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Kuo YF, Liaw V, Yu X, Raji MA. Opioid and Benzodiazepine Substitutes: Impact on Drug Overdose Mortality in Medicare Population. Am J Med 2022; 135:e194-e206. [PMID: 35341773 PMCID: PMC9232943 DOI: 10.1016/j.amjmed.2022.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Gabapentinoids (GABAs) and serotonergic drugs (selective serotonin reuptake inhibitors [SSRIs]/serotonin and norepinephrine reuptake inhibitors [SNRIs]) are increasingly being prescribed as potential substitutes to opioids and benzodiazepines (benzos), respectively, to treat co-occurring pain and anxiety disorders. The toxicities of these drug classes and their combinations are not well understood. METHODS We conducted a matched case-control study using 2013-2016 Medicare files linked to the National Death Index. Cases were enrollees who died from drug overdose. Controls were enrollees who died from other causes. Cases and controls were matched on patient characteristics and prior chronic conditions. Possession of any opioids, GABAs, benzos, and SSRIs/SNRIs in the month prior to death was defined as drug use. Combination drug use was defined as possessing at least 2 types of these prescriptions for an overlapping period of at least 7 days in the month prior to death. RESULTS Among 4323 matches, benzo possession was associated with twice the risk for drug overdose death in cases vs controls. Compared with opioid-benzo co-prescribing, combinations involving SSRIs/SNRIs and opioids (or GABAs) were associated with decreased risk (adjusted odds ratio 0.55; 95% confidence interval, 0.44-0.69 for opioids and SSRIs/SNRIs; adjusted odds ratio 0.59; 95% confidence interval, 0.44-0.79 for GABAs and SSRIs/SNRIs). Fatal drug overdose risk was similar in users of GABA-opioid, GABA-benzo, and opioid-benzo combinations. CONCLUSIONS Benzodiazepines, prescribed alone or in combination, were associated with an increased risk of drug overdose death. SSRIs/SNRIs were associated with lower risk of overdose death vs benzodiazepines. GABAs were not associated with decreased risk compared with opioids, raising concerns for GABAs' perceived relative safety.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging; Department of Preventive Medicine and Population Health; Institute for Translational Science; Office of Biostatistics, University of Texas Medical Branch, Galveston.
| | - Victor Liaw
- School of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Xiaoying Yu
- Department of Preventive Medicine and Population Health; Office of Biostatistics, University of Texas Medical Branch, Galveston
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging; Department of Preventive Medicine and Population Health
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State Injury Programs' Response to the Opioid Epidemic: The Role of CDC's Core Violence and Injury Prevention Program. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 24 Suppl 1 Suppl, Injury and Violence Prevention:S23-S31. [PMID: 29189501 DOI: 10.1097/phh.0000000000000704] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Centers for Disease Control and Prevention's (CDC's) Core Violence and Injury Prevention Program (Core) supports capacity of state violence and injury prevention programs to implement evidence-based interventions. Several Core-funded states prioritized prescription drug overdose (PDO) and leveraged their systems to identify and respond to the epidemic before specific PDO prevention funding was available through CDC. This article describes activities employed by Core-funded states early in the epidemic. Four case examples illustrate states' approaches within the context of their systems and partners. While Core funding is not sufficient to support a comprehensive PDO prevention program, having Core in place at the beginning of the emerging epidemic had critical implications for identifying the problem and developing systems that were later expanded as additional resources became available. Important components included staffing support to bolster programmatic and epidemiological capacity; diverse and collaborative partnerships; and use of surveillance and evidence-informed best practices to prioritize decision-making.
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Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol 2017; 4:24. [PMID: 28762157 PMCID: PMC5545182 DOI: 10.1186/s40621-017-0118-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/20/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis. FINDINGS Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51). CONCLUSIONS This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses.
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Affiliation(s)
- Joanne E. Brady
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
| | - Rebecca Giglio
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Katherine M. Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Charles DiMaggio
- Department of Surgery, Division of Trauma, New York University, New York, NY USA
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY USA
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Abstract
Drug-related overdoses are now the leading injury-related death in the USA, and many of these deaths are associated with illicit opioids and prescription opiate pain medication. This study uses multiple sources of data to examine accidental opioid overdoses across 6 years, 2010 through 2015, in Marion County, IN, an urban jurisdiction in the USA. The primary sources of data are toxicology reports from the county coroner, which reveal that during this period, the most commonly detected opioid substance was heroin. During the study period, 918 deaths involved an opiod, and there were significant increases in accidental overdose deaths involving both heroin and fentanyl. In order to disentangle the nature and source of opioid overdose deaths, we also examine data from Indiana's prescription drug monitoring program and the law enforcement forensic services agency. Results suggest that there have been decreases in the number of opiate prescriptions dispensed and increases in law enforcement detection of both heroin and fentanyl. Consistent with recent literature, we suggest that increased regulation of prescription opiates reduced the likelihood of overdoses from these substances, but might have also had an iatrogenic effect of increasing deaths from heroin and fentanyl. We discuss several policy implications and recommendations for Indiana.
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Affiliation(s)
- Bradley Ray
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Kenna Quinet
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Timothy Dickinson
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Dennis P. Watson
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Alfarena Ballew
- Marion County (Indiana) Coroner’s Office, Indianapolis, IN USA
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Martins SS, Sampson L, Cerdá M, Galea S. Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature. Am J Public Health 2016; 105:e29-49. [PMID: 26451760 DOI: 10.2105/ajph.2015.302843] [Citation(s) in RCA: 205] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. OBJECTIVES The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. RESULTS We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. CONCLUSIONS There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.
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Affiliation(s)
- Silvia S Martins
- Silvia S. Martins is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Laura Sampson and Sandro Galea are with the Department of Epidemiology, Boston University School of Public Health, Boston, MA. Magdalena Cerdá is with the Department of Emergency Medicine, University of California, Davis
| | - Laura Sampson
- Silvia S. Martins is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Laura Sampson and Sandro Galea are with the Department of Epidemiology, Boston University School of Public Health, Boston, MA. Magdalena Cerdá is with the Department of Emergency Medicine, University of California, Davis
| | - Magdalena Cerdá
- Silvia S. Martins is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Laura Sampson and Sandro Galea are with the Department of Epidemiology, Boston University School of Public Health, Boston, MA. Magdalena Cerdá is with the Department of Emergency Medicine, University of California, Davis
| | - Sandro Galea
- Silvia S. Martins is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Laura Sampson and Sandro Galea are with the Department of Epidemiology, Boston University School of Public Health, Boston, MA. Magdalena Cerdá is with the Department of Emergency Medicine, University of California, Davis
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Smolina K, Ball L, Humphries KH, Khan N, Morgan SG. Sex Disparities in Post-Acute Myocardial Infarction Pharmacologic Treatment Initiation and Adherence: Problem for Young Women. Circ Cardiovasc Qual Outcomes 2015; 8:586-92. [PMID: 26462876 DOI: 10.1161/circoutcomes.115.001987] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/21/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prevalence of the use of secondary prevention cardiovascular medications is lower among women than men, but it is unclear if this is a result of lower treatment initiation among women or lower treatment adherence. We aimed to map the treatment pathway for survivors of acute myocardial infarction (AMI) by sex and age. METHODS AND RESULTS This retrospective population-based cohort study used linked administrative data sets in British Columbia (2004-2011), which include health care, prescription drugs, sociodemographic, and mortality information. The study cohort included all individuals admitted to hospital for AMI in 2007-2009 and survived for 1 year after hospital discharge. Patients were evaluated for whether they initiated and then subsequently filled prescriptions angiotensin-converting enzyme inhibitors, β-blockers, and statins. More than two thirds of AMI survivors initiated treatment on all appropriate medications, given their contraindications, within 2 months of discharge. Younger men were significantly more likely than younger women to initiate appropriate treatment (adjusted odds ratio, 1.38; 95% confidence interval, 1.10-1.75). By the end of 1 year after discharge, only one third of all AMI survivors filled all appropriate prescriptions for at least 80% of the year. There was no significant difference in adherence to medication therapy between women and men. CONCLUSIONS The majority of AMI survivors either discontinue treatment or do not refill their prescriptions consistently. Women <55 years are significantly less likely to be on optimal therapy by the end of 1 year after discharge, which is driven by a sex disparity in treatment initiation and not treatment adherence.
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Affiliation(s)
- Kate Smolina
- From the Centre for Health Services and Policy Research, School of Population and Public Health (K.S., L.B., S.G.M.), Division of Cardiology (K.H.H.), and Division of General Internal Medicine (N.K.), University of British Columbia, Vancouver, British Columbia, Canada.
| | - Laura Ball
- From the Centre for Health Services and Policy Research, School of Population and Public Health (K.S., L.B., S.G.M.), Division of Cardiology (K.H.H.), and Division of General Internal Medicine (N.K.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Karin H Humphries
- From the Centre for Health Services and Policy Research, School of Population and Public Health (K.S., L.B., S.G.M.), Division of Cardiology (K.H.H.), and Division of General Internal Medicine (N.K.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadia Khan
- From the Centre for Health Services and Policy Research, School of Population and Public Health (K.S., L.B., S.G.M.), Division of Cardiology (K.H.H.), and Division of General Internal Medicine (N.K.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven G Morgan
- From the Centre for Health Services and Policy Research, School of Population and Public Health (K.S., L.B., S.G.M.), Division of Cardiology (K.H.H.), and Division of General Internal Medicine (N.K.), University of British Columbia, Vancouver, British Columbia, Canada
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Gladstone EJ, Smolina K, Morgan SG. Trends and sex differences in prescription opioid deaths in British Columbia, Canada. Inj Prev 2015. [DOI: 10.1136/injuryprev-2015-041604] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study. J Orthop Trauma 2014; 28:502-6. [PMID: 24667804 DOI: 10.1097/bot.0000000000000085] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The prudent use of prescription opiates is a central aspect of current postsurgical pain management, but surgeons have no guidelines on appropriate duration of opiate treatment. Furthermore, there are no established data on the effect of physician counseling on the duration of opiate use postoperatively. DESIGN Retrospective surgeon-controlled cohort study. SETTING Level I regional academic trauma center. PATIENTS All Utah residents admitted to the orthopaedic trauma service with isolated operative musculoskeletal injury. INTERVENTION One group of patients was instructed at the time of index procedure that they would receive prescription opiates for a maximum of 6 weeks. The remaining patients were not counseled preoperatively on duration of opiate use postoperatively. MAIN OUTCOME MEASURES The presence and frequency of prescription opiate use before injury, cessation of opiate use by 6 weeks postoperatively, cessation of opiates by 12 weeks postoperatively, and continuation of prescription opiates greater than 12 weeks postoperatively. RESULTS Six hundred thirteen patients met inclusion criteria. Those counseled preoperatively to cease opiate use by 6 weeks were significantly more likely to do so than those who did not receive counseling (73% and 64%, respectively; P = 0.012). By 12 weeks, this effect was no longer seen, and patients were just as likely to have stopped (80% and 80%, respectively; P = 0.90). CONCLUSIONS The orthopaedic trauma population is significantly more likely than the general population to be using prescription opiates before injury. Physician discussion of 6-week opiate prescription limitation at the time of injury seems to lead to a lower rate of use at the 6-week postoperative mark but has no effect on rates of longer-term use. Twenty percent of patients in either group will continue to use opiates after 12 weeks, compared with 15% before injury. Given the scope of prescription opiate use in the United States, surgeons may want to consider preoperative discussion of this issue, but it may not have any effect on usage rates at longer intervals. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review. Am J Public Health 2014; 104:e32-42. [PMID: 24922138 PMCID: PMC4103240 DOI: 10.2105/ajph.2014.301966] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2014] [Indexed: 11/04/2022]
Abstract
We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-related mortality and mortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population, making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations.
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Affiliation(s)
- Nicholas B King
- Nicholas B. King is with the Biomedical Ethics Unit and the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec. Veronique Fraser is with the Biomedical Ethics Unit, McGill University. Constantina Boikos, Robin Richardson, and Sam Harper are with the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University
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Association between opioid use and health care utilization as measured by emergency room visits and hospitalizations among persons living with HIV. Clin J Pain 2014; 29:957-61. [PMID: 23370078 DOI: 10.1097/ajp.0b013e31827c7b05] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidemiologic studies in the non-human immunodeficiency virus (HIV) positive population have shown greater health care utilization among persons with chronic non-cancer pain on opioid therapy. However, we are not aware of any similar data in the HIV positive population. METHODS We evaluated health care utilization, as measured by emergency room (ER) visits and hospitalizations, among persons with HIV and chronic pain seen at an academic medical center, during the calendar year 2005. We compared these outcomes between patients on chronic opioid therapy with those not on opioids. RESULTS In univariate models chronic opioid therapy was associated with both ER visits and hospitalization: ER visits odds ratio (OR)=2.18 (95% confidence interval [CI], 1.30-3.66), hospitalization OR=1.90 (95% CI, 1.03-3.51). After multivariate analyses only nonsignificant trends remain: ER visits OR=1.71 (95% CI, 0.95-3.08); hospitalization OR=1.28 (95% CI, 0.66-2.49). CONCLUSIONS In our study HIV positive individuals with chronic pain were more likely to be seen in the ER and be hospitalized if they were on opioids. However, after controlling for other variables, the association with opioids no longer remained significant.
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Abstract
The misuse and abuse of prescription medications in the United States continues to increase despite interventions by health care professionals, regulatory, and law enforcement agencies. Opioid analgesics are the leading class of prescription drugs that have caused unintentional overdose deaths. Benzodiazepines when taken alone are relatively safe agents in overdose. However, a 5-fold increase in deaths attributed to benzodiazepines occurred from 1999 to 2009. Emergency department visits related to opioid analgesics increased by 111% followed by benzodiazepines 89%. During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression. Physician and pharmacy shopping by patients occurs, and prescription drug-monitoring programs can provide important information on benzodiazepine and opioid analgesic prescribing patterns and patient usage. Health care professionals need to inform patients and work closely with regulatory agencies and legislatures to stem the increasing fatalities from prescription drug unintentional overdoses.
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Nordstrom DL, Yokoi-Shelton ML, Zosel A. Using multiple cause-of-death data to improve surveillance of drug-related mortality. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2013; 19:402-11. [PMID: 23266754 PMCID: PMC4594873 DOI: 10.1097/phh.0b013e318271c622] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Many states and local areas are affected by the national epidemic of drug-related mortality, which recently has shown signs of a rising "licit-to-illicit drug" death ratio. Appropriate local public health surveillance can help monitor and control this epidemic. OBJECTIVE Using our state as an example, we sought to illustrate how to describe the changes in drug death rates, causes, and circumstances. In contrast to most other surveillance reports, our approach includes both drug-induced and drug-related deaths as well as both demographic and socioeconomic characteristics of decedents. DESIGN Cross-sectional study. SETTING All residents of the state of Wisconsin. PARTICIPANTS Decedents from 1999 to 2008. MAIN OUTCOME MEASURE Annual numbers and population-based rates of deaths due to drugs, including both identified and unidentified drugs. Information was obtained from death certificates with any of approximately 270 underlying, immediate, or contributing cause-of-death codes from the International Classification of Diseases, 10th Revision. RESULTS Drug-related death rates increased during much of the 10-year study period, and the male-to-female death ratio rose. The median age at death from drug-related causes was 43 years. Opioid analgesic poisoning surpassed cocaine and heroin poisoning as the most frequent type of fatal drug poisoning. Of all 4828 deaths from drug-related causes--virtually all of which were certified by a county medical examiner or coroner--3410 (71%) were unintentional and 1053 (22%) were suicides. The unintentional-to-suicide death rate ratio grew from 1.6 to 3.5 during the study period. Methadone-related deaths increased from 10 in 1999 to 118 in 2008 (1080%), while benzodiazepine-related deaths rose from 23 to 106 (361%). CONCLUSIONS Although premature deaths from drug use and abuse continue to rise, even surpassing deaths due to motor vehicle crash in some states, "multiple causes of death" information from death certificates is available to monitor their occurrence and nature and to inform selection of prevention strategies.
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Affiliation(s)
- David L Nordstrom
- Department of Occupational and Environmental Safety and Health, College of Education and Professional Studies, University of Wisconsin-Whitewater, Whitewater, WI 53190, USA.
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Holman JE, Stoddard GJ, Higgins TF. Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use. J Bone Joint Surg Am 2013; 95:1075-80. [PMID: 23783203 PMCID: PMC6948805 DOI: 10.2106/jbjs.l.00619] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prudent use of prescription opiate medications is a central aspect of postoperative pain management. The mortality associated with prescription opiate overdose is reaching epidemic proportions nationally, and is the leading cause of accidental death in greater than half the states in the United States. This study sought to determine the rates of preinjury opiate use in patients with orthopaedic trauma and the risk factors for prolonged use postinjury. METHODS The Utah Controlled Substance Database was queried to determine the use of prescription opiates by all patients admitted to the orthopaedic trauma service for a two-year period with isolated musculoskeletal injuries. Usage three months prior to injury and six months postinjury was examined. RESULTS Six hundred and thirteen patients met inclusion criteria. Among patients with orthopaedic trauma, 15.5% had filled a prescription for opiates in the three months prior to injury, compared with 9.2% of the general population (p < 0.001). More than one prescription was filled by 12.2% of the patients with trauma preinjury compared with 6.4% of the general population (p < 0.001). Postoperatively, 68.4% of all patients filled opiate prescriptions for less than six weeks, 11.9% filled opiate prescriptions between six and twelve weeks, and 19.7% filled opiate prescriptions past twelve weeks. Patients with preinjury use of more than one opiate prescription in the three months preinjury were six times as likely to continue use past twelve weeks, and 3.5 times as likely to obtain opiates from a provider other than their surgeon (p < 0.001). Opiate use was briefest with upper-extremity injuries, followed by lower-extremity injuries and pelvic or acetabular injuries. Regression models demonstrate that risk factors for prolonged use of opiates include advancing age and extent of preinjury use. CONCLUSIONS Patients with orthopaedic trauma are significantly more likely than the general population to use prescription opiates prior to injury. Preinjury opiate use is predictive of prolonged use postinjury and predictive of patients who will seek opiates from other providers.
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Affiliation(s)
- Joel E. Holman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for T.F. Higgins:
| | - Gregory J. Stoddard
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for T.F. Higgins:
| | - Thomas F. Higgins
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for T.F. Higgins:
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Havens JR, Lofwall MR, Frost SDW, Oser CB, Leukefeld CG, Crosby RA. Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users. Am J Public Health 2012; 103:e44-52. [PMID: 23153148 DOI: 10.2105/ajph.2012.300874] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users. METHODS This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics. RESULTS The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network. CONCLUSIONS One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.
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Affiliation(s)
- Jennifer R Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY 40504, USA.
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Merrill RM, Johnson EM, Sloan A, Lanier WA. Characterizing Unintentional Nonillicit and Illicit Drug-Related Deaths. JOURNAL OF DRUG ISSUES 2012. [DOI: 10.1177/0022042612462217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study characterized individuals dying from illicit and nonillicit drug overdoses in Utah. Data were gathered from medical examiner records, death certificates, and next-of-kin interviews, 2008-2009. Among 374 decedents, 92 (25%) involved illicit drugs, 244 (65%) involved nonillicit drugs, and 38 (10%) involved a combination of both as the cause of death. Nonillicit compared with illicit drug-related decedents were more likely older, married, and of normal or overweight, and had a history of chronic pain. Nonillicit drug-related decedents were less likely to have had a history of alcohol and/or illicit drug use. Nevertheless, most decedents in both drug categories had a history of alcohol drinking and illicit substance use. Several psychological maladies characterized both illicit and nonillicit decedent cases, with a majority experiencing past anxiety, sadness, pain, insomnia, mood swings, irritability, hopelessness, and excessive daytime sleepiness. Impulsive tendencies and mood swings were more common in illicit drug-related deaths.
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Affiliation(s)
| | | | | | - William A. Lanier
- Utah Department of Health, Salt Lake City, USA
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Shah NG, Lathrop SL, Flores JE, Landen MG. The influence of living along the U.S.-Mexico border on unintentional drug overdose death, New Mexico (USA), 2005-2009. Drug Alcohol Depend 2012; 125:19-26. [PMID: 22513379 DOI: 10.1016/j.drugalcdep.2012.02.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 02/08/2012] [Accepted: 02/08/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The objective of this study was to characterize unintentional drug overdose death patterns among Hispanic ethnicity/sex strata by residence in New Mexico counties that border Mexico and non-border counties. METHODS We analyzed medical examiner data for all unintentional drug overdose death in New Mexico during 2005-2009. Logistic and Poisson regression was used to examine the relationship of unintentional drug overdose death with border residence and demographics. Risk of overdose death was examined by the interactions of ethnicity, sex and border residence. RESULTS During 2005-2009, the statewide drug overdose death rate was 17.6 per 100,000 (n=1812). Border decedents were more likely to have died from overdose of prescription opioids other than methadone (Schedule II, Adjusted Odds Ratio (aOR)=1.98; Schedule III/IV, aOR=1.56) but less likely to have died from heroin overdose (aOR=0.35), compared to non-border decedents. In population-based analyses, people living in border counties had lowest rates of overall overdose death and from illicit drugs, particularly heroin and cocaine. Hispanic males (adjusted incidence rate ratio [aRR]=2.41), Hispanic females (aRR=1.77) and non-Hispanic males (aRR=1.37) from non-border counties had higher risk of drug overdose death than their counterparts from border counties. Border residence had no effect on risk of drug overdose death among non-Hispanic females. CONCLUSIONS Residents in border counties incurred a protective effect for drug overdose death, most pronounced among Hispanics. There is a component of overdose death risk for which border residence is a proxy, likely an array of cultural and healthcare-related factors.
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Affiliation(s)
- Nina G Shah
- New Mexico Department of Health, 1190 St. Francis Dr., PO Box 26110, Santa Fe, NM 87502-6110, USA.
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Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. A History of Being Prescribed Controlled Substances and Risk of Drug Overdose Death. PAIN MEDICINE 2012; 13:87-95. [DOI: 10.1111/j.1526-4637.2011.01260.x] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lathrop SL. Forensic Pathology and Epidemiology, Public Health and Population-Based Research. Acad Forensic Pathol 2011. [DOI: 10.23907/2011.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Forensic pathology can play a pivotal role in safeguarding public health. While medicolegal death investigation focuses on certifying cause and manner of individual deaths, taken in aggregate this information provides a powerful tool for epidemiologic research. The published literature provides numerous examples of the utility of forensic pathology in public health research, from describing trends in substance abuse deaths to reducing occupational fatalities and identifying unusual infectious disease deaths. Medical examiner and coroner (ME/C) offices contribute to public health research by participating in surveillance systems, including those for sudden unexplained infant deaths and violent deaths, and by alerting public health agencies to emerging threats. Accessing and utilizing ME/C data for epidemiologic research can be challenging, given the wide variation in types of jurisdictions and the availability of electronic data, but the rewards for researchers justify the endeavor. Mutually beneficial relationships can develop between epidemiologists and ME/Cs, improving both public health and medicolegal death investigation.
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Affiliation(s)
- Sarah L. Lathrop
- New Mexico's Office of the Medical Investigator and University of New Mexico Health Sciences Center
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Green TC, Grau LE, Carver HW, Kinzly M, Heimer R. Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997-2007. Drug Alcohol Depend 2011; 115:221-8. [PMID: 21131140 PMCID: PMC3095753 DOI: 10.1016/j.drugalcdep.2010.11.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 11/07/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths ("overdoses") in CT over an 11-year period. METHODS We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type. RESULTS Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities. CONCLUSIONS The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts.
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Affiliation(s)
- Traci C. Green
- The Warren Alpert Medical School of Brown University, Box G-1, Providence, RI 02912 USA
| | - Lauretta E. Grau
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
| | - H. Wayne Carver
- Office of the Chief Medical Examiner, 11 Shuttle Road, Farmington, CT 06032 USA
| | - Mark Kinzly
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
| | - Robert Heimer
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
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Increase in unintentional medication overdose deaths: Oklahoma, 1994-2006. Am J Prev Med 2010; 39:357-63. [PMID: 20837287 DOI: 10.1016/j.amepre.2010.05.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 12/08/2009] [Accepted: 05/28/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND During 1999-2006, rates of unintentional drug-related deaths increased 120% in the U.S. PURPOSE This report describes demographics and trends of unintentional medication overdose deaths among Oklahoma residents to target prevention strategies. METHODS Oklahoma medical examiner data regarding fatal unintentional poisonings involving at least one prescription or over-the-counter medication during 1994-2006 and opioid retail sales data during 1997-2006 were analyzed during 2008-2009 to determine demographic-specific rates of overdose deaths and changes in 3-year mean death rates. RESULTS A total of 2112 fatal unintentional medication overdoses were identified (4.7 deaths/100,000 population) involving a median of two substances/decedent. The highest fatality rates occurred among men (5.9/100,000) and people aged 35-54 years (11/100,000). Crude overdose death rates increased sevenfold during the investigation period, peaking at 11/100,000 in 2006. Death rates increased more for women (ninefold) than men (sixfold); rates among residents of rural counties increased more (eightfold) than urban county rates (sixfold). Leading drug types involved in fatalities were opioids and anxiolytics. The individual drugs contributing most frequently included methadone (31%); hydrocodone (19%); alprazolam (15%); and oxycodone (15%). During 1997-2006, Oklahoma prescription opioid sales increased fourfold. Methadone was associated with the highest number of deaths per equianalgesic dose sold (23.3), whereas hydrocodone and oxycodone had the highest increases in deaths per equianalgesic dose sold (threefold increase each). CONCLUSIONS Unintentional medication-related deaths are increasing in Oklahoma and often involve multiple substances. Substances most frequently contributing to deaths were prescription opioid analgesics. Prevention strategies should target people aged 35-54 years and emphasize the dangers of coingesting substances and misusing prescription pain medications.
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Brownstein JS, Green TC, Cassidy TA, Butler SF. Geographic information systems and pharmacoepidemiology: using spatial cluster detection to monitor local patterns of prescription opioid abuse. Pharmacoepidemiol Drug Saf 2010; 19:627-37. [PMID: 20535759 DOI: 10.1002/pds.1939] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE Understanding the spatial distribution of opioid abuse at the local level may facilitate public health interventions. METHODS Using patient-level data from addiction treatment facilities in New Mexico from ASI-MV Connect, we applied geographic information system (GIS) in combination with a spatial scan statistic to generate risk maps of prescription opioid abuse and identify clusters of product- and compound-specific abuse. Prescribed opioid volume data was used to determine whether identified clusters are beyond geographic differences in availability. RESULTS Data on 24 452 patients residing in New Mexico were collected. Among those patients, 1779 (7.3%) reported abusing any prescription opioid (past 30 days). According to opioid type, 979 patients (4.0%) reported abuse of any hydrocodone, 1007 (4.1%) for any oxycodone, 108 (0.4%) for morphine, 507 (2.1%) for Vicodin or generic equivalent, 390 (1.6%) for OxyContin, and 63 (0.2%) for MS Contin or generic equivalent. Highest rates of abuse were found in the area surrounding Albuquerque with 8.6 patients indicating abuse per 100 interviewed patients. We found clustering of abuse around Albuquerque (P = 0.001; Relative Risk = 1.35, and a radius of 146 km). At the compound level, we found that drug availability was partly responsible for clustering of prescription opioid abuse. After accounting for drug availability, we identified a second foci of Vicodin abuse in the southern rural portion of the state near Las Cruces, NM and El Paso, Texas and bordering Mexico (RR = 2.1; P = 0.001). CONCLUSIONS A better understanding of local risk distribution may have implications for response strategies to future introductions of prescription opioids.
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Bohnert ASB, Roeder K, Ilgen MA. Unintentional overdose and suicide among substance users: a review of overlap and risk factors. Drug Alcohol Depend 2010; 110:183-92. [PMID: 20430536 DOI: 10.1016/j.drugalcdep.2010.03.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 03/09/2010] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
Substance use is a risk factor for suicide, suicide attempts, and fatal and non-fatal overdose, but to date, little has been done to integrate the research on suicidal behavior and overdose among substance users. This study reviews the literature on suicide and overdose among substance users with the goal of illuminating the similarities and differences between these two events. A structured review resulted in 15 articles (describing 14 unique studies) published between 1990 and 2010 that examined both overdose and suicide in samples of substance users. There is some evidence that substance users who attempt suicide are more likely to report an overdose and vice versa. This relationship may be partially explained by the fact that overdose is a common method of suicide. The results of the literature review also indicate that substance users with a history of both events may represent a group with particularly poor psychological and social functioning and severe drug-related problems. Further research is needed to understand the overlap of, and differences between, suicide and accidental overdose among individuals who misuse substances, particularly individuals who primarily use substances other than heroin. An improved understanding of the interrelationships between suicide and unintentional overdose among individuals who use alcohol or drugs is necessary to guide the development of effective prevention and intervention approaches.
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Affiliation(s)
- Amy S B Bohnert
- Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs, 2215 Fuller Road (11H), Ann Arbor, MI 48105, USA.
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Sternfeld I, Perras N, Culross PL. Development of a coroner-based surveillance system for drug-related deaths in Los Angeles county. J Urban Health 2010; 87:656-69. [PMID: 20440654 PMCID: PMC2900566 DOI: 10.1007/s11524-010-9455-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Existing data sources do not provide comprehensive and timely information to adequately monitor drug-related mortality in Los Angeles County. To fill this gap, a surveillance system using coroner data was developed to examine patterns in drug-related deaths. The coroner provided data on all injury deaths in Los Angeles County. A list of keywords that indicate a death was caused by drug use was developed. The cause of death variables in the coroner data were searched for mentions of one of the keywords; if a keyword was detected, that death was classified as drug related. The effectiveness of the keyword list in classifying drug-related deaths was evaluated by matching records in the coroner death data to records in the state death files. Then, the drug-related deaths identified using the keywords were compared to drug-related deaths in the state mortality files identified using International Classification of Death codes. Toxicological test results were used to categorize drug-related deaths based on the type and legality of the drug(s) ingested. Mortality rates were calculated for each category of drug and legal status and for different demographic groups. Compared to the gold standard state mortality files, the coroner data had a sensitivity of 95.6% for identifying drug-related deaths. Over three quarters of all drug-related deaths tested positive for opiates and/or stimulants. Males, Whites, and 35-54-year-olds each accounted for more than half of all drug-related deaths. The surveillance of drug-related deaths using coroner data has several advantages: data are available in a timely fashion, the data include information about the specific substances each victim ingested, and the data can be broken down to compare mortality among specific subpopulations.
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Affiliation(s)
- Isabelle Sternfeld
- Injury & Violence Prevention Program, Los Angeles County Department of Public Health, 3530 Wilshire Blvd., Ste. 800, Los Angeles, CA, 90010, USA.
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Jönsson AK, Spigset O, Tjäderborn M, Druid H, Hägg S. Fatal drug poisonings in a Swedish general population. BMC CLINICAL PHARMACOLOGY 2009; 9:7. [PMID: 19397805 PMCID: PMC2679715 DOI: 10.1186/1472-6904-9-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 04/27/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pharmaceutical drug poisonings have previously been reported using single sources of information, either hospital data or forensic data, which might not reveal the true incidence. We therefore aimed to estimate the incidence of suspected fatal drug poisonings, defined as poisonings by pharmaceutical agents, by using all relevant case records from various sources in a Swedish population. METHODS Every seventh randomly selected deceased in three counties in southeastern Sweden during a one-year period was identified in the Cause of Death Register. Relevant case records (death certificates, files from hospitals and/or primary care centres and medico-legal files) were reviewed for all study subjects. RESULTS Of 1574 deceased study subjects, 12 cases were classified as pharmaceutical drug poisonings according to the death certificates and 10 according to the medico-legal files. When reviewing all available data sources, 9 subjects (0.57%; 95% confidence interval: 0.20-0.94%) were classified as drug poisonings, corresponding to an incidence of 6.5 (95% confidence interval: 2.3-10.7) per 100,000 person-years in the general population. The drug groups most often implicated were benzodiazepines (33%), antihistamines (33%) and analgesics (22%). CONCLUSION Fatal drug poisonings is a relatively common cause of death in Sweden. By using multiple sources of information when investigating the proportion of fatal poisonings in a population, more accurate estimates may be obtained.
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Affiliation(s)
- Anna K Jönsson
- Nordic School of Public Health, Gothenburg, Sweden
- Division of Clinical Pharmacology, Linköping University, Linköping, Sweden
| | - Olav Spigset
- Division of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Micaela Tjäderborn
- Division of Clinical Pharmacology, Linköping University, Linköping, Sweden
| | - Henrik Druid
- Department of Forensic Medicine, Karolinska Institute, Stockholm, Sweden
| | - Staffan Hägg
- Division of Clinical Pharmacology, Linköping University, Linköping, Sweden
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Wunsch MJ, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: a description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict 2009; 18:5-14. [PMID: 19219660 DOI: 10.1080/10550490802544938] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35-54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers.
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Affiliation(s)
- Martha J Wunsch
- Edward Via Virginia College of Osteopathic Medicine, Blacksburg, Virginia, USA.
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Abstract
STUDY DESIGN Retrospective population-based cohort study. OBJECTIVE To describe mortality after lumbar fusion surgery in Washington State workers' compensation claimants in the perioperative period and beyond. SUMMARY OF BACKGROUND DATA Although lumbar fusion surgery can be associated with serious complications, perioperative mortality is generally considered rare. Population-based mortality estimates have been limited to surgery in older adults. METHODS We identified all Washington State workers' compensation claimants who underwent fusion between January 1994 and December 2001 (n = 2378) and assessed the frequency, timing, and causes of death. Mortality follow-up was concluded in 2004. Death was ascertained from Washington State vital statistics records and from the workers' compensation claims database. Poisson regression was used to obtain age- and gender-adjusted mortality rates. Years of potential life lost, percent of potential life lost, and mean potential life lost were calculated for the leading 5 causes of death and we calculated the risk of death associated with selected predictors. RESULTS Among the 2378 lumbar fusion subjects in the study cohort, 103 were deceased by 2004. The 3-year cumulative mortality rate was 1.93% (95% confidence interval, 1.41%-2.57%). The 90-day perioperative mortality rate was 0.29% (95% confidence interval, 0.11%-0.60%). The risk of perioperative mortality was positively associated with repeat fusions. The age- and gender-adjusted all-cause mortality rate was 3.1 deaths per 1000 worker-years (95% confidence interval, 0.9-9.8). Analgesic-related deaths were responsible for 21% of all deaths and 31.4% of all potential life lost. The risk of analgesic-related death was higher among workers who received instrumentation or intervertebral cage devices compared with recipients of bone-only fusions (1.1% vs. 0.0%; P = 0.03) and among workers with degenerative disc disease (age- and gender-adjusted mortality rate ratio, 2.71) (95% confidence interval, 1.17-6.28). The burden was especially high among subjects between 45 and 54 years old with degenerative disc disease (rate ratio, 7.45). CONCLUSION Analgesic-related deaths are responsible for more deaths and more potential life lost among workers who underwent lumbar fusion than any other cause. Risk of analgesic-related death was especially high among young and middle-aged workers with degenerative disc disease.
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Shah NG, Lathrop SL, Reichard RR, Landen MG. Unintentional drug overdose death trends in New Mexico, USA, 1990-2005: combinations of heroin, cocaine, prescription opioids and alcohol. Addiction 2008; 103:126-36. [PMID: 18028518 DOI: 10.1111/j.1360-0443.2007.02054.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIMS To determine the contribution of heroin, prescription opioids, cocaine and alcohol/drug combinations to the total overdose death rate and identify changes in drug overdose patterns among New Mexico subpopulations. DESIGN We analyzed medical examiner data for all unintentional drug overdose deaths in New Mexico during 1990-2005. Age-adjusted drug overdose death rates were calculated by sex and race/ethnicity; we modeled overall drug overdose death adjusting for age and region. FINDINGS The total unintentional drug overdose death rate in New Mexico increased from 5.6 per 100 000 in 1990 to 15.5 per 100 000 in 2005. Deaths caused by heroin, prescription opioids, cocaine and alcohol/drug combinations together ranged from 89% to 98% of the total. Heroin caused the most deaths during 1990-2005, with a notable rate increase in prescription opioid overdose death during 1998-2005 (58%). During 1990-2005, the 196% increase in single drug category overdose death was driven by prescription opioids alone and heroin alone; the 148% increase in multi-drug category overdose death was driven by heroin/alcohol and heroin/cocaine. Hispanic males had the highest overdose death rate, followed by white males, white females, Hispanic females and American Indians. The most common categories causing death were heroin alone and heroin/alcohol among Hispanic males, heroin/alcohol among American Indian males and prescription opioids alone among white males and all female subpopulations. CONCLUSIONS Interventions to prevent drug overdose death should be targeted according to use patterns among at-risk subpopulations. A comprehensive approach addressing both illicit and prescription drug users, and people who use these drugs concurrently, is needed to reduce overdose death.
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Affiliation(s)
- Nina G Shah
- Epidemiology and Response Division, New Mexico Department of Health, Santa Fe, NM 87502-6110, USA.
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Abstract
BACKGROUND The prescription drugs or drug classes that are most frequently associated with death in the US might be identifiable from death certificate data. OBJECTIVE To identify the drugs/drug classes associated with the greatest numbers of deaths in the US that might be considered as possible targets for prevention. STUDY DESIGN US vital statistics data were accessed in order to identify International Classification of Diseases (10th Revision) [ICD-10] codes indicating that prescription drugs had caused or contributed to death and diseases with significant drug-related mortality. MAIN OUTCOME MEASURE ICD-10 codes for primarily prescription drugs that were listed as the underlying cause or as 'total mentions' on death certificates and were implicated in >or=1000 deaths in any one year were selected. The annual number of deaths by ICD-10 code was obtained from the Division of Vital Statistics, National Center for Health Statistics. Codes for diseases with significant drug-related aetiologies and involvement in >or=1000 deaths in any one year were also identified and analysed separately. RESULTS For the selected ICD-10 codes, a total of 25 031 deaths were listed as having a prescription drug as the underlying cause in 2003, compared with 16 135 in 1999, a 55% increase. Total mentions of these codes increased from 46 523 in 1999 to 72 080 in 2003, also a 55% increase. Most codes involved 'poisonings' (overdose or the wrong substance given or taken in error that is accidental, intentional or with undetermined intent). Drugs associated with poisoning deaths had central nervous system effects. Among the codes associated with specified drug classes, poisonings and accidental poisonings involving narcotics, hallucinogens, psychoactive substances and opioids (other than opium and heroin) were associated with the largest numbers of deaths. Drug-related codes associated with the largest percentage increases in deaths between 1999 and 2003 included poisoning due to methadone (275%); poisoning by other and unspecified antidepressants (primarily selective serotonin reuptake inhibitors) [130%]; and poisoning by psychostimulants with potential for abuse (amfetamines and drugs for attention deficit hyperactivity disorder) [117%]. Anticoagulants were associated with the largest numbers of deaths with codes involving "adverse effects in therapeutic use". Among diseases with significant drug-related aetiologies, Clostridium difficile enterocolitis (associated primarily with antibacterials) had the largest percentage increase in total mentions, with a 203% rise between 1999 and 2003. CONCLUSIONS Deaths due to overdoses are the most prominent cause of drug-related mortality in death certificate data. Certain drugs and drug classes, especially the opioids (e.g. narcotics, methadone), psychoactive drugs (e.g. antidepressants, amfetamines), anticoagulants and antibacterials (which cause or contribute to C. difficile enterocolitis) are associated with large and increasing numbers of deaths and preventive strategies should be considered.
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Affiliation(s)
- Diane K Wysowski
- Division of Drug Risk Evaluation, Food and Drug Administration, Silver Spring, Maryland 20993, USA
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