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Bishop M, Schumann JL, Gerostamoulos D, Wong A. The impact of codeine upscheduling on overdoses, Emergency Department presentations and mortality in Victoria, Australia. Drug Alcohol Depend 2021; 226:108837. [PMID: 34216868 DOI: 10.1016/j.drugalcdep.2021.108837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Prior to February 2018, codeine was available over-the-counter (OTC) in Australia as a pharmacist-only medicine (Schedule 3) in low-strength formulations when in combination with simple analgesics. In February 2018, The Advisory Committee on Medicines Scheduling (ACMS) upscheduled codeine-containing medicines (CCM) to Schedule 4 (prescription-only medicine). This study aimed to determine the impact of upscheduling on prescriptions, overdoses and deaths. METHODS This study used interrupted time series analysis, a quasi-experimental design, to retrospectively evaluate the impact of upscheduling on overdose poisoning calls to the Victorian Poisons Information Centre (VPIC), Emergency Department (ED) presentations to Austin Health, and deaths reported to the Victorian Coroner from 1 January 2013-31 December 2019. RESULTS There was a significant reduction in the trend of high-strength codeine poisoning calls by 0.36 (P = 0.03, 95 % CI = [-0.69, -0.04]). Low-strength codeine poisoning calls to the VPIC reduced by 13.31 (P <0.001, 95 % CI = [-16.80, 9.82]]) calls in February 2018, followed by continued reduction of 0.12 calls per month. High-strength codeine overdose ED presentations reduced in the first quarter of 2018 by 3.72 presentations (P = 0.004, 95 % CI = [-6.13, -1.31]). Low-strength codeine overdose ED presentations after the first quarter of 2018 by 0.33 (P = 0.03, 95 % CI = [-0.63, -0.03]) presentations per month. Codeine-related deaths reduced by 7.19 (P < 0.001, 95 % CI = [-9.44, -4.94]) deaths in February 2018. CONCLUSIONS Codeine upscheduling to prescription-only medicine has reduced codeine-related poisoning calls, overdoses and unnatural death in Victoria.
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Affiliation(s)
- Milly Bishop
- The Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Australia.
| | - Jennifer L Schumann
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia; Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC, 3006, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia; Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC, 3006, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Emergency Department, Austin Health, Victoria, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia; Centre for Integrated Critical Care, The University of Melbourne, Victoria, Australia
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Andersson L, Håkansson A, Berge J, Johnson B. Changes in opioid-related deaths following increased access to opioid substitution treatment. Subst Abuse Treat Prev Policy 2021; 16:15. [PMID: 33568184 PMCID: PMC7876792 DOI: 10.1186/s13011-021-00351-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths. METHODS Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention. RESULTS There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89-1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12-6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51-1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84-0,97, p= 0.004). CONCLUSIONS Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.
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Affiliation(s)
- Lisa Andersson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Anders Håkansson
- Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden
| | - Jonas Berge
- Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden
- Malmö Addiction Centre, Region Skåne, Malmö, Sweden
| | - Björn Johnson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden
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Cobert J, Lantos PM, Janko MM, Williams DGA, Raghunathan K, Krishnamoorthy V, JohnBull EA, Barbeito A, Gulur P. Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses. J Urban Health 2020; 97:814-822. [PMID: 32367203 PMCID: PMC7704893 DOI: 10.1007/s11524-020-00436-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.
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Affiliation(s)
- Julien Cobert
- Department of Anesthesia, Critical Care Medicine division, University of California at San Francisco, 505 Parnassus Ave, Room M917, Box 0624, San Francisco, CA, 94143, USA.
| | - Paul M Lantos
- Department of Internal Medicine, Duke University Medical Center, Durham, NC, 27710, USA
- Duke University Global Health Institute, Durham, NC, 27710, USA
| | - Mark M Janko
- Duke University Global Health Institute, Durham, NC, 27710, USA
| | - David G A Williams
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Eric A JohnBull
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Atilio Barbeito
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
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Brandenburg MA. American Indian and Non-Hispanic White Midlife Mortality Is Associated With Medicaid Spending: An Oklahoma Ecological Study (1999-2016). Front Public Health 2020; 8:139. [PMID: 32411646 PMCID: PMC7202289 DOI: 10.3389/fpubh.2020.00139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: A one third reduction of premature deaths from non-communicable diseases by 2030 is a target of the United Nations Sustainable Development Goal for Health. Unlike in other developed nations, premature mortality in the United States (US) is increasing. The state of Oklahoma suffers some of the greatest rates in the US of both all-cause mortality and overdose deaths. Medicaid opioids are associated with overdose death at the patient level, but the impact of this exposure on population all-cause mortality is unknown. The objective of this study was to look for an association between Medicaid spending, as proxy measure for Medicaid opioid exposure, and all-cause mortality rates in the 45–54-year-old American Indian/Alaska Native (AI/AN45-54) and non-Hispanic white (NHW45-54) populations. Methods: All-cause mortality rates were collected from the US Centers for Disease Control & Prevention Wonder Detailed Mortality database. Annual per capita (APC) Medicaid spending, and APC Medicare opioid claims, smoking, obesity, and poverty data were also collected from existing databases. County-level multiple linear regression (MLR) analyses were performed. American Indian mortality misclassification at death is known to be common, and sparse populations are present in certain counties; therefore, the two populations were examined as a combined population (AI/NHW45-54), with results being compared to NHW45-54 alone. Results: State-level simple linear regressions of AI/NHW45-54 mortality and APC Medicaid spending show strong, linear correlations: females, coefficient 0.168, (R2 0.956; P < 0.0001; CI95 0.15, 0.19); and males, coefficient 0.139 (R2 0.746; P < 0.0001; CI95 0.10, 0.18). County-level regression models reveal that AI/NHW45-54 mortality is strongly associated with APC Medicaid spending, adjusting for Medicare opioid claims, smoking, obesity, and poverty. In females: [R2 0.545; (F)P < 0.0001; Medicaid spending coefficient 0.137; P < 0.004; 95% CI 0.05, 0.23]. In males: [R2 0.719; (F)P < 0.0001; Medicaid spending coefficient 0.330; P < 0.001; 95% CI 0.21, 0.45]. Conclusions: In Oklahoma, per capita Medicaid spending is a very strong risk factor for all-cause mortality in the combined AI/NHW45-54 population, after controlling for Medicare opioid claims, smoking, obesity, and poverty.
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Affiliation(s)
- Mark A Brandenburg
- Department of Medicine, Bristow Medical Center, Bristow, OK, United States
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Khan TS, Boyle A, Talbot S. Unintentional Drug-related Deaths in Cambridgeshire: A Retrospective Observational Study. Cureus 2020; 12:e6750. [PMID: 32140318 PMCID: PMC7039352 DOI: 10.7759/cureus.6750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Drug-related deaths are a growing public health problem in the United Kingdom, overtaking road fatalities and homicides in terms of annual deaths. In this study, we investigated the causes and circumstances of unintentional drug-related deaths occurring in the county of Cambridgeshire, with the objective of identifying the prevalence of physical, mental, and social health problems within this cohort. METHODS We collected data on the demographics and mental and physical health of, and drugs contributing to, 30 consecutive unintentional drug-related deaths recorded by the Cambridgeshire and Peterborough County Council Coroners in 2017. A retrospective observational study was used, and data were collected by manual extraction from coroners' files. RESULTS Social isolation was identified as a recurring theme amongst the decedents, although homelessness was found in very few cases. Pharmacologically, multiple drug toxicity and opioid toxicity were highly prevalent, whilst prescription opioids were implicated in more cases than heroin. Chronic pain was also highly prevalent amongst the decedents, and a history of mental illness was found to occur in the majority of cases. DISCUSSION Our findings show that reports from the coronial system provide a rich narrative to understand the causes of drug-related deaths. We have identified that individuals who die from drug-related deaths frequently have multiple adverse physical, mental, and social problems. This implies that any attempt to reduce drug-related deaths requires a multi-faceted and multi-disciplinary approach.
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Affiliation(s)
- Tahir S Khan
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Adrian Boyle
- Emergency Medicine, Addenbrookes Hospital Cambridge University, Cambridge, GBR
| | - Susie Talbot
- Public Health Directorate, Cambridgeshire County Council, Cambridge, GBR
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McClellan CB. Disparities in opioid related mortality between United States counties from 2000 to 2014. Drug Alcohol Depend 2019; 199:151-158. [PMID: 31054422 DOI: 10.1016/j.drugalcdep.2019.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The general increase in opioid-related deaths is well documented, and disparities by geographic regions and demographic characteristics have been observed as well. However, the distribution of opioid-related deaths among U.S. counties and the trends in that distribution have not been fully explored. This study examines the inequality in opioid death rates to assess convergence or divergence in opioid-related mortality between counties. METHODS Using mortality data from the NVSS for 2000-2014, this study examines the Gini coefficient of the county opioid mortality distribution. RESULTS The distribution of opioid mortality became more equal, with the Gini coefficient falling from 0.81 in 2000 to 0.61 in 2014. Counties with lower initial opioid mortality rates experienced faster growth in mortality than counties with high initial mortality. CONCLUSIONS Counties have experienced a convergence in opioid mortality rates. This poses potential challenges for addressing the crisis, as measures must become much broader in scope and be implemented in areas in which the dangers of the opioid crisis are not as apparent.
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Affiliation(s)
- Chandler B McClellan
- Agency for Healthcare Research and Quality, 5900 Fishers Lane, Rockville, MD, 20852, USA.
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Santistevan JR, Sharp BR, Hamedani AG, Fruhan S, Lee AW, Patterson BW. By Default: The Effect of Prepopulated Prescription Quantities on Opioid Prescribing in the Emergency Department. West J Emerg Med 2018; 19:392-397. [PMID: 29560071 PMCID: PMC5851516 DOI: 10.5811/westjem.2017.10.33798] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 10/11/2017] [Accepted: 10/09/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Opioid prescribing patterns have come under increasing scrutiny with the recent rise in opioid prescriptions, opioid misuse and abuse, and opioid-related adverse events. To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry. Methods We performed a retrospective observational study at a single academic, urban ED with 58,000 annual visits. We identified all adult patients (18 years or older) seen in the ED and discharged home with prescriptions for tablet forms of hydrocodone and oxycodone (including mixed formulations with acetaminophen). We compared the quantity of tablets prescribed per opioid prescription 12 months before and 10 months after the electronic order-entry prescription default quantity of 20 tablets was removed and replaced with no default quantity. No specific messaging was given to providers, to avoid influencing prescribing patterns. We used two-sample Wilcoxon rank-sum test, two-sample test of proportions, and Pearson's chi-squared tests where appropriate for statistical analysis. Results A total of 4,104 adult patients received discharge prescriptions for opioids in the pre-intervention period (151.6 prescriptions per 1,000 discharged adult patients), and 2,464 post-intervention (106.69 prescriptions per 1,000 discharged adult patients). The median quantity of opioid tablets prescribed decreased from 20 (interquartile ration [IQR] 10-20) to 15 (IQR 10-20) (p<0.0001) after removal of the default quantity. While the most frequent quantity of tablets received in both groups was 20 tablets, the proportion of patients who received prescriptions on discharge that contained 20 tablets decreased from 0.5 (95% confidence interval [CI] [0.48-0.52]) to 0.23 (95% CI [0.21-0.24]) (p<0.001) after default quantity removal. Conclusion Although the median number of tablets differed significantly before and after the intervention, the clinical significance of this is unclear. An observed wider distribution of the quantity of tablets prescribed after removal of the default quantity of 20 may reflect more appropriate prescribing patterns (i.e., less severe indications receiving fewer tabs and more severe indications receiving more). A default value of 20 tablets for opioid prescriptions may be an example of the electronic medical record's ability to reduce practice variability in medication orders actually counteracting optimal patient care.
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Affiliation(s)
- Jamie R Santistevan
- University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin
| | - Brian R Sharp
- University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin
| | - Azita G Hamedani
- University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin
| | - Scott Fruhan
- University of California San Francisco, Zuckerberg San Francisco General.,Kaiser Permanente Oakland Medical Center, Emergency Department, Oakland, California
| | - Andrew W Lee
- University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin
| | - Brian W Patterson
- University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.,Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
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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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Gomes T, Juurlink DN, Mamdani MM, Paterson JM, van den Brink W. Prevalence and characteristics of opioid-related deaths involving alcohol in Ontario, Canada. Drug Alcohol Depend 2017; 179:416-423. [PMID: 28867560 DOI: 10.1016/j.drugalcdep.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/10/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND While it is well known that patients receiving opioids should refrain from alcohol consumption, little is known about the involvement of alcohol in opioid-related deaths. METHODS We conducted a population-based analysis of opioid-related deaths in Ontario with and without alcohol involvement between 1993 and 2013, and reported rates overall and stratified by manner of death. We compared the characteristics of individuals who died of an opioid overdose based on the presence or absence of alcohol involvement. RESULTS The rate of opioid-related deaths increased 288% from 11.9 per million (95% confidence interval (CI) 9.8-13.9 per million) in 1993-46.2 per million (95% CI 42.6-49.8 per million) in 2013. The rate of opioid-related deaths without alcohol involvement increased 388% from 7.4 per million to 36.1 per million, while deaths involving alcohol increased by 125% from 4.5 per million to 10.1 per million. Therefore, although the annual number of opioid-related deaths involving alcohol rose, the proportion of opioid-related deaths involving alcohol declined from 37.8% in 1993-21.9% by 2013. Generally, opioid-related deaths involving alcohol were less likely to involve other central nervous system depressants, and more likely to occur among men and those with a history of alcohol use disorder. CONCLUSIONS Although the relative contribution of alcohol in opioid-related deaths has declined, 1 in 5 fatal opioid overdoses still involved alcohol in 2013. Our findings highlight the ongoing need for targeted messaging around risks of opioids alone, and in combination with alcohol and other CNS depressants.
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Affiliation(s)
- Tara Gomes
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, Ontario, M5S 3M2, Canada.
| | - David N Juurlink
- The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; The Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada
| | - Muhammad M Mamdani
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; The Department of Medicine, St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, Ontario, M5S 3M2, Canada
| | - J Michael Paterson
- The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Department of Family Medicine, McMaster University, 100 Main St. W., Hamilton, Ontario, L8P 1H6, Canada
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam-Zuidoost, Netherlands
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Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:172-179. [PMID: 28687187 PMCID: PMC5783633 DOI: 10.1016/j.drugpo.2017.06.005] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/28/2017] [Accepted: 06/12/2017] [Indexed: 01/12/2023]
Abstract
Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.
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Affiliation(s)
- Nadia Fairbairn
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada; Department of Medicine, University of British Columbia, Canada.
| | - Phillip O Coffin
- San Francisco Department of Public Health, United States; University of California, San Francisco, United States
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston Medical Center, United States
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Carter GT, Javaher SP, Nguyen MH, Garret S, Carlini BH. Re-branding cannabis: the next generation of chronic pain medicine? Pain Manag 2015; 5:13-21. [PMID: 25537695 DOI: 10.2217/pmt.14.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The field of pain medicine is at a crossroads given the epidemic of addiction and overdose deaths from prescription opioids. Cannabis and its active ingredients, cannabinoids, are a much safer therapeutic option. Despite being slowed by legal restrictions and stigma, research continues to show that when used appropriately, cannabis is safe and effective for many forms of chronic pain and other conditions, and has no overdose levels. Current literature indicates many chronic pain patients could be treated with cannabis alone or with lower doses of opioids. To make progress, cannabis needs to be re-branded as a legitimate medicine and rescheduled to a more pharmacologically justifiable class of compounds. This paper discusses the data supporting re-branding and rescheduling of cannabis.
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12
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Visconti AJ, Santos GM, Lemos NP, Burke C, Coffin PO. Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities. J Urban Health 2015; 92:758-72. [PMID: 26077643 PMCID: PMC4524842 DOI: 10.1007/s11524-015-9967-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription opioid decedents in San Francisco from 2010 to 2012. During this time period, 331 individuals died from accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). Deaths most commonly involved methadone (45.9%), morphine (26.9%), and oxycodone (21.8%). Most deaths also involved other substances (74.9%), most commonly cocaine (35.3%), benzodiazepines (27.5%), antidepressants (22.7%), and alcohol (19.6%). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids. Overall, heroin overdose death, previously common in San Francisco, is now rare. Prescription opioid overdose has emerged as a significant concern, particularly among individuals in high-poverty areas. Deaths in poor and affluent regions involve different causative opioids and co-occurring substances.
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Affiliation(s)
- Adam J Visconti
- San Francisco Department of Public Health, 25 Van Ness Ave., San Francisco, CA, 94102, USA,
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Brady JE, DiMaggio CJ, Keyes KM, Doyle JJ, Richardson LD, Li G. Emergency department utilization and subsequent prescription drug overdose death. Ann Epidemiol 2015; 25:613-619.e2. [PMID: 25935710 PMCID: PMC4675463 DOI: 10.1016/j.annepidem.2015.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 03/15/2015] [Accepted: 03/26/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. METHODS Using data from the New York Statewide Planning and Research Cooperative System for 2006-2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18-64 years and subsequent PDO death. RESULTS The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50-5.34) for those with two ED visits, 16.61 (95% CI: 14.72-18.75) for those with three ED visits, and 48.24 (95% CI: 43.23-53.83) for those with four ED visits or more. CONCLUSIONS Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality.
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Affiliation(s)
- Joanne E Brady
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York, NY.
| | - Charles J DiMaggio
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York, NY
| | - John J Doyle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Lynne D Richardson
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY
| | - Guohua Li
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York, NY
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Diversion of methadone and buprenorphine by patients in opioid substitution treatment in Sweden: Prevalence estimates and risk factors. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:183-90. [DOI: 10.1016/j.drugpo.2014.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 09/10/2014] [Accepted: 10/19/2014] [Indexed: 11/23/2022]
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Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil 2015; 6:1-14. [PMID: 25610012 PMCID: PMC4293937 DOI: 10.2147/sar.s45585] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine-naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Germany
- Private Hospital Meiringen, Meiringen, Switzerland
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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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Wang KH, Fiellin DA, Becker WC. Source of prescription drugs used nonmedically in rural and urban populations. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2014; 40:292-303. [DOI: 10.3109/00952990.2014.907301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Karen H. Wang
- Department of Medicine, The Veterans Affairs Connecticut Healthcare System
West Haven, CT, USA
- Department of Internal Medicine
- Robert Wood Johnson Foundation Clinical Scholars Program
| | - David A. Fiellin
- Department of Internal Medicine
- Investigative Medicine Program, Yale University School of Medicine
New Haven, CTUSA
| | - William C. Becker
- Department of Medicine, The Veterans Affairs Connecticut Healthcare System
West Haven, CT, USA
- Department of Internal Medicine
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Abstract
OBJECTIVES Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction. METHODS A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field. RESULTS Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks. CONCLUSIONS Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.
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Rossen LM, Khan D, Warner M. Trends and geographic patterns in drug-poisoning death rates in the U.S., 1999-2009. Am J Prev Med 2013; 45:e19-25. [PMID: 24237925 PMCID: PMC4659504 DOI: 10.1016/j.amepre.2013.07.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/11/2013] [Accepted: 07/29/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Drug poisoning mortality has increased substantially in the U.S. over the past 3 decades. Previous studies have described state-level variation and urban-rural differences in drug-poisoning deaths, but variation at the county level has largely not been explored in part because crude county-level death rates are often highly unstable. PURPOSE The goal of the study was to use small-area estimation techniques to produce stable county-level estimates of age-adjusted death rates (AADR) associated with drug poisoning for the U.S., 1999-2009, in order to examine geographic and temporal variation. METHODS Population-based observational study using data on 304,087 drug-poisoning deaths in the U.S. from the 1999-2009 National Vital Statistics Multiple Cause of Death Files (analyzed in 2012). Because of the zero-inflated and right-skewed distribution of drug-poisoning death rates, a two-stage modeling procedure was used in which the first stage modeled the probability of observing a death for a given county and year, and the second stage modeled the log-transformed drug-poisoning death rate given that a death occurred. Empirical Bayes estimates of county-level drug-poisoning death rates were mapped to explore temporal and geographic variation. RESULTS Only 3% of counties had drug-poisoning AADRs greater than ten per 100,000 per year in 1999-2000, compared to 54% in 2008-2009. Drug-poisoning AADRs grew by 394% in rural areas compared to 279% for large central metropolitan counties, but the highest drug-poisoning AADRs were observed in central metropolitan areas from 1999 to 2009. CONCLUSIONS There was substantial geographic variation in drug-poisoning mortality across the U.S.
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Affiliation(s)
- Lauren M Rossen
- Office of Analysis and Epidemiology, National Center for Health Statistics, CDC, Hyattsville, Maryland.
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Hall MT, Leukefeld CG, Havens JR. Factors associated with high-frequency illicit methadone use among rural Appalachian drug users. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2013; 39:241-6. [PMID: 23841864 DOI: 10.3109/00952990.2013.805761] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In recent years there has been a sharp increase in the use of illicit methadone as well as methadone-related overdose deaths. OBJECTIVE The purpose of this study was to describe factors associated with low- and high-frequency methadone use in a cohort of rural Appalachian drug users. METHODS Interviews assessing sociodemographics, illicit drug use and drug treatment, psychiatric disorders, health and sociometric drug network characteristics were conducted with 503 rural drug users between 2008 and 2010. A two-level mixed effects regression model was utilized to differentiate low- (one use per month or less in the past six months) versus high-frequency (daily or weekly use in the past six months) illicit methadone users. RESULTS The lifetime prevalence of illicit methadone use in this population was 94.7% (n = 476) and slightly less than half (46.3%) were high-frequency users. In the mixed effects regression model, initiating illicit methadone use at a younger age was associated with high-frequency illicit methadone use. Taking a prescribed medication for a physical problem, undergoing additional weeks of outpatient drug free treatment, daily OxyContin® use in the past month, and having fewer ties and second-order connections in the drug network reduced the odds of high-frequency illicit methadone use. CONCLUSIONS Rates of illicit methadone use and high-frequency illicit methadone use among this sample of rural drug users were considerably higher than those previously reported in the literature. Health practitioners in rural areas should routinely screen for illicit opioid use, including methadone.
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Affiliation(s)
- Martin T Hall
- Kent School of Social Work, University of Louisville, Louisville, Kentucky, USA.
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Cerdá M, Ransome Y, Keyes KM, Koenen KC, Tracy M, Tardiff KJ, Vlahov D, Galea S. Prescription opioid mortality trends in New York City, 1990-2006: examining the emergence of an epidemic. Drug Alcohol Depend 2013; 132:53-62. [PMID: 23357743 PMCID: PMC3748247 DOI: 10.1016/j.drugalcdep.2012.12.027] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/29/2012] [Accepted: 12/29/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990-2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas. METHODS We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990-2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas. RESULTS Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990-2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents. CONCLUSIONS The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts.
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Affiliation(s)
- Magdalena Cerdá
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA.
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Sansone RA, Watts DA, Wiederman MW. Pain, Pain Catastrophizing, and History of Intentional Overdoses and Attempted Suicide. Pain Pract 2013; 14:E29-32. [DOI: 10.1111/papr.12094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/06/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Randy A. Sansone
- Department of Internal Medicine; Wright State University School of Medicine; Dayton Ohio U.S.A
- Department of Psychiatry; Write State University School of Medicine; Dayton Ohio U.S.A
- Psychiatry Education; Kettering Medical Center; Kettering Ohio U.S.A
| | - Daron A. Watts
- Department of Psychiatry; Write State University School of Medicine; Dayton Ohio U.S.A
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Cheng M, Sauer B, Johnson E, Porucznik C, Hegmann K. Comparison of opioid-related deaths by work-related injury. Am J Ind Med 2013; 56:308-16. [PMID: 23143851 DOI: 10.1002/ajim.22138] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To infer whether work-related injuries may impact opioid-related deaths. METHODS Descriptive comparisons were done using data from the Utah Department of Health, the Office of Medical Examiners, and the Labor Commission on all Utah residents who died from opioid-related deaths from 2008 to 2009. RESULTS The majority of decedents (145 of 254, 57%) had at least one prior work-related injury. Demographics were similar regardless of work injury status. However, lack of high school diploma (18% vs. 7%, P < 0.001), prevalence of mental illness (50% vs. 15%, P < 0.001), tobacco (61% vs. 12%, P < 0.001), alcohol (87% vs. 28%, P < 0.001), and illicit drug (50% vs. 4%, P < 0.001) use were all substantially higher than the background population. CONCLUSION A detailed history and screening for mental illness and substance abuse, including tobacco use, among injured workers may be helpful in avoiding potential opioid-related deaths.
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Affiliation(s)
- Melissa Cheng
- Rocky Mountain Center for Occupational, Environmental Medicine at the University of Utah School of Medicine, Salt Lake City, Utah.
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Wang KH, Becker WC, Fiellin DA. Prevalence and correlates for nonmedical use of prescription opioids among urban and rural residents. Drug Alcohol Depend 2013; 127:156-62. [PMID: 22819293 DOI: 10.1016/j.drugalcdep.2012.06.027] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 06/05/2012] [Accepted: 06/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND In the United States, rural areas have reported an increase in overdose deaths secondary to nonmedical use of prescription opioids. Little is known about the differences in nonmedical use of prescription opioids among urban and rural adults. METHODS Using the 2008-2009 National Survey on Drug Use and Health, we examined the prevalence of nonmedical use of prescription opioids in urban and rural counties and determined bivariate and multivariate associations, stratified by county. We also compared type of opioids, stratified by county. RESULTS Among 75,964 respondents, the prevalence of nonmedical use of prescriptions opioids was similar among residents in urban and rural counties (4.7% vs. 4.3%, p=0.15). Urban and rural residents with severe psychological distress and nonmedical use of other prescription medications were more likely to report nonmedical use of opioids. Urban residents whose first use of illicit drugs was between the age of 18 and 25 and who reported alcohol use were more likely to report nonmedical use. Black and Hispanic urban residents were less likely to use prescription opioids nonmedically compared to white urban residents. Rural residents were more likely than urban residents to use acetaminophen with propoxyphene (61.1% vs. 55.8%, p=0.02), methadone (14.8% vs. 9.1%, p=0.003) and acetaminophen with codeine (3.5% vs. 1.9%, p=0.05). CONCLUSIONS Prevalence and risk factors related to nonmedical use of opioids are similar between urban and rural residents; however rural residents report propoxyphene, codeine, and methadone use more than their urban counterparts. Prevention and treatment interventions may need to be tailored for specific communities.
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Affiliation(s)
- Karen H Wang
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, CT 06520-8088, United States.
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Lanier WA, Johnson EM, Rolfs RT, Friedrichs MD, Grey TC. Risk Factors for Prescription Opioid-Related Death, Utah, 2008–2009. PAIN MEDICINE 2012; 13:1580-9. [DOI: 10.1111/j.1526-4637.2012.01518.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ogle A, Moore K, Barrett B, Young MS, Pearson J. Clinical history and characteristics of persons with oxycodone-related deaths in Hillsborough County, Florida in 2009. Forensic Sci Int 2012; 223:47-52. [DOI: 10.1016/j.forsciint.2012.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 07/18/2012] [Accepted: 07/28/2012] [Indexed: 10/28/2022]
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Cantrill SV, Brown MD, Carlisle RJ, Delaney KA, Hays DP, Nelson LS, O'Connor RE, Papa A, Sporer KA, Todd KH, Whitson RR. Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department. Ann Emerg Med 2012; 60:499-525. [DOI: 10.1016/j.annemergmed.2012.06.013] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Muazzam S, Swahn MH, Alamgir H, Nasrullah M. Differences in poisoning mortality in the United States, 2003-2007: epidemiology of poisoning deaths classified as unintentional, suicide or homicide. West J Emerg Med 2012; 13:230-8. [PMID: 22900120 PMCID: PMC3415827 DOI: 10.5811/westjem.2012.3.11762] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/13/2012] [Accepted: 03/14/2012] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Poisoning, specifically unintentional poisoning, is a major public health problem in the United States (U.S.). Published literature that presents epidemiology of all forms of poisoning mortalities (i.e., unintentional, suicide, homicide) together is limited. This report presents data and summarizes the evidence on poisoning mortality by demographic and geographic characteristics to describe the burden of poisoning mortality and the differences among sub-populations in the U.S. for a 5-year period. METHODS Using mortality data from the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we presented the age-specific and age-adjusted unintentional and intentional (suicide, homicide) poisoning mortality rates by sex, age, race, and state of residence for the most recent years (2003-2007) of available data. Annual percentage changes in deaths and rates were calculated, and linear regression using natural log were used for time-trend analysis. RESULTS There were 121,367 (rate=8.18 per 100,000) unintentional poisoning deaths. Overall, the unintentional poisoning mortality rate increased by 46.9%, from 6.7 per 100,000 in 2003 to 9.8 per100.000 in 2007, with the highest mortality rate among those aged 40-59 (rate=15.36), males (rate=11.02) and whites (rate=8.68). New Mexico (rate=18.2) had the highest rate. Unintentional poisoning mortality rate increased significantly among both sexes, and all racial groups except blacks (p<0.05 time-related trend for rate). Among a total of 29,469 (rate=1.97) suicidal poisoning deaths, the rate increased by 9.9%, from 1.9 per 100,000 in 2003 to 2.1 per 100,000 in 2007, with the highest rate among those aged 40-59 (rate=3.92), males (rate=2.20) and whites (rate=2.24). Nevada (rate=3.9) had the highest rate. Mortality rate increased significantly among females and whites only (p<0.05 time-related trend for rate). There were 463 (rate=0.03) homicidal poisoning deaths and the rate remained the same during 2003-2007. The highest rates were among aged 0-19 (rate=0.05), males (rate=0.04) and blacks (rate=0.06). CONCLUSION Prevention efforts for poisoning mortalities, especially unintentional poisoning, should be developed, implemented and strengthened. Differences exist in poisoning mortality by age, sex, location, and these findings underscore the urgency of addressing this public health burden as this epidemic continues to grow in the U.S.
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Effects of combined opioids on pain and mood in mammals. PAIN RESEARCH AND TREATMENT 2012; 2012:145965. [PMID: 22550575 PMCID: PMC3324919 DOI: 10.1155/2012/145965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/02/2012] [Indexed: 11/22/2022]
Abstract
The authors review the opioid literature for evidence of increased analgesia and reduced adverse side effects by combining mu-opioid-receptor (MOR) agonists, kappa-opioid-receptor (KOR) agonists, and nonselective low-dose-opioid antagonists (LD-Ant). We tested fentanyl (MOR agonist) and spiradoline (KOR agonist), singly and combined, against somatic and visceral pain models. Combined agonists induced additive analgesia in somatic pain and synergistic analgesia in visceral pain. Other investigators report similar effects and reduced tolerance and dependence with combined MOR agonist and KOR agonist. LD-Ant added to either a MOR agonist or KOR agonist markedly enhanced analgesia of either agonist. In accordance with other place-conditioning (PC) studies, our PC investigations showed fentanyl-induced place preference (CPP) and spiradoline-induced place aversion (CPA). We reduced fentanyl CPP with a low dose of spiradoline and reduced spiradoline CPA with a low dose of fentanyl. We propose combined MOR agonist, KOR agonist, and LD-Ant to produce superior analgesia with reduced adverse side effects, particularly for visceral pain.
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Abstract
OBJECTIVE Opioid therapy for pain in chronic pancreatitis (CP) is associated with tolerance and possibly opioid-induced hyperalgesia. We thus examined opioid use and pain rating in CP patients. METHODS Medical records of patients with established CP treated at the University of Pittsburgh Medical Center's Digestive Disorders Center between April 2008 and December 2009 were retrospectively reviewed. RESULTS Two hundred nineteen unique patients (53% men; age, 50 ± 1 years) were identified. At least moderate pain was initially present in 37% of the patients. Half (51%) of the patients received opioids (average morphine equivalent, 78.1 ± 12.4 mg/d). Pain severity correlated with age (r = -0.22), history of alcohol abuse (r = 0.14), affective spectrum disorders (r = 0.14), presence of coexisting pain syndromes (r = 0.24), opioid use (r = 0.49), and days with concerns about physical (r = 0.55) or mental problems (r = 0.35). In contrast, computed tomography-defined pancreatic abnormalities (calcification, pseudocysts, ductal stones, or dilation) did not correlate with pain rating. Regression analysis identified age, days with physical problems, and a coexisting chronic pain syndrome as best independent predictors of pain. CONCLUSIONS Chronic pancreatitis etiology, especially alcohol use, and psychosocial factors are important determinants of pain severity in CP. Successful management thus needs to go beyond treatment of changes in pancreatic morphology to effectively improve quality of life and utilization of medical resources.
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Marshall BDL, Milloy MJ, Wood E, Galea S, Kerr T. Temporal and geographic shifts in urban and nonurban cocaine-related fatal overdoses in British Columbia, Canada. Ann Epidemiol 2012; 22:198-206. [PMID: 22266349 DOI: 10.1016/j.annepidem.2011.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/13/2011] [Accepted: 12/30/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Illicit drug overdose is a leading cause of premature mortality. We sought to examine fatal overdose trends from 2001 to 2005 in urban and nonurban areas of British Columbia, Canada. METHODS We conducted a review of all provincial coroner files in which drug overdose was the cause of death between January 1, 2001, and December 31, 2005. We compared cocaine and non-cocaine-related overdoses and examined temporal changes in cocaine-related mortality rates in urban and nonurban areas. Multilevel mixed effects models were used to determine the independent risk factors for cocaine-related death. Spatial analyses were conducted to identify clusters of these cases. RESULTS During the study period, 904 illicit drug overdoses were recorded, including 369 (40.8%) in nonurban areas and 532 (58.9%) related to cocaine consumption. In a multilevel model, we observed a significant interaction (p = .010) between population density and year, indicating a considerable and differential increase in the likelihood of cocaine-related deaths in nonurban areas. Cocaine-related deaths were clustered in the southeast region of the province. CONCLUSIONS Cocaine-related overdoses in nonurban areas should be a public health concern. Evidence-based interventions to reduce the risks associated with cocaine consumption and reach drug users in nonurban settings are needed.
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Affiliation(s)
- Brandon D L Marshall
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada
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Carter GT, Flanagan AM, Earleywine M, Abrams DI, Aggarwal SK, Grinspoon L. Cannabis in palliative medicine: improving care and reducing opioid-related morbidity. Am J Hosp Palliat Care 2011; 28:297-303. [PMID: 21444324 DOI: 10.1177/1049909111402318] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Unlike hospice, long-term drug safety is an important issue in palliative medicine. Opioids may produce significant morbidity. Cannabis is a safer alternative with broad applicability for palliative care. Yet the Drug Enforcement Agency (DEA) classifies cannabis as Schedule I (dangerous, without medical uses). Dronabinol, a Schedule III prescription drug, is 100% tetrahydrocannabinol (THC), the most psychoactive ingredient in cannabis. Cannabis contains 20% THC or less but has other therapeutic cannabinoids, all working together to produce therapeutic effects. As palliative medicine grows, so does the need to reclassify cannabis. This article provides an evidence-based overview and comparison of cannabis and opioids. Using this foundation, an argument is made for reclassifying cannabis in the context of improving palliative care and reducing opioid-related morbidity.
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Affiliation(s)
- Gregory T Carter
- Hospice Services, Providence Medical Group, Olympia, WA 98531, USA.
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