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Pfeifer P, Nigg-Trawally N, Bartsch C, Reisch T. Characteristics of Suicides and Toxicology in a Cohort of Individuals With Opioid Use Disorder. Arch Suicide Res 2021; 25:287-296. [PMID: 32281522 DOI: 10.1080/13811118.2020.1746941] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Suicide in patients with opioid use disorder (OUD) is a complex issue. In addition to accidental intoxications, a higher prevalence of fatal suicides in patients with OUD can be found compared to the general population. In this study, suicides with a diagnosis of OUD documented in the project "Suicides, A National Survey" were extracted from our data bank. Individuals with a diagnosis of OUD in their medical history were compared to other suicides. The analyses included clinical and demographic factors as well as an investigation of suicide methods and toxicology of psychotropic drugs. For the statistical analyses, we applied chi-square tests and calculated odds ratios. Out of 6,495 suicide cases in Switzerland between 2000 and 2010, 215 individuals with a medical history of OUD could be identified. Persons in OUD cases were significantly younger than in other suicide cases (p < .001) and had more frequently a positive history for suicide attempts (p = .02). In addition, persons in OUD cases were more often female (p = .076). Intentional self-poisoning with medication was applied more often in individuals with OUD compared to other suicide methods (p < .001). When self-poisoning with drugs was compared to violent suicide methods, a combination of benzodiazepines with antidepressants was predominantly found. Our study yielded significant characteristics and risk factors for suicides in individuals with OUD. The predominant method of suicide in individuals with OUD was intended self-poisoning by medication. This knowledge is of clinical importance for the monitoring of at-risk individuals with OUD as well as for suicide prevention in this patient group.
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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:metabo11030189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
- Correspondence:
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Iwersen-Bergmann S, Plattner S, Hischke S, Müller A, Andresen-Streichert H, Jungen H, Erb R, Beer-Sandner B. Brain/blood ratios of methadone and ABCB1 polymorphisms in methadone-related deaths. Int J Legal Med 2021; 135:473-482. [PMID: 33454797 PMCID: PMC7870766 DOI: 10.1007/s00414-021-02502-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023]
Abstract
Methadone is an opioid that often leads to fatalities. Interpretation of toxicological findings can be challenging if no further information about the case history is available. The aims of this study were (1) to determine whether brain/blood ratios can assist in the interpretation of methadone findings in fatalities; (2) to examine whether polymorphisms in the gene encoding the P-glycoprotein (also known as multidrug resistance protein 1 (MDR1) or ATP-binding cassette sub-family B member 1 (ABCB1)), which functions as a multispecific efflux pump in the blood–brain barrier, affect brain/blood ratios of methadone. Femoral venous blood and brain tissue (medulla oblongata and cerebellum) from 107 methadone-related deaths were analysed for methadone by gas chromatography-mass spectrometry. In addition, all the samples were genotyped for three common ABCB1 single nucleotide polymorphisms (SNPs rs1045642, rs1128503, and rs2032582) using ion-pair reversed-phase high-performance liquid chromatography-electrospray ionization mass spectrometry (ICEMS). In nearly all cases, methadone concentrations were higher in the brain than in the blood. Inter-individual brain/blood ratios varied (0.6–11.6); the mean ratio was 2.85 (standard deviation 1.83, median 2.35). Moreover, significant differences in mean brain/blood ratios were detected among the synonymous genotypes of rs1045642 in ABCB1 (p = 0.001). Cases with the T/T genotype had significantly higher brain/blood ratios than cases with the other genotypes (T/T vs. T/C difference (d) = 1.54, 95% CI [1.14, 2.05], p = 0.002; T/T vs. C/C d = 1.60, 95% CI [1.13, 2.29], p = 0.004). Our results suggest that the rs1045642 polymorphisms in ABCB1 may affect methadone concentrations in the brain and its site of action and may be an additional factor influencing methadone toxicity.
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Affiliation(s)
- S Iwersen-Bergmann
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - S Plattner
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - S Hischke
- Institute for Health Services Research in Dermatology and Nursing, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - A Müller
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - H Andresen-Streichert
- Institute of Legal Medicine, Faculty of Medicine, University of Cologne, Köln, Germany
| | - H Jungen
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - R Erb
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - B Beer-Sandner
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
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Andersson L, Håkansson A, Krantz P, Johnson B. Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances. Harm Reduct J 2020; 17:5. [PMID: 31918732 PMCID: PMC6953255 DOI: 10.1186/s12954-019-0354-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/27/2019] [Indexed: 12/23/2022] Open
Abstract
Background Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths. Methods The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson’s chi-square test, Fisher’s exact test and the Mann-Whitney U test to analyse group differences. Results A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death. Conclusions The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.
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Affiliation(s)
- Lisa Andersson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden.
| | - Anders Håkansson
- Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden.,Malmö Addiction Centre, Region Skåne, Malmö, Sweden
| | - Peter Krantz
- Faculty of Medicine, Department of Clinical Sciences Lund, Forensic Medicine, Lund University, Lund, Sweden
| | - Björn Johnson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden
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Methadone Maintenance Treatment: A 15-year Retrospective Study in Split-Dalmatia County, Croatia. Ther Drug Monit 2018; 40:486-494. [PMID: 29649094 DOI: 10.1097/ftd.0000000000000519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this retrospective study is to use existing epidemiological data on patients in methadone maintenance treatment in Split-Dalmatia County from 2001 to 2015 to evaluate the substitution treatment system and policy of opiate addicts treatment, the epidemiological trend, and risk of overdose mortality. In addition, we would like to highlight the problem of poor control of methadone therapy and thus the possibility of selling methadone. The result is a greater number of deaths caused by methadone in people who were not in methadone therapy. METHODS The research included data collected from 3189 patients who had been in the drug abuse treatment program in Split-Dalmatia County during 2001-2015 and data gathered from autopsy examinations of patients in Split-Dalmatia County with emphasis on data for 186 overdosed patients during research period. RESULTS The total number of patients in the methadone treatment program in Split-Dalmatia County during the research period, except in 2005 and 2006, has been stable, while the number of new opiate patients, being in first-time treatment, decreased by 62.5%. The number of addicts who were in a long-term maintenance program has increased by 198%, whereas the number of addicts who were in a short-term detoxification treatment has decreased by 96.4%. According to results obtained from performed autopsies, 186 death cases were determined as overdoses. Methadone was found in 56 of those cases and was declared as the cause of death in 39 cases (70%). Of the total number of autopsied patients with diagnosed methadone overdose, only 23 (59%) had been recorded to receive methadone therapy in Public Health Institute of Split-Dalmatia County database. CONCLUSIONS The results of this study show the favorable epidemiological trend because of the decreasing number of new opiate patients in treatment. The retention of opiate patients in substitution therapy indicates the effectiveness of methadone maintenance programs. Our research did not determine any influence of methadone substitution therapy on an increasing risk of specific (overdose) mortality.
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Dunn KE, Barrett FS, Fingerhood M, Bigelow GE. Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain. PAIN MEDICINE 2018; 18:1505-1515. [PMID: 27651504 DOI: 10.1093/pm/pnw228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective More than 100 million adults in the United States experience chronic pain, and prescription opioids are the third most widely prescribed class of medications. Current opioid overdose prevention efforts almost exclusively target illicit opioid users, and little is known about the experience of overdose among patients being treated for chronic pain (CP) with a prescription opioid. Methods Patients experiencing CP for three or more months and receiving a prescription opioid for pain management (N = 502) completed a self-report survey that asked questions about opioid overdose history, past 30-day risk factors, and knowledge of opioid overdose, overdose risk, and naloxone. Results Approximately one in five CP participants reported experiencing a lifetime overdose. CP participants reported engaging in several behaviors associated with overdose risk and were unlikely to have been trained to administer naloxone. Fewer than 50% of participants answered any knowledge item correctly. The likelihood of having experienced an overdose increased as the scores on the SOAPP-R and DSM-5 opioid use disorder checklist increased, and a SOAPP-R score of 7 or higher or meeting DSM-5 mild opioid use disorder criteria were significantly associated with reporting a lifetime overdose (85% and 84% of participants who experienced an overdose, respectively). Conclusions Opioid overdose occurs at a high rate among CP participants, and this group is relatively uninformed about risk factors for overdose. Established SOAPP-R and DSM thresholds provide an opportunity to identify participants at elevated risk for having experienced an opioid overdose. These data support development of additional concentrated efforts to prevent overdose among chronic pain patients.
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Affiliation(s)
- Kelly E Dunn
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
| | - Frederick S Barrett
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
| | - Michael Fingerhood
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21224
| | - George E Bigelow
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
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7
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Dunn KE, Barrett FS, Yepez-Laubach C, Meyer AC, Hruska BJ, Petrush K, Berman S, Sigmon SC, Fingerhood M, Bigelow GE. Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting. J Subst Abuse Treat 2018; 71:1-7. [PMID: 27672239 DOI: 10.1016/j.jsat.2016.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Opioid use is highly prevalent in the United States and there has been an increased incidence in the rate of opioid-related overdose. While evidence suggests there are substantial differences in opioid use among rural versus urban settings, the rate of overdose and corresponding frequency of opioid overdose risk behaviors and overdose knowledge between rural and urban settings have not been examined. METHODS Individuals with opioid use disorder from rural (N=98) and urban (N=247) settings completed a self-report survey regarding their lifetime history of overdose and overdose risk behaviors. Participants also completed the Brief Opioid Overdose Knowledge (BOOK) questionnaire, a 12-item self-report measure of opioid overdose knowledge. RESULTS Overall, 35.6% of participants had experienced an overdose, and prevalence of overdose was significantly higher (p<.01) among rural (45.9%) vs. urban (31.6%) participants, though fewer rural participants reported past 30-day risk behaviors. There were few differences observed between the subset of rural and urban participants who had experienced an overdose, and fewer rural participants with a history of overdose reported past 30-day risk behaviors. Both rural and urban participants performed poorly on the BOOK, though the percent of correct responses was lowest among rural participants with a history of overdose. CONCLUSION Results demonstrate higher rates of overdose among rural opioid users, though rural participants were less likely to report recent risk behaviors. Results also suggest that knowledge regarding key factors related to opioid overdose is severely lacking, particularly among rural opioid users, which could be a potential target for future intervention efforts.
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Affiliation(s)
- Kelly E Dunn
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences
| | - Frederick S Barrett
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences
| | - Claudia Yepez-Laubach
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences
| | | | | | - Kathy Petrush
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Medicine
| | - Suzan Berman
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Medicine
| | - Stacey C Sigmon
- University of Vermont, Department of Psychiatry; University of Vermont, Department of Psychology
| | - Michael Fingerhood
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Medicine
| | - George E Bigelow
- Johns Hopkins University School of Medicine, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences
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Dunn KE, Yepez-Laubach C, Nuzzo PA, Fingerhood M, Kelly A, Berman S, Bigelow GE. Randomized controlled trial of a computerized opioid overdose education intervention. Drug Alcohol Depend 2017; 173 Suppl 1:S39-S47. [PMID: 28363318 PMCID: PMC5918281 DOI: 10.1016/j.drugalcdep.2016.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Opioid overdose (OD) has become a significant public health problem in need of effective interventions. The majority of existing educational interventions target provision of naloxone and are conducted in-person; these elements present logistical barriers that may limit wide-spread implementation. This study developed and evaluated an easily disseminated opioid OD educational intervention and compared computerized versus pamphlet delivery METHODS: Participants (N=76) undergoing opioid detoxification were randomly assigned to receive OD education via a Pamphlet (N=25), Computer (N=24), or Computer+Mastery (N=27) with identical content for all delivery modalities. Primary outcomes were changes from pre- to post-intervention in knowledge of opioid effects, opioid OD symptoms, and recommended opioid OD responses, as well as intervention acceptability. Also assessed at 1 and 3-month follow-ups were retention of knowledge and change in reported OD risk behaviors. RESULTS Knowledge increased following all three intervention-delivery modalities with few between-group differences observed in knowledge gain or acceptability ratings. Largest gains were in the domain of opioid OD response (from 41.8% to 73.8% mean correct responses; p<0.001). Knowledge was well sustained at the 1 and 3-month follow-ups among completers, where a significant reduction was seen in the critical behavioral risk factor of using opioids while alone. CONCLUSION Opioid overdose education delivered by computer or written pamphlet produced sustained increases in knowledge and reduction in a key behavioral risk factor. RESULTS Results support further evaluation of this educational intervention that can be used alone or to complement naloxone-training programs.
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Affiliation(s)
- Kelly E Dunn
- Johns Hopkins University School of Medicine, Departments of Psychiatry and Behavioral Sciences, United States.
| | - Claudia Yepez-Laubach
- Johns Hopkins University School of Medicine, Departments of Psychiatry and Behavioral Sciences, United States
| | - Paul A Nuzzo
- Johns Hopkins University School of Medicine, Departments of Psychiatry and Behavioral Sciences, United States
| | - Michael Fingerhood
- Johns Hopkins University School of Medicine, Departments of Medicine, United States
| | - Anne Kelly
- Johns Hopkins University School of Medicine, Departments of Medicine, United States
| | - Suzan Berman
- Johns Hopkins University School of Medicine, Departments of Medicine, United States
| | - George E Bigelow
- Johns Hopkins University School of Medicine, Departments of Psychiatry and Behavioral Sciences, United States
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Roux P, Lions C, Vilotitch A, Michel L, Mora M, Maradan G, Marcellin F, Spire B, Morel A, Carrieri PM. Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study). Harm Reduct J 2016; 13:12. [PMID: 27048152 PMCID: PMC4822310 DOI: 10.1186/s12954-016-0100-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 03/24/2016] [Indexed: 11/11/2022] Open
Abstract
Background Cocaine use is frequent in patients receiving methadone maintenance treatment (MMT) and can jeopardize their treatment response. Identifying clinical predictors of cocaine use during methadone treatment can potentially improve clinical management. We used longitudinal data from the ANRS Methaville trial both to describe self-reported occasional and regular cocaine use during MMT and to identify clinical predictors. Methods We selected 183 patients who had data on cocaine (or crack) use at months 0 (M0), M6, and/or M12, accounting for 483 visits. The outcome was “cocaine use” in three categories: “no,” “occasional,” and “regular” use. To identify factors associated with the outcome over time, we performed a mixed multinomial logistic regression. Results Time on methadone was significantly associated with a decrease in occasional but not in regular cocaine use from 14.7 % at M0 to 7.1 % at M12, and from 10.7 % at baseline to 6.5 % at M12, respectively. After multiple adjustments, opiate injection, individuals screening positive for attention deficit hyperactivity disorder (ADHD) symptoms, and those presenting depressive symptoms were more likely to regularly use cocaine. Conclusions Although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present ADHD and depressive symptoms. Early screening of these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT. Trial registration The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials, number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397, and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.
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Affiliation(s)
- Perrine Roux
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France. .,Aix Marseille Université, UMR_S 912, IRD, Marseille, France. .,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France.
| | - Caroline Lions
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Antoine Vilotitch
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Laurent Michel
- INSERM, Research Unit 669, Paris, France.,Univ Paris-Sud and Univ Paris Descartes, UMR-S0669, Paris, France.,Centre Pierre Nicole, Paris, France
| | - Marion Mora
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Gwenaelle Maradan
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Fabienne Marcellin
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Bruno Spire
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | | | - Patrizia M Carrieri
- INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.,Aix Marseille Université, UMR_S 912, IRD, Marseille, France.,ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
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Lusetti M, Licata M, Silingardi E, Reggiani Bonetti L, Palmiere C. Therapeutic and recreational methadone cardiotoxicity. J Forensic Leg Med 2016; 39:80-4. [PMID: 26859696 DOI: 10.1016/j.jflm.2016.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/07/2015] [Accepted: 01/18/2016] [Indexed: 11/30/2022]
Abstract
Several classes of drugs have been associated with an increased risk of cardiovascular disease and occurrence of arrhythmias potentially involved in sudden deaths in chronic users even at therapeutic doses. The study presented herein focuses on pathological changes involving the heart possibly due to methadone use. 60 cases were included in the study in total and were divided into three groups (therapeutic methadone users: 20 cases, recreational methadone users: 20 cases, and sudden death group in subjects who had never taken methadone: 20 cases). Autopsies, histology, biochemistry and toxicology were performed in all cases. Macroscopic and microscopic investigation results in therapeutic methadone users were similar to those observed in sudden, unexpected deaths in non-methadone users. In recreational methadone consumers, macroscopic and microscopic examination of the heart failed to provide results consistent with acute or chronic myocardial or coronary damage, thereby corroborating the hypothesis of death most likely following respiratory depression.
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Affiliation(s)
- Monia Lusetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Manuela Licata
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Enrico Silingardi
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Luca Reggiani Bonetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Clinical Pathology, Modena, Italy
| | - Cristian Palmiere
- University Center of Legal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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Bernard JP, Khiabani HZ, Hilberg T, Karinen R, Slørdal L, Waal H, Mørland J. Characteristics of methadone-related fatalities in Norway. J Forensic Leg Med 2015; 36:114-20. [PMID: 26439870 DOI: 10.1016/j.jflm.2015.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 05/15/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
There are currently over 7000 patients enrolled in opioid maintenance treatment (OMT) programs in Norway. A rise in methadone-related deaths proportional to increasing methadone sales over the period 2000-2006 has been observed, but the causative factors for these fatalities have been elusive. In the present study, individual characteristics, methadone concentrations and additional toxicological findings were analyzed. Methadone intoxication deaths (n = 264) were divided into 3 groups according to toxicological findings in whole blood: group 1 - methadone detected alone, or together with one additional drug at low or therapeutic levels, or a low concentration of ethanol (<1 g/L) (n = 21); group 2 - multiple additional drugs/substances detected below lethal levels (n = 175); group 3 - one or more additional drugs/substances detected at lethal levels, or ethanol >3 g/L (n = 55). Methadone blood concentrations in decedents who had been enrolled in OMT were higher than for decedents not in treatment, in all groups. Blood methadone concentrations around 1 mg/L were present in fatal multi-drug intoxications in OMT patients. Results suggest that some patients may be at risk of dying when combining therapeutic concentrations of methadone with other psychoactive substances. Somatic disease was a common finding among deceased OMT patients. Concentrations in methadone users not enrolled in OMT were predominantly between 0.3 and 0.4 mg/L and were not related to the presence of other drugs. However, methadone concentrations below 0.1 mg/L may be associated with intoxication following methadone use, both alone and in combination with other drugs. Younger male users (mean age 34 years) seemed to have a higher susceptibility to methadone intoxication.
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Affiliation(s)
- Jean-Paul Bernard
- Norwegian Institute of Public Health, Division of Forensic Sciences, Oslo, Norway; Centre for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.
| | - Hassan Z Khiabani
- Norwegian Institute of Public Health, Division of Forensic Sciences, Oslo, Norway; Oslo University Hospital, Rikshospitalet, Department of Pharmacology, Oslo, Norway
| | - Thor Hilberg
- Norwegian Institute of Public Health, Division of Forensic Sciences, Oslo, Norway; Fürst Medical Laboratory, Oslo, Norway
| | - Ritva Karinen
- Norwegian Institute of Public Health, Division of Forensic Sciences, Oslo, Norway
| | - Lars Slørdal
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway; Department of Clinical Pharmacology, St. Olav's Hospital, Trondheim, Norway
| | - Helge Waal
- SERAF-Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway; Oslo University Hospital, Division of Mental Health and Addiction, Oslo, Norway
| | - Jørg Mørland
- Norwegian Institute of Public Health, Division of Forensic Sciences, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
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Petrushevska T, Jakovski Z, Poposka V, Stefanovska VV. Drug-related deaths between 2002 and 2013 with accent to methadone and benzodiazepines. J Forensic Leg Med 2015; 31:12-8. [PMID: 25735778 DOI: 10.1016/j.jflm.2014.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 10/23/2014] [Accepted: 12/29/2014] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Tatjana Petrushevska
- Ministry of Health, Head of Sector for Controlled Substances, National Focal Point for EMCDDA, Macedonia.
| | - Zlatko Jakovski
- Institute of Forensic Medicine, Criminology and Medical Deontology at the Medical Faculty in Skopje, University "Sv.Kiril and Metodij", Skopje, Macedonia
| | - Verica Poposka
- Institute of Forensic Medicine, Criminology and Medical Deontology at the Medical Faculty in Skopje, University "Sv.Kiril and Metodij", Skopje, Macedonia
| | - Vesna Velik Stefanovska
- Institute for Epidemiology and Medical Biostatistics, Head of Cathedra, Medical Faculty "Ss. Cyril and Methodius" University of Skopje, Skopje, Macedonia
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Use of Disulfiram for Alcohol Relapse Prevention in Patients in Opioid Maintenance Treatment. Clin Neuropharmacol 2014; 37:161-5. [DOI: 10.1097/wnf.0000000000000050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prognostic factors in acute methadone toxicity: a 5-year study. J Toxicol 2014; 2014:341826. [PMID: 25197273 PMCID: PMC4146352 DOI: 10.1155/2014/341826] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Delayed or recurrent profound respiratory depression, ventricular dysrhythmias, acute lung injury, and death are the major complications of MTD overdose. We aimed to clarify the prognostic factors in MTD toxicity. Materials and Methods. Retrospectively, medical files of all patients poisoned by MTD and older than 12 years of age who had presented to Loghman Hakim Poison Center between 2007 and 2012 were evaluated. The data was compared between survivors and nonsurvivors. Results. Twenty-eight out of 322 patients died (mortality rate = 8.7%). MTD-related death was higher in patients with acute on chronic toxicity who were on daily dose of MTD and had ingested higher doses (in comparison to those with acute toxicity due to first-time exposure; 13% versus 6%). Renal failure was the most common medical complication related to deaths due to MTD toxicity. Conclusions. Based on previous researches, the most common cause of MTD overdose-related deaths is respiratory impairment; however, in our study, acute renal failure with or without rhabdomyolysis was the main delayed cause of deaths in MTD-poisoned patients. Antidotal therapy, early recognition, and treatment of hemodynamic compromise and rhabdomyolysis can be life-saving in these patients.
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Iwersen-Bergmann S, Jungen H, Andresen-Streichert H, Müller A, Elakkary S, Püschel K, Heinemann A. Intravenous methadone application as a serious risk factor for an overdose death: methadone-related fatalities in Hamburg from 2007 to 2012. Int J Legal Med 2014; 128:751-64. [PMID: 24859230 DOI: 10.1007/s00414-014-1017-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/30/2014] [Indexed: 11/28/2022]
Abstract
Methadone plays an increasing role in drug-related deaths in Hamburg. To find out whether intravenous application of methadone plays a relevant role in methadone-related deaths, body fluids of all methadone-positive cases (n=130) and three buprenorphine-positive cases where a urine sample was available (n=58+3) were investigated for disaccharides (sucrose and lactose as markers for intravenous methadone abuse). Sixty-four percent of the urine samples of the methadone cases showed positive results for disaccharides (22 times sucrose alone, range 2 to >1,000 mg/L; 6 times lactose and sucrose; and 9 times lactose alone, range 22 to 382 mg/L). The three buprenorphine cases showed positive results for lactose in urine. In blood, it was not possible to detect any disaccharides. Of the 116 fatal methadone intoxications, 49 % were under opiate maintenance treatment (OMT) at the point of death (A-OMT), 30 % were never in OMT (N-OMT) and 21 % were formerly in an OMT, but not at the point of death (F-OMT). Of the deceased in the OMT group, 12 % (n=7) died within the first 2 weeks of treatment, six of them within the first week. Overall, intravenous abuse of methadone plays a relevant role in methadone-related fatal cases of substituted patients and of drug consumers not in therapy. Thus, it is necessary that therapists keep to the statutory regulations and give take-home doses only after at least 6 months of successful therapy and when there is no suspicion of intravenous abuse.
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Affiliation(s)
- Stefanie Iwersen-Bergmann
- Institute of Legal Medicine, Department of Toxicology, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany,
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Mijatović V, Samojlik I, Ajduković N, Đurendić-Brenesel M, Petković S. Methadone-related deaths - epidemiological, pathohistological, and toxicological traits in 10-year retrospective study in Vojvodina, Serbia. J Forensic Sci 2014; 59:1280-5. [PMID: 24502699 DOI: 10.1111/1556-4029.12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 04/12/2013] [Accepted: 05/24/2013] [Indexed: 12/01/2022]
Abstract
The number of methadone-related deaths (MRDs) during a 10-year period (2002-2011) in the region of Vojvodina, Serbia, was increased. The cases were evaluated according to epidemiological parameters, pathohistological findings, and toxicological screening. The majority of victims were men, aged from 20 to 38. Pathohistologically, the signs of acute focal myocardial damage were present in the heart of victims with drug abuse history shorter than 2 years, while both signs of recent and chronic focal myocardial damage were developed among victims with longer drug abuse history (2-5 years). In postmortem blood samples of 54.84% of victims, methadone was detected in combination with diazepam, both in therapeutic range. Alcohol was absent in most cases. Other detected drugs were antipsychotics and antidepressants in therapeutic concentrations. These findings raise the attention to the concomitant use of methadone and benzodiazepines with the need for further studies to clarify the mechanism of death in such cases.
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Affiliation(s)
- Vesna Mijatović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
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Duffy P, Mackridge AJ. Use and diversion of illicit methadone – under what circumstances does it occur, and potential risks associated with continued use of other substances. JOURNAL OF SUBSTANCE USE 2013. [DOI: 10.3109/14659891.2012.734539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hsu YC, Chen BG, Yang SC, Wang YS, Huang SP, Huang MH, Chen TJ, Liu HC, Lin DL, Liu RH, Jones AW. Methadone concentrations in blood, plasma, and oral fluid determined by isotope-dilution gas chromatography–mass spectrometry. Anal Bioanal Chem 2012; 405:3921-8. [DOI: 10.1007/s00216-012-6460-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 08/29/2012] [Accepted: 09/26/2012] [Indexed: 11/24/2022]
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20
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Jones A, Holmgren A, Ahlner J. Blood Methadone Concentrations in Living and Deceased Persons: Variations Over Time, Subject Demographics, and Relevance of Coingested Drugs. J Anal Toxicol 2012; 36:12-8. [DOI: 10.1093/jat/bkr013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wurst FM, Thon N, Yegles M, Halter C, Weinmann W, Laskowska B, Strasser J, Skipper G, Wiesbeck GA, Dürsteler-Macfarland K. Optimizing heroin-assisted treatment (HAT): assessment of the contribution of direct ethanol metabolites in identifying hazardous and harmful alcohol use. Drug Alcohol Depend 2011; 115:57-61. [PMID: 21145180 DOI: 10.1016/j.drugalcdep.2010.10.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 10/15/2010] [Accepted: 10/16/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites. METHOD Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair. RESULTS Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake. CONCLUSIONS The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.
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Affiliation(s)
- Friedrich M Wurst
- Department of Psychiatry and Psychotherapy II, Christian-Doppler-Hospital, Paracelsus Medical University, Ignaz-Harrer-Straße 79, Salzburg A-5020, Austria.
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