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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. Differences in heroin overdose deaths in Australia by age, 2020-2022: Disease and estimated survival times. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 10:100217. [PMID: 38332901 PMCID: PMC10850106 DOI: 10.1016/j.dadr.2024.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 02/10/2024]
Abstract
Background The age of people who use illicit opioids has increased, with a clinical picture of accelerated ageing. The study aimed to determine, stratified by age: 1. The circumstances and characteristics of heroin-related toxicity deaths in Australia, 2020-2022; 2. The toxicological profile and autopsy findings; 3. The proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a measure of survival time. Methods Retrospective study of 610 cases of fatal heroin-related drug toxicity in Australia, 2020-2022. Cases were stratified as: <30 years, 30-39 years, 40-49 years, ≥50 years. Results Compared to the youngest group, those aged ≥50 years were more likely to have a history of chronic pain (12.4 v 3.3 %), to have their death attributed to combined drug toxicity/disease (20.1 v 3.3 %), and to have evidence of a sudden collapse (21.3 v 11.1 %). There were no differences in free morphine concentrations or glucuronide concentrations. Compared to the youngest group, however, the two older groups were significantly more likely to have 6AM present in blood, a proxy measure of a shorter survival time (52.0, 55.2 v 34.5 %). Compared to the youngest group, cases aged ≥50 years were more likely to be diagnosed with cardiomegaly (44.0 v 16.7 %), coronary artery disease (46.0 v 15.0 %), emphysema (35.0 v 5.1 %), hepatic steatosis (15.4 v 3.4 %), hepatic fibrosis (17.6 v 3.4 %), and cirrhosis (19.8 v 0.0 %). Conclusions Older cases of heroin overdose had more extensive heart, lung, and liver disease, and appeared more likely to have shorter survival times.
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Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
| | - Johan Duflou
- National Drug & Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
- Sydney Medical School, University of Sydney, NSW, Australia
| | - Amy Peacock
- National Drug & Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
- School of Psychiatry, University of New South Wales, NSW, Australia
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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times. Addiction 2024; 119:559-569. [PMID: 37921084 DOI: 10.1111/add.16377] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND AIMS Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation. DESIGN Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System. SETTING This study was conducted Australia-wide. CASES There were 610 cases of fatal heroin-related drug toxicity. MEASUREMENTS Information was collected on characteristics, manner of death, toxicology and autopsy results. FINDINGS The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood. CONCLUSIONS The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Julia Lappin
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- School of Psychiatry, University of New South Wales, Sydney, Australia
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Underner M, Perriot J, Peiffer G, Brousse G, Jaafari N. [Bronchial diseases and heroin use. A systematic review]. Rev Mal Respir 2023; 40:783-809. [PMID: 37925326 DOI: 10.1016/j.rmr.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/11/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD). OBJECTIVES A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management. DOCUMENTARY SOURCES Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD. RESULTS Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors. CONCLUSION Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.
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Affiliation(s)
- M Underner
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France.
| | - J Perriot
- Dispensaire Émile-Roux, CLAT, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - G Peiffer
- Service de pneumologie, CHR Metz-Thionville, 57038 Metz, France
| | - G Brousse
- Service d'addictologie, CHU de Clermont-Ferrand, université Clermont Auvergne, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique Pierre-Deniker, centre hospitalier Laborit, 370, avenue Jacques-Cœur, CS 10587, 86021 Poitiers cedex, France
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Schumann JL, Sarkar R, Grbic M, Drummer OH, Gerostamoulos D, Iles L, Bassed R. Changing trends and characteristics of one punch deaths in Australia (2012-2018). Forensic Sci Int 2023; 345:111621. [PMID: 36878145 DOI: 10.1016/j.forsciint.2023.111621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/22/2022] [Accepted: 02/25/2023] [Indexed: 03/02/2023]
Abstract
One-punch assaults also known as 'coward punches', are characterised by a single severe blow to the head causing the victim to lose consciousness, resulting in a secondary impact between the head and surrounding environment. Such impacts may result in brain injury leading to fatality or permanent neurological impairment. In a previous publication, there were 90 one punch deaths around Australia between 2000 and 2012, mostly involving young men drinking alcohol at a licensed venue at the weekend. This prompted a surge of public education and awareness campaigns around Australia, in addition to regulatory and legislative changes aimed at curbing social violence. This retrospective descriptive study aimed to examine one punch deaths since 2012 in Australia to determine if there has been a decrease in deaths, and whether the demographics and circumstances of these deaths have changed. A search of the National Coronial Information System was undertaken for all closed coronial cases between 1 January 2012 and 31 December 2018. Additional information was collected from medicolegal reports including toxicology, pathology and coronial findings. There were 80 one punch fatalities in Australia, almost exclusively involving males. The median age was 43.5 (range 18-71) years and there was a decreasing trend in the number of deaths annually. Most fatal assaults occurred in the state of New South Wales (28.8%) followed by Queensland (23.8%), and in metropolitan locations (64.6%) rather than regional areas (35.4%). Alcohol was the most commonly detected drug, found in 47 cases of the 71 cases where toxicology results were available (66%), with a median concentration of 0.14 and 0.19 g/100 mL in antemortem and postmortem samples, respectively (range 0.005-0.32 g/100 mL). Five deaths reported methylamphetamine, with THC detected in 21.1% of cases. Assaults more commonly occurred on a footpath or roadside (41.3%), followed by a home or dwelling (32.5%). 8.8% of assaults occurred inside hotels, bars or other licenced venues. Most transpired on a weekday, which differed from the pre-2012 period when these assaults occurred mainly on the weekend. While some trends are positive, there has been a shift in the victim demographic as well as the typical environment for fatal one punch assaults, highlighting the importance of public health surveillance in providing a current evidence base to inform policy and practice.
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Affiliation(s)
- Jennifer L Schumann
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia; Monash Addiction Research Centre, Victoria, Australia.
| | - Reena Sarkar
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
| | - Marko Grbic
- Victorian Institute of Forensic Medicine, Victoria, Australia
| | - Olaf H Drummer
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
| | - Dimitri Gerostamoulos
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
| | - Linda Iles
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
| | - Richard Bassed
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
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Bech AB, Clausen T, Waal H, Delaveris GJM, Skeie I. Organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder: a nation-wide 2-year cross-sectional study. Addiction 2022; 117:977-985. [PMID: 34648218 DOI: 10.1111/add.15705] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 09/01/2021] [Indexed: 11/26/2022]
Abstract
AIMS To document organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder and estimate the extent to which individual characteristics are associated with pulmonary, cardiovascular, hepatic or renal pathologies. DESIGN Two-year cross-sectional nation-wide study. SETTING Norway. PARTICIPANTS Among all 200 patients who died during opioid agonist treatment between 1 January 2014 and 31 December 2015, 125 patients (63%) were autopsied. Among these, 122 patients (75% men) had available autopsy reports and were included. The mean age at the time of death was 48 years. MEASUREMENTS Information on pulmonary, cardiovascular, hepatic and renal pathologies were retrieved from forensic or medical autopsy reports, with no (0) and yes (1) as outcome variables and age, sex and body mass index as covariates in logistic regression analyses. FINDINGS Pathologies in several organs were common. Two-thirds (65%) of the decedents had more than two organ system diseases. The most common organ pathologies were chronic liver disease (84%), cardiovascular disease (68%) and pulmonary emphysema (41%). In bivariate analyses, only older age was associated with any pulmonary pathology [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.01-1.10], cardiovascular pathology (OR = 1.11; 95% CI = 1.05-1.17) and renal pathology (OR = 1.05; 95% CI = 1.00-1.11). Older age remained independently associated with cardiovascular pathology (OR = 1.10; 95% CI = 1.04-1.16) and renal pathology (OR = 1.06; 95% CI = 1.01-1.12) adjusted for body mass index and sex. CONCLUSIONS Among autopsied Norwegians who died during opioid agonist treatment in 2014 and 2015, two-thirds had more than two organ system diseases, despite their mean age of 48 years at the time of death. Older age was independently associated with at least one cardiovascular or renal pathology after adjusting for sex and body mass index.
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Affiliation(s)
- Anne Berit Bech
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Helge Waal
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, Oslo, Norway
- National Advisory Unit on Substance Use Disorder Treatment, Oslo University Hospital, Oslo, Norway
| | | | - Ivar Skeie
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, Oslo, Norway
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Vallecillo G, Pedro-Botet J, Fernandez S, Román I, Elosua R, Camps A, Torrens M, Marrugat J. High cardiovascular risk in older patients with opioid use disorder: Differences with the general population. Drug Alcohol Rev 2022; 41:1078-1084. [PMID: 35178806 DOI: 10.1111/dar.13449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cardiovascular disease is a health concern in ageing population with opioid use disorders (OUD). The study aims to analyse the cardiovascular risk factors in individuals with OUD. METHODS An observational study was carried out to compare cardiovascular risk factors of adults >50 years with OUD on methadone therapy from public outpatient drug treatment centres, with that of an age- and gender-matched sample (ratio of 1:5) of subjects from a sample of the Spanish population (REGICOR cohort). High cardiovascular risk (HCVR) at 10 years was defined according to Framingham-REGICOR and SCORE risk functions. RESULTS The individuals studied included 94 people with OUD and 495 from the general population; the mean age was 55.7 ± 4.8 years and 432 (72.7%) were men. Obesity (21.2% vs. 35.2%), hypertension (26.3% vs. 42.1%), total cholesterol (30.3% vs. 65.4%) and LDL-cholesterol ≥130 mg/dL (27.2% vs. 59.3%) were significantly more prevalent in the general population group, while tobacco smoking (96.0% vs. 25.9%), low HDL-cholesterol (46.5% vs. 21.2%), hypertriglyceridaemia (39.4% vs. 18.8%) and atherogenic dyslipidaemia (30.3% vs. 10.5%) were significantly higher in individuals with OUD. Differences in abdominal obesity (62.6% vs. 65.3%) were not significant. HCVR was more prevalent in patients with OUD: 15.2% versus 5.8% (Framingham-REGICOR function) and 21.2% versus 11.3% (SCORE function). DISCUSSION AND CONCLUSIONS Older adults with OUD on methadone therapy have a different prevalence of cardiovascular risk factors and HCVR than the general population. Preventive measures, particularly tobacco smoking cessation and weight control, should be included in the routine care of individuals with OUD.
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Affiliation(s)
- Gabriel Vallecillo
- Drug Addiction Program, Instituto de Neuropsiquiatría y Adicciones, Barcelona, Spain.,IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Juan Pedro-Botet
- Lipid and Cardiovascular Risk Unit, Department of Endocrinology, Hospital del Mar, Barcelona, Spain.,Departmento de Medicina, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Silvia Fernandez
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Irene Román
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Cardiovascular Epidemiology and Genetics Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Roberto Elosua
- Cardiovascular Epidemiology and Genetics Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,CIBERCV of Cardiovascular Research, Madrid, Spain
| | - Anna Camps
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Program, Instituto de Neuropsiquiatría y Adicciones, Barcelona, Spain.,IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Departmento de Medicina, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Jaume Marrugat
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,CIBERCV of Cardiovascular Research, Madrid, Spain
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Association Between Benzodiazepine and Opioid Prescription and Mortality Among Patients in a Large Healthcare System. J Addict Med 2022; 16:65-71. [PMID: 35120065 PMCID: PMC8817063 DOI: 10.1097/adm.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Coprescription of opioids and benzodiazepines (BDZ) is associated with adverse outcomes, including greater healthcare utilization and overdose risk. This study aims to examine opioid and BDZ coprescription, dosing, and mortality among patients with and without opioid use disorder (OUD) in a large healthcare system. METHODS Using data from the California state Prescription Drug Monitoring Program during 2010 to 2014 linked with a large healthcare system electronic health record database and mortality records from the Centers for Disease Control National Death Index, this study examined 5202 patients (1978 with OUD, 3224 controls). Multiple logistic regression analyses were conducted to examine relationships between most recent BDZ and opioid prescription, and their interaction with respect to mortality. RESULTS About 10.5% of the sample died on or before December 31, 2014. About 17.7% were prescribed BDZ during the final month of observation. Individuals with OUD were prescribed higher average BDZ and opioid doses than those without OUD. After adjusting for covariates, increased prescribed doses of BDZ (odds ratio [OR]=1.34, 95%CI: 1.15-1.55 per 10 mg/d increment) and opioids (OR = 1.04, 95%CI: 1.02-1.05 per 10 mg/d increment) were positively associated with mortality. Non-OUD patients who received both BDZ and opioid prescriptions had a higher mortality than those who received only BDZ or opioids (The ratio of odds ratio (ROR) = 3.83, 95%CI: 1.78-8.21). CONCLUSIONS Study findings highlight significant mortality associated with the coprescription of opioids and BDZ in a general healthcare setting. Further research is needed to elucidate factors associated with mortality among non-OUD patients who are co-prescribed opioids and BDZ.
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Voronkov M, Ataiants J, Cocchiaro B, Stock JB, Lankenau SE. A vicious cycle of neuropathological, cognitive and behavioural sequelae of repeated opioid overdose. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103362. [PMID: 34314956 DOI: 10.1016/j.drugpo.2021.103362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/03/2021] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
In the midst of an escalating U.S. opioid crisis, the immediate focus of public health interventions is on fatal overdose prevention. Few studies, however, have sought to examine the long-term health consequences of exposure to repeated nonfatal opioid overdose. We reviewed recent literature to examine three corresponding downstream health outcomes of repeated overdose: a) neurodegenerative processes; b) cognition and memory; and c) overdose risk behaviours. We found a remarkable congruency among available biochemical and cognitive data on how nonfatal overdose precipitates various pathological feedforward and feedback loops that affect people who use opioids for years to come. We found however that downstream behavioural implications of neurodegenerative and cognitive sequelae are less studied despite being most proximal to an overdose. Findings point to a vicious cycle of nonfatal overdose leading to neurodegeneration - closely resembling Alzheimer Disease - that results in cognitive decline that in turn leads to potentially reduced adherence to safe drug use behaviours. The collected evidence not only brings into the focus the long-term health consequences of nonfatal overdose from the perspectives of biology, neuroscience, and public health, but also creates new cross-disciplinary context and awareness in the research and public health community that should benefit people at risk.
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Affiliation(s)
| | - Janna Ataiants
- Dornsife School of Public Health, Drexel University, Philadelphia, PA 19104, USA.
| | - Benjamin Cocchiaro
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jeffry B Stock
- Department of Molecular Biology, Princeton University, Princeton, NJ 08544, USA
| | - Stephen E Lankenau
- Dornsife School of Public Health, Drexel University, Philadelphia, PA 19104, USA
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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
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Bech AB, Clausen T, Waal H, Vindenes V, Edvardsen HE, Frost J, Skeie I. Post-mortem toxicological analyses of blood samples from 107 patients receiving opioid agonist treatment: substances detected and pooled opioid and benzodiazepine concentrations. Addiction 2020; 116:845-855. [PMID: 32738014 DOI: 10.1111/add.15211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
AIMS To present the substances and their concentrations detected post-mortem in patients receiving opioid agonist treatment (OAT) stratified by cause of death, estimate the pooled opioid and benzodiazepine concentrations using established conversion factors for blood concentrations from the Norwegian Road Traffic Act, and explore the association between drug-induced cause of death and the pooled opioid and benzodiazepine concentrations. DESIGN Cross-sectional nationwide study. SETTING Norway. PARTICIPANTS One hundred and seven patients who died during OAT (i.e. within 5 days after the last intake of OAT medication) between 1 January 2014 and 31 December 2015, with post-mortem femoral blood available for toxicology. Data were collected from hospital records, the Norwegian Cause of Death Registry and autopsy reports. MEASUREMENTS Presence of alcohol and non-alcohol substances in the bloodstream at time of death, determined through records of toxicology of post-mortem femoral blood. FINDINGS A median of four substances was detected across the causes of death. At least one benzodiazepine was detected in 81 (76%) patients. The median pooled opioid concentration was significantly higher in drug-induced deaths compared with other causes of death (362 ng/mL versus 182 ng/mL, P < 0.001), in contrast to the pooled benzodiazepine concentration (5466 versus 5701 ng/mL, P = 0.353). The multivariate regression analysis showed that only increasing pooled opioid concentration (ng/ML) was associated with increased odds of a drug-induced cause of death (odds ratio, 1.003; 95% confidence interval: 1.001-1.006). CONCLUSIONS In Norway, overall opioid concentration seems to play an important role in drug-induced deaths during opioid agonist treatment in patients prescribed methadone or buprenorphine. Patients prescribed buprenorphine tend to replace their agonist with full agonists, while patients prescribed methadone tend to have high opioid concentrations from methadone as the only opioid.
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Affiliation(s)
- Anne Berit Bech
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Helge Waal
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
- National Advisory Unit on Substance Use Disorder Treatment, Oslo University Hospital, Sognsvannsveien 21, Bygg 6, P.O. Box 4959 Nydalen, 0424, Oslo, Norway
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Hilde Erøy Edvardsen
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
| | - Joachim Frost
- Department of Clinical Pharmacology, St. Olav's Hospital Trondheim University Hospital, P.O. Box 3250 Torgarden, 7006, Trondheim, Norway
| | - Ivar Skeie
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
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Hulin J, Brodie A, Stevens J, Mitchell C. Prevalence of respiratory conditions among people who use illicit opioids: a systematic review. Addiction 2020; 115:832-849. [PMID: 31692109 DOI: 10.1111/add.14870] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/28/2019] [Accepted: 10/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS There are growing concerns over the respiratory health of people who use illicit opioids due to high rates of opioid inhalation and tobacco smoking in this group. This study aimed to summarize the evidence relating illicit opioid use with poor respiratory health. METHODS A systematic review of the literature on the association between illicit opioid use and respiratory health was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance (PROSPERO ID = CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken (English language, published January 1980-November 2018). All study designs excluding case studies were considered. Studies were undertaken in community and hospital settings in the United States (n = 23), United Kingdom (n = 7), Australia (n = 7), the Netherlands (n = 2), Canada (n = 2), Ireland (n = 1), Spain (n = 1) and Iran (n = 1). Measurements of respiratory disease, including asthma and chronic obstructive pulmonary disease (COPD) and related symptoms were extracted. Data on respiratory-related deaths and hospital admissions were also extracted. Meta-analysis of prevalence data was undertaken using a random effects meta-analysis model with parameters estimated using Markov chain Monte Carlo simulation. RESULTS Meta-analyses estimated prevalence of asthma in people who inject illicit opioids as 8.5% [95% predictive interval (PrI) = 0.2%, 74.0%] and as 20.2% (95% PrI = 4.2%, 59.2%) in people who inhale illicit opioids. Prevalence of COPD in people who inject illicit opioids was estimated as 2.7% (95% PrI = 0.0%, 50.4%) and as 17.9% (95% PrI = 0.6%, 89.5%) in people who inhale illicit opioids. There was evidence of moderate to extreme heterogeneity across studies. CONCLUSIONS There is evidence of increased burden of respiratory diseases in people who use illicit opioids. Due to the heterogeneity of study design and samples, it is difficult to gain accurate estimates of the prevalence of respiratory disease in this population.
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Affiliation(s)
- Joe Hulin
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Arjuna Brodie
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
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Mahajan R, Gupta Y, Singh A, Dhiman P, Midha V, Kakkar C, Narang V, Mehta V, Saggar K, Sood A. Clinical profile and outcomes of opioid abuse gastroenteropathy: an underdiagnosed disease entity. Intest Res 2020; 18:238-244. [PMID: 32088943 PMCID: PMC7206348 DOI: 10.5217/ir.2019.00104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Opioid-induced bowel dysfunction includes nausea, vomiting, constipation and abdominal distension. We describe patients presenting with gastrointestinal (GI) ulcers and ulcerated strictures secondary to opioid abuse, an entity not well described in literature. Methods This retrospective observational study included patients with opioid abuse gastroenteropathy presenting to Dayanand Medical College and Hospital, Ludhiana, India between January 2013 and December 2018. Opioid abuse gastroenteropathy was defined as gastric or small bowel ulcers and ulcerated strictures in patients abusing opioids, where all other possible etiologies of GI ulcers/strictures were excluded. Clinical, biochemical, endoscopic, radiological and histological parameters as well as response to treatment were assessed. Results During the study period, 20 patients (mean age, 38.5±14.2 years; 100% males) were diagnosed to have opioid induced GI ulcers and/or ulcerated strictures. The mean duration of opioid consumption was 6.2±3.4 years. The mean duration of symptoms at presentation was 222.1±392.3 days. Thirteen patients (65%) had gastroduodenal involvement, 6 (30%) had a jejunoileal disease and 1 (5%) had an ileocecal stricture. Two patients (10%) presented with upper GI bleeding, 11 (55%) had features of gastric outlet obstruction and 7 (35%) presented with small bowel obstruction. Abdominal pain and iron deficiency anemia were the most common presentations. Only 1 patient (5%) responded to proton pump inhibitors, 3 (15%) had a lasting response to endoscopic balloon dilatation, while all other (80%) required surgical intervention. Conclusions Opioid abuse gastroenteropathy presents as ulcers and ulcerated strictures which respond poorly to medical management and endoscopic balloon dilatation. A majority of these cases need surgical intervention.
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Affiliation(s)
- Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Yogesh Gupta
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Pulkit Dhiman
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, India
| | - Chandan Kakkar
- Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vikram Narang
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Varun Mehta
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Kavita Saggar
- Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
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Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden. BMC Psychiatry 2020; 20:49. [PMID: 32028921 PMCID: PMC7006080 DOI: 10.1186/s12888-020-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. METHODS Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. DISCUSSION Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. TRIAL REGISTRATION Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.
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Affiliation(s)
- Katja Troberg
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden. .,Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden. .,Malmö Addiction Centre, Clinical Research Unit, Södra Förstadsg. 35, Plan 4, S-205 02, Malmö, Sweden.
| | - Pernilla Isendahl
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden ,Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.426217.40000 0004 0624 3273Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden
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15
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Stam NC, Gerostamoulos D, Pilgrim JL, Smith K, Moran L, Parsons S, Drummer OH. An analysis of issues in the classification and reporting of heroin-related deaths. Addiction 2019; 114:504-512. [PMID: 30397976 DOI: 10.1111/add.14486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 11/28/2022]
Abstract
AIMS To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases. METHODS Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes. RESULTS A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes. CONCLUSIONS In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare.
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Affiliation(s)
- Nathan C Stam
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Victorian Institute of Forensic Medicine, Melbourne, Australia
| | - Jennifer L Pilgrim
- Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lauren Moran
- Mortality Data Centre, Health and Vital Statistics Section, Australian Bureau of Statistics, Brisbane, Australia
| | - Sarah Parsons
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Victorian Institute of Forensic Medicine, Melbourne, Australia
| | - Olaf H Drummer
- Department of Forensic Medicine, Monash University, Melbourne, Australia
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Methadone Maintenance Treatment: A 15-year Retrospective Study in Split-Dalmatia County, Croatia. Ther Drug Monit 2018; 40:486-494. [PMID: 29649094 DOI: 10.1097/ftd.0000000000000519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this retrospective study is to use existing epidemiological data on patients in methadone maintenance treatment in Split-Dalmatia County from 2001 to 2015 to evaluate the substitution treatment system and policy of opiate addicts treatment, the epidemiological trend, and risk of overdose mortality. In addition, we would like to highlight the problem of poor control of methadone therapy and thus the possibility of selling methadone. The result is a greater number of deaths caused by methadone in people who were not in methadone therapy. METHODS The research included data collected from 3189 patients who had been in the drug abuse treatment program in Split-Dalmatia County during 2001-2015 and data gathered from autopsy examinations of patients in Split-Dalmatia County with emphasis on data for 186 overdosed patients during research period. RESULTS The total number of patients in the methadone treatment program in Split-Dalmatia County during the research period, except in 2005 and 2006, has been stable, while the number of new opiate patients, being in first-time treatment, decreased by 62.5%. The number of addicts who were in a long-term maintenance program has increased by 198%, whereas the number of addicts who were in a short-term detoxification treatment has decreased by 96.4%. According to results obtained from performed autopsies, 186 death cases were determined as overdoses. Methadone was found in 56 of those cases and was declared as the cause of death in 39 cases (70%). Of the total number of autopsied patients with diagnosed methadone overdose, only 23 (59%) had been recorded to receive methadone therapy in Public Health Institute of Split-Dalmatia County database. CONCLUSIONS The results of this study show the favorable epidemiological trend because of the decreasing number of new opiate patients in treatment. The retention of opiate patients in substitution therapy indicates the effectiveness of methadone maintenance programs. Our research did not determine any influence of methadone substitution therapy on an increasing risk of specific (overdose) mortality.
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17
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Amraei M, Mohamadpour M, Ahmadi MRH, Azizi M, Daemi A, Omidi M, Shirzadpour E. Histopathological study of liver tissue due to methadone consumption and its effect on liver enzymes and inflammatory indices in rat. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:3785-3795. [PMID: 30464409 PMCID: PMC6225910 DOI: 10.2147/dddt.s182032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Methadone (MET)-based treatment is currently one of the best known approaches in the treatment of opioid dependence. It is claimed that MET use exerts adverse effects on the performance of some organs, especially liver. Thus, the present study aims to investigate MET effects on the hepatic tissue as well as its effect on the hepatic enzyme levels and inflammatory markers in rats. Materials and methods Twenty-eight mature male Wistar rats underwent an 8-week treatment in four equal groups including the control group (an ordinary daily dietary regime) as well as the experimental groups 1, 2, and 3 (an ordinary daily dietary regime and gavage-fed on MET syrup for 5, 20, and 40 mg/kg body weight per day). Blood samples were collected from all rats in the beginning and end of the study to measure their hepatic enzyme levels and inflammatory markers. In the end, their livers were subjected to histological examinations. Results The mean serum levels of hepatic enzymes (alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase) increased considerably across all the three groups that had received various dosages of MET (5, 20, and 40 mg/kg) in the end of the study as compared to the beginning of the study (P<0.001). It was also found that the inflammatory indicators (interleukin-6, tumor necrosis factor-alpha, and C-reactive protein) rose significantly in the groups that had received various dosages of MET in contrast to the control group (P<0.01, P<0.001, and P<0.001, respectively). The histopathological images of the liver cross-sections revealed dosage-dependent tissue changes in the groups that had received various dosages of MET. Conclusion The present study tried to prove the adverse effects of MET in the development of liver damage. Since MET-based treatment is frequently prescribed by physicians for curing the addiction to narcotics, better strategies are required for its correct usage.
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Affiliation(s)
- Mansour Amraei
- Department of Physiology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Mahmoud Mohamadpour
- Department of Biochemistry, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran,
| | | | - Monireh Azizi
- Department of Anatomy, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Ahmad Daemi
- Department of Biochemistry, Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Mohammad Omidi
- Department of Biochemistry, Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Ehsan Shirzadpour
- Department of Biochemistry, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran,
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Matłosz B, Pietraszkiewicz E, Firląg-Burkacka E, Grycner E, Horban A, Kowalska JD. Risk factors for kidney disease among HIV-1 positive persons in the methadone program. Clin Exp Nephrol 2018; 23:342-348. [PMID: 30218298 DOI: 10.1007/s10157-018-1644-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Kidney injury is a serious comorbidity among HIV-infected patients. Intravenous drug use is listed as one of the risk factors for impaired renal function; however, this group is rarely assessed for specific renal-related risks. METHODS Patients attending methadone program from 1994 to 2015 were included in the study. Data collected included demographic data, laboratory tests, antiretroviral treatment history, methadone dosing and drug abstinence. Patients' drug abstinence was checked monthly on personnel demand. We have evaluated two study outcomes: (1) having at least one or (2) three eGFR < 60 ml/min (MDRD formula). RESULTS In total, 267 persons, with 2593 person-years of follow-up were included into analyses. At the time of analyses, 251 (94%) were on antiretroviral therapy (ARV). Fifty-two (19.5%) patients had 1eGFR and 20 (7.5%) 3eGFR < 60. In univariate analysis, factors significantly increasing the odds of impaired renal function were: female gender, detectable HIV RNA on ART, age at registration per 5 years older, atazanavir use and time on antiretroviral treatment per 1 year longer. In the multivariate model, only female gender (OR 4.7; p = 0.002), time on cART (OR 1.11; p = 0.01) and baseline eGFR (OR 0.71; p = 0.001) were statistically significant. CONCLUSIONS We have demonstrated a high rate of kidney function impairment among HIV-1 positive patients in the methadone program. All risk factors for decreased eGFR in this subpopulation of patients were similar to those described for general HIV population with very high prevalence in women. These findings imply the need for more frequent kidney function monitoring in this subgroup of patients.
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Affiliation(s)
- Bartłomiej Matłosz
- HIV Out-Patient Clinic, Hospital for Infectious Diseases, ul. Wolska 37, 01-201, Warsaw, Poland.
| | - Ewa Pietraszkiewicz
- HIV Out-Patient Clinic, Hospital for Infectious Diseases, ul. Wolska 37, 01-201, Warsaw, Poland
| | - Ewa Firląg-Burkacka
- HIV Out-Patient Clinic, Hospital for Infectious Diseases, ul. Wolska 37, 01-201, Warsaw, Poland
| | - Ewa Grycner
- HIV Out-Patient Clinic, Hospital for Infectious Diseases, ul. Wolska 37, 01-201, Warsaw, Poland
| | - Andrzej Horban
- Department for Adults Infectious Diseases, Medical University of Warsaw, ul. Wolska 37, 01-201, Warsaw, Poland
| | - Justyna D Kowalska
- HIV Out-Patient Clinic, Hospital for Infectious Diseases, ul. Wolska 37, 01-201, Warsaw, Poland.,Department for Adults Infectious Diseases, Medical University of Warsaw, ul. Wolska 37, 01-201, Warsaw, Poland
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Stam NC, Pilgrim JL, Drummer OH, Smith K, Gerostamoulos D. Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment. Clin Toxicol (Phila) 2018; 56:1135-1142. [DOI: 10.1080/15563650.2018.1478093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Nathan C. Stam
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | | | - Olaf H. Drummer
- Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Victorian Institute of Forensic Medicine, Melbourne, Australia
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Joshi A, Falodia S, Kumar N, Solanki RL. Small intestine strictures in opium addicts: An unrecognized cause of intestinal obstruction. Indian J Gastroenterol 2018; 37:169-173. [PMID: 29512022 DOI: 10.1007/s12664-018-0831-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/11/2018] [Indexed: 02/08/2023]
Abstract
Strictures of the small intestine have been attributed many causes of Crohn's disease, nonsteroidal anti-inflammatory drugs, neoplastic, post-surgical, and corrosive ingestion. Opium as a cause of small intestine strictures has not been described. Six cases of opium addicts diagnosed with small intestine strictures were selected after excluding the possible etiology of strictures. Investigations like upper gastrointestinal endoscopy, colonoscopy (in patients with small intestinal obstruction), barium meal follow-through, and histopathology of strictures were done in all patients. Among the six cases, two patients were diagnosed with small intestinal obstruction and four patients with gastric outlet obstruction. Histopathology of the strictures revealed marked thickening of submucosa with infiltration by lymphocytes, plasma cells, and plenty of eosinophils. There was dilatation of vessels and lymphatics. The granulomatous reaction was not seen. These histological features are suggestive of concentric fibrous thickening in submucosa with stricture formation possibly as a result of drug abuse like opioids and opioid-like products resulting in transient ischemia of the small intestine leading to fibrosis. Patients were managed by surgery and deaddiction treatment was given to prevent further complications. Opium and opioid-like drugs can cause small intestinal strictures causing ulceration and fibrosis in opioid-dependent patients.
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Affiliation(s)
- Ashish Joshi
- Department of Gastroenterology, Sardar Patel Medical College, Bikaner, 334 001, India
| | - Sushil Falodia
- Department of Gastroenterology, Sardar Patel Medical College, Bikaner, 334 001, India
| | - Naveen Kumar
- Department of General Medicine, Sardar Patel Medical College, Bikaner, 334 001, India.
| | - R L Solanki
- Department of Pathology, M N Hospital and Research Centre, Bikaner, 334 001, India
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Darke S, Kaye S, Duflou J. Rates, characteristics and circumstances of methamphetamine-related death in Australia: a national 7-year study. Addiction 2017; 112:2191-2201. [PMID: 28603836 DOI: 10.1111/add.13897] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/10/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022]
Abstract
AIMS To (1) assess trends in the number and mortality rates of methamphetamine-related death in Australia, 2009-15; (2) assess the characteristics and the cause, manner and circumstances of death; and (3) assess the blood methamphetamine concentrations and the presence of other drugs in methamphetamine-related death. DESIGN Analysis of cases of methamphetamine-related death retrieved from the National Coronial Information System (NCIS). SETTING Australia. CASES All cases in which methamphetamine was coded in the NCIS database as a mechanism contributing to death (n = 1649). MEASUREMENTS Information was collected on cause and manner of death, demographics, location, circumstances of death and toxicology. FINDINGS The mean age of cases was 36.9 years, and 78.4% were male. The crude mortality rate was 1.03 per 100 000. The rate increased significantly over time (P < 0.001), and at 2015 the mortality rate was 1.8 [confidence interval (CI) = 1.2-2.4] times that of 2009. Deaths were due to accidental drug toxicity (43.2%), natural disease (22.3%), suicide (18.2%), other accident (14.9%) and homicide (1.5%). In 40.8% of cases, death occurred outside the major capital cities. The median blood methamphetamine concentration was 0.17 mg/l, and cases in which only methamphetamine was detected had higher concentrations than other cases (0.30 versus 0.15 mg/l, P < 0.001). The median blood methamphetamine concentration varied within a narrow range (0.15-0.20 mg/l) across manner of death. In the majority (82.8%) of cases, substances other than methamphetamine were detected, most frequently opioids (43.1%) and hypnosedatives (38.0%). CONCLUSIONS Methamphetamine death rates doubled in Australia from 2009 to 2015. While toxicity was the most frequent cause, natural disease, suicide and accident comprised more than half of deaths.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Sharlene Kaye
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia.,Justice Health and Forensic Mental Health Network, NSW Health, NSW, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia.,Sydney Medical School, University of Sydney, NSW, Australia
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22
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Stam NC, Gerostamoulos D, Dietze PM, Parsons S, Smith K, Lloyd B, Pilgrim JL. The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths. Forensic Sci Int 2017; 281:18-28. [DOI: 10.1016/j.forsciint.2017.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/11/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
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23
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Roxburgh A, Darke S, Salmon AM, Dobbins T, Jauncey M. Frequency and severity of non-fatal opioid overdoses among clients attending the Sydney Medically Supervised Injecting Centre. Drug Alcohol Depend 2017; 176:126-132. [PMID: 28535454 DOI: 10.1016/j.drugalcdep.2017.02.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pharmaceutical opioid overdose rates have increased in recent years. The current study aimed to compare rates per 1000 injections of non-fatal overdose after heroin or oxycodone injection, and their comparative clinical severity. METHODS Analysis of prospectively collected data from the Sydney Medically Supervised Injecting Centre (MSIC). Severity of overdose was measured using the Glasgow Coma Scale, oxygen saturation levels, and the administration of naloxone. RESULTS Heroin overdoses occurred at three times the rate of oxycodone overdoses (12.7 v 4.1 per 1000 injections). Heroin overdoses appeared to be more severe than oxycodone overdoses, with higher levels of compromised consciousness (31 v 18%) and severe respiratory depression (67 v 48%), but there were no differences in naloxone doses (20 v 17%). Concurrent use of other depressants at the time of overdose was also associated with compromised consciousness, and the need for naloxone. CONCLUSIONS Heroin overdoses occurred at a greater rate than oxycodone overdoses, and had more severe clinical indicators.
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Affiliation(s)
- Amanda Roxburgh
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia.
| | - Shane Darke
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia
| | - Allison M Salmon
- Uniting Sydney Medically Supervised Injecting Centre, Kings Cross, Sydney, NSW 1340, Australia
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia
| | - Marianne Jauncey
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia; Uniting Sydney Medically Supervised Injecting Centre, Kings Cross, Sydney, NSW 1340, Australia
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24
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Xu X, Huang E, Tai Y, Zhao X, Chen X, Chen C, Chen R, Liu C, Lin Z, Wang H, Xie WB. Nupr1 Modulates Methamphetamine-Induced Dopaminergic Neuronal Apoptosis and Autophagy through CHOP-Trib3-Mediated Endoplasmic Reticulum Stress Signaling Pathway. Front Mol Neurosci 2017; 10:203. [PMID: 28694771 PMCID: PMC5483452 DOI: 10.3389/fnmol.2017.00203] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/08/2017] [Indexed: 12/13/2022] Open
Abstract
Methamphetamine (METH) is an illegal and widely abused psychoactive stimulant. METH exposure causes detrimental effects on multiple organ systems, primarily the nervous system, especially dopaminergic pathways, in both laboratory animals and humans. In this study, we hypothesized that Nuclear protein 1 (Nupr1/com1/p8) is involved in METH-induced neuronal apoptosis and autophagy through endoplasmic reticulum (ER) stress signaling pathway. To test this hypothesis, we measured the expression levels of Nupr1, ER stress protein markers CHOP and Trib3, apoptosis-related protein markers cleaved-caspase3 and PARP, as well as autophagy-related protein markers LC3 and Beclin-1 in brain tissues of adult male Sprague-Dawley (SD) rats, rat primary cultured neurons and the rat adrenal pheochromocytoma cells (PC12 cells) after METH exposure. We also determined the effects of METH exposure on the expression of these proteins after silencing Nupr1, CHOP, or Trib3 expression with synthetic small hairpin RNA (shRNA) or siRNA in vitro, and after silencing Nupr1 in the striatum of rats by injecting lentivirus containing shRNA sequence targeting Nupr1 gene to rat striatum. The results showed that METH exposure increased Nupr1 expression that was accompanied with increased expression of ER stress protein markers CHOP and Trib3, and also led to apoptosis and autophagy in rat primary neurons and in PC12 cells after 24 h exposure (3.0 mM), and in the prefrontal cortex and striatum of rats after repeated intraperitoneal injections (15 mg/kg × 8 injections at 12 h intervals). Silencing of Nupr1 expression partly reduced METH-induced apoptosis and autophagy in vitro and in vivo. These results suggest that Nupr1 plays an essential role in METH-caused neuronal apoptosis and autophagy at relatively higher doses and may be a potential therapeutic target in high-dose METH-induced neurotoxicity.
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Affiliation(s)
- Xiang Xu
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China.,School of Forensic Medicine, Wannan Medical CollegeWuhu, China
| | - Enping Huang
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Yunchun Tai
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Xu Zhao
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Xuebing Chen
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Chuanxiang Chen
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Rui Chen
- Department of Forensic Medicine, Guangdong Medical UniversityDongguan, China
| | - Chao Liu
- Guangzhou Forensic Science InstituteGuangzhou, China
| | - Zhoumeng Lin
- Institute of Computational Comparative Medicine and Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State UniversityManhattan, KS, United States
| | - Huijun Wang
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
| | - Wei-Bing Xie
- School of Forensic Medicine, Southern Medical UniversityGuangzhou, China
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25
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Mallappallil M, Sabu J, Friedman EA, Salifu M. What Do We Know about Opioids and the Kidney? Int J Mol Sci 2017; 18:E223. [PMID: 28117754 PMCID: PMC5297852 DOI: 10.3390/ijms18010223] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/30/2016] [Accepted: 01/17/2017] [Indexed: 12/12/2022] Open
Abstract
Evidence suggests a link between opioid use and kidney disease. This review summarizes the known renal manifestations of opioid use including its role in acute and chronic kidney injury. Both the direct and indirect effects of the drug, and the context which leads to the development of renal failure, are explored. While commonly used safely for pain control and anesthesia in those with kidney disease, the concerns with respect to side effects and toxicity of opioids are addressed. This is especially relevant with the worldwide increase in the use of opioids for medical and recreational use.
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Affiliation(s)
- Mary Mallappallil
- Department of Internal Medicine, State University of New York at Downstate, Brooklyn, New York, NY 11203, USA.
| | - Jacob Sabu
- Department of Internal Medicine, State University of New York at Downstate, Brooklyn, New York, NY 11203, USA.
| | - Eli A Friedman
- Department of Internal Medicine, State University of New York at Downstate, Brooklyn, New York, NY 11203, USA.
| | - Moro Salifu
- Department of Internal Medicine, State University of New York at Downstate, Brooklyn, New York, NY 11203, USA.
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26
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Abstract
BACKGROUND AND AIMS This narrative review aims to provide a brief history of the development of the heroin overdose field by discussing a selection of major 'classics' from the latter part of the 20th century. METHODS Papers considered landmarks were selected from 1972, 1977, 1983, 1984 and 1999. RESULTS Findings of earlier works suggest much of what later research was to demonstrate. These include arguing that overdoses occurred primarily among tolerant older users, that most 'overdose' deaths involved low morphine concentrations, that most overdoses involve polypharmacy, that drug purity has only a moderate influence on overdose rates and that instant death following heroin administration is rare. CONCLUSIONS Landmark studies of heroin overdose from the 1970s, 1980s and 1990s laid the foundations for subsequent overdose research, mainly by identifying the major demographic characteristics of overdose cases, risk factors, survival times and behaviours at overdose events.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia.
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27
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Patterns and Correlates of Injecting Among Heroin Users: A 11-Year Follow-up of the Australian Treatment Outcome Study Cohort. ADDICTIVE DISORDERS & THEIR TREATMENT 2016. [DOI: 10.1097/adt.0000000000000082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Sorg MH, Long DL, Abate MA, Kaplan JA, Kraner JC, Greenwald MS, Andrew TA, Shapiro SL, Wren JA. Additive Effects of Cointoxicants in Single-Opioid Induced Deaths. Acad Forensic Pathol 2016; 6:532-542. [PMID: 29399239 PMCID: PMC5794021 DOI: 10.23907/2016.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/24/2016] [Accepted: 07/01/2016] [Indexed: 01/11/2023]
Abstract
A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.
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Affiliation(s)
| | - D. Leann Long
- West Virginia University School of Public Health -
Statistics
| | | | - James A. Kaplan
- West Virginia Department of Health and Human Resources - Office
of the Chief Medical Examiner
| | - James C. Kraner
- West Virginia Department of Health and Human Resources - Office
of the Chief Medical Examiner
| | | | | | - Steven L. Shapiro
- Office of Chief Medical Examiner - Vermont State Department of
Health
| | - Jamie A. Wren
- University of Maine - Margaret Chase Smith Policy Center
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29
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Darke S, Duflou J. The toxicology of heroin-related death: estimating survival times. Addiction 2016; 111:1607-13. [PMID: 27082514 DOI: 10.1111/add.13429] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/05/2016] [Accepted: 04/14/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS The feasibility of intervention in heroin overdose is of clinical importance. The presence of 6-monoacetyl morphine (6MAM) in the blood is suggestive of survival times of less than 20-30 minutes following heroin administration. The study aimed to determine the proportions of cases in which 6MAM was present, and compare concentrations of secondary metabolites and circumstances of death by 6MAM status. DESIGN Analysis of cases of heroin-related death presenting to the Department of Forensic Medicine Sydney, 1 January 2013-12 December 2014. SETTING Sydney, Australia. CASES A total of 145 cases. The mean age was 40.5 years and 81% were male. MEASUREMENTS Concentrations of 6MAM, free morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Circumstances of death included bronchopneumonia, apparent sudden collapse, location and other central nervous system (CNS) depressants. FINDINGS 6MAM was detected in 43% [confidence interval (CI) = 35-51%] of cases. The median free morphine concentration of 6MAM-positive cases was more than twice that of cases without 6MAM (0.26 versus 0.12 mg/l). 6MAM-positive cases also had lower concentrations of the other major heroin metabolites: M3G (0.05 versus 0.29 mg/l), M6G (0.02 versus 0.05 mg/l) with correspondingly lower M3G/morphine (0.54 versus 2.71) and M6G/morphine (0.05 versus 0.50) ratios. Significant independent correlates of 6MAM were a higher free morphine concentration [odds ratio (OR) = 1.7], a lower M6G/free morphine ratio (OR = 0.5) and signs of apparent collapse (OR = 6.7). CONCLUSIONS In heroin-related deaths in Sydney, Australia during 2013 and 2014, 6- monoacetyl morphine was present in the blood in less than half of cases, suggesting that a minority of cases had survival times after overdose of less than 20-30 minutes. The toxicology of heroin metabolites and the circumstances of death were consistent with 6- monoacetyl morphine as a proxy for a more rapid death.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Australia.,Department of Forensic Medicine Sydney, NSW Health Pathology, Sydney Medical School, University of Sydney, NSW, Australia
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30
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Darke S, Farrell M. Which medications are suitable for agonist drug maintenance? Addiction 2016; 111:767-74. [PMID: 26503542 DOI: 10.1111/add.13158] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/26/2015] [Accepted: 09/04/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS We examine the feasibility of agonist maintenance treatment for the major psychoactive drug classes: opioids, nicotine, benzodiazepines, cannabis, psychostimulants and alcohol. METHODS Eight clinical criteria for an agonist maintenance drug were assessed for each major drug class. These related to pharmacological aspects of the drug (agonist, pharmacological stability, dose-response, non-toxic) and neurocognitive sequelae (psychiatric, cognitive, craving, salience). RESULTS Opioids and nicotine met all eight criteria for a maintenance drug. While nicotine has not been promoted widely or used for maintenance, it has the potential to fulfil that role. Cannabis met five criteria and has potential, but long-term data on cognitive impairment are required. Benzodiazepine maintenance would appear an option for the high-dose chaotic abuser, also meeting five criteria, although clinic dosing appears the safest option. Psychostimulants (three of eight criteria) and alcohol (one of eight) appear poor propositions for maintenance, in terms of both their pharmacological and their neurocognitive characteristics. CONCLUSIONS Drug classes have properties that distinguish them in their suitability for maintenance treatment. Some classes not yet used for maintenance (notably nicotine and cannabis) have potential to fulfil such a role. Others, however, by their inherent nature, appear unsuitable for such a treatment regimen.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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31
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Manhapra A, Quinones L, Rosenheck R. Characteristics of veterans receiving buprenorphine vs. methadone for opioid use disorder nationally in the Veterans Health Administration. Drug Alcohol Depend 2016; 160:82-9. [PMID: 26804898 PMCID: PMC4767635 DOI: 10.1016/j.drugalcdep.2015.12.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/24/2015] [Accepted: 12/17/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND The advent of buprenorphine as an alternative to methadone has dramatically shifted the landscape of opioid agonist therapy (OAT) for opioid use disorder (OUD). However, there is limited US national level data describing thedifferences between patients who are prescribed these two OAT options. METHODS From veterans with OUD diagnosis who used Veterans Health Administration services in 2012, we identified 3 mutually exclusive groups: those who received (1) buprenorphine only (n=5,670); (2) methadone only (n=6,252); or (3) both buprenorphine and methadone in the same year (n=2513). We calculated the bi-varate effect size differences (risk ratios and Cohen's d) forcharacteristics that differentiated these groups. Logistic regression analysis was then used to identify factors independently differentiating the groups. RESULTS Ten year increment in age (OR 0.67; 95% CI 0.64-0.70), urban residence (OR 0.26; 95% CI 0.25-0.33), and black race (OR 0.39; 95% CI 0.35-0.43) were strongly and negatively associated with odds of receiving buprenorphine compared to methadone, while medical and psychiatric comorbidities or receipt of other psychiatric medications did not demonstrate substantial differences between groups. CONCLUSIONS Differences between veterans receiving buprenorphine or methadone based OAT seems to be largely shaped by demographic characteristics rather than medical or psychiatric or service use characteristics. A clearer understanding of the reasons for racial differences could be helpful in assuring that black OUD patients are not denied the opportunity to receive buprenorphine if that is their preference.
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Affiliation(s)
- Ajay Manhapra
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States; VA New England Mental Illness Research and Education Center, West Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States.
| | - Lantie Quinones
- Department of Psychiatry, Harvard Medical School & McLean Hospital, Belmont, MA, United States
| | - Robert Rosenheck
- VA New England Mental Illness Research and Education Center, West Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
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32
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Shahid M, Subhan F, Ullah I, Ali G, Alam J, Shah R. Beneficial effects of Bacopa monnieri extract on opioid induced toxicity. Heliyon 2016; 2:e00068. [PMID: 27441247 PMCID: PMC4945900 DOI: 10.1016/j.heliyon.2016.e00068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 12/05/2015] [Accepted: 01/20/2016] [Indexed: 11/30/2022] Open
Abstract
The present study examined the hepatotoxicity and nephrotoxicity of morphine and illicit street heroin and their amelioration by a standardized methanolic extract of Bacopa monnieri (L.) (mBME) in rats. Morphine or street heroin was administered at a dose of 20 mg/kg for 14 and 21 days. mBME (40 mg/kg) or ascorbic acid (50 mg/kg) was administered two hours before morphine or street heroin. High performance liquid chromatography (HPLC) was used for the standardization of bacoside-A major components in mBME. The antioxidant potential of mBME was evaluated by 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical scavenging assay. Administration of morphine and street heroin resulted in marked elevation of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and creatinine. Histopathological changes induced by morphine and street heroin after 14 days were of reversible nature while treatment for 21 days was associated with irreversible changes. Pretreatment with mBME or ascorbic acid restored the elevation of serum ALT, AST and creatinine and protected liver and kidneys from the toxicological influence of morphine and street heroin. HPLC analysis showed that mBME contained bacoside-A major components i.e. bacoside-A3 (37.5 μg/mg), bacopaside-II (4.62 μg/mg) and bacopasaponin-C (1.91 μg/mg). The EC50 for the DPPH free radical scavenging assay revealed that mBME possessed strong antioxidant potential. These results concluded that as compared to morphine, street heroin was associated with severe biochemical and histopathological changes in the liver and kidneys. Bacopa monnieri having strong antioxidant potential may provide a beneficial herbal remedy for the efficient management of opioid related hepatotoxicity and nephrotoxicity.
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Affiliation(s)
- Muhammad Shahid
- Department of Pharmacy, Sarhad University of Science and Information Technology, Peshawar 25000, Khyber Pakhtunkhwa, Pakistan
- Department of Pharmacy, University of Peshawar, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
- Corresponding author.
| | - Fazal Subhan
- Department of Pharmacy, University of Peshawar, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
- Corresponding author.
| | - Ihsan Ullah
- Department of Pharmacy, University of Swabi, Swabi, Khyber Pakhtunkhwa, Pakistan
| | - Gowhar Ali
- Department of Pharmacy, University of Peshawar, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
| | - Javaid Alam
- Department of Pharmacy, University of Peshawar, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
| | - Rehmat Shah
- Department of Pharmacy, University of Peshawar, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
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33
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Cobaugh DJ, Gainor C, Gaston CL, Kwong TC, Magnani B, McPherson ML, Painter JT, Krenzelok EP. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health Syst Pharm 2015; 71:1539-54. [PMID: 25174015 DOI: 10.2146/ajhp140157] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The current epidemic of prescription opioid abuse and misuse in the United States is discussed, with an emphasis on the pharmacist's role in ensuring safe and effective opioid use. SUMMARY U.S. sales of prescription opioids increased fourfold from 1999 to 2010, with an alarming rise in deaths and emergency department visits associated with the use of fentanyl, hydrocodone, oxycodone, and other opioid medications. Signs and symptoms of opioid toxicity may include altered mental status, hypoventilation, decreased bowel motility, central nervous system and respiratory depression, peripheral vasodilation, pulmonary edema, hypotension, bradycardia, and seizures. In patients receiving long-term opioid therapy for chronic pain, urine drug testing is an important tool for monitoring and assessment of therapy; knowledge of opioid metabolic pathways and assay limitations is essential for appropriate use and interpretation of screening and confirmatory tests. In recent years, there has been an increase in federal enforcement actions against pharmacies and prescription drug wholesalers involved in improper opioid distribution, as well as increased reliance on state-level prescription drug monitoring programs to track patterns of opioid use and improper sales. Pharmacies are urged to implement or promote appropriate guidelines on opioid therapy, including the use of pain management agreement plans; policies to ensure adequate oversight of opioid prescribing, dispensing, and waste disposal; and educational initiatives targeting patients as well as hospital and pharmacy staff. CONCLUSION Pharmacists in hospitals and health systems can play a key role in recognizing the various forms of opioid toxicity and in preventing inappropriate prescribing and diversion of opioids.
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Affiliation(s)
- Daniel J Cobaugh
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh.
| | - Carl Gainor
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Cynthia L Gaston
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Tai C Kwong
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Barbarajean Magnani
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Mary Lynn McPherson
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Jacob T Painter
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Edward P Krenzelok
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
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Darke S, Slade T, Ross J, Marel C, Mills KL, Tessson M. Patterns and correlates of alcohol use amongst heroin users: 11-year follow-up of the Australian Treatment Outcome Study cohort. Addict Behav 2015; 50:78-83. [PMID: 26111657 DOI: 10.1016/j.addbeh.2015.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/01/2015] [Accepted: 06/06/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The study aimed to determine long-term alcohol use patterns and correlates amongst heroin users. METHODS Longitudinal cohort. 11-year post-baseline follow-up of the Australian Treatment Outcome Study cohort. RESULTS At 11-year follow-up, 431 (70%) participants were interviewed. Alcohol was used in the preceding month by 56%, with 27% reporting daily use and 11% heavy daily drinking. Alcohol use patterns showed remarkable consistency across waves, with the proportion who drank in the preceding month ranging between 49 and 56%, with no significant trend across time. Daily drinking ranged between 20 and 27%, and heavy daily drinking between 7 and 12%. Both declined slightly from baseline to 3-year follow-up, but by 11 years were at levels similar to baseline. Compared to female referents, males were more likely to drink (OR 1.6, CI 1.3-2.1, p < .05), to drink daily (OR 1.8, CI 1.4-2.4, p < .05) and to drink heavily (OR 1.7, 1.1-2.5, p < .05). Compared to those not in enrolled in a drug treatment programme, those enrolled were significantly less likely to drink (OR 0.7, CI 0.5-0.8, p < .05) and to drink daily (OR 0.6, 0.5-0.8, p < .05). Compared to those who did not drink heavily, heavy drinking was associated with a higher likelihood of recent overdose (OR 1.6, CI 1.0-2.4, p < .05), of criminality (OR 1.9, 1.3-2.7, p < .001), and with lower SF12 physical (mean difference -3.0, CI -4.7 to -1.4, p < .001) and mental (-2.4, CI -4.3 to -0.5, p < .001) health scores. CONCLUSIONS There were consistently high levels of both abstinence and regular drinking, with drinking patterns staying relatively stable across the decade. From the clinical perspective, the high rates of heavy drinking are of particular relevance, given the observed associations with a poorer clinical profile.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Australia.
| | - Tim Slade
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Joanne Ross
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Christina Marel
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Katherine L Mills
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Maree Tessson
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
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Darke S, Duflou J, Torok M. The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users. Addiction 2015; 110:1144-51. [PMID: 25808360 DOI: 10.1111/add.12930] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/03/2015] [Accepted: 03/19/2015] [Indexed: 11/27/2022]
Abstract
AIMS To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997-2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology. DESIGN Analysis of consecutive case presentations with foreign body pulmonary embolization. SETTING/PARTICIPANTS Sydney, Australia, with a total of 373 cases (271 males, 102 females). MEASUREMENTS Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right-sided heart failure were examined. FINDINGS Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate-abundant in extent. Cases with moderate-abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right-sided heart pathology in 5.4%. Cases with moderate-abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right-sided heart pathology (OR = 5.3). CONCLUSIONS Cases of foreign body pulmonary embolization (resulting from injecting crushed tablets meant for oral use, such as benzodiazepines and pharmaceutical opioids) in Sydney, Australia increased markedly from 1997 to 2013. In a large proportion there were clinical consequences. More extensive embolization was associated with higher levels of pulmonary hypertension and right-sided heart pathology.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Australia.,Department of Forensic Medicine Sydney, NSW Health Pathology, Sydney Medical School, University of Sydney, NSW, Australia
| | - Michelle Torok
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
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Wilens T, Zulauf C, Ryland D, Carrellas N, Catalina‐Wellington I. Prescription medication misuse among opioid dependent patients seeking inpatient detoxification. Am J Addict 2015; 24:173-177. [DOI: 10.1111/ajad.12159] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/06/2014] [Accepted: 08/26/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Timothy Wilens
- Department of PsychiatryMassachusetts General HospitalHarvard Medical SchoolBostonMassachusetts
- Bay Cove Human ServicesAndrew House Detoxification CenterQuincyMassachusetts
| | - Courtney Zulauf
- Department of PsychiatryMassachusetts General HospitalHarvard Medical SchoolBostonMassachusetts
| | - Denece Ryland
- Bay Cove Human ServicesAndrew House Detoxification CenterQuincyMassachusetts
| | - Nicholas Carrellas
- Department of PsychiatryMassachusetts General HospitalHarvard Medical SchoolBostonMassachusetts
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Wilens T, Zulauf C, Ryland D, Carrellas N, Catalina-Wellington I. Prescription medication misuse among opioid dependent patients seeking inpatient detoxification. Am J Addict 2014. [DOI: 10.1111/j.1521-0391.2014.12159.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Timothy Wilens
- Department of Psychiatry; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
- Bay Cove Human Services; Andrew House Detoxification Center; Quincy Massachusetts
| | - Courtney Zulauf
- Department of Psychiatry; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Denece Ryland
- Bay Cove Human Services; Andrew House Detoxification Center; Quincy Massachusetts
| | - Nicholas Carrellas
- Department of Psychiatry; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
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Darke S, Marel C, Mills KL, Ross J, Slade T, Burns L, Teesson M. Patterns and correlates of non-fatal heroin overdose at 11-year follow-up: findings from the Australian Treatment Outcome Study. Drug Alcohol Depend 2014; 144:148-52. [PMID: 25278146 DOI: 10.1016/j.drugalcdep.2014.09.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Overdose is a major cause of morbidity and mortality amongst opioid users. This paper reported recent non-fatal overdose amongst the Australian Treatment Outcome Study (ATOS) cohort at 11-year follow-up, and characteristics that predict recent overdose. METHODS Longitudinal cohort, with 431 (70.1%) of the original 615 participants interviewed. Participants were administered the ATOS structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and psychopathology. FINDINGS Mean time since heroin initiation was 20.4 years. By 11-year follow-up, the proportion who had overdosed was 67.5%, and 24.4% had experienced five or more overdoses. In the 12 months preceding 11-year follow-up, 4.9% had overdosed (11.8% of those who had used heroin in that period). Of the 21 participants who had recently overdosed, 20 (95.2%) had overdosed previously, and 19 (90.5%) were not enrolled in a treatment programme at the time. Those who had recently overdosed reported higher levels of use of opiates other than heroin (57.1% vs 24.9%), benzodiazepines (61.9% vs 30.5%,), methamphetamine (38.1% vs 16.8%) and cocaine (19.0% vs 3.7%). They also had exhibited higher levels of heroin use and other drug use at baseline, 12 and 24 month follow-ups. CONCLUSIONS While the prevalence had declined, overdoses still occurred. A history of overdose and polydrug use patterns continued to provide strong markers for those at continued risk.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia.
| | - Christina Marel
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Katherine L Mills
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Joanne Ross
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Timothy Slade
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia
| | - Maree Teesson
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia
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Darke S. Opioid overdose and the power of old myths: what we thought we knew, what we do know and why it matters. Drug Alcohol Rev 2014; 33:109-14. [PMID: 24589077 DOI: 10.1111/dar.12108] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Darke S, Farrell M. Would legalizing illicit opioids reduce overdose fatalities? Implications from a natural experiment. Addiction 2014; 109:1237-42. [PMID: 24456133 DOI: 10.1111/add.12456] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/18/2013] [Accepted: 12/06/2013] [Indexed: 11/29/2022]
Abstract
Overdose is the leading cause of premature mortality among heroin users. We examine whether the provision of regulated and quality-controlled heroin to users in specified doses would reduce heroin overdose rates. We also address this in the context of the epidemic of prescription opioid use and deaths seen in recent years in the United States and internationally. We explore the extent to which any change in legal access to heroin would affect overdose rates, and note that this depends upon the validity of the two main assumptions that variations in illicit drug purity and/or the presence of drug contaminants are major causes of overdose. Toxicological and demographic data from studies of heroin overdose deaths do not support these assumptions. The surge in the use of pharmaceutical opioids provides an example of the legal delivery of opioids of known dosage and free of contaminants, where overdose deaths can be examined to test these assumptions. Rates of fatal opioid overdose have escalated, with increased rates of prescribing of pharmaceutical opioids. On the basis of the experience with prescription opioids, unregulated legal heroin access would not reduce overdose rates.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Abstract
Buprenorphine-naloxone (bup/nal in 4:1 ratio; Suboxone; Reckitt Benckiser Pharmaceuticals Incorporation, Richmond, VA) is approved by the Food and Drug Administration for outpatient office-based addiction treatment. In the past few years, bup/nal has been increasingly prescribed off-label for chronic pain management. The current data suggest that bup/nal may provide pain relief in patients with chronic pain with opioid dependence or addiction. However, the unique pharmacological profile of bup/nal confers it to be a weak analgesic that is unlikely to provide adequate pain relief for patients without opioid dependence or addiction. Possible mechanisms of pain relief by bup/nal therapy in opioid-dependent patients with chronic pain may include reversal of opioid-induced hyperalgesia and improvement in opioid tolerance and addiction. Additional studies are needed to assess the implication of bup/nal therapy in clinical anesthesia and perioperative pain management.
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Reece AS, Hulse GK. Impact of lifetime opioid exposure on arterial stiffness and vascular age: cross-sectional and longitudinal studies in men and women. BMJ Open 2014; 4:e004521. [PMID: 24889849 PMCID: PMC4054659 DOI: 10.1136/bmjopen-2013-004521] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To characterise and compare the potentiation of arterial stiffness and vascular ageing by opioids in men and women. DESIGN Cross-sectional and longitudinal studies of 576 clinical controls and 687 opioid-dependent patients (ODP) on 710 and 1305 occasions, respectively, over a total of 2382 days (6.52 years), 2006-2011. Methodology Radial pulse wave analysis with Atcor SphygmoCor system (Sydney). SETTING Primary care. CONTROLS General practice patients with non-cardiovascular disorders, and university student controls. ODP: Patients undergoing clinical management of their opioid dependence. CONTROLS had lower chronological ages (CAs) than ODP (30.0±0.5 vs 34.5±0.3, mean±SEM, p<0.0001). 69.6% and 67.7% participants were men, and 16% and 92.3% were smokers (p<0.0001) for controls and ODP, respectively. 86.3%, 10.3% and 3.4% of ODP were treated with buprenorphine (6.98±0.21 mg), methadone (63.04±4.01 mg) or implant naltrexone, respectively. Body mass index (BMI) was depressed in ODP. INTERVENTIONS Nil. PRIMARY OUTCOME MEASURES Vascular Reference Age (RA) and the ratio of vascular age to chronological age (RA/CA). SECONDARY OUTCOME MEASURES Arterial stiffness including Augmentation Index. RESULTS After BMI adjustment, RA in ODP was higher as a function of CA and of time (both p<0.05). Modelled mean RA in control and ODP was 35.6 and 36.3 years (+1.97%) in men, and 34.5 and 39.2 years (+13.43%) in women, respectively. Changes in RA and major arterial stiffness indices were worse in women both as a factor (p = 0.0036) and in interaction with CA (p = 0.0040). Quadratic, cubic and quartic functions of opioid exposure duration outperformed linear models with RA/CA over CA and over time. The opioid dose-response relationship persisted longitudinally after multiple adjustments from p=0.0013 in men and p=0.0073 in women. CONCLUSIONS Data show that lifetime opioid exposure, an interactive cardiovascular risk factor, particularly in women, is related to linear, quadratic, cubic and quartic functions of treatment duration and is consistent with other literature of accelerated ageing in patients with OD.
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Affiliation(s)
- Albert Stuart Reece
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Gary Kenneth Hulse
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia, Australia
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Abstract
Acute alcohol (ethanol) toxicity is a definition that encompasses both the metabolic toxicity of alcohol and the association of alcohol with traumatic deaths, suicide, and criminal activities. As with any postmortem measurement, there must be control of postmortem sampling, storage of specimens, and appropriate analysis to ensure that there is not artifactual alcohol production or incorrect measurement of other postmortem alcohols. It is almost unheard of for acute alcohol toxicity to cause death secondary to metabolic effects in a naïve individual, although there has been a recent trend in social media dares that have led to deaths due to isolated episodes of extreme alcohol consumption. However, in most cases, there will be evidence for chronic alcohol misuse at the postmortem examination.
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Affiliation(s)
- Stephen R. Morley
- Leicster Royal Infirmary, UK and Kings college London, UK, and the University of the West Indies
| | - Paul Smith
- Leicster Royal Infirmary - Toxicology Section, Leicster, UK
| | - Christopher Johnson
- University of Leicester - East Midlands Forensic Pathology Unit, Leicester, UK
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Impact of opioid pharmacotherapy on arterial stiffness and vascular ageing: cross-sectional and longitudinal studies. Cardiovasc Toxicol 2014; 13:254-66. [PMID: 23456431 DOI: 10.1007/s12012-013-9204-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Whilst there is a small literature on the cardiovascular toxicity of opiates, there is no detailed antemortem data on non-cardiovascular patient populations. A cross-sectional and longitudinal naturalistic observational study was performed comparing methadone (N = 71)-, buprenorphine (N = 593)-, naltrexone (N = 23)-treated patients with controls (N = 576) on indices of arterial stiffness and vascular age by Pulse Wave Analysis in primary care, 2006-2011. Controls were younger 29.96 ± 0.45 (mean ± SEM) vs. 34.00 ± 0.34-39.22 ± 1.11 years (all P < 0.005) and had fewer smokers (15.9 % vs. 86.9 %-92.96 %, all P < 0.0001). The sex ratio was similar (69.6 vs. 67.7 % male, P = 0.46). These baseline differences were controlled for by multiple regression. Linear regression of vascular age, central augmentation pressure, central augmentation index and other measures against chronologic age showed significant protective effects by treatment group against the treatment standard of methadone, in both sexes in additive and interactive models (all P < 0.02). Interactive terms in treatment type remained significant including all conventional risk factors accounting for differing opiate exposures. The principal findings from multiple regression were confirmed in the time series analysis up to 5 years by repeated measures nonlinear regression. These studies show that the deleterious impact of chronic opiate pharmacotherapy on vascular age and arterial stiffness varies significantly by treatment type.
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Mijatović V, Samojlik I, Ajduković N, Đurendić-Brenesel M, Petković S. Methadone-related deaths - epidemiological, pathohistological, and toxicological traits in 10-year retrospective study in Vojvodina, Serbia. J Forensic Sci 2014; 59:1280-5. [PMID: 24502699 DOI: 10.1111/1556-4029.12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 04/12/2013] [Accepted: 05/24/2013] [Indexed: 12/01/2022]
Abstract
The number of methadone-related deaths (MRDs) during a 10-year period (2002-2011) in the region of Vojvodina, Serbia, was increased. The cases were evaluated according to epidemiological parameters, pathohistological findings, and toxicological screening. The majority of victims were men, aged from 20 to 38. Pathohistologically, the signs of acute focal myocardial damage were present in the heart of victims with drug abuse history shorter than 2 years, while both signs of recent and chronic focal myocardial damage were developed among victims with longer drug abuse history (2-5 years). In postmortem blood samples of 54.84% of victims, methadone was detected in combination with diazepam, both in therapeutic range. Alcohol was absent in most cases. Other detected drugs were antipsychotics and antidepressants in therapeutic concentrations. These findings raise the attention to the concomitant use of methadone and benzodiazepines with the need for further studies to clarify the mechanism of death in such cases.
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Affiliation(s)
- Vesna Mijatović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
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Reece AS, Hulse GK. Duration of opiate exposure as a determinant of arterial stiffness and vascular age in male opiate dependence: a longitudinal study. J Clin Pharm Ther 2013; 39:158-67. [PMID: 24329809 DOI: 10.1111/jcpt.12121] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 11/20/2013] [Indexed: 01/27/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Despite intriguing initial and associational studies, there remains little research on opiate-related arterial dysfunction and no longitudinal studies. As opiates act potently via P16INK4A/CDKN2A identified on GWAS screens, and as arterial ageing is a surrogate for organismal ageing, this area is of general concern. METHODS Thirty-eight male controls compared with 198 opiate-dependent male patients were studied longitudinally using SphygmoCor pulse wave analysis. RESULTS AND DISCUSSION Healthy male controls and opiate-dependent male patients were studied on 125 and 625 occasions, respectively. The mean (±SEM) chronological age (CA) was 42·32 ± 2·22 for controls and 35·04 ± 0·61 for opiate dependent (P = 0·0029). 94·4% and 13·2% smoked tobacco (P < 0·0001). Controlling for BMI and CA, there was a significant time: addictive status interaction for vascular age (P = 0·0127) and central augmentation pressure and index (both P < 0·02). Central systolic and diastolic pressures were also worse over time by addictive status (P < 0·005). At repeated measures multiple regression adjusted for classical risk factors, opiate dose and duration of opiate use remained significant. The dose-duration effect was significant in 8 terms and by time. A similar model quadratic in opiate duration was more powerfully predictive, suggesting the salience of the duration of opiate treatment (AIC 191·6898 and 191·5966, P = 0·0116). WHAT IS NEW AND CONCLUSION Data suggest that increased length of opiate dependence is associated with advanced vascular stiffness and ageing and are therefore consistent with accelerated ageing organismally. The superiority of power functions of the opiate duration of exposure underscores the significance of the duration of treatment and of putative senescence induction.
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Affiliation(s)
- A S Reece
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, WA, Australia
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Opium use and risk of mortality from digestive diseases: a prospective cohort study. Am J Gastroenterol 2013; 108:1757-65. [PMID: 24145676 PMCID: PMC5752100 DOI: 10.1038/ajg.2013.336] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/19/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Opium use, particularly in low doses, is a common practice among adults in northeastern Iran. We aimed to investigate the association between opium use and subsequent mortality from disorders of the digestive tract. METHODS We used data from the Golestan Cohort Study, a prospective cohort study in northeastern Iran, with detailed, validated data on opium use and several other exposures. A total of 50,045 adults were enrolled during a 4-year period (2004-2008) and followed annually until December 2012, with a follow-up success rate of 99%. We used Cox proportional hazard regression models to evaluate the association between opium use and outcomes of interest. RESULTS In all, 8,487 (17%) participants reported opium use, with a mean duration of 12.7 years. During the follow-up period 474 deaths from digestive diseases were reported (387 due to gastrointestinal cancers and 87 due to nonmalignant etiologies). Opium use was associated with an increased risk of death from any digestive disease (adjusted hazard ratio (HR)=1.55, 95% confidence interval (CI)=1.24-1.93). The association was dose dependent, with a HR of 2.21 (1.57-3.31) for the highest quintile of cumulative opium use vs. no use (Ptrend=0.037). The HRs (95% CI) for the associations between opium use and malignant and nonmalignant causes of digestive mortality were 1.38 (1.07-1.76) and 2.60 (1.57-4.31), respectively. Increased risks were seen both for smoking opium and for ingestion of opium. CONCLUSIONS Long-term opium use, even in low doses, is associated with increased risk of death from both malignant and nonmalignant digestive diseases.
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Reece AS, Hulse GK. Elevation of central arterial stiffness and vascular ageing in opiate withdrawal: cross-sectional and longitudinal studies. Cardiovasc Toxicol 2013; 13:55-67. [PMID: 22991174 DOI: 10.1007/s12012-012-9186-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The central cardiovascular impacts of clinical opiate withdrawal have not been explored in detail. Pulse Wave Analysis (SphygmoCor) was conducted in healthy controls and opiate-dependent populations. A total of 1,294 patients (69.2 % male) were studied in quintuplicate on 2,089 occasions. Four groups were studied: control (N = 576), buprenorphine stabilized (N = 592), withdrawal (N = 112) and severe withdrawal (N = 14). Control patients were younger than the other groups (29.96 ± 0.45 years v. 32.53 ± 0.74-39.28 ± 3.86) but had similar sex ratios. Multiple regression was used to correct for the effects of age, and significant exacerbations were found in withdrawal in the vascular age (RA), augmentation index, subendocardial perfusion ratio (SEVR <100; R.R. 2.07 95 % C.I. 1.17-3.68, P = 0.02) and central systolic pressure both as factors themselves and in interactions with age (all P < 0.01). The elevation of modelled RA at 60 years was from 69.66 in controls to 97.54 in withdrawal (40.02 %). The effects on RA were found in both sexes and confirmed on longitudinal analysis. The elevation of RA in withdrawal was most marked after 40 years of age (P = 0.027). These results show increased vascular stiffness and cardiovascular age but reduced subendocardial perfusion in opiate withdrawal. Given the daily recurrent nature of withdrawal, these effects are likely cumulative.
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Affiliation(s)
- Albert Stuart Reece
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, 39 Gladstone Rd, Highgate Hill, Brisbane, QLD, Australia.
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Reece AS, Hulse GK. Lifetime opiate exposure as an independent and interactive cardiovascular risk factor in males: a cross-sectional clinical study. Vasc Health Risk Manag 2013; 9:551-61. [PMID: 24124373 PMCID: PMC3794871 DOI: 10.2147/vhrm.s48030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction While several studies have identified an increased incidence of cardiovascular disorders in opiate dependence, neither opiates as a cardiovascular risk factor nor their effect on central arterial function has been considered. Methods Pulse wave analysis (SphygmoCor, AtCorMedical Pty Limited, Sydney, NSW, Australia) was undertaken on a cohort of controls and opiate dependent patients and the results compared to their lifetime opiate exposure. Results Controls (N = 401) were compared with 465 opiate dependent men. The mean (log) ages were different and were found to be 28.80 ± 0.49 years versus 35.02 ± 0.39 years (P < 0.0001), respectively. Of the opiate dependent group, 87.7% were treated with buprenorphine, 8.8% with methadone, and 3.4% with naltrexone. Multiple regression analysis was used to adjust for chronologic age (CA). At CA of 60 years, the modeled age in the controls was 66.40 years, and that in the addicted group was 73.11 years, an advancement of 6.71 years, or 10.10%. Exacerbations of age dependent changes in central arterial stiffness, central pressures, pulse rate, ejection duration, diastolic duration, and subendocardial perfusion ratio by opiate dependence were all noted (P < 0.05). Current heroin dose, heroin duration, and the dose duration interaction were all significantly related to the vascular (or “reference”) age (RA)/CA ratio (all P < 0.006). After multivariate adjustment, the opiate dose duration was independently predictive of RA (P < 0.02). Opiate dose and/or duration were included in a further 25 terms. Conclusion These data show that opiate use is not benign for the male cardiovascular system, but has a dose response relationship to central arterial stiffness and thus cardiovascular aging, acting independently and interactively with established cardiovascular risk factors. These findings imply accelerated organismal aging.
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Affiliation(s)
- Albert S Reece
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, WA, Australia
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Darke S, Duflou J, Torok M, Prolov T. Toxicology, circumstances and pathology of deaths from acute alcohol toxicity. J Forensic Leg Med 2013; 20:1122-5. [PMID: 24237834 DOI: 10.1016/j.jflm.2013.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 09/02/2013] [Accepted: 09/07/2013] [Indexed: 02/02/2023]
Abstract
Alcohol consumption makes a large contribution to premature mortality. In order to extend our understanding of the characteristics, circumstances, toxicology and pathology of alcohol toxicity deaths, all cases presenting to the Department of Forensic Medicine Sydney between 1/1/1997-31/12/2011 with blood alcohol concentrations (BACs) ≥0.300 g/100 ml and where the direct cause of death was acute alcohol toxicity were retrieved (n = 83). The mean age was 47.2 yrs and 77.1% were male. The majority (81.9%) of deaths occurred in a home environment, and did not vary across month or day of the week. In 91.6% of cases, a history of alcoholism or heavy alcohol consumption was reported. None were in any form of substance dependence treatment at the time of death. The mean BAC was 0.420 g/100 ml (range 0.300-0.741 g/100 ml). In 33.7% of cases, other substances were detected, predominantly diazepam (28.9%). BACs did not vary significantly by gender, age or BMI. Urine/BAC ratios of >1.25 were seen in 6/43 cases where both samples were available. Cardiac disease was noted in 75.9% of cases and hepatic disease in 91.6%. The only alcohol-related organic brain syndrome pathology identified at autopsy was vermal cerebellar degeneration.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia; New South Wales Forensic & Analytical Science Service, Sydney West Local Health District, NSW, Australia.
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