of nonmedical prescription drug use and an overview of each class of prescription drug that is at risk for nonmedical use are presented along with details of specific drugs that are associated with significant morbidity or mortality.

Hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers

BACKGROUND

Unintentional poisoning deaths have been increasing dramatically over the past decade, and the majority of this increase has resulted from overdoses of specific prescription drugs. Despite this trend, there are limited existing data examining hospitalizations for poisonings, both unintentional and intentional, associated with prescription drugs. A better understanding of these hospitalizations may help identify high-risk populations in need of intervention to prevent subsequent mortality.

PURPOSE

This article aims to describe the incidence and characteristics of hospitalizations resulting from poisoning by prescription opioids, sedatives, and tranquilizers in the U.S. from 1999 to 2006 and make comparisons to hospitalizations for all other poisonings during this time period.

METHODS

Hospitalizations for poisonings were selected from the Nationwide Inpatient Sample (NIS), a stratified, representative sample of approximately 8 million hospitalizations each year, according to the principal discharge diagnosis. Intentionality of the poisoning was determined by external cause of injury codes. SAS callable SUDAAN software was used to calculate weighted estimates of poisoning hospitalizations by type and intentionality. Demographic and clinical characteristics of poisoning cohorts were compared. Data were analyzed in 2009.

RESULTS

From 1999 to 2006, U.S. hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers increased a total of 65%. This increase was double the increase observed in hospitalizations for poisoning by other drugs and substances. The largest increase in the number of hospitalized cases over the 7-year period was seen for poisonings by benzodiazepines, whereas the largest percentage increase was observed for methadone (400%). In comparison to patients hospitalized for poisoning from other substances, those hospitalized for prescription opioids, sedatives, and tranquilizers were more likely to be women, aged >34 years, and to present to a rural or urban nonteaching hospital.

CONCLUSIONS

Prescription opioids, sedatives, and tranquilizers are an increasing cause of hospitalization. The hospital admission provides an opportunity to better understand the contextual factors contributing to these cases, which may aid in the development of targeted prevention strategies.