Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlates of overdose risk perception among illicit opioid users

BACKGROUND

Opioid-related mortality continues to increase in the United States. The current study assesses demographic and behavioral predictors of perceived overdose risk among individuals who use opioids illicitly. By examining these correlates in the context of established overdose risk factors, we aim to assess whether characteristics and behaviors that have been associated with actual overdose risk translate to higher perception of risk.

METHODS

We conducted a cross-sectional survey of 172 adult illicit opioid users in San Francisco, CA and used multivariable logistic regression to identify predictors of perception of high risk for opioid overdose.

RESULTS

Age (aOR=0.96, 95%CI=0.93-1.00) and number of injection days per month (0.91, 0.86-0.97) were associated with a lower odds of perceived high overdose risk. There was no independent association between use of opioid analgesics, concurrent use of opioids and benzodiazepines or cocaine, or HIV status and overdose risk perception.

CONCLUSIONS

Opioid users who injected more frequently and those who were older were less likely to perceive themselves as being at risk of overdose, notwithstanding that those who inject more are at higher risk of overdose and those who are older are at higher risk overdose mortality. In addition, despite being established overdose risk factors, there was no relationship between use of opioid analgesics, concurrent use of opioids and cocaine or benzodiazepines, or self-reported HIV status and overdose risk perception. These findings highlight key populations of opioid users and established risk factors that may merit focused attention as part of education-based overdose prevention and opioid management strategies.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature

BACKGROUND

Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality.

OBJECTIVES

The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts.

RESULTS

We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally.

CONCLUSIONS

There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.

Institutional stakeholder perceptions of barriers to addiction treatment under Mexico's drug policy reform

Mexico has experienced disproportionate drug-related harms given its role as a production and transit zone for illegal drugs destined primarily for the USA. In response, in 2009, the Mexican federal government passed legislation mandating pre-arrest diversion of drug-dependent individuals towards addiction treatment. However, this federal law was not specific about how the scale-up of the addiction treatment sector was to be operationalised. We therefore conducted in-depth qualitative interviews with key 'interactors' in fields affected by the federal legislation, including participants from the law enforcement, public health, addiction treatment, and governmental administration sectors. Among 19 participants from the municipal, state and federal levels were interviewed and multiple barriers to policy reform were identified. First, there is a lack of institutional expertise to implement the reform. Second, the operationalisation of the reform was not accompanied by a coordinated action plan. Third, the law is an unfunded mandate. Institutional barriers are likely hampering the implementation of Mexico's policy reform. Addressing the concerns expressed by interactors through the scale-up of services, the provision of increased training and education programmes for stakeholders and a coordinated action plan to operationalise the policy reform are likely needed to improve the policy reform process.

Differences in Mexican Americans' Prevalence of Chronic Pain and Co-Occurring Analgesic Medication and Substance Use Relative to Non-Hispanic White and Black Americans: Results from NHANES 1999-2004

OBJECTIVE

Little is known about the burgeoning Mexican American (MA) population's pain experience.

METHODS

Using 1999-2004 National Health and Nutrition Examination Survey (NHANES) data, prevalence of chronic pain, analgesic medication use, and substance use were examined among MA, non-Hispanic White (NHW), and non-Hispanic Black (NHB) respondents. Logistic and linear regression models examined racial/ethnic differences in: 1) chronic pain prevalence among all respondents, 2) location and number of pain sites among respondents with chronic pain, and 3) analgesic medication and substance use among respondents with chronic pain.

RESULTS

Compared to NHWs and NHBs, MAs were less likely to report any chronic pain. Among respondents with chronic pain, MAs had higher odds of reporting headache, abdominal pain, and a greater number of pain sites than NHWs. Compared to NHWs, MAs with chronic pain had lower odds of reporting past-month analgesic medication and COX-2 inhibitor use. MAs with chronic pain had lower odds of being a current cigarette smoker and heavy alcohol drinker but had similar street drug/cocaine use relative to NHWs.

CONCLUSIONS

Results suggest that: 1) MAs are less likely to develop chronic pain than NHWs, 2) MAs with chronic pain report greater headache and abdominal pain than NHWs, and 3) MAs with chronic pain are less likely to use analgesic medications and other substances compared to NHWs. These results suggest that providers should consider taking extra time to discuss analgesic medications with MAs. Future investigations should examine reasons underlying these racial/ethnic differences in chronic pain, as well as differences in the use of other substances, such as marijuana.

Impact of binge alcohol on mortality among people who inject drugs

INTRODUCTION

While the impacts of illicit drug use on mortality have been well described, the impact of poly-substance that includes alcohol has received less attention. We examined the impact of binge alcohol use on mortality among a cohort of people who inject drugs (PWID) in a Canadian setting.

METHODS

Using data derived from a prospective cohort study of PWID in Vancouver, Canada recruited between May 1996 and November 2013. We ascertained dates and causes of death through a confidential linkage with the provincial registry and examined the impact of binge alcohol use. The primary outcome of interest was all-cause mortality. We used Cox proportional hazard regression to determine factors associated with mortality, including socio-demographic characteristics, drug use patterns and other risk behaviours.

RESULTS

During the study period, 2550 individuals were followed (844 of whom were HIV positive at baseline) for a median of 75.4 months (interquartile range 37.9 113.2). Of these, 795 (31%) participants reported binge alcohol use at some time during the study period. In multivariable analyses, binge alcohol use remained independently associated with all-cause-mortality (adjusted hazard ratio=1.41; 95% confidence interval: 1.06-1.88) after adjustment for other drug use patterns.

CONCLUSIONS

Binge alcohol use was associated with time to all-cause mortality among PWID in this setting. Since alcohol use is often overlooked as a risk factor for mortality among this population, these findings highlight the continued need to incorporate addiction treatment and public health interventions and policies that address binge alcohol use to reduce alcohol related-harms.

Are overdoses treated by ambulance services an opportunity for additional interventions? A prospective cohort study

AIMS

To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods).

DESIGN

A prospective cohort study.

SETTING

Oslo, Norway.

PARTICIPANTS

A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004.

MEASUREMENTS

Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated.

FINDINGS

Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period.

CONCLUSIONS

Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods.

Patterns and correlates of alcohol use amongst heroin users: 11-year follow-up of the Australian Treatment Outcome Study cohort

INTRODUCTION

The study aimed to determine long-term alcohol use patterns and correlates amongst heroin users.

METHODS

Longitudinal cohort. 11-year post-baseline follow-up of the Australian Treatment Outcome Study cohort.

RESULTS

At 11-year follow-up, 431 (70%) participants were interviewed. Alcohol was used in the preceding month by 56%, with 27% reporting daily use and 11% heavy daily drinking. Alcohol use patterns showed remarkable consistency across waves, with the proportion who drank in the preceding month ranging between 49 and 56%, with no significant trend across time. Daily drinking ranged between 20 and 27%, and heavy daily drinking between 7 and 12%. Both declined slightly from baseline to 3-year follow-up, but by 11 years were at levels similar to baseline. Compared to female referents, males were more likely to drink (OR 1.6, CI 1.3-2.1, p < .05), to drink daily (OR 1.8, CI 1.4-2.4, p < .05) and to drink heavily (OR 1.7, 1.1-2.5, p < .05). Compared to those not in enrolled in a drug treatment programme, those enrolled were significantly less likely to drink (OR 0.7, CI 0.5-0.8, p < .05) and to drink daily (OR 0.6, 0.5-0.8, p < .05). Compared to those who did not drink heavily, heavy drinking was associated with a higher likelihood of recent overdose (OR 1.6, CI 1.0-2.4, p < .05), of criminality (OR 1.9, 1.3-2.7, p < .001), and with lower SF12 physical (mean difference -3.0, CI -4.7 to -1.4, p < .001) and mental (-2.4, CI -4.3 to -0.5, p < .001) health scores.

CONCLUSIONS

There were consistently high levels of both abstinence and regular drinking, with drinking patterns staying relatively stable across the decade. From the clinical perspective, the high rates of heavy drinking are of particular relevance, given the observed associations with a poorer clinical profile.

The CHANGE Study: Methods and Sample Description for a Cross-Sectional Study of Heroin Cessation in New York City

The CHANGE (Cessation of Heroin: A Neighborhood Grounded Exploration) Study aimed to understand factors associated with the initiation and maintenance of sustained heroin cessation from the perspective of users themselves and specifically set out to document the correlates of natural recovery. The CHANGE Study was a case-control study conducted in New York City from 2009 to 2011. Cases were former heroin users, abstinent for 1-5 years in the past 5 years. Controls used heroin at least weekly during the past 5 years and were (1) continuous heroin users without a quit attempt of ≥2 weeks' duration or (2) relapsed heroin users who were currently using and had a quit attempt of ≥2 weeks' duration during the past 5 years. Recruitment and data collection methods are described along with limitations and a brief description of the study sample. In contrast to many studies of drug use and cessation, the CHANGE Study was designed to model success (i.e., initiation and maintenance of heroin cessation) and not failure.

Drugs of abuse and addiction: A slippery slope toward liver injury

Substances of abuse induce alteration in neurobehavioral symptoms, which can lead to simultaneous exacerbation of liver injury. The biochemical changes of liver are significantly observed in the abused group of people using illicit drugs or drugs that are abused. A huge amount of work has been carried out by scientists for validation experiments using animal models to assess hepatotoxicity in cases of drugs of abuse. The risk of hepatotoxicity from these psychostimulants has been determined by different research groups. Hepatotoxicity of these drugs has been recently highlighted and isolated case reports always have been documented in relation to misuse of the drugs. These drugs induce liver toxicity on acute or chronic dose dependent process, which ultimately lead to liver damage, acute fatty infiltration, cholestatic jaundice, liver granulomas, hepatitis, liver cirrhosis etc. Considering the importance of drug-induced hepatotoxicity as a major cause of liver damage, this review emphasizes on various drugs of abuse and addiction which induce hepatotoxicity along with their mechanism of liver damage in clinical aspect as well as in vitro and in vivo approach. However, the mechanisms of drug-induced hepatotoxicity is dependent on reactive metabolite formation via metabolism, modification of covalent bonding between cellular components with drug and its metabolites, reactive oxygen species generation inside and outside of hepatocytes, activation of signal transduction pathways that alter cell death or survival mechanism, and cellular mitochondrial damage, which leads to alteration in ATP generation have been notified here. Moreover, how the cytokines are modulated by these drugs has been mentioned here.

Can differences in the type, nature or amount of polysubstance use explain the increased risk of non-fatal overdose among psychologically distressed people who inject drugs?

BACKGROUND

This study investigates whether the type, nature or amount of polysubstance use can explain the increased risk of non-fatal overdose among people who inject drugs with severe psychological distress.

METHODS

Data came from three years (2011-2013) of the Illicit Drug Reporting System (IDRS), an annual sentinel sample of injecting drug users across Australia (n=2673). Structural Equation Modelling (SEM) was used on 14 drug types to construct five latent factors, each representing a type of polysubstance use. Tests of measurement invariance were carried out to determine if polysubstance use profiles differed between those with and without severe psychological distress. Next, we regressed non-fatal overdose on the polysubstance use factors with differences in the relationships tested between groups.

FINDINGS

Among those with severe psychological distress a polysubstance use profile characterised by heroin, oxycodone, crystal methamphetamine and cocaine use was associated with greater risk of non-fatal overdose. Among those without severe psychological distress, two polysubstance use profiles, largely characterised by opioid substitution therapies and prescription drugs, were protective against non-fatal overdose.

CONCLUSION

The types of polysubstance use profiles did not differ between people who inject drugs with and without severe psychological distress. However, the nature of use of one particular polysubstance profile placed the former group at a strongly increased risk of non-fatal overdose, while the nature of polysubstance use involving opioid substitution therapies was protective only among the latter group. The findings identify polysubstance use profiles of importance to drug-related harms among individuals with psychological problems.

Risk factors for concurrent use of benzodiazepines and opioids among individuals under community corrections supervision

BACKGROUND

The use of heroin and prescription opioids has increased over the past decade. The concurrent use of opioids with other depressants such as benzodiazepines increases the risk of overdose death compared with use of either drug alone. This study examined factors associated with concurrent use of opioids and benzodiazepines in a criminal justice sample in the state of Alabama.

METHODS

The Addiction Severity Index (ASI) and urine drug screen results from 28,570 individuals who were under community corrections supervision from 2002-2012 were examined for independent or concurrent opioid and benzodiazepine use. Multinomial logistic regression analyses were conducted to determine associations between socio-demographic characteristics and drug use.

RESULTS

Concurrent use was detected in 11.5% of the sample. Concurrent use of opioids and benzodiazepines or use of either drug alone was associated with being White, female, married, prescribed psychiatric medications, having seen a physician in the past two years, cannabis use, and having a drug-related offense. Concurrent users were more likely to be unemployed or disabled and have received counseling, and less likely to have completed college, live with relatives or friends, have a history of hallucinations, or have an offense against a person relative to nonusers.

DISCUSSION

While significant overlap of risk factors exists between individuals with concurrent use versus sole use of opioids or benzodiazepines, individuals with concurrent use generally have more social dysfunction than individuals who tested for either substance alone. Concurrent users may need more psychosocial resources and intensive treatments to promote recovery.

Co-occurrence between mental distress and poly-drug use: a ten year prospective study of patients from substance abuse treatment

INTRODUCTION

Longitudinal research investigating psychiatric trajectories among patients with poly-drug use patterns remains relatively scant, even though this specific population is at elevated risk for multiple negative outcomes. The present study examined temporal associations between poly-drug use (i.e. heroin, cannabis, tranquilizers, and amphetamines) and mental distress over a 10-year period.

METHODS

A clinical cohort of 481 patients was recruited from substance use treatment facilities in Norway, and prospectively interviewed 1, 2, 7 and 10years after the initial data collection at treatment admission. At each assessment participants completed a questionnaire addressing their substance use and mental distress. Longitudinal growth models were used to examine whether, and if so, how, levels of drug use were associated with the level and rate of change in mental distress over time.

RESULTS

Results from the longitudinal growth models showed a co-occurrence between active poly-drug use and mental distress, such that there was a dose-response effect where mental distress increased both in magnitude and over time with the number of drugs used. Reduction in mental distress during the 10-year study period was evident only in the no-drug use condition. Use of multiple drugs and mental distress appear strongly co-related over time.

CONCLUSIONS

Pre-treatment assessment should carefully identify individuals manifesting poly-drug use and mental disorders. Treatment and follow-up services should be tailored to their specific needs.

Mortality from treatable illnesses in marginally housed adults: a prospective cohort study

OBJECTIVES

Socially disadvantaged people experience greater risk for illnesses that may contribute to premature death. This study aimed to evaluate the impact of treatable illnesses on mortality among adults living in precarious housing.

DESIGN

A prospective cohort based in a community sample.

SETTING

A socially disadvantaged neighbourhood in Vancouver, Canada.

PARTICIPANTS

Adults (N=371) living in single room occupancy hotels or recruited from the Downtown Community Court and followed for median 3.8 years.

MAIN OUTCOME MEASURES

Participants were assessed for physical and mental illnesses for which treatment is currently available. We compared cohort mortality rates with 2009 Canadian rates. Left-truncated Cox proportional hazards modelling with age as the time scale was used to assess risk factors for earlier mortality.

RESULTS

During 1269 person-years of observation, 31/371 (8%) of participants died. Compared with age-matched and sex-matched Canadians, the standardised mortality ratio was 8.29 (95% CI 5.83 to 11.79). Compared with those that had cleared the virus, active hepatitis C infection was a significant predictor for hepatic fibrosis adjusting for alcohol dependence and age (OR=2.96, CI 1.37 to 7.08). Among participants <55 years of age, psychosis (HR=8.12, CI 1.55 to 42.47) and hepatic fibrosis (HR=13.01, CI 3.56 to 47.57) were associated with earlier mortality. Treatment rates for these illnesses were low (psychosis: 32%, hepatitis C virus: 0%) compared with other common disorders (HIV: 57%, opioid dependence: 61%) in this population.

CONCLUSIONS

Hepatic fibrosis and psychosis are associated with increased mortality in people living in marginal conditions. Timely diagnosis and intervention could reduce the high mortality in marginalised inner city populations.

Re-branding cannabis: the next generation of chronic pain medicine?

The field of pain medicine is at a crossroads given the epidemic of addiction and overdose deaths from prescription opioids. Cannabis and its active ingredients, cannabinoids, are a much safer therapeutic option. Despite being slowed by legal restrictions and stigma, research continues to show that when used appropriately, cannabis is safe and effective for many forms of chronic pain and other conditions, and has no overdose levels. Current literature indicates many chronic pain patients could be treated with cannabis alone or with lower doses of opioids. To make progress, cannabis needs to be re-branded as a legitimate medicine and rescheduled to a more pharmacologically justifiable class of compounds. This paper discusses the data supporting re-branding and rescheduling of cannabis.

Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention

BACKGROUND

Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs.

METHODS

573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs.

RESULTS

Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months.

CONCLUSIONS

Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.

Need and utility of a polyethylene glycol marker to ensure against urine falsification among heroin users

BACKGROUND

Deceptive methods of falsifying urine samples are of concern for anyone who relies on accurate urine toxicology results. A novel method to combat these efforts utilizes polyethylene glycol (PEG) markers administered orally prior to providing a urine sample. By using various PEG combinations to create a tracer capsule of unique composition, each urine sample can be matched to that individual. The goal of this study was to determine the effectiveness of using the PEG marker system among active heroin users screening for research studies.

METHODS

Upon each screening visit, participants (N=55) were randomized to provide an unobserved urine sample, or the PEG tracer procedure was used. LCMS analysis was used to distinguish the PEG combinations, and allowed us to provide a unique qualitative analysis of patterns of drug use (N=168, total urine specimens).

RESULTS

The unique composition of the tracer capsules was accurately detected in 83.5% of the urine specimens. Analyses of inconsistencies implicated a number of possible attempts at fraudulence (11.4%) and investigator/lab error (5.1%). Among this sample, the concurrent use of multiple classes of psychoactive drugs was more common than not, though concomitant drug use was often underreported.

CONCLUSION

Urine drug testing should be the minimum standard for obtaining information about drug use as self-report was unreliable even in a situation where there were no perceived adverse consequences for full disclosure. In cases where there are significant pressures for individuals to falsify these data, more protective collection methods such as the PEG marker system should be considered.

The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users

AIMS

To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997-2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology.

DESIGN

Analysis of consecutive case presentations with foreign body pulmonary embolization.

SETTING/PARTICIPANTS

Sydney, Australia, with a total of 373 cases (271 males, 102 females).

MEASUREMENTS

Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right-sided heart failure were examined.

FINDINGS

Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate-abundant in extent. Cases with moderate-abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right-sided heart pathology in 5.4%. Cases with moderate-abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right-sided heart pathology (OR = 5.3).

CONCLUSIONS

Cases of foreign body pulmonary embolization (resulting from injecting crushed tablets meant for oral use, such as benzodiazepines and pharmaceutical opioids) in Sydney, Australia increased markedly from 1997 to 2013. In a large proportion there were clinical consequences. More extensive embolization was associated with higher levels of pulmonary hypertension and right-sided heart pathology.

The relative risk of fatal poisoning by methadone or buprenorphine within the wider population of England and Wales

OBJECTIVE

To examine the population-wide overdose risk emerging from the prescription of methadone and buprenorphine for opioid substitution treatment in England and Wales.

DESIGN

Retrospective administrative data study.

SETTING

National databases for England and Wales.

PARTICIPANTS/CASES

Drug-related mortality data were drawn from the Office for National Statistics, and prescription data for methadone and buprenorphine were obtained from the National Health Service for the years 2007-2012. During this 6-year period, a total of 2366 methadone-related deaths and 52 buprenorphine-related deaths were registered, corresponding to 17,333,163 methadone and 2,602,374 buprenorphine prescriptions issued. The analysis encompassed poisoning deaths among members of the wider population of England and Wales who consumed, but were not prescribed these medications, in addition to patients prescribed methadone or buprenorphine.

MAIN OUTCOME MEASURES

Mortality risk: substance-specific overdose rate per 1000 prescriptions issued; relative risk ratio of methadone in relation to buprenorphine.

RESULTS

During the years 2007-2012, the pooled overdose death rate was 0.137/1000 prescriptions of methadone, compared to 0.022/1000 prescriptions of buprenorphine (including buprenorphine-naloxone). The analysis generated a relative risk ratio of 6.23 (95% CI 4.79 to 8.10) of methadone in relation to buprenorphine. UK Borders Agency data were taken into consideration and revealed that only negligible amounts of methadone and buprenorphine were seized on entering UK territory between 2007 and 2012, suggesting domestic diversion.

CONCLUSIONS

Our analysis of the relative safety of buprenorphine and methadone for opioid substitution treatment reveals that buprenorphine is six times safer than methadone with regard to overdose risk among the general population. Clinicians should be aware of the increased risk of prescribing methadone, and tighter regulations are needed to prevent its diversion.

Motivations for prescription drug misuse among young men who have sex with men (YMSM) in Philadelphia

BACKGROUND

Prescription drug misuse (i.e. opioids, tranquilizers and stimulants) has become the fastest growing area of substance abuse among young adults. Limited studies focus on prescription drug misuse among young men who have sex with men (YMSM, aged 18-29 years). Furthermore, little is known about YMSM's motivations for misuse. The purpose of this study was to explore personal motivations for prescription drug misuse among YMSM, including the possible connection between misuse and sexual behaviors.

METHODS

As part of a larger mixed methods study of 191 YMSM recruited in Philadelphia during 2012-2013, we conducted semi-structured qualitative interviews with 25 of these participants to gather additional contextual information about their prescription drug misuse. We conducted thematic analysis of qualitative data.

RESULTS

While our results corroborated previous literature on motives for misuse of prescription drugs, our data yielded some distinct motivations specific among YMSM. These motives included social/recreational motives, facilitating sex with other men (including motives such as use of opioids for less painful anal receptive sex), and psychological motives such as depression, stress management, coping with everyday hardships (opioids and tranquilizers) or feeling more energized (stimulants). Prescription drugs were commonly misused within the broader contexts of participants' polysubstance use, adding to the significance of this problem.

CONCLUSIONS

Our findings offer insights into YMSM's motivations for prescription drug misuse, and point to the importance of recognizing and addressing them. While substance use is likely related to various psychosocial issues impacting YMSM, it also may lead to significant health consequences. Results support the need to include prescription drugs and polysubstance use in harm reduction messages and treatment approaches aimed at substance using YMSM.

Prescription opioid use and non-fatal overdose in a cohort of injection drug users

BACKGROUND

There is growing concern regarding rising rates of prescription drug-related deaths among the general North American population as well as increasing availability of illicitly obtained prescription opioids. Concurrently among people who inject drugs (IDU), illicit prescription opioid use has increased while non-fatal overdose remains a major source of morbidity.

OBJECTIVES

To evaluate whether the use of prescription opioids was associated with non-fatal overdose among IDU in Vancouver, Canada.

METHODS

Data was obtained from two open prospective cohorts of IDU between December 2005 and May 2013. We used generalized estimating equation (GEE) logistic regression to evaluate the association between prescription opioid use and non-fatal overdose, adjusting for various social, demographic, and behavioral factors.

RESULTS

There were 1614 IDU, including 541 (33.5%) women, who were recruited and included in this analysis. At baseline, 526 (32.6%) reported using prescription opioids and 118 (7.3%) reported experiencing an overdose in the previous six months. In a multivariable analysis, prescription opioid use remained independently associated with non-fatal overdose (adjusted odds ratio: 1.61, 95% confidence interval: 1.32-1.95), after adjusting for confounders.

CONCLUSION

We observed relatively high rates of prescription opioid use among IDU in this setting, and found an independent association between prescription opioid use and non-fatal overdose. Our data is likely representative of riskier substance use associated with those who use prescription opioids within our sample. Interventions to prevent and respond to overdoses should consider the higher risk profiles of IDU who use prescription opioids.

Drug-related deaths between 2002 and 2013 with accent to methadone and benzodiazepines

AIM

The aim of the study is to assess the trends of overdose and drug related fatalities in the Republic of Macedonia during the 11 years.

MATERIAL AND METHODS

Cross-sectional retrospective survey and reviewed of postmortem toxicological analyses which examined fatal poisonings with illegal drugs in years 2002-2013. Information about gender, age, drug consumption, reported years were analyzed. Narcotics were confirmed with toxicological semi quantitative fluorescence polarization immunoassay (FPIA) in urine (range 250-4000 ng/ml).

RESULTS

Total of 165 deaths were observed. Out of them 145 (87.9%) were male. There is statistical significant differences between male and female DRD due to age (Mann-Whitney U Test = 925, Z = -2626, p = 0.0087). For p < 0.05 there is significant differences between genders due to cause of overdose (Pearson Chi-square = 9743, df = 4, p = 0.0449). DRD among male were mainly because of overdose due to heroin in 80 (51.17%) cases followed by DRD due to combination of methadone and BZD in 25 (11.72%) cases. Out of all DRD cases 50 (30.3%) are related to polydrug use. For p < 0.01 there is a significant differences between analyzed age groups due to cause of overdose (Pearson Chi-square = 33,886, df = 12, p = 0.0007).

CONCLUSIONS

Death cause analysis reveals the difficulties in determining the role of substitution drugs, as many other factors may be involved. The findings also highlight the importance of further enhancing treatment interventions for benzodiazepine misuse among patients on methadone substitution treatment.

Patterns of drug use, risky behavior, and health status among persons who inject drugs living in San Diego, California: a latent class analysis

BACKGROUND

Among persons who inject drugs (PWID), polydrug use (the practice of mixing multiple drugs/alcohol sequentially or simultaneously) increases risk for HIV transmission and unintentional overdose deaths. Research has shown local drug markets influence drug use practices. However, little is known about the impact of drug mixing in markets dominated by black tar heroin and methamphetamine, such as the western United States.

METHODS

Data were collected through an ongoing longitudinal study examining drug use, risk behavior, and health status among PWID. Latent class analysis (LCA) was used to identify patterns of substance use (heroin, methamphetamine, prescription drugs, alcohol, and marijuana) via multiple administration routes (injecting, smoking, and swallowing). Logistic regression was used to identify behaviors and health indicators associated with drug use class.

RESULTS

The sample included 511 mostly white (51.5%) males (73.8%), with mean age of 43.5 years. Two distinct classes of drug users predominated: methamphetamine by multiple routes (51%) and heroin by injection (49%). In multivariable logistic regression, class membership was associated with age, race, and housing status. PWID who were HIV-seropositive and reported prior sexually transmitted infections had increased odds of belonging to the methamphetamine class. Those who were HCV positive and reported previous opioid overdose had an increased odds of being in the primarily heroin injection class (all P-values < .05).

CONCLUSION

Risk behaviors and health outcomes differed between PWID who primarily inject heroin vs. those who use methamphetamine. The findings suggest that in a region where PWID mainly use black tar heroin or methamphetamine, interventions tailored to sub-populations of PWID could improve effectiveness.

Self-administration of cocaine and remifentanil by monkeys under concurrent-access conditions

RATIONALE

Cocaine and opioids are often co-abused. Laboratory research has focused largely on the reinforcing effects of mixtures of drugs relative to the drugs alone. Less research has examined drug mixing by the subject under concurrent-access conditions.

OBJECTIVE

Self-administration of various doses of cocaine and remifentanil was examined under concurrent-access conditions. It was hypothesized that if cocaine and opioid combinations were more effective reinforcers than the single drugs, subjects would mix the two drugs by adjusting their responding to cocaine and an opioid alternative to maintain an optimal ratio of cocaine/remifentanil intake.

METHOD

Three male rhesus monkeys were allowed to self-administer cocaine (0.05-0.2 mg/kg/inj) or saline on one lever and remifentanil (0.05-0.4 μg/kg/inj) or saline on the other lever under concurrent fixed-ratio (FR) 10 schedules. Daily sessions lasted 2 h, and there was a 1-s timeout after every 10-s injection.

RESULTS

When saline and drug were concurrently available, responding on the saline-associated lever was low relative to the drug alternative. When cocaine and remifentanil were concurrently available, both drugs were self-administered above saline levels. Cocaine intake decreased, and remifentanil intake increased as a function of the remifentanil dose that was available. Conversely, cocaine intake and remifentanil intake did not change systematically as a function of the cocaine dose that was available.

CONCLUSION

Monkeys will mix cocaine and an opioid when the two drugs are available concurrently. However, there was no indication that monkeys titrated drug intake to maintain an optimal ratio of intake of the two compounds.

Health profiles of clients in substance abuse treatment: a comparison of clients dependent on alcohol or cocaine with those concurrently dependent

The purpose of this study was to assess whether, among clients receiving substance abuse treatment (n = 616), those dependent on alcohol or cocaine differed significantly from those concurrently dependent on both drugs in terms of physical, mental, social, and economic harms as well as substance use behaviors.

METHODS

Clients from five substance abuse treatment agencies presenting with a primary problem of cocaine or alcohol were classified into three groups as dependent on: (1) alcohol alone, (2) cocaine alone, or (3) both cocaine and alcohol (i.e. concurrent dependence). Participants completed a self-administered questionnaire that included details of their drug and alcohol use, physical health, mental health, social health, economic health, and demographic characteristics.

RESULTS

The concurrent group drank similar amounts of alcohol as those in the alcohol group and used similar amounts of cocaine as the cocaine group. The alcohol group had significantly (p < .05) poorer health profiles than the concurrent group across most variables of the four health domains. An exception was significantly more accidental injuries (p < .05) in the alcohol group. In both bivariate and multivariate analyses, the concurrent group had significantly (p < .05) more accidental injuries, violence, and overdoses than the cocaine group. As well, the concurrent group had significantly (p < .05) higher scores on the anxiety and sexual compulsion scales than the cocaine group, controlling for demographic variables.

CONCLUSION

These findings can aid health care professionals to better respond to issues related to concurrent dependence of cocaine and alcohol.

The impact of drug use patterns on mortality among polysubstance users in a Canadian setting: a prospective cohort study

Background

Illicit drug use is a well-established risk factor for morbidity and mortality. However, few studies have examined the impact of different drug use patterns on mortality among polysubstance using populations. This study aimed to identify drug-specific patterns of mortality among a cohort of polysubstance using persons who inject drugs (PWIDs).

Methods

PWIDs in Vancouver, Canada were prospectively followed between May 1996 and December 2011. Participants were linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariate Cox proportional hazards regression to investigate the relationships between drug use patterns (daily alcohol use, heroin injection and non-injection use, cocaine injection, amphetamine injection and non-injection use, crack smoking and speedball injecting) and time to all-cause mortality.

Results

2330 individuals were followed for a median of 61 months (inter-quartile range: 33 – 112). In total, 466 (19.1%) individuals died for an incidence density of 3.1 (95% confidence interval [CI]: 2.8 – 3.4) deaths per 100 person-years. In multivariate analyses, after adjusting for HIV infection and other potential confounders, only daily cocaine injection remained independently associated with all-cause mortality (adjusted hazard ratio [AHR] = 1.36, 95% CI: 1.06 – 1.76).

Conclusions

Although heroin injecting is traditionally viewed as carrying the highest risk of mortality, in this setting, only daily cocaine injecting was associated with all-cause mortality. These findings highlight the urgent need to identify novel treatments and harm reduction strategies for cocaine injectors.

The relationship between US heroin market dynamics and heroin-related overdose, 1992-2008

BACKGROUND AND AIMS

Heroin-related overdose is linked to polydrug use, changes in physiological tolerance and social factors. Individual risk can also be influenced by the structural risk environment including the illicit drug market. We hypothesized that components of the US illicit drug market, specifically heroin source/type, price and purity, will have independent effects on the number of heroin-related overdose hospital admissions.

METHODS

Yearly, from 1992 to 2008, Metropolitan Statistical Area (MSA) price and purity series were estimated from the US Drug Enforcement Administration data. Yearly heroin overdose hospitalizations were constructed from the Nationwide Inpatient Sample. Socio-demographic variables were constructed using several databases. Negative binomial models were used to estimate the effect of price, purity and source region of heroin on yearly hospital counts of heroin overdoses controlling for poverty, unemployment, crime, MSA socio-demographic characteristics and population size.

RESULTS

Purity was not associated with heroin overdose, but each $100 decrease in the price per pure gram of heroin resulted in a 2.9% [95% confidence interval (CI) = 4.8%, 1.0%] increase in the number of heroin overdose hospitalizations (P = 0.003). Each 10% increase in the market share of Colombian-sourced heroin was associated with a 4.1% (95% CI = 1.7%, 6.6%) increase in number of overdoses reported in hospitals (P = 0.001) independent of heroin quality.

CONCLUSIONS

Decreases in the price of pure heroin in the United States are associated with increased heroin-related overdose hospital admissions. Increases in market concentration of Colombian-source/type heroin is also associated with an increase in heroin-related overdose hospital admissions. Increases in US heroin-related overdose admissions appear to be related to structural changes in the US heroin market.

Personally prescribed psychoactive drugs in overdose deaths among drug abusers: a retrospective register study

INTRODUCTION AND AIMS

Psychoactive prescription drug (PPD) abuse-related overdose deaths have increased in many countries in recent decades. We aimed to investigate the role of personally prescribed psychoactive drugs in abuse-related overdose mortality and explore any associations with level of social disadvantage.

DESIGN AND METHODS

This register linkage study included all 243 people who had died of abuse-related drug-induced poisoning in Finland in 2000 and 2008. Data on registered purchases of psychoactive drugs within one and three years of death were linked to data on the psychoactive drug/s contributing to death in each case. Social disadvantage was measured by receipt of income support, long-term unemployment and disability pension.

RESULTS

Thirty-six percent of those abusers who had died of a drug overdose had purchased a similarly acting drug within three years of death. In all overdoses, the proportion increased from 20% in 2000 to 49% in 2008 (P < 0.001). A similar increase was seen in purchases within one year of death; from one-tenth in 2000 to one-third of all cases in 2008 (P < 0.001). The majority (83%) of the deceased had received income support, while only 13-14% were long-term unemployed or on disability pension. Disability pension recipients had significantly more prescribed psychoactive drug purchases than non-recipients (P < 0.001 for three and one years within death).

DISCUSSION AND CONCLUSIONS

Personally prescribed PPDs pose a potential threat to people who abuse drugs. Health-care services should invest greater effort in identifying people who abuse drugs and in monitoring their drug prescriptions.

Use of synthetic cathinones and cannabimimetics among injection drug users in San Diego, California

BACKGROUND

Use of synthetic cathinones (SC) and cannabimimetics (i.e., "THC homologues" [TH]) is associated with adverse health effects. We investigated the epidemiology of synthetic drug use among a cohort of injection drug users (IDUs) in San Diego, California.

METHODS

We used logistic regression analysis to identify correlates of SC and TH use among 485 IDUs enrolled from June 2012 to September 2013.

RESULTS

Seven percent of participants reported ever using SC and 30% reported ever using TH. In multivariate logistic regression, age and recent hospitalization were significantly associated with odds of SC use (Adjusted Odds Ratio [AOR] 0.93, 95% Confidence Interval [C.I.] 0.90, 0.97; and AOR 2.34 95% C.I. 1.00, 5.49, respectively) and TH use (AOR 0.96, 95% C.I. 0.94, 0.98; and AOR 2.62, 95% C.I. 1.47, 4.68, respectively). Use of methamphetamine (AOR 9.35, 95% C.I. 1.20, 72.79) and club drugs in the past six months (AOR 3.38, 95% C.I. 1.17, 9.76) were significantly associated with SC use. Being on probation/parole (AOR 2.42, 95% C.I. 1.44, 4.07), initiating injection drug use with stimulants (AOR 1.89 95% C.I. 1.13, 3.16), and past six-month marijuana (AOR 9.22, 95% C.I. 4.49, 18.96) and prescription drug use (AOR 1.98, 95% C.I. 1.20, 3.27) were significantly associated with TH use.

CONCLUSIONS

A considerable proportion of IDU use synthetic drugs and may experience harms associated with their use. Findings have implications for criminal justice system management. Prevention efforts should emphasize the risks associated with rapidly changing synthetic formulations, and the potential harms associated with polydrug use.

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

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

Impact of supervised injection facilities on community HIV levels: a public health perspective

The health and social consequences of intravenous drug use pose major challenges to cities across North America. Preventable drug-related harms including accidental overdose, serious bacterial infections, injuries of violence and more recently, the emergence of HIV and hepatitis C, have major impacts on community health. Among the various interventions designed to reduce the harms associated with injection drug use, the establishment of a supervised injection facility is perhaps the most controversial. This review will focus on the potential impact of supervised injection facilities on HIV transmission in conjunction with current HIV prevention initiatives. This will include a review of the health and social consequences associated with illicit drugs use, the limitations of drug enforcement, and the potential impact of supervised injection facilities on reducing the harms associated with injection drug use.

Neighborhood of residence and risk of initiation into injection drug use among street-involved youth in a Canadian setting

BACKGROUND

While research has suggested that exposure to environments where drug use is prevalent may be a key determinant of drug-related risk, little is known regarding the impact of such exposure on the initiation of illicit injection drug use. We assessed whether neighborhood of residence predicted rates of injecting initiation among a cohort of street-involved youth in Vancouver, British Columbia.

METHODS

We followed street-involved injecting naïve youth aged 14-26 and compared rates of injecting initiation between youth residing in Vancouver's Downtown Eastside (DTES) neighborhood (the site of a large street-based illicit drug market) to those living in other parts of the city. Univariate and multivariate Cox regression analyses were employed to determine whether residence in the DTES was independently associated with increased risk of initiation of injection drug use.

RESULTS

Between September, 2005 and November, 2011, 422 injection-naïve individuals were followed, among whom 77 initiated injecting for an incidence density of injecting of 10.3 (95% confidence interval [CI] 5.0-18.8) per 100 person years. In a multivariate model, residence in the DTES was independently associated with initiating injection drug use (adjusted hazard ratio [AHR]=2.16, 95% CI: 1.33-3.52, p=0.002).

CONCLUSIONS

These results suggest neighborhood of residence affects the risk of initiation into injection drug use among street-involved youth. The development of prevention interventions should target high-risk neighborhoods where risk of initiating into injecting drug use may be greatest.

Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial

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.

The temporal relationship between drug supply indicators: an audit of international government surveillance systems

OBJECTIVES

Illegal drug use continues to be a major threat to community health and safety. We used international drug surveillance databases to assess the relationship between multiple long-term estimates of illegal drug price and purity.

DESIGN

We systematically searched for longitudinal measures of illegal drug supply indicators to assess the long-term impact of enforcement-based supply reduction interventions.

SETTING

Data from identified illegal drug surveillance systems were analysed using an a priori defined protocol in which we sought to present annual estimates beginning in 1990. Data were then subjected to trend analyses.

MAIN OUTCOME MEASURES

Data were obtained from government surveillance systems assessing price, purity and/or seizure quantities of illegal drugs; systems with at least 10 years of longitudinal data assessing price, purity/potency or seizures were included.

RESULTS

We identified seven regional/international metasurveillance systems with longitudinal measures of price or purity/potency that met eligibility criteria. In the USA, the average inflation-adjusted and purity-adjusted prices of heroin, cocaine and cannabis decreased by 81%, 80% and 86%, respectively, between 1990 and 2007, whereas average purity increased by 60%, 11% and 161%, respectively. Similar trends were observed in Europe, where during the same period the average inflation-adjusted price of opiates and cocaine decreased by 74% and 51%, respectively. In Australia, the average inflation-adjusted price of cocaine decreased 14%, while the inflation-adjusted price of heroin and cannabis both decreased 49% between 2000 and 2010. During this time, seizures of these drugs in major production regions and major domestic markets generally increased.

CONCLUSIONS

With few exceptions and despite increasing investments in enforcement-based supply reduction efforts aimed at disrupting global drug supply, illegal drug prices have generally decreased while drug purity has generally increased since 1990. These findings suggest that expanding efforts at controlling the global illegal drug market through law enforcement are failing.

Prescription opioid mortality trends in New York City, 1990-2006: examining the emergence of an epidemic

BACKGROUND

The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990-2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas.

METHODS

We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990-2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas.

RESULTS

Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990-2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents.

CONCLUSIONS

The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts.

Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities

OBJECTIVE

To evaluate the cost-effectiveness of distributing naloxone to illicit opioid users for lay overdose reversal in Russian cities.

METHOD

This study adapted an integrated Markov and decision analytic model to Russian cities. The model took a lifetime, societal perspective, relied on published literature, and was calibrated to epidemiologic findings.

RESULTS

For each 20% of heroin users reached with naloxone distribution, the model predicted a 13.4% reduction in overdose deaths in the first 5 years and 7.6% over a lifetime; on probabilistic analysis, one death would be prevented for every 89 naloxone kits distributed (95% CI = 32-260). Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity analyses and cost-saving if resulting in a reduction in overdose events. Naloxone distribution increased costs by US$13 (95% CI = US$3-US$32) and QALYs by 0.137 (95% CI = 0.022-0.389) for an incremental cost of US$94 per QALY gained (95% CI = US$40-US$325). In a worst-case scenario where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost was US$1987 per QALY gained. If national expenditures on drug-related HIV, tuberculosis, and criminal justice were applied to heroin users, the incremental cost was US$928 per QALY gained.

CONCLUSIONS

Naloxone distribution to heroin users for lay overdose reversal is highly likely to reduce overdose deaths in target communities and is robustly cost-effective, even within the constraints of this conservative model.

Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample

OBJECTIVE

To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders.

METHOD

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850-E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning.

RESULTS

Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs.

CONCLUSIONS

SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.

Physical harm due to chronic substance use

Chronic use at high dose of illicit drugs, alcohol and tobacco is associated with physical disease. The relative physical harm of these substances has not been described before, but will benefit the guiding of policy measures about licit and illicit substances. The physical harm of 19 addictive substances (including alcohol and tobacco), consisting of toxicity and the risk and severity of somatic disease (not psychiatric disease) was assessed based on literature data and the professional opinion of experts using scores ranging from 0 (no physical harm) to 3 (very serious physical harm). For alcohol, tobacco and some illicit drugs strong associations between long-term use or use in high dose versus the risk of somatic disease have been described, whereas for other substances such data are not available. Magic mushrooms, LSD and methylphenidate obtained relatively low scores (0.45-0.65) for physical harm, whereas relatively high scores were given for heroin (2.09), crack (2.32), alcohol (2.13) and tobacco (2.10). For cannabis, tobacco, and alcohol the estimated societal disease burden was higher than at individual level. The present ranking solely based on their physical harm was very similar to a previous ranking based on a combination of dependence liability, physical harm and social impairments.

Neuropathological Alterations in Illicit Drug Abuse

A variety of neuropathological findings has been described in illicit drug abusers. The majority of these alterations result from the consequences of hypoxia-ischemia and from cerebrovascular diseases. Within the last few years, widespread morphological alterations of the cellular elements of the brain have been detected. These changes consist of neuronal loss, a numerical reduction of astrocytes, widespread axonal damage with concomitant microglial activation and reactive and degenerative changes of the cerebral microvessels. Based on various studies there is also concern that drug abusers develop neurodegeneration or Parkinsonism as they age. However, whether or to what extent neurodegeneration occurs in human drug abusers remains to be established. In the present paper a brief overview on the neuropathological changes in drug abuse is presented for the forensic pathologist/toxi-cologist with reference to the most pertinent literature.

Prevalence and trends of non-medical opioid and other drug use histories among federal correctional inmates in methadone maintenance treatment in Canada

BACKGROUND

The prevalence of illicit drug use among correctional populations is high, and associated with high levels of drug related morbidity risks and harms. The purpose of this study was to examine temporal and regional patterns of illicit drug use among a sample of Canadian federal correctional inmates participating in correctional methadone maintenance treatment (MMT).

METHODS

Socio-demographic and drug use data collected from 1272 male federal offenders admitted to Correctional Service Canada's (CSC) MMT program between 2003 and 2008 were examined. Univariate analyses were conducted on inmates' key demographic and correctional characteristics, pre-MMT opioid use and other problematic drug use, and opioid and injecting use while incarcerated. Bivariate associations on drug use measures across regions and over time were computed.

RESULTS

Prevalence of heroin use decreased, and prevalence of prescription opioid (PO) use increased over the study period. Significant regional differences existed for PO use, specifically for morphine/hydromorphone and oxycodone use. The majority used opioids and injected while incarcerated, with overall downward trends over time and regional variations. Approximately half the sample indicated a history of lifetime non-opioid problematic drug use, most commonly cocaine (72%) for which substantial regional differences were found.

CONCLUSIONS

Pre-MMT opioid and other problematic non-opioid drug use in the sample was high. Temporal and regional patterns of drug use observed may reflect developments in the general population, e.g. increasing PO misuse. The observed drug use patterns underscore the need for targeted drug specific prevention/treatment measures in correctional environments beyond existing interventions.

Estimating the prevalence of illicit opioid use in New York City using multiple data sources

BACKGROUND

Despite concerns about its health and social consequences, little is known about the prevalence of illicit opioid use in New York City. Individuals who misuse heroin and prescription opioids are known to bear a disproportionate burden of morbidity and mortality. Service providers and public health authorities are challenged to provide appropriate interventions in the absence of basic knowledge about the size and characteristics of this population. While illicit drug users are underrepresented in population-based surveys, they may be identified in multiple administrative data sources.

METHODS

We analyzed large datasets tracking hospital inpatient and emergency room admissions as well as drug treatment and detoxification services utilization. These were applied in combination with findings from a large general population survey and administrative records tracking prescriptions, drug overdose deaths, and correctional health services, to estimate the prevalence of heroin and non-medical prescription opioid use among New York City residents in 2006. These data were further applied to a descriptive analysis of opioid users entering drug treatment and hospital-based medical care.

RESULTS

These data sources identified 126,681 cases of opioid use among New York City residents in 2006. After applying adjustment scenarios to account for potential overlap between data sources, we estimated over 92,000 individual opioid users. By contrast, just 21,600 opioid users initiated drug treatment in 2006. Opioid users represented 4 % of all individuals hospitalized, and over 44,000 hospitalizations during the calendar year.

CONCLUSIONS

Our findings suggest that innovative approaches are needed to provide adequate services to this sizeable population of opioid users. Given the observed high rates of hospital services utilization, greater integration of drug services into medical settings could be one component of an effective approach to expanding both the scope and reach of health interventions for this population.