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Stephenson L, Van Den Heuvel C, Humphries M, Byard RW. Prescribed and Diverted Methadone Toxicity in South Australia: An Update. Am J Forensic Med Pathol 2024; 45:124-129. [PMID: 38064311 DOI: 10.1097/paf.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
ABSTRACT Methadone is one of the most common medications currently prescribed for the treatment of opioid use disorders (OUDs). While methadone maintenance programs (MMPs) have been highly successful in the management and treatment of OUDs resulting in a reduced number of fatalities, the risk of overdose/toxicity remains. The current study was undertaken to analyze trends in overdoses attributed to prescribed and diverted methadone in South Australia (SA) between 2000 and 2019. Over the 20-year period, 344 methadone-related deaths occurred in SA with a significant increase in deaths over the study period ( P = 0.03). The mean age of decedents was 42.5 years with a male to female ratio of 1.8:1, with approximately 20% of decedents enrolled in a MMP at the time of death. Overall, only 5.2% of cases demonstrated methadone diversion, which was associated with methadone prescribed for chronic pain and was most likely to be diverted from a friend/housemate or a partner. However, the source of methadone in more than half of cases was unknown, so this is likely a significant underestimate of actual MMP methadone diversion and total methadone diversion.
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Friedmann Z, Kinkel HT, Kühner C, Zsolnai A, Mick I, Binder A. Supervised on-site dosing in injectable opioid agonist treatment-considering the patient perspective. Findings from a cross-sectional interview study in two German cities. Harm Reduct J 2023; 20:162. [PMID: 37915058 PMCID: PMC10619267 DOI: 10.1186/s12954-023-00896-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) is an effective option to support people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral OAT. However, iOAT has been criticised based on theoretical and practical grounds for its dosing policies: Current regulations demand supervised, on-site application and require patients to frequently visit their treatment facility. The current study aims to investigate how patients experience on-site application and derive strategies to enhance the acceptability and effectiveness of iOAT-delivery. METHODS This article is based on semi-structured interviews with 27 individuals currently or previously in iOAT in two German outpatient iOAT-clinics. We undertook an inductive qualitative content analysis, which included blinded, independent coding and the analysis of individual cases. RESULTS Comments regarding on-site application and daily visits to the clinic were grouped into positive and negative aspects, iOAT as the best alternative option, facilitators of daily visits, and suggestions for improvement. Positive aspects took the factors stability and social support in regard. Negative aspects ranged from general inconveniences to major impediments to individuals' daily lives and towards achieving psychosocial goals. Participants reported rigorous adherence to iOAT's treatment regime, often due to a perceived lack of alternative options. Meeting iOAT's demands was eased by the patients' coping-strategies and through facilitating measures implemented by iOAT-clinics. Despite acknowledgement of the potential detriments from easing regulations, take-home arrangements were frequently suggested by participants to improve iOAT. CONCLUSIONS Being required to attend the clinic for supervised iOAT-application is not experienced uniformly. While clinics can support their patients to cope with strict regulations, alternative approaches to iOAT-application should be considered to accommodate patients' individual needs. Examples from other treatment modalities (e.g., remote supervision and delivery services) might aid to reconcile individualisation while providing adequate safety measures and improve iOAT in the long term.
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Affiliation(s)
- Zoe Friedmann
- Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany.
| | - Hans-Tilmann Kinkel
- Praxiskombinat Neubau, Schwerpunktpraxis für Suchtmedizin (Outpatient Clinic for Addiction Medicine), Ruschestraße 103, 10365, Berlin, Germany
| | - Claudia Kühner
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Kriegsbergstraße 40, 70174, Stuttgart, Germany
| | - Andreas Zsolnai
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Kriegsbergstraße 40, 70174, Stuttgart, Germany
| | - Inge Mick
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany
| | - Annette Binder
- Department of General Psychiatry and Psychotherapy, Addiction Medicine and Addiction Research Section, University Hospital Tuebingen, University of Tuebingen, Calwerstraße 14, 72076, Tuebingen, Germany
- DZPG (German Centre for Mental Health), Tuebingen, Germany
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Abid M, Kietzerow J, Iwersen-Bergmann S, Schnitgerhans T, Andresen-Streichert H. Characteristics and dose-effect relationship of clinical gamma-hydroxybutyrate intoxication: A case series. J Forensic Sci 2021; 67:416-427. [PMID: 34523720 DOI: 10.1111/1556-4029.14880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/20/2021] [Accepted: 08/17/2021] [Indexed: 11/27/2022]
Abstract
Gamma-Hydroxybutyrate (GHB) overdoses cause respiratory depression, coma, or even death. Symptoms and severity of poisoning depend on blood-concentrations and individual factors such as tolerance. A retrospective case study was conducted, evaluating GHB intoxication cases. GHB-concentrations in blood and urine were determined by gas chromatography-mass spectrometry (GC-MS) along with, in part, via enzymatic assay. GHB-concentrations, demographic data, and additional drug use, as well as specific clinical information, were evaluated. The correlation between GHB-levels in blood and associated symptoms were examined. In total, 75 cases originating from the Emergency Departments (EDs) of Hamburg and surrounding hospitals were included. Fifty-four of the patients (72%) were male. The mean GHB-concentration in blood was 248 mg/L (range 21.5-1418 mg/L). Out of the group with detailed clinical information (n = 18), the comatose group (n = 10/18) showed a mean of 244 mg/L (range 136-403 mg/L), which was higher than that of the somnolent and awake patients. Of the comatose collective, 70% (n = 7) showed co-use of one or more substances, with the additional use of cocaine being the most frequently detected (n = 5). In conclusion, a moderate dose-effect relationship was observed, although, there was some overlap in dosage concentration levels of GHB in awake and comatose patients. In GHB-intoxication cases, co-use was common as were clinical effects such as acidosis, hypotension, and impact on the heart rate. Timely analytical determination of the GHB-concentration in blood could support correct diagnosis of the cause of unconsciousness.
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Affiliation(s)
- Madelaine Abid
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Kietzerow
- Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Stefanie Iwersen-Bergmann
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tino Schnitgerhans
- Department of Internal Medicine, Asklepios-Klinik Nord - Heidberg, Hamburg, Germany
| | - Hilke Andresen-Streichert
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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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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Fugelstad A, Bremberg S, Hjelmström P, Thiblin I. Methadone-related deaths among youth and young adults in Sweden 2006-15. Addiction 2021; 116:319-327. [PMID: 32533568 DOI: 10.1111/add.15152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/10/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
AIMS To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15. DESIGN, SETTING AND PARTICIPANTS National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes. MEASUREMENTS Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death. FINDINGS We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone. CONCLUSION Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.
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Affiliation(s)
- Anna Fugelstad
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Sven Bremberg
- Department of Public Health, Karolinska Institute, Stockholm, Sweden
| | | | - Ingmar Thiblin
- Department of Surgical Sciences, Section for Forensic Medicine, Uppsala University, Uppsala, Sweden
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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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Bech AB, Clausen T, Waal H, Vindenes V, Edvardsen HE, Frost J, Skeie I. Post-mortem toxicological analyses of blood samples from 107 patients receiving opioid agonist treatment: substances detected and pooled opioid and benzodiazepine concentrations. Addiction 2020; 116:845-855. [PMID: 32738014 DOI: 10.1111/add.15211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
AIMS To present the substances and their concentrations detected post-mortem in patients receiving opioid agonist treatment (OAT) stratified by cause of death, estimate the pooled opioid and benzodiazepine concentrations using established conversion factors for blood concentrations from the Norwegian Road Traffic Act, and explore the association between drug-induced cause of death and the pooled opioid and benzodiazepine concentrations. DESIGN Cross-sectional nationwide study. SETTING Norway. PARTICIPANTS One hundred and seven patients who died during OAT (i.e. within 5 days after the last intake of OAT medication) between 1 January 2014 and 31 December 2015, with post-mortem femoral blood available for toxicology. Data were collected from hospital records, the Norwegian Cause of Death Registry and autopsy reports. MEASUREMENTS Presence of alcohol and non-alcohol substances in the bloodstream at time of death, determined through records of toxicology of post-mortem femoral blood. FINDINGS A median of four substances was detected across the causes of death. At least one benzodiazepine was detected in 81 (76%) patients. The median pooled opioid concentration was significantly higher in drug-induced deaths compared with other causes of death (362 ng/mL versus 182 ng/mL, P < 0.001), in contrast to the pooled benzodiazepine concentration (5466 versus 5701 ng/mL, P = 0.353). The multivariate regression analysis showed that only increasing pooled opioid concentration (ng/ML) was associated with increased odds of a drug-induced cause of death (odds ratio, 1.003; 95% confidence interval: 1.001-1.006). CONCLUSIONS In Norway, overall opioid concentration seems to play an important role in drug-induced deaths during opioid agonist treatment in patients prescribed methadone or buprenorphine. Patients prescribed buprenorphine tend to replace their agonist with full agonists, while patients prescribed methadone tend to have high opioid concentrations from methadone as the only opioid.
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Affiliation(s)
- Anne Berit Bech
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Helge Waal
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
- National Advisory Unit on Substance Use Disorder Treatment, Oslo University Hospital, Sognsvannsveien 21, Bygg 6, P.O. Box 4959 Nydalen, 0424, Oslo, Norway
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Hilde Erøy Edvardsen
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
| | - Joachim Frost
- Department of Clinical Pharmacology, St. Olav's Hospital Trondheim University Hospital, P.O. Box 3250 Torgarden, 7006, Trondheim, Norway
| | - Ivar Skeie
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
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Post-mortem analysis of prescription opioids—A follow-up examination by LC–MS/MS with focus on fentanyl. Forensic Sci Int 2019; 305:109970. [DOI: 10.1016/j.forsciint.2019.109970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022]
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Vergiftungen durch Suchtstoffe, Laboruntersuchungen und rechtsmedizinische Todesfallaufklärung bei Vergiftungen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1362-1369. [DOI: 10.1007/s00103-019-03027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Keltanen TN, Heikman PK, Muhonen LH, Gunnar TO, Ojanperä IA. Enzymatic assay for urine lactose in the assessment of recent intravenous abuse of buprenorphine. Drug Test Anal 2019; 11:1412-1418. [DOI: 10.1002/dta.2654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Terhi N. Keltanen
- Forensic Toxicology UnitNational Institute for Health and Welfare Helsinki Finland
- Department of Forensic MedicineUniversity of Helsinki Helsinki Finland
| | - Pertti K. Heikman
- PsychiatryUniversity of Helsinki Helsinki Finland
- PsychiatryHelsinki University Central Hospital Helsinki Finland
| | - Leea H. Muhonen
- PsychiatryHelsinki University Central Hospital Helsinki Finland
| | - Teemu O. Gunnar
- Forensic Toxicology UnitNational Institute for Health and Welfare Helsinki Finland
| | - Ilkka A. Ojanperä
- Forensic Toxicology UnitNational Institute for Health and Welfare Helsinki Finland
- Department of Forensic MedicineUniversity of Helsinki Helsinki Finland
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Reddon H, Ho J, DeBeck K, Milloy MJ, Liu Y, Dong H, Ahamad K, Wood E, Kerr T, Hayashi K. Increasing diversion of methadone in Vancouver, Canada, 2005-2015. J Subst Abuse Treat 2018; 85:10-16. [PMID: 29291766 PMCID: PMC5753607 DOI: 10.1016/j.jsat.2017.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/02/2017] [Accepted: 11/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Although methadone, an opioid agonist, has been an effective medication used to treat opioid use disorder for over 40years, recent studies have found that methadone was identified in more than a quarter of prescription opioid-related deaths among people who use illicit drugs in Vancouver, Canada. Thus, we sought to longitudinally examine the availability of diverted methadone among people who inject drugs (PWID). DESIGN AND METHODS Data were collected from three prospective cohorts of PWID in Vancouver, Canada between December 2005 and May 2015. Multivariable generalized estimating equation logistic regression was used to identify temporal trends in the immediate availability of diverted methadone (defined as the ability to acquire illicit methadone in <10min). RESULTS A total of 2092 participants, including 727 (34.8%) women, were included in the present study. In the multivariable analyses after adjusting for a range of potential confounders, later calendar year (adjusted odds ratio [AOR]=1.21 per year; 95% confidence interval [CI]: 1.19-1.23) was independently and positively associated with reporting immediate availability of diverted methadone. CONCLUSIONS We observed a significant increase in the reported availability of diverted methadone among PWID over a ten-year follow-up period. Further research is needed to identify strategies to limit methadone diversion and assess the impact of alternative medications that are equally effective but safer, such as buprenorphine/naloxone.
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Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Joel Ho
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, GC425-820 Sherbrook Street, Winnipeg, MB R3T 2N2, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Public Policy, Simon Fraser University, 515 W Hastings St, Vancouver, BC V6B 5K3, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Yang Liu
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3 E Mall, Vancouver, BC V6T 1Z3, Canada
| | - Keith Ahamad
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Family Practice, University of British Columbia, St. Paul's Hospital, Department of Family and Community Medicine, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.
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Deering DEA, Adamson SJ, Sellman JD, Henderson C, Sheridan J, Pooley S, Robertson RM, Noller G, Frampton CMA. Potential risk for fatal drug overdose perceived by people using opioid drugs. Drug Alcohol Rev 2017. [DOI: 10.1111/dar.12635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Daryle E. A. Deering
- National Addiction Centre, Department of Psychological Medicine; University of Otago; Christchurch New Zealand
| | - Simon J. Adamson
- National Addiction Centre, Department of Psychological Medicine; University of Otago; Christchurch New Zealand
| | - John D. Sellman
- National Addiction Centre, Department of Psychological Medicine; University of Otago; Christchurch New Zealand
| | - Charles Henderson
- New Zealand Needle Exchange Programme (trading as Needle Exchange Services Trust); Christchurch New Zealand
| | - Janie Sheridan
- School of Pharmacy; University of Auckland; Āotearoa New Zealand
| | - Sheridan Pooley
- Community Alcohol and Drug Service; Waitemata District Health Board; Auckland New Zealand
| | - Rhonda Marie Robertson
- Salvation Army Addiction; Supportive Accommodation and Reintegration Services; Auckland New Zealand
| | - Geoff Noller
- Substance Use and Policy Analysis; Dunedin New Zealand
| | - Christopher M. A. Frampton
- National Addiction Centre, Department of Psychological Medicine; University of Otago; Christchurch New Zealand
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13
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Jungen H, Andresen-Streichert H, Müller A, Iwersen-Bergmann S. Monitoring Intravenous Abuse of Methadone or Buprenorphine in Opiate Maintenance Treatment (OMT): A Simple and Fast LC–MS-MS Method for the Detection of Disaccharides in Urine Samples. J Anal Toxicol 2016; 41:22-31. [DOI: 10.1093/jat/bkw099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 06/10/2016] [Accepted: 07/03/2016] [Indexed: 11/12/2022] Open
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14
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Keltanen T, Mariottini C, Walta AM, Rahikainen AL, Ojanperä I. Enzymatic assays for detecting lactose and sucrose in urine to reveal intravenous drug abuse with emphasis on buprenorphine. Drug Test Anal 2016; 9:949-952. [DOI: 10.1002/dta.2050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/02/2016] [Accepted: 08/03/2016] [Indexed: 11/11/2022]
Affiliation(s)
- T. Keltanen
- University of Helsinki; Department of Forensic Medicine; P.O. Box 40 FI-00014 Helsinki Finland
| | - C. Mariottini
- University of Helsinki; Department of Forensic Medicine; P.O. Box 40 FI-00014 Helsinki Finland
| | - A. M. Walta
- University of Helsinki; Department of Forensic Medicine; P.O. Box 40 FI-00014 Helsinki Finland
| | - A. L. Rahikainen
- University of Helsinki; Department of Forensic Medicine; P.O. Box 40 FI-00014 Helsinki Finland
| | - I. Ojanperä
- University of Helsinki; Department of Forensic Medicine; P.O. Box 40 FI-00014 Helsinki Finland
- National Institute for Health and Welfare; Forensic Toxicology Unit; P.O. Box 30 FI-00271 Helsinki Finland
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15
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Launonen E, Wallace I, Kotovirta E, Alho H, Simojoki K. Factors associated with non-adherence and misuse of opioid maintenance treatment medications and intoxicating drugs among Finnish maintenance treatment patients. Drug Alcohol Depend 2016; 162:227-35. [PMID: 27068849 DOI: 10.1016/j.drugalcdep.2016.03.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/19/2016] [Accepted: 03/21/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The intravenous (IV) use of opioid maintenance treatment (OMT) medications and other intoxicating drugs among OMT patients is a challenge for many OMT units and affects treatment outcomes. The aim of this study is to examine factors associated with IV use of OMT medications and other intoxicating drugs among Finnish OMT patients. METHODS A cross-sectional study was conducted among all Finnish OMT patients of whom 60% (n=1508) participated. The data were collected by anonymous questionnaire. Binominal regression analysis with unadjusted and adjusted ORs was conducted to evaluate predictors for IV use. FINDINGS Factors associated with the injection of a patient's own OMT medication were: being treated with buprenorphine-naloxone (BNX) (OR 2.60, p=0.005) with a low dose (<9.0mg/day; OR 5.70, p<0.001) and being treated in a health-care centre (OR 2.03, p=0.029). Factors associated with the injection of illicit OMT medications were: being treated with BNX (OR 5.25, p<0.001) with a low dose (<9.0mg/day; OR 2.89, p=0.017), lack of psychosocial support (OR 2.62, p<0.001) and concurrent use of psychotropic medications from illicit sources (OR 4.28, p<0.001). Associated factors for the injection of other intoxicating drugs were: concurrent use of illicit drugs (OR 1.72, p=0.015), psychotropic medications from illicit sources (OR 4.78, p<0.001) and from a doctor (OR 1.93, p=0.004). CONCLUSIONS More effort should be made to reduce concurrent injecting use during OMT. This may be done by addressing concurrent substance use orders more effectively, by ensuring that patients receive an optimal BNX dose and by providing more psychosocial support.
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Affiliation(s)
- Essiina Launonen
- Clinicum, University of Helsinki and Helsinki University Hospital, P.O. Box 63, FI-00014 Helsinki University, Finland; University of Eastern Finland, School of Medicine, Faculty of Health Sciences, P.O. Box 1627, FI-70211 Kuopio, Finland.
| | - Isla Wallace
- Department of Applied Health Research, University College London, Torrington Place, London WC1E 7HB, UK
| | - Elina Kotovirta
- Ministry of Social Affairs and Health, Department for Promotion of Welfare and Health, Unit for Harm Prevention, P.O. Box 33, FI-00023 Government, Finland
| | - Hannu Alho
- Clinicum, University of Helsinki and Helsinki University Hospital, P.O. Box 63, FI-00014 Helsinki University, Finland; National Institute of Health and Welfare, Department of Mental and Substance Abuse Services, P.O. Box 30, FI-00271 Helsinki, Finland
| | - Kaarlo Simojoki
- Clinicum, University of Helsinki and Helsinki University Hospital, P.O. Box 63, FI-00014 Helsinki University, Finland; A-Clinic Foundation, Maistraatinportti 2, 00240 Helsinki, Finland
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16
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Gutwinski S, Schoofs N, Stuke H, Riemer TG, Wiers CE, Bermpohl F. Opioid tolerance in methadone maintenance treatment: comparison of methadone and levomethadone in long-term treatment. Harm Reduct J 2016; 13:7. [PMID: 26879120 PMCID: PMC4754801 DOI: 10.1186/s12954-016-0095-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/04/2016] [Indexed: 12/05/2022] Open
Abstract
Background This study aimed to investigate the development of opioid tolerance in patients receiving long-term methadone maintenance treatment (MMT). Methods A region-wide cross-sectional study was performed focusing on dosage and duration of treatment. Differences between racemic methadone and levomethadone were examined. All 20 psychiatric hospitals and all 110 outpatient clinics in Berlin licensed to offer MMT were approached in order to reach patients under MMT fulfilling the DSM IV criteria of opiate dependence. In the study, 720 patients treated with racemic methadone or levomethadone gave information on the dosage of treatment. Out of these, 679 patients indicated the duration of MMT. Results Treatment with racemic methadone was reported for 370 patients (54.5 %), with levomethadone for 309 patients (45.5 %). Mean duration of MMT was 7.5 years. We found a significant correlation between dosage and duration of treatment, both in a conjoint analysis for the two substances racemic methadone and levomethadone and for each substance separately. These effects remained significant when only patients receiving MMT for 1 year or longer were considered, indicating proceeding tolerance development in long-term treatment. When correlations were compared between racemic methadone and levomethadone, no significant difference was found. Conclusions Our data show a tolerance development under long-term treatment with both racemic methadone and levomethadone. Tolerance development did not differ significantly between the two substances.
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Affiliation(s)
- Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Nikola Schoofs
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Heiner Stuke
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Thomas G Riemer
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Corinde E Wiers
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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17
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Reimer J, Wright N, Somaini L, Roncero C, Maremmani I, McKeganey N, Littlewood R, Krajci P, Alho H, D'Agnone O. The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus. Eur Addict Res 2016; 22:99-106. [PMID: 26426530 DOI: 10.1159/000438988] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Opioid substitution treatment (OST) improves outcomes in opioid dependence. However, controlled drugs used in treatment may be misused or diverted, resulting in negative treatment outcomes. This review defines a framework to assess the impact of misuse and diversion. METHODS A systematic review of published studies of misuse and diversion of OST medicines was completed; this evidence was paired with expert real-world experience to better understand the impact of misuse and diversion on the individual and on society. RESULTS Direct impact to the individual includes failure to progress in recovery and negative effects on health (overdose, health risks associated with injecting behaviour). Diversion of OST has impacts on a community that is beyond the intended OST recipient. The direct impact includes risk to others (unsupervised use; unintended exposure of children to diverted medication) and drug-related criminal behavior. The indirect impact includes the economic costs of untreated opioid dependence, crime and loss of productivity. CONCLUSION While treatment for opioid dependence is essential and must be supported, it is vital to reduce misuse and diversion while ensuring the best possible care. Understanding the impact of OST misuse and diversion is key to defining strategies to address these issues.
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Affiliation(s)
- Jens Reimer
- Centre for Interdisciplinary Addiction Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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18
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Diversion of opioid maintenance treatment medications and predictors for diversion among Finnish maintenance treatment patients. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:875-82. [DOI: 10.1016/j.drugpo.2015.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/20/2015] [Accepted: 03/22/2015] [Indexed: 11/22/2022]
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19
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Tucker D, Milloy MJ, Hayashi K, Nguyen P, Kerr T, Wood E. Factors associated with illicit methadone injecting in a Canadian setting. Am J Addict 2015; 24:532-7. [PMID: 26282339 DOI: 10.1111/ajad.12257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 06/14/2015] [Accepted: 06/16/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES While methadone is well established as an evidence-based treatment for opioid use disorder, safety concerns persist regarding its diversion. The authors examine the prevalence of and risk factors associated with injection of methadone in an urban population. METHODS Between December 2005 and November 2013, data were derived from two open prospective studies of persons who inject drugs (PWID) in Vancouver, Canada. Generalized estimating equations (GEE) logistic regression was used to determine factors independently associated with illicit methadone injecting. RESULTS During the study, 1911 individuals (34% women) were recruited; 134 (7%) participants reported methadone injecting at least once. In multivariable analysis, Caucasian ethnicity [adjusted odds ratio (AOR) = 1.90, 95% confidence interval (CI) = 1.20-3.00]; homelessness (AOR = 1.46, 95% CI = 1.09-1.95); drug dealing (AOR = 2.10, 95% CI = 1.50-2.93); ≥daily heroin injection (AOR = 1.57, 95% CI = 1.08-2.26); ≥daily crack smoking (AOR = 2.06, 95% CI = 1.44-2.95); being a victim of violence (AOR = 1.48, 95% CI = 1.04-2.12); and non-fatal overdose (AOR = 1.67, 95% CI = 1.67 (1.00-2.79) were independently and positively associated with methadone injection; female gender (AOR = 0.47, 95% CI = 0.30-0.75) was negatively associated. DISCUSSION AND CONCLUSIONS The diversion of methadone for illicit injection in this urban setting was associated with several markers of addiction severity and other health and social vulnerabilities. SCIENTIFIC SIGNIFICANCE These findings underscore the need to ensure methadone accessibility while limiting diversion-related risk.
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Affiliation(s)
- Devin Tucker
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Nguyen
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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