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Tolan NV, Uljon S, Lauren Donnelly-Morell M, Zhao M, Mahowald GK, Snyder ML, Contella L, Urwiller ED, Daluz Fernandes M, Kang P, Melanson SE. Despite the improved clinical sensitivity of the Roche benzodiazepines II assay it cannot replace mass spectrometry in all patient populations. J Mass Spectrom Adv Clin Lab 2024; 33:14-20. [PMID: 39041051 PMCID: PMC11262176 DOI: 10.1016/j.jmsacl.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/10/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction Benzodiazepines are frequently prescribed and misused therefore urine drug screening (UDS) is performed in many patient populations. Most current benzodiazepine immunoassays have poor sensitivity, particularly for detecting the metabolites of newer benzodiazepines such as lorazepam in urine. Objectives We aimed to verify the clinical performance of the new qualitative Roche Benzodiazepines II (BNZ2) immunoassay, as well as compare its performance to the Roche Benzodiazepines Plus (BENZ) assay in two patient populations: UDS in the emergency department (ED) and compliance monitoring. Methods An initial verification study was performed, selecting for samples containing clonazepam and lorazepam metabolites. Performance of the BNZ2 and BENZ assays was compared to liquid chromatography-tandem mass spectrometry (LC-MS/MS) as the reference method. Sensitivity, specificity, false positive rate (FPR) and false negative rate (FNR) were determined. Results We verified the performance claims in the initial verification and demonstrated similar precision, with coefficient of variations (CVs) of 12.8% and 7.7% for negative and positive controls, respectively. Furthermore, we observed higher clinical sensitivity and lower FNR with the BNZ2 assay in both the ED and compliance monitoring populations due to improved cross-reactivity for lorazepam and clonazepam metabolites. Despite these improvements, the BNZ2 assay was unable to detect 27% of specimens positive by LC-MS/MS, including specimens from patients using benzodiazepines without prescription. Discussion Due to its improved performance and rapid turnaround time, the BNZ2 assay should be implemented for UDS in the ED. However, the assay should not replace LC-MS/MS testing for compliance monitoring, as unsuspected benzodiazepine use may go undetected.
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Affiliation(s)
- Nicole V. Tolan
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Sacha Uljon
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - M. Lauren Donnelly-Morell
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Melissa Zhao
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Grace K. Mahowald
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | | | | | | | | | - Phillip Kang
- Department of Pathology, Mass General Brigham, Boston, MA, United States
| | - Stacy E.F. Melanson
- Department of Pathology, Mass General Brigham, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Kahn L, Kriikku P, Jönsson A. Loperamide positive deaths in Sweden 2012-2022 and Finland 2017-2022: Fatal loperamide intoxication exclusively for Sweden. Forensic Sci Int 2024; 361:112130. [PMID: 38986227 DOI: 10.1016/j.forsciint.2024.112130] [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: 03/11/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/12/2024]
Abstract
Loperamide, a potent μ-opioid receptor agonist used as an antidiarrheal drug, exhibits increased bioavailability at supratherapeutic doses, causing potential central nervous system effects. Its misuse for opioid withdrawal relief and euphoria can lead to dangerously elevated blood levels, causing severe cardiac dysrhythmias and death. This study aimed to compare loperamide positive autopsy cases in Sweden and Finland after the introduction of postmortem toxicological analysis of loperamide, focusing on loperamide's role in fatalities and identifying common characteristics among those affected. All cases with detected loperamide in femoral blood at forensic autopsies in Sweden (2012-2022) and Finland (2017-2022) were included. In Sweden, loperamide was detected in 126 individuals, and in Finland, in 111 individuals. The incidence of individuals positive for loperamide in postmortem femoral blood increased steadily over the study duration in both Sweden and Finland. Loperamide related fatalities were observed exclusively in Sweden (n=80), predominantly involving younger males with histories of substance abuse, typically classified as accidental deaths. The group of loperamide nonrelated deaths in Sweden mirrored the entirety of cases in Finland. The concentration of loperamide in postmortem femoral blood was significantly higher in cases where loperamide was considered the cause of death (median 0.140 μg/g) compared to cases where loperamide contributed (median 0.080 μg/g), as well as in deaths unrelated to loperamide in both countries (Sweden: median 0.029 μg/g; Finland: median 0.010 μg/ml). The high limit of quantification for loperamide in Sweden may underestimate therapeutic users in epidemiological assessments. This study underscores the absence of loperamide misuse in Finland and indicates a rising trend of loperamide abuse in Sweden.
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Affiliation(s)
- Lydia Kahn
- Department of Forensic Medicine, National Board of Forensic Medicine, Stockholm 171 25, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm 171 77, Sweden.
| | - Pirkko Kriikku
- Forensic Chemistry Unit, Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Forensic Medicine, University of Helsinki, Finland
| | - Anna Jönsson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping 587 58, Sweden; Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping 581 83, Sweden
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Ghodrati S, Carey LM, France CP. Antinociceptive effects of fentanyl and nonopioid drugs in methocinnamox-treated rats. Drug Alcohol Depend 2024; 260:111320. [PMID: 38723374 DOI: 10.1016/j.drugalcdep.2024.111320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND A single administration of the opioid receptor antagonist methocinnamox (MCAM) antagonizes the antinociceptive effects of µ-opioid receptor agonists for 2 weeks or longer. Such a long duration of antagonism could necessitate the use of nonopioid drugs for treating pain in patients receiving MCAM for opioid use disorder (OUD). METHODS The antinociceptive effects of fentanyl and nonopioid drugs were assessed in 24 male Sprague Dawley rats using a complete Freund's adjuvant (CFA) model of inflammatory pain. Twelve rats received 10mg/kg MCAM and 12 received vehicle; half (n=6) of the animals from each treatment group were treated (intraplantar) with CFA or saline. Hypersensitivity to mechanical stimulation was measured using a von Frey anesthesiometer. Fentanyl (0.01-0.1mg/kg), ketamine (17.8-56mg/kg), gabapentin (32-100mg/kg), meloxicam (3.2-10mg/kg), and ∆9-tetrahydrocannabinol (THC, 1-10mg/kg) were administered intraperitoneally and tested every 3 days in a pseudorandom order. Next, the same drugs were studied for effects on motor performance using a rotarod apparatus. RESULTS CFA-induced hypersensitivity was attenuated by fentanyl in vehicle- but not MCAM-treated rats. THC, ketamine, and gabapentin attenuated (up to 82, 66, and 46 %, respectively) CFA-evoked mechanical hypersensitivity in both MCAM- and vehicle-treated rats. Meloxicam failed to alter CFA-evoked mechanical hypersensitivity in either group. Fentanyl, THC, gabapentin, and meloxicam did not affect motor performance in either group whereas ketamine impaired motor performance in both groups (up to 71 % reduction in latency to fall). CONCLUSIONS These data suggest that ketamine, gabapentin, and THC could be effective for treating inflammatory pain under conditions of long term µ-opioid receptor antagonism.
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Affiliation(s)
- Saba Ghodrati
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, TX 78229, USA; Addiction Research, Treatment & Training Center of Excellence, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Lawrence M Carey
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, TX 78229, USA; Addiction Research, Treatment & Training Center of Excellence, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Charles P France
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, TX 78229, USA; Addiction Research, Treatment & Training Center of Excellence, University of Texas Health Science Center, San Antonio, TX 78229, USA; Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX 78229, USA.
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Swartz JA, Zhao P, Jacobucci R, Watson DP, Mackesy-Amiti ME, Franceschini D, Jimenez AD. Associations among drug acquisition and use behaviors, psychosocial attributes, and opioid-involved overdoses. BMC Public Health 2024; 24:1692. [PMID: 38918744 PMCID: PMC11197316 DOI: 10.1186/s12889-024-19217-y] [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: 01/04/2024] [Accepted: 06/20/2024] [Indexed: 06/27/2024] Open
Abstract
AIMS This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. DESIGN We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. SETTING AND PARTICIPANTS We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe services program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). MEASUREMENTS Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. FINDINGS The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β = .234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β = .683, p < .001) and drug use (β = .567, p = .001). Drug use behaviors (β = .287, p = .04) but not drug acquisition (β = .105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. CONCLUSIONS Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. Further research is needed to replicate these findings with populations at high-risk of an opioid-related overdose to assess generalizability and refine the metrics used to assess psychosocial characteristics.
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Affiliation(s)
- James A Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States.
| | - Peipei Zhao
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States
| | - Ross Jacobucci
- University of Notre Dame, 390 N. Corbett Family Hall, South Bend, IN, 46556, United States
| | - Dennis P Watson
- Lighthouse Institute, Chestnut Health Systems, 221 W Walton St, Chicago, IL, 60610, United States
| | - Mary Ellen Mackesy-Amiti
- Community Outreach Intervention Projects, School of Public Health, University of Illinois Chicago, 1603 W. Taylor St, Chicago, IL, 60612, United States
| | - Dana Franceschini
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States
| | - A David Jimenez
- Community Outreach Intervention Projects, School of Public Health, University of Illinois Chicago, 1603 W. Taylor St, Chicago, IL, 60612, United States
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Santo T, Gisev N, Campbell G, Colledge-Frisby S, Wilson J, Tran LT, Lynch M, Martino-Burke D, Taylor S, Degenhardt L. Prevalence of comorbid substance use disorders among people with opioid use disorder: A systematic review & meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104434. [PMID: 38677160 DOI: 10.1016/j.drugpo.2024.104434] [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: 01/17/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Comorbid substance use disorders (SUDs) among people with opioid use disorder (OUD) contribute to poor clinical outcomes, including overdose and mortality. We present the first systematic review and meta-analysis to estimate the prevalence of specific non-opioid SUDs among people with OUD. METHODS We searched Embase, PsycINFO, and MEDLINE from 1990 to 2022 for studies that used Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria to assess the prevalence of non-opioid SUDs among individuals with OUD. We used random-effects meta-analyses with 95% Confidence Intervals (CIs) to pool current and lifetime prevalence estimates separately. Meta-regressions and stratified meta-analyses were used to examine differences in prevalence estimates by sample characteristics and methodological factors. RESULTS Of the 36,971 publications identified, we included data from 194 studies and 77,212 participants with OUD. The prevalence of any comorbid SUD among people with OUD was 59.5% (95%CI 49.1-69.5%) for current non-opioid SUDs, with 72.0% (95%CI 52.5-87.9%) experiencing a comorbid SUD in their lifetime. Of the studies that examined current comorbid SUDs, cocaine use disorder (30.5%, 95%CI 23.0-38.7%) was most common, followed by alcohol (27.1%, 95%CI 24.4- 30.0%), cannabis (22.7%, 95%CI 19.0-26.6%), sedative (16.1%, 95%CI 13.1-19.3%), and methamphetamine (11.4%, 95%CI 6.8-17.1%) use disorders. Substantial heterogeneity (I2>90%) across estimates was observed. Substantial heterogeneity (I2>90%) was observed across estimates, with significant variations in prevalence identified across geographic locations, recruitment settings, and other study-level factors. CONCLUSION Findings from this study emphasize the importance of comorbid SUD treatment access for people with OUD. Our estimates can inform the provision of treatment and harm reduction strategies for people with OUD and specific subpopulations.
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Affiliation(s)
- Thomas Santo
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia; School of Psychology, University of Queensland, St. Lucia, Queensland, Australia
| | - Samantha Colledge-Frisby
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia; National Drug Research Institute, Curtin University, Melbourne, Australia; Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Jack Wilson
- Matilda Centre, The University of the Sydney, Sydney, Australia
| | - Lucy Thi Tran
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
| | - Michelle Lynch
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
| | - Daniel Martino-Burke
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
| | - Sophia Taylor
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, New South Wales, Australia
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Thornton JD, Varisco T, Patel H, Shrestha M, Wanat M, Schaefer E, Leslie D, Zhao H, Saadi RA, Shen C. Characterising incident opioid use among incident users of prescription sedative hypnotics: A national cohort study. BMJ Open 2024; 14:e082339. [PMID: 38816043 PMCID: PMC11138274 DOI: 10.1136/bmjopen-2023-082339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/15/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To evaluate co-prescribing of sedatives hypnotics and opioids. DESIGN Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing. SETTING AND PARTICIPANTS Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA. OUTCOME MEASURES Coprescription of sedative-hypnotics and opioids. RESULTS A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date. CONCLUSIONS Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.
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Affiliation(s)
- James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Tyler Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Harshil Patel
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mina Shrestha
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Matthew Wanat
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Eric Schaefer
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Douglas Leslie
- Center for Applied Studies in Health Economics, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Randa Al Saadi
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Chan Shen
- Division of Outcomes Research and Quality, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Bjørnestad ED, Vederhus JK, Clausen T. Change in substance use among patients in opioid maintenance treatment: baseline to 1-year follow-up. Harm Reduct J 2024; 21:101. [PMID: 38790008 PMCID: PMC11127449 DOI: 10.1186/s12954-024-01005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/11/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Individuals with opioid use disorder (OUD) often have concurrent use of non-opioid substances. When patients enter opioid maintenance treatment (OMT), less is known about outcomes regarding the use of other types of drugs. Here we aimed to investigate changes in substance use among patients entering outpatient OMT, from treatment initiation to 1-year follow-up. METHODS We used data from the prospective Norwegian Cohort of Patient in OMT and Other Drug Treatment Study (NorComt). Among 283 patients who entered OMT at participating facilities across Norway, 179 were assessed at follow-up. Of these patients, 131 were in a non-controlled environment, and were included in the present analysis. The main outcome was change in substance use. Logistic regression analysis was applied to identify factors associated with abstinence from all substances (other than agonist medication) at follow-up. RESULTS Along with opioid use, most patients reported polysubstance use prior to entering treatment. No significant differences were found in baseline characteristics between the included and non-included groups when examining attrition. At the 1-year follow-up, reduced substance use was reported. While in treatment, around two-thirds of patients continued using other drugs to varying degrees. At follow-up, about one-third of patients reported abstinence from all drugs, apart from the agonist medication. Factors related to abstinence included a goal of abstinence at baseline (OR = 5.26; 95% CI 1.14-19.55; p = 0.013) and increasing age (OR = 1.05; 95% CI 1.00-1.09; p = 0.034). CONCLUSIONS The majority of patients entering OMT used other substances in addition to opioids. About one-third of patients reported abstinence at the 1-year follow up. Although the majority of patients continued co-use of other drugs while in treatment, for most substances, less than 10% reported daily use at follow-up, with the exception of cannabis which was used daily/almost daily by about 2 in 10. Higher age and treatment goal at the start of OMT were important factors related to reducing concomitant substance use during treatment. These findings suggest that many patients entering OMT are in need of treatment and support related to the use of other substances, to further improve prognosis. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov no. NCT05182918. Registered 10/01/2022 (the study was retrospectively registered).
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Affiliation(s)
| | - John-Kåre Vederhus
- Addiction Unit, Sørlandet Hospital HF, Po. box 416, Kristiansand, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), University of Oslo, Kirkeveien 166, Oslo, N-0407, Norway
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M FM, Doug LM, Peter F, Vivian F G, Wiley J, P Todd K, William M, Mai P, David S, Tom S, Ryan W, William Z, M YA, Lf CH. Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites. Drug Alcohol Depend 2024; 258:111261. [PMID: 38581919 DOI: 10.1016/j.drugalcdep.2024.111261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD. METHODS This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework. RESULTS The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]). CONCLUSION As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.
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Affiliation(s)
- Fadanelli Monica M
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA.
| | | | - Friedmann Peter
- UMass Chan Medical School - Baystate, 3601 Main Street, Springfield, MA 01199, USA
| | - Go Vivian F
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Jenkins Wiley
- SIU School of Medicine, 801 N Rutledge St., Springfield, IL 62702, USA
| | - Korthuis P Todd
- Oregon Health & Science University, School of Medicine, 3266 SW Research Dr, Portland, OR 97239, USA
| | - Miller William
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Pho Mai
- The University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Seal David
- Tulane School of Public Health & Tropical Medicine, 1440 Canal St, New Orleans, LA 70112, USA
| | - Stopka Tom
- Tufts University School of Medicine, Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Westergaard Ryan
- University of Wisconsin, School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705-2281, USA
| | - Zule William
- Research Triangle Park, 3040 East Cornwallis Road, P.O. Box 12194, NC 27709-2194, USA
| | - Young April M
- University of Kentucky, College of Public Health, 111 Washington Ave., Lexington, KY 40536, USA
| | - Cooper Hannah Lf
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA
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Marland V, Reid R, Brandon AM, Hill K, Cruickshanks F, McKenzie C, Norman C, Nic Daéid N, Menard H. Changing trends in novel benzodiazepine use within Scottish prisons: detection, quantitation, prevalence, and modes of use. Drug Test Anal 2024; 16:457-472. [PMID: 37587559 DOI: 10.1002/dta.3560] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023]
Abstract
Drug use within prisons is increasingly complex and unpredictable. Benzodiazepines are currently one of the most common drugs detected in individuals leaving Scottish prisons; however, understanding illicit benzodiazepine use within prisons and assessing the potential harm to individuals is challenging due to the lack of available analytical data on the substances circulating. Increasingly, materials, such as paper and clothing, infused with novel benzodiazepines have been identified as a smuggling route into Scottish prisons. Methods were developed for the qualitative and quantitative analysis of benzodiazepines using gas chromatography-mass spectrometry (GC-MS) and applied to 495 seized samples from 11 Scottish prisons, including papers, cards, blotters, powders, tablets, and clothing. Evolution in the benzodiazepines being detected was demonstrated, with etizolam being the most prevalent throughout 2020/2021 following which flubromazepam and bromazolam detections increased. Additionally, significant changes in the smuggling methods and drug formats detected occurred over time following policy changes within prisons. These data represent the first reported widescale etizolam quantitation data and demonstrate high levels of variability across all sample types, most notably within tablets (0.34-2.33 mg per tablet). Additionally, concentration mapping of a whole seized card sample revealed the total concentration of drug present (312.5 mg) and demonstrated variability across the surface of the card (1.16-1.87 mg/cm2). These data highlight the challenges of consistent dosing for individuals and the high risks of unintentional overdose. Increased understanding of the challenge of such drug smuggling and benzodiazepine use will aid in the development of strategies to reduce supply and mitigate harm.
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Affiliation(s)
- Victoria Marland
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Robert Reid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Andrew M Brandon
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Kevin Hill
- Public Protection Unit, Scottish Prison Service, Edinburgh, UK
| | | | - Craig McKenzie
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
- Chiron AS, Trondheim, Norway
| | - Caitlyn Norman
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Niamh Nic Daéid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Herve Menard
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
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10
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Chang Y, Xie X, Liu Y, Liu M, Zhang H. Exploring clinical applications and long-term effectiveness of benzodiazepines: An integrated perspective on mechanisms, imaging, and personalized medicine. Biomed Pharmacother 2024; 173:116329. [PMID: 38401518 DOI: 10.1016/j.biopha.2024.116329] [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: 11/21/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
Benzodiazepines have been long-established treatments for various conditions, including anxiety disorders and insomnia. Recent FDA warnings emphasize the risks of misuse and dependence associated with benzodiazepines. This article highlights their benefits and potential drawbacks from various perspectives. It achieves this by explaining how benzodiazepines work in terms of neuroendocrinology, immunomodulation, sleep, anxiety, cognition, and addiction, ultimately improving their clinical effectiveness. Benzodiazepines play a regulatory role in the HPA axis and impact various systems, including neuropeptide Y and cholecystokinin. Benzodiazepines can facilitate sleep-dependent memory consolidation by promoting spindle wave activity, but they can also lead to memory deficits in older individuals due to reduced slow-wave sleep. The cognitive effects of chronic benzodiazepines use remain uncertain; however, no adverse findings have been reported in clinical imaging studies. This article aims to comprehensively review the evidence on benzodiazepines therapy, emphasizing the need for more clinical studies, especially regarding long-term benzodiazepines use.
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Affiliation(s)
- Yiheng Chang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xueting Xie
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yudan Liu
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Meichen Liu
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Huimin Zhang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
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11
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van Hest N, Brothers TD, Williamson A, Lewer D. Health-care resource use among patients who use illicit opioids in England, 2010-20: A descriptive matched cohort study. Addiction 2024; 119:730-740. [PMID: 38049387 DOI: 10.1111/add.16401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/27/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND AIMS People who use illicit opioids have higher mortality and morbidity than the general population. Limited quantitative research has investigated how this population engages with health-care, particularly regarding planned and primary care. We aimed to measure health-care use among patients with a history of illicit opioid use in England across five settings: general practice (GP), hospital outpatient care, emergency departments, emergency hospital admissions and elective hospital admissions. DESIGN This was a matched cohort study using Clinical Practice Research Datalink and Hospital Episode Statistics. SETTING Primary and secondary care practices in England took part in the study. PARTICIPANTS A total of 57 421 patients with a history of illicit opioid use were identified by GPs between 2010 and 2020, and 172 263 patients with no recorded history of illicit opioid use matched by age, sex and practice. MEASUREMENTS We estimated the rate (events per unit of time) of attendance and used quasi-Poisson regression (unadjusted and adjusted) to estimate rate ratios between groups. We also compared rates of planned and unplanned hospital admissions for diagnoses and calculated excess admissions and rate ratios between groups. FINDINGS A history of using illicit opioids was associated with higher rates of health-care use in all settings. Rate ratios for those with a history of using illicit opioids relative to those without were 2.38 [95% confidence interval (CI) = 2.36-2.41] for GP; 1.99 (95% CI = 1.94-2.03) for hospital outpatient visits; 2.80 (95% CI = 2.73-2.87) for emergency department visits; 4.98 (95% CI = 4.82-5.14) for emergency hospital admissions; and 1.76 (95% CI = 1.60-1.94) for elective hospital admissions. For emergency hospital admissions, diagnoses with the most excess admissions were drug-related and respiratory conditions, and those with the highest rate ratios were personality and behaviour (25.5, 95% CI = 23.5-27.6), drug-related (21.2, 95% CI = 20.1-21.6) and chronic obstructive pulmonary disease (19.4, 95% CI = 18.7-20.2). CONCLUSIONS Patients who use illicit opioids in England appear to access health services more often than people of the same age and sex who do not use illicit opioids among a wide range of health-care settings. The difference is especially large for emergency care, which probably reflects both episodic illness and decompensation of long-term conditions.
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Affiliation(s)
- Naomi van Hest
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Thomas D Brothers
- Department of Epidemiology and Public Health, University College London, London, UK
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Andrea Williamson
- School of Health and Wellbeing, MVLS, University of Glasgow, Glasgow, UK
| | - Dan Lewer
- Department of Epidemiology and Public Health, University College London, London, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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12
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Farronato DM, Pezzulo JD, Paulik J, Miltenberg B, Johns WL, Davis DE. The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00222-2. [PMID: 38548094 DOI: 10.1016/j.jse.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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13
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Mocanu C, Woodall KL, Solbeck P. Prevalence and blood concentrations of benzodiazepines and opioids in opioid-positive death investigations in Ontario, Canada, from 2017 to 2021. J Forensic Sci 2024; 69:607-617. [PMID: 38282130 DOI: 10.1111/1556-4029.15463] [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: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
The aim of this study was to investigate the incidence of benzodiazepines in opioid-positive death investigations, including trends in frequency and combination of drugs, as well as demographic data and blood concentrations, where available. Additionally, naloxone concentrations in polysubstance compared to opioid-only cases were analyzed. This was a retrospective study that consisted of all post-mortem toxicology cases in Ontario, Canada, from January 01, 2017, to December 31, 2021, with an opioid finding in any analyzed autopsy specimen. There were 11,033 death investigations identified. The overall rate of benzodiazepine co-involvement was 54.5%. Males accounted for the majority of cases (71%), and the most affected age group was 30- to 39-year-olds. The most frequently detected opioid was fentanyl and the most frequently detected benzodiazepine was etizolam, which was also the most frequently observed opioid/benzodiazepine combination. Findings related to differences in concentrations of opioids when naloxone was also present were mostly non-significant, except for methadone. The rate of benzodiazepine detection with opioids grew faster than opioid detections overall, potentially due to the increasingly toxic drug supply. Detection of novel psychoactive drugs fluctuated more unpredictably than opioids and benzodiazepines associated with clinical use. These findings can help inform policy decisions by public health agencies in exploring harm reduction efforts, for example, education and drug-checking services.
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Affiliation(s)
- Cora Mocanu
- University of Toronto, Toronto, Ontario, Canada
| | - Karen L Woodall
- University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Patricia Solbeck
- Quality Assurance Unit, Centre of Forensic Sciences, Toronto, Ontario, Canada
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Åhman A, Wingren CJ, Håkansson A. Causes and circumstances of death in stimulant and opioid use-A comparative study. PLoS One 2024; 19:e0297838. [PMID: 38324514 PMCID: PMC10849257 DOI: 10.1371/journal.pone.0297838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
AIMS To investigate the individual characteristics, causes and circumstances around deaths in stimulant use, and to examine how individuals who died with stimulants in their body differ from individuals who died with opioids in their body. METHODS This study includes individuals who died during the years 2000-2018 and underwent a forensic autopsy at Forensic Medicine in Lund, Skåne County, Sweden. All individuals over 18 years of age with stimulants (n = 310), opioids (n = 2,039) or both stimulants and opioids (n = 385) in the body at the time of death, were included. The three groups were assessed regarding gender, age, place of death, BMI, other substances detected in forensic toxicological analysis, organ weights and underlying and contributing causes of death. The data were analysed by frequency and proportion calculations, cross-tabulations and comparisons of medians. RESULTS The median age at death of the study population (n = 2,734) was 45.5 years (interquartile range ☯IQR] 32-60 years) and 73.2% were men. The most common cause of death in the stimulant group was suicide (26.8%), higher proportion compared to the opioid group (20.8%) (p = 0.017) and in the polysubstance group accidental poisoning (38.2%), higher proportion compared to the opioid group (18.0%) (p<0.001). Death by transport accidents was significantly associated with the stimulant group (p<0.001) as well as death by other accidents (p = 0.016). CONCLUSIONS Individuals who died with stimulants in their body died at a higher rate from suicide, transport accidents and other accidents, compared to individuals who died with opioids in their body. This study indicates the need to identify and prevent psychiatric conditions, elevated suicide risk, and risk-taking behaviors among people who use stimulants.
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Affiliation(s)
- Ada Åhman
- Department of Clinical Sciences Lund, Lund University, Psychiatry, Lund, Sweden
| | - Carl Johan Wingren
- Unit for Forensic Medicine, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
| | - Anders Håkansson
- Department of Clinical Sciences Lund, Lund University, Psychiatry, Lund, Sweden
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15
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Swartz JA, Zhao P, Jacobucci R, Watson D, Mackesy-Amiti ME, Franceschini D, Jimenez AD. Associations among Drug Acquisition and Use Behaviors, Psychosocial Attributes, and Opioid-Involved Overdoses: A SEM Analysis. RESEARCH SQUARE 2024:rs.3.rs-3834948. [PMID: 38260334 PMCID: PMC10802739 DOI: 10.21203/rs.3.rs-3834948/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Aims This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. Methods We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe service program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. Results The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β=.234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β=.683, p < .001) and drug use (β=.567, p = .001). Drug use behaviors (β=.287, p = .04) but not drug acquisition (β=.105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. Conclusions Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. To increase effectiveness, prevention efforts might address the interacting overdose risks that span multiple functional domains.
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Mullin A, Scott M, Vaccaro G, Floresta G, Arillotta D, Catalani V, Corkery JM, Stair JL, Schifano F, Guirguis A. Benzodiazepine Boom: Tracking Etizolam, Pyrazolam, and Flubromazepam from Pre-UK Psychoactive Act 2016 to Present Using Analytical and Social Listening Techniques. PHARMACY 2024; 12:13. [PMID: 38251407 PMCID: PMC10801481 DOI: 10.3390/pharmacy12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION The designer benzodiazepine (DBZD) market continues to expand whilst evading regulatory controls. The widespread adoption of social media by pro-drug use communities encourages positive discussions around DBZD use/misuse, driving demand. This research addresses the evolution of three popular DBZDs, etizolam (E), flubromazepam (F), and pyrazolam (P), available on the drug market for over a decade, comparing the quantitative chemical analyses of tablet samples, purchased from the internet prior to the implementation of the Psychoactive Substances Act UK 2016, with the thematic netnographic analyses of social media content. METHOD Drug samples were purchased from the internet in early 2016. The characterisation of all drug batches were performed using UHPLC-MS and supported with 1H NMR. In addition, netnographic studies across the platforms X (formerly Twitter) and Reddit, between 2016-2023, were conducted. The latter was supported by both manual and artificial intelligence (AI)-driven thematic analyses, using numerous.ai and ChatGPT, of social media threads and discussions. RESULTS UHPLC-MS confirmed the expected drug in every sample, showing remarkable inter/intra batch variability across all batches (E = 13.8 ± 0.6 to 24.7 ± 0.9 mg; F = 4.0 ± 0.2 to 23.5 ± 0.8 mg; P = 5.2 ± 0.2 to 11.5 ± 0.4 mg). 1H NMR could not confirm etizolam as a lone compound in any etizolam batch. Thematic analyses showed etizolam dominated social media discussions (59% of all posts), with 24.2% of posts involving sale/purchase and 17.8% detailing new administration trends/poly-drug use scenarios. Artificial intelligence confirmed three of the top five trends identified manually. CONCLUSIONS Purity variability identified across all tested samples emphasises the increased potential health risks associated with DBZD consumption. We propose the global DBZD market is exacerbated by surface web social media discussions, recorded across X and Reddit. Despite the appearance of newer analogues, these three DBZDs remain prevalent and popularised. Reporting themes on harm/effects and new developments in poly-drug use trends, demand for DBZDs continues to grow, despite their potent nature and potential risk to life. It is proposed that greater controls and constant live monitoring of social media user content is warranted to drive active regulation strategies and targeted, effective, harm reduction strategies.
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Affiliation(s)
- Anthony Mullin
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Mark Scott
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Giorgia Vaccaro
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Giuseppe Floresta
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
- Department of Drug and Health Sciences, University of Catania, 95131 Catania, Italy
| | - Davide Arillotta
- School of Clinical Pharmacology and Toxicology, University of Florence, 50121 Florence, Italy;
| | - Valeria Catalani
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - John M. Corkery
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Jacqueline L. Stair
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.); (M.S.); (G.V.); (G.F.); (V.C.); (J.M.C.); (J.L.S.); (F.S.)
| | - Amira Guirguis
- Pharmacy, Medical School, The Grove Extension, Swansea University, Swansea SA2 8PP, UK
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Karamouzian M, Cui Z, Hayashi K, DeBeck K, Reddon H, Buxton JA, Kerr T. Longitudinal polysubstance use patterns and non-fatal overdose: A repeated measures latent class analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024:104301. [PMID: 38182524 PMCID: PMC11222307 DOI: 10.1016/j.drugpo.2023.104301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 11/06/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Polysubstance use (PSU) is common among people who use opioids (PWUO) and has been associated with drug-related harms. We aimed to identify latent longitudinal PSU classes among a cohort of PWUO and characterize non-fatal overdose risks among different sub-classes over time. METHODS We used longitudinal data (2005-2018) from three ongoing prospective cohorts of people who use drugs in Vancouver, Canada. The primary outcome of interest was self-reported non-fatal overdose during the past six months. The primary exposure of interest was longitudinal PSU patterns among PWUO, obtained from repeated measures latent class analysis (RMLCA) of weekly substance use-related outcome indicators. Multivariable generalized estimating equations models were built to assess the association between latent PSU class membership and non-fatal overdose, adjusting for potential sociodemographic, behavioural, and structural confounders. RESULTS 2627 PWUO were included in the analysis, and 1094 (41.6 %) had experienced at least one non-fatal overdose during the study period. RMLCA revealed five distinct latent longitudinal PSU classes, including low/infrequent use (Class 1; 30 %), primarily opioid and methamphetamine use (Class 2; 22 %), primarily cannabis use (Class 3; 15 %), primarily opioid and crack use (Class 4; 29 %), and frequent PSU (Class 5; 4 %). In comparison with Class 1 (low), membership in all latent PSU classes except Class 3 (cannabis) was associated with increased odds of non-fatal overdose: Class 2 (opioids + meth) vs. Class 1 (Adjusted odds ratios [aOR] = 2.20, 95 % confidence intervals [CI]: 1.51-3.22), Class 4 (opioids + crack) vs. Class 1 (aOR = 1.06, 95 % CI: 0.85-1.33), and Class 5 (frequent) vs. Class 1 (aOR = 2.39, 95 % CI: 1.92-2.97). CONCLUSION Our findings highlighted the heterogeneous characteristics of PWUO in terms of patterns of PSU and non-fatal overdose risk. The diverse nature of PWUO and the potential additive or multiplicative impact of using several substances on overdoses should be reflected across the substance use treatment continuum and care provision.
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Affiliation(s)
- Mohammad Karamouzian
- Centre on Drug Policy Evaluation, Saint Michael's Hospital, Toronto, ON M5B 1T8, Canada; British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada.
| | - Zishan Cui
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; School of Public Policy, Simon Fraser University, Burnaby, BC V6B 5K3, Canada
| | - Hudson Reddon
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
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Bansal N, Campbell SM, Lin CY, Ashcroft DM, Chen LC. Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study. BMC Med 2024; 22:5. [PMID: 38167142 PMCID: PMC10763174 DOI: 10.1186/s12916-023-03213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care. METHODS Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated. RESULTS The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery. CONCLUSIONS The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.
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Affiliation(s)
- Neetu Bansal
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
| | - Stephen M Campbell
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria, 0208, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Chiu-Yi Lin
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Darren M Ashcroft
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, M13 9PL, UK
| | - Li-Chia Chen
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
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19
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Kozak Z, Urquhart GJ, Rouhani S, Allen ST, Park JN, Sherman SG. Factors associated with daily use of benzodiazepines/tranquilizers and opioids among people who use drugs. Am J Addict 2024; 33:83-91. [PMID: 37717256 DOI: 10.1111/ajad.13483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/22/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription. We examined associations of daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO). METHODS PWUO (N = 417) were recruited from Baltimore City and neighboring Anne Arundel County, Maryland, and surveyed on sociodemographic characteristics, structural vulnerabilities, healthcare access and utilization, substance use, and overdose experiences. Multivariable logistic regression was used to identify factors associated with self-reported co-use. RESULTS Participants were 46 years old on average, and predominantly Black (74%) males (62%). Daily co-use was reported by 22%. In multivariable analyses, odds of co-use were significantly higher among participants who did not have a high school degree/GED (adjusted odds ratio [aOR]: 1.71, 95% confidence interval [CI]: 1.02-2.88), endorsed receiving mental health treatment in the past 6 months (aOR: 2.13, 95% CI: 1.28-3.56), reported daily use of powdered cocaine (aOR: 3.57, 95% CI: 1.98-6.45), and synthetic cannabinoids (aOR: 3.11, 95% CI: 1.40-6.93). Odds of co-use were significantly lower among Black participants compared to white participants (aOR: 0.39, 95% CI: 0.19-0.82). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Clinicians working with PWUO or who prescribe BZDs or opioids should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose.
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Affiliation(s)
- Zofia Kozak
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Glenna J Urquhart
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Saba Rouhani
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, New York University School of Global Public Health, New York, USA
| | - Sean T Allen
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ju N Park
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- The Warren Alpert Medical School, Brown University, Providence, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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20
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Bergström MA, Andersson ME, Larsson SB. Detection of drugs and hepatitis C virus in used syringes from a needle exchange in Gothenburg, Sweden. Drug Test Anal 2023. [PMID: 38044807 DOI: 10.1002/dta.3614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
People who inject drugs (PWID) are exposed to serious health risks such as lethal overdoses, addiction and infections. The patterns of drug use and the prevalence of hepatitis C virus (HCV) infection vary greatly between and even within countries. Data on drugs used for injection are important to inform PWID of risks and adapt healthcare. This study aimed to determine which substances are injected in Gothenburg, Sweden, and estimate the risk of HCV transmission. A total of 150 syringes handed in at the needle and syringe exchange program (NEP) in Gothenburg over a week in November 2021 were analysed for drug content using liquid chromatography coupled with high-resolution mass spectrometry. Using a dose-adjusted comparison, the main drug(s) injected was distinguished from the impurities in the syringes containing several drugs. HCV RNA was quantified by real-time PCR in an additional set of 150 syringes. Drugs were detected in >99% of analysed syringes, and the most common drugs were amphetamine (81%), followed by buprenorphine (8.0%), heroin (6.7%) and alprazolam (4.6%). Less common findings were testosterone (2.7%), methylphenidate (2.0%), MDMA (0.7%), trenbolone (0.7%) and zopiclone (0.7%). Eleven syringes (7.3%) contained more than one drug. HCV RNA was detected in 13% of the syringes, and one in 10 contained enough to potentially transmit an infection. This study underlines the importance of access to NEPs for PWID to reduce the risks associated with drug injection.
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Affiliation(s)
- Moa Andresen Bergström
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria E Andersson
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon B Larsson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Addiction and Dependency, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
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21
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Hochstatter KR, Nordeck C, Mitchell SG, Schwartz RP, Welsh C, Gryczynski J. Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder. Prev Med Rep 2023; 36:102494. [PMID: 38116282 PMCID: PMC10728463 DOI: 10.1016/j.pmedr.2023.102494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.
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22
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Norman C, Webling K, Kyslychenko O, Reid R, Krotulski AJ, Farrell R, Deventer MH, Liu H, Connolly MJ, Guillou C, Vinckier IMJ, Logan BK, NicDaéid N, McKenzie C, Stove CP, Gréen H. Detection in seized samples, analytical characterization, and in vitro metabolism of the newly emerged 5-bromo-indazole-3-carboxamide synthetic cannabinoid receptor agonists. Drug Test Anal 2023. [PMID: 38037247 DOI: 10.1002/dta.3609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/02/2023]
Abstract
Synthetic cannabinoid receptor agonists (SCRAs) are a diverse class of new psychoactive substances (NPS) and new structural scaffolds have emerged on the recreational drug market since the enactment of Chinese SCRA analog controls in 2021. This study reports the first SCRAs to be detected with a bromide at the 5 position (5'Br) on the phenyl ring of the indazole core and without a tail moiety. ADB-5'Br-INACA (ADMB-5'Br-INACA) and MDMB-5'Br-INACA were detected in seized samples from Scottish prisons, Belgian customs, and US forensic casework. The brominated analog with a tail moiety, ADB-5'Br-BUTINACA (ADMB-5'Br-BUTINACA), was also detected in Scottish prisons and US forensic casework. The metabolites of these compounds and the predicted compound MDMB-5'Br-BUTINACA were identified through incubation with primary human hepatocytes to aid in their toxicological identification. The bromide on the indazole remains intact on metabolites, allowing these compounds to be easily distinguished in toxicological samples from their non-brominated analogs. Glucuronidation was more common for tail-less analogs than their butyl tail-containing counterparts. Forensic toxicologists are advised to update their analytical methods with the characteristic ions for these compounds, as well as their anticipated urinary markers: amide hydrolysis and monoOH at tert-butyl metabolites (after β-glucuronidase treatment) for ADB-5'Br-INACA; monoOH at tert-butyl and amide hydrolysis metabolites for ADB-5'Br-BUTINACA; and ester hydrolysis metabolites with additional metabolites for MDMB-5'Br-INACA and MDMB-5'Br-BUTINACA. Toxicologists should remain vigilant to the emergence of new SCRAs with halogenation of the indazole core and tail-less analogs, which have already started to emerge.
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Affiliation(s)
- Caitlyn Norman
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Kristin Webling
- Department of Biomedical and Clinical Science, Division of Clinical Chemistry and Pharmacology, Linköping University, Linköping, Sweden
| | - Oleksandra Kyslychenko
- Department of Biomedical and Clinical Science, Division of Clinical Chemistry and Pharmacology, Linköping University, Linköping, Sweden
| | - Robert Reid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, Pennsylvania, USA
| | - Ryan Farrell
- Indianapolis-Marion County Forensic Services Agency, Indianapolis, Indiana, USA
| | - Marie H Deventer
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | | | - Claude Guillou
- European Commission, Joint Research Centre, Directorate F-Health, Consumers and Reference Materials, Ispra, Italy
| | | | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, Pennsylvania, USA
- Toxicology Department, NMS Labs, Horsham, Pennsylvania, USA
| | - Niamh NicDaéid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Craig McKenzie
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
- Chiron AS, Trondheim, Norway
| | - Christophe P Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Henrik Gréen
- Department of Biomedical and Clinical Science, Division of Clinical Chemistry and Pharmacology, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
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23
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Perino J, Ramaroson H, Ong N, Lancelot V, Bezin J, Gilleron V, Daveluy A, Tournier M. Psychoactive substance intoxication leading to general hospital admission in young and middle-aged people during and after the first lockdown. Therapie 2023:S0040-5957(23)00186-5. [PMID: 38036330 DOI: 10.1016/j.therap.2023.10.017] [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: 07/13/2023] [Revised: 09/19/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Incidence of hospitalisations related to psychoactive substance (H-PS) intoxication has been strongly decreased during the coronavirus disease 2019 (COVID-19) pandemic especially in young adult and French region of Nouvelle-Aquitaine was mostly concerned. This study aimed to describe (i) the incidence of H-PS in Bordeaux teaching hospital during and after the first 2020 lockdown in adults aged 18-29 years or 30+ then (ii) their characteristics specifically associated with the pandemic period by comparing 2020 with 2017-2019 baseline period. MATERIAL AND METHODS This historical cohort study was conducted in adults admitted to the Bordeaux teaching hospital with main or associated diagnosis codes of intoxication with benzodiazepine, methadone, buprenorphine, codeine, morphine, heroin, cocaine, ecstasy and alcohol. Data were collected locally through the discharge database. Incidence and characteristics of H-PS were described according to patients' age, in 2020 before (01/01-16/03), during (17/03-10/05), and after the first lockdown (11/05-31/07). RESULTS Among the 5,824 stays included over the study period, PS most involved were alcohol and benzodiazepines. Compared to baseline, the decrease in H-PS's incidence was more important in young adults (-40%; nbaseline=450) in comparison to those aged 30+ (-18%; nbaseline=1,101) during the pandemic period, especially during the lockdown compared to 2017 (-59%; n2017=145 vs. -35%; n2017=166) with far decrease in alcohol and ecstasy intoxications. Seriousness of hospitalisation indications was increased regardless of age during the pandemic. Particularly in young adults, the proportion of suicides attempts increased during lockdown compared to the baseline period (almost 50% vs. 29%) and the period after lockdown was associated with 1.7 more-time road accident increased and 3 more-time fights compared with pre-lockdown period. DISCUSSION/CONCLUSION The period following lockdown should be considered at risk H-PS due to accident. Recreational use of alcohol and ecstasy could be a target for minimize serious consequences associated to PS use in young adult.
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Affiliation(s)
- Justine Perino
- Department of Medical Pharmacology, Addictovigilance Center of Bordeaux, University Hospital of Bordeaux, 33000 Bordeaux, France; Inserm, BPH, U1219, University of Bordeaux, 33000 Bordeaux, France; CHU de Bordeaux, 33000 Bordeaux, France.
| | - Hanta Ramaroson
- Service d'information médicale, unité de coordination et d'analyse de l'information médicale - département d'information médicale (UCAIM-DIM), CHU de Bordeaux, 33000 Bordeaux, France
| | - Nathalie Ong
- Service d'information médicale, unité de coordination et d'analyse de l'information médicale - département d'information médicale (UCAIM-DIM), CHU de Bordeaux, 33000 Bordeaux, France
| | | | - Julien Bezin
- Inserm, BPH, U1219, University of Bordeaux, 33000 Bordeaux, France; CHU de Bordeaux, 33000 Bordeaux, France
| | - Véronique Gilleron
- Service d'information médicale, unité de coordination et d'analyse de l'information médicale - département d'information médicale (UCAIM-DIM), CHU de Bordeaux, 33000 Bordeaux, France
| | - Amélie Daveluy
- Department of Medical Pharmacology, Addictovigilance Center of Bordeaux, University Hospital of Bordeaux, 33000 Bordeaux, France; Inserm, BPH, U1219, University of Bordeaux, 33000 Bordeaux, France
| | - Marie Tournier
- Inserm, BPH, U1219, University of Bordeaux, 33000 Bordeaux, France; Hospital Charles-Perrens, 33000 Bordeaux, France
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24
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Vekic N, Armstrong-Price D, Woodall K. Flualprazolam and flubromazolam: Blood concentrations and prevalence of two novel psychoactive substances in forensic case work in Ontario, Canada. J Anal Toxicol 2023; 47:762-769. [PMID: 37930844 DOI: 10.1093/jat/bkad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/26/2023] [Accepted: 08/16/2023] [Indexed: 11/08/2023] Open
Abstract
Flualprazolam and flubromazolam are synthetic benzodiazepines that have not been approved for use in humans. They are categorized as novel psychoactive substances (NPS), and have been increasingly encountered in forensic case work. This report examines information from cases analyzed for flualprazolam and flubromazolam between July 1 and December 31, 2021 to identify the prevalence, trends and demographic data associated with these novel drugs in Ontario, Canada. Flualprazolam was identified in blood, serum or liver in 395 death investigations, 108 impaired driving and five sexual assault cases. Among all case types, blood concentrations were determined in 123 individuals aged 19-66 years. In impaired driving and sexual assault cases, flualprazolam blood concentrations ranged from <1.3 to 227 ng/mL (median 11.0 ng/mL), whereas a range of 3-59 ng/mL (median 6.8 ng/mL) was reported in death investigations. Flubromazolam was identified in blood, serum or liver in 137 death investigations, 55 impaired driving and one sexual assault case. Blood concentrations ranged from <1.3 to 323 ng/mL in 65 individuals, aged 14-61 years. In impaired driving and sexual assault cases, flubromazolam blood concentrations ranged from <1.3 to 323 ng/mL (median 7.7 ng/mL), which overlapped with the range of 2-220 ng/mL (median 8.0 ng/mL) reported in death investigations. Other drugs were frequently detected with flualprazolam and flubromazolam with opioids identified in more than 89% of positive flualprazolam and flubromazolam cases. These results demonstrated the prevalence of flualprazolam and flubromazolam in Ontario, Canada. Trends showed that over the 6-month period, as the number of flubromazolam cases decreased, the incidences of flualprazolam increased. An overlap in concentrations of these drugs was observed in both death investigations and cases involving living individuals. These data provide valuable information for the scientific community regarding the use of these drugs in antemortem and postmortem casework.
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Affiliation(s)
- Nella Vekic
- University of Toronto, 3359 Mississauga Rd., Mississauga, ON L5L 1C6, Canada
| | - Delaney Armstrong-Price
- Toxicology Section, Centre of Forensic Sciences, 25 Morton Shulman Ave., Toronto, ON M3M 0B1, Canada
| | - Karen Woodall
- University of Toronto, 3359 Mississauga Rd., Mississauga, ON L5L 1C6, Canada
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25
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Diaz L, Eiden C, Jouanjus E, Frauger E, Fouilhé N, Djezzar S, Gibaja V, Boucher A, Le Boisselier R, Libert F, Caous AS, Monzon E, Guerlais M, Daveluy A, Fauconneau B, Peyrière H. Alprazolam misuse: Analysis of French Addictovigilance Network data from 2011 to 2020. Therapie 2023; 78:647-657. [PMID: 36918317 DOI: 10.1016/j.therap.2023.02.002] [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: 10/19/2022] [Revised: 01/17/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Alprazolam, a high-potency and short-acting anxiolytic benzodiazepine, is one of the most misused benzodiazepines in France. In the context of various reports on alprazolam misuse during the COVID-19 pandemic, the objective of this study was to assess alprazolam abuse potential by analyzing French addictovigilance and international data. METHODS Data collected from 2011 to 2020 using the following epidemiological tools of the French Addictovigilance Network were analyzed: spontaneous reports (SRs), OPPIDUM (addiction care center data), OSIAP (falsified prescriptions), DRAMES (substance-related deaths), and chemical submission surveys. Moreover, the VigiBase™ database was analyzed to evaluate alprazolam abuse liability worldwide. RESULTS During the study period, 675 SRs concerning alprazolam misuse were recorded (sex ratio: ̴1; median age: 39 years). The desired effects were intensification of the therapeutic anxiolytic effect, euphoric effect, and management of substance withdrawal. Alprazolam was the third and first benzodiazepine listed in OPPIDUM and OSIAP surveys. Analysis of the SR and OPPIDUM data showed a recent increase in the alprazolam-opioid combination. In DRAMES data, alprazolam was directly linked to 11 deaths (associated with opioids in 10/11). VigiBase™ data analysis highlighted that France was the third country with the most cases of alprazolam misuse. The disproportionality analysis showed that in France, alprazolam was associated with higher risk of misuse and dependence compared with other benzodiazepines: reporting odds ratio=1.43, (95% CI: 1.04-1.95) and=1.97 (95% CI:1.50-2.59), respectively. CONCLUSIONS This study highlighted an increase in various signals of alprazolam abuse in France, and an increased use of the alprazolam-opioid combination that was also linked to most of the recorded alprazolam-linked deaths. These signals have been reported also in the international literature, and should be thoroughly investigated.
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Affiliation(s)
- Laurine Diaz
- Addictovigilance Centre, Lapeyronie Hospital, CHU de Montpellier, Univ Montpellier, 34000 Montpellier, France
| | - Céline Eiden
- Addictovigilance Centre, Lapeyronie Hospital, CHU de Montpellier, Univ Montpellier, 34000 Montpellier, France
| | - Emilie Jouanjus
- Addictovigilance Centre, Medecine Faculty, CHU, 31000 Toulouse, France
| | | | | | - Samira Djezzar
- Addictovigilance Centre, Fernand Widal Hospital, 75000 Paris, France
| | | | | | | | - Frédéric Libert
- Addictovigilance Centre-CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | | | - Emilie Monzon
- Agence Nationale de Sécurité des Médicaments et Produits de Santé (ANSM), 93210 Saint Denis La Plaine, France
| | | | - Amélie Daveluy
- Addictovigilance Centre-CHU Bordeaux, 33000 Bordeaux, France
| | | | - Hélène Peyrière
- Addictovigilance Centre, Lapeyronie Hospital, CHU de Montpellier, Univ Montpellier, 34000 Montpellier, France; Pathogenesis and Control of Chronic Infections, Univ Montpellier, INSERM, EFS, CHU Montpellier, 34000 Montpellier, France.
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26
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Coates S, Lazarus P. Hydrocodone, Oxycodone, and Morphine Metabolism and Drug-Drug Interactions. J Pharmacol Exp Ther 2023; 387:150-169. [PMID: 37679047 PMCID: PMC10586512 DOI: 10.1124/jpet.123.001651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023] Open
Abstract
Awareness of drug interactions involving opioids is critical for patient treatment as they are common therapeutics used in numerous care settings, including both chronic and disease-related pain. Not only do opioids have narrow therapeutic indexes and are extensively used, but they have the potential to cause severe toxicity. Opioids are the classical pain treatment for patients who suffer from moderate to severe pain. More importantly, opioids are often prescribed in combination with multiple other drugs, especially in patient populations who typically are prescribed a large drug regimen. This review focuses on the current knowledge of common opioid drug-drug interactions (DDIs), focusing specifically on hydrocodone, oxycodone, and morphine DDIs. The DDIs covered in this review include pharmacokinetic DDI arising from enzyme inhibition or induction, primarily due to inhibition of cytochrome p450 enzymes (CYPs). However, opioids such as morphine are metabolized by uridine-5'-diphosphoglucuronosyltransferases (UGTs), principally UGT2B7, and glucuronidation is another important pathway for opioid-drug interactions. This review also covers several pharmacodynamic DDI studies as well as the basics of CYP and UGT metabolism, including detailed opioid metabolism and the potential involvement of metabolizing enzyme gene variation in DDI. Based upon the current literature, further studies are needed to fully investigate and describe the DDI potential with opioids in pain and related disease settings to improve clinical outcomes for patients. SIGNIFICANCE STATEMENT: A review of the literature focusing on drug-drug interactions involving opioids is important because they can be toxic and potentially lethal, occurring through pharmacodynamic interactions as well as pharmacokinetic interactions occurring through inhibition or induction of drug metabolism.
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Affiliation(s)
- Shelby Coates
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
| | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
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McAuley A, Palmateer N, Goldberg DJ, Shivaji T, Ritchie T, Licence K, Carter D, Hutchinson SJ. Increased risk of non-fatal overdose associated with non-prescribed benzodiazepine use in Scotland, UK. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104236. [PMID: 37865531 DOI: 10.1016/j.drugpo.2023.104236] [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: 07/28/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Drug-related deaths (DRDs) in Scotland increased for seven years in a row between 2014 and 2020, consolidating Scotland's place at the top of the United Kingdom and European drug-related mortality charts. One of the defining features of this recent and rapid rise has been the role of benzodiazepines, which are now involved in the majority of all DRDs. These deaths are linked to use of non-prescribed, benzodiazepine-type novel psychoactive substances (NPS) which have been identified by the United Nations as a global threat to public health. This study aimed to estimate the prevalence and determinants of non-prescribed benzodiazepine use and its association with recent non-fatal overdose among a national sample of people who inject drugs (PWID). METHODS Data from the 2019-20 Needle Exchange Surveillance Initiative (NESI) was analysed using logistic regression. NESI is a voluntary, anonymous, biennial, cross-sectional, bio-behavioural survey of PWID attending community-based services providing injecting equipment in mainland Scotland. RESULTS Prevalence of non-prescribed benzodiazepine use in the past six months was 52% and significantly associated with age (aOR 0.97, 0.96-0.98), frequent incarceration (aOR 1.29, 1.07-1.57), recent public injecting (aOR 3.25, 2.33-4.55), a recent methadone prescription (aOR 1.87, 1.51-2.33), and a history of benzodiazepine prescription (aOR 1.92, 1.47-2.52). In addition, non-prescribed benzodiazepine use was significantly associated with non-fatal overdose in the past year among PWID (aOR 2.47, 1.90-3.21). CONCLUSION This study found a high prevalence of non-prescribed benzodiazepine use among a national sample of PWID in Scotland. Prevalence was highest among populations known to be at increased risk of drug-related death and use was strongly associated with overdose. These novel findings highlight the scale of the non-prescribed benzodiazepine issue Scotland faces, and the urgency required to expand its harm reduction infrastructure to address this unique element of its overdose crisis.
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Affiliation(s)
- A McAuley
- Public Health Scotland, Glasgow, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
| | - N Palmateer
- Public Health Scotland, Glasgow, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - D J Goldberg
- Public Health Scotland, Glasgow, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - T Ritchie
- Glasgow Alcohol and Drug Recovery Services, Glasgow, UK
| | | | - D Carter
- Glasgow Alcohol and Drug Recovery Services, Glasgow, UK
| | - S J Hutchinson
- Public Health Scotland, Glasgow, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Durand L, Keenan E, O'Reilly D, Bennett K, O'Hara A, Cousins G. Prescription drugs with potential for misuse in Irish prisons: analysis of national prison prescribing trends, by gender and history of opioid use disorder, 2012 to 2020. BMC Psychiatry 2023; 23:725. [PMID: 37803285 PMCID: PMC10559424 DOI: 10.1186/s12888-023-05195-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Pharmacotherapy is essential for the delivery of an equivalent standard of care in prison. Prescribing can be challenging due to the complex health needs of prisoners and the risk of misuse of prescription drugs. This study examines prescribing trends for drugs with potential for misuse (opioids, benzodiazepines, Z-drugs, and gabapentinoids) in Irish prisons and whether trends vary by gender and history of opioid use disorder (OUD). METHODS A repeated cross-sectional study between 2012 and 2020 using electronic prescribing records from the Irish Prison Services, covering all prisons in the Republic of Ireland was carried out. Prescribing rates per 1,000 prison population were calculated. Negative binomial (presenting adjusted rate ratios (ARR) per year and 95% confidence intervals) and joinpoint regressions were used to estimate time trends adjusting for gender, and for gender specific analyses of prescribing trends over time by history of OUD. RESULTS A total of 10,371 individuals were prescribed opioid agonist treatment (OAT), opioids, benzodiazepines, Z-drugs or gabapentinoids during study period. History of OUD was higher in women, with a median rate of 597 per 1,000 female prisoners, compared to 161 per 1,000 male prisoners. Prescribing time trends, adjusted for gender, showed prescribing rates decreased over time for prescription opioids (ARR 0.82, 95% CI 0.80-0.85), benzodiazepines (ARR 0.99, 95% CI 0.98-0.999), Z-drugs (ARR 0.90, 95% CI 0.88-0.92), but increased for gabapentinoids (ARR 1.07, 95% CI 1.05-1.08). However, prescribing rates declined for each drug class between 2019 and 2020. Women were significantly more likely to be prescribed benzodiazepines, Z-drugs and gabapentinoids relative to men. Gender-specific analyses found that men with OUD, relative to men without, were more likely to be prescribed benzodiazepines (ARR 1.49, 95% CI 1.41-1.58), Z-drugs (ARR 10.09, 95% CI 9.0-11.31), gabapentinoids (ARR 2.81, 95% CI 2.66-2.97). For women, history of OUD was associated with reduced gabapentinoid prescribing (ARR 0.33, 95% CI 0.28-0.39). CONCLUSIONS While the observed reductions in prescription opioid, benzodiazepine and Z-drug prescribing is consistent with guidance for safe prescribing in prisons, the increase in gabapentinoid (primarily pregabalin) prescribing and the high level of prescribing to women is concerning. Our findings suggest targeted interventions may be needed to address prescribing in women, and men with a history of OUD.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin 2, Ireland.
| | - Eamon Keenan
- National Social Inclusion Office, Health Service Executive, Mill Lane, Palmerstown, Dublin 20, Ireland
| | - Deirdre O'Reilly
- Irish Prison Service, IDA Business Park, Ballinalee Road, Longford, Ireland
| | - Kathleen Bennett
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Lower Mercer Street, Dublin 2, Ireland
| | - Andy O'Hara
- UISCE, National Advocacy Service for People who use Drugs in Ireland, 8 Cabra road, Dublin 7, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin 2, Ireland
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Wolitzky-Taylor K, Mooney LJ, Otto MW, Metts A, Parsons EM, Hanano M, Ram R. Augmenting the efficacy of benzodiazepine taper with telehealth-delivered cognitive behavioral therapy for anxiety disorders in patients using prescription opioids: A pilot randomized controlled trial. Contemp Clin Trials 2023; 133:107334. [PMID: 37730196 PMCID: PMC10960249 DOI: 10.1016/j.cct.2023.107334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/07/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
The risks of concomitant benzodiazepine (BZ) and opioid use are significant. Despite the urgent need to reduce BZ use among patients taking opioids, no treatment intervention research to our knowledge has addressed treatment for this concurrent, high-risk use. The current study will evaluate the efficacy of augmenting BZ taper procedures with CBT for anxiety disorders that has been adapted specifically for patients with concomitant BZ and opioid use (either use as prescribed or misuse), a high-risk patient population. Research combining rapidly scalable behavioral interventions ancillary to pharmacological approaches delivered via telehealth in primary care settings is innovative and important given concerning trends in rising prevalence of BZ/opioid co-prescription, BZ-associated overdose deaths, and known barriers to implementation of behavioral health interventions in primary care. CBT delivery using telehealth has the potential to aid adherence and promote access and dissemination of procedures in primary care. Lastly, the current study will utilize an experimental therapeutics approach to preliminarily explore the mechanism of action for the proposed interventions. The overall aim of the present pilot randomized controlled trial is to examine the feasibility and preliminary efficacy of a BZ taper with CBT for anxiety disorders adapted for patients with concomitant BZ (BZT + CBT) and opioid use to a BZ taper with a control health education program (BZT + HE) in a sample of individuals (N = 54) who have been prescribed and are taking benzodiazepines and opioids for at least 3 months prior to baseline and experience anxious distress. Screening and outcome measures, methods, and implications are described. Trial Registration: ClinicalTrials.gov (NCT05573906).
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Affiliation(s)
| | - Larissa J Mooney
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, USA
| | - Michael W Otto
- Boston University, Department of Psychological and Brain Sciences, Boston, MA, USA
| | | | - E Marie Parsons
- Boston University, Department of Psychological and Brain Sciences, Boston, MA, USA
| | - Maria Hanano
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA
| | - Reuben Ram
- UCLA Toluca Lake Clinic, Los Angeles, CA, USA
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Zahlan G, De Clifford-Faugère G, Nguena Nguefack HL, Guénette L, Pagé MG, Blais L, Lacasse A. Polypharmacy and Excessive Polypharmacy Among Persons Living with Chronic Pain: A Cross-Sectional Study on the Prevalence and Associated Factors. J Pain Res 2023; 16:3085-3100. [PMID: 37719270 PMCID: PMC10505027 DOI: 10.2147/jpr.s411451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/27/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose Polypharmacy can be defined as the concomitant use of ≥5 medications and excessive polypharmacy, as the use of ≥10 medications. Objectives were to (1) assess the prevalence of polypharmacy and excessive polypharmacy among persons living with chronic pain, and (2) identify sociodemographic and clinical factors associated with excessive polypharmacy. Patients and Methods This cross-sectional study used data from 1342 persons from the ChrOnic Pain trEatment (COPE) Cohort (Quebec, Canada). The self-reported number of medications currently used by participants (regardless of whether they were prescribed or taken over-the-counter, or were used for treating pain or other health issues) was categorized to assess polypharmacy and excessive polypharmacy. Results Participants reported using an average of 6 medications (median: 5). The prevalence of polypharmacy was 71.4% (95% CI: 69.0-73.8) and excessive polypharmacy was 25.9% (95% CI: 23.6-28.3). No significant differences were found across gender identity groups. Multivariable logistic regression revealed that factors associated with greater chances of reporting excessive polypharmacy (vs <10 medications) included being born in Canada, using prescribed pain medications, and reporting greater pain intensity (0-10) or pain relief from currently used pain treatments (0-100%). Factors associated with lower chances of excessive polypharmacy were using physical and psychological pain treatments, reporting better general health/physical functioning, considering pain to be terrible/feeling like it will never get better, and being employed. Conclusion Polypharmacy is the rule rather than the exception among persons living with chronic pain. Close monitoring and evaluation of the different medications used are important for all persons, especially those with limited access to care.
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Affiliation(s)
- Ghita Zahlan
- Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | | | - Hermine Lore Nguena Nguefack
- Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | - Line Guénette
- Faculté de pharmacie, Université Laval, Quebec, Quebec, Canada
- Centre de recherche, CHU de Québec - Université Laval, Quebec, Quebec, Canada
| | - M Gabrielle Pagé
- Centre de recherche, Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Département d’anesthésiologie et de médecine de la douleur, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Lucie Blais
- Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Anaïs Lacasse
- Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
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Chatterton CN, Handy RP. Fentanyl concentrations in ligated femoral blood in the presence and absence of NPS benzodiazepine drugs. A review of over 1250 benzo-dope / fentanyl toxicity cases in Alberta, Canada. Forensic Sci Int 2023; 350:111777. [PMID: 37478730 DOI: 10.1016/j.forsciint.2023.111777] [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: 04/12/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023]
Abstract
The drug combination referred to as 'benzo dope' has become prevalent in recent years, with an increasing number of fentanyl-related deaths reporting the concomitant presence of one or more benzodiazepine drug, such as etizolam, flualprazolam and flubromazepam. The central nervous system (CNS) depressant effects of these benzodiazepine drugs can exacerbate respiratory and CNS depressant effects resulting from the use/misuse of potent opioids such as fentanyl. This combined and enhanced drug-induced toxicity can pose a significant threat to life. Over a three-year period (2020-2022), the Office of the Chief Medical Examiner, Edmonton, Alberta, Canada issued 2812 case reports with fentanyl detected; of these cases, approximately 45% (1261) were positive for at least one benzodiazepine drug. This study presents concentrations of both fentanyl and benzodiazepine drugs in post mortem blood collected from a visualized, ligated femoral vein. The study demonstrates that the blood concentration of fentanyl in benzo-dope case reports is considerably higher than in cases where no benzodiazepine drug was detected.The median concentration of fentanyl in femoral blood for cases that also contained a benzodiazepine drug was 12.4 ng/mL (2020), 11.9 ng/mL (2021) and 14.0 ng/mL (2022). The median concentration of fentanyl in femoral blood for cases that did not contain a benzodiazepine drug was 8.5 ng/mL (2020), 7.0 ng/mL (2021) and 7.2 ng/mL (2022). The percent differences between the groups were similar with those observed from quantitative analysis of drug powders from unrelated police seizures in Alberta, Canada, suggesting the observed differences in blood fentanyl concentration may be due to the use of a drug substance with a higher concentration of fentanyl.Furthermore, the reported concentration of the benzodiazepine drug(s) is low, such that the role/contribution, if any, that this drug may have played in the decedents' death should be questioned and carefully considered by the certifying medical examiner/coroner.
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Affiliation(s)
- C N Chatterton
- Office of the Chief Medical Examiner, 7007-116 Street NW, Edmonton, Alberta, Canada.
| | - R P Handy
- Office of the Chief Medical Examiner, 7007-116 Street NW, Edmonton, Alberta, Canada
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Dowd JB, Angus C, Zajacova A, Tilstra AM. Comparing trends in mid-life 'deaths of despair' in the USA, Canada and UK, 2001-2019: is the USA an anomaly? BMJ Open 2023; 13:e069905. [PMID: 37591647 PMCID: PMC10441077 DOI: 10.1136/bmjopen-2022-069905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/27/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVES In recent years, 'deaths of despair' due to drugs, alcohol and suicide have contributed to rising mid-life mortality in the USA. We examine whether despair-related deaths and mid-life mortality trends are also changing in peer countries, the UK and Canada. DESIGN Descriptive analysis of population mortality rates. SETTING The USA, UK (and constituent nations England and Wales, Northern Ireland and Scotland) and Canada, 2001-2019. PARTICIPANTS Full population aged 35-64 years. OUTCOME MEASURES We compared all-cause and 'despair'-related mortality trends at mid-life across countries using publicly available mortality data, stratified by three age groups (35-44, 45-54 and 55-64 years) and by sex. We examined trends in all-cause mortality and mortality by causes categorised as (1) suicides, (2) alcohol-specific deaths and (3) drug-related deaths. We employ several descriptive approaches to visually inspect age, period and cohort trends in these causes of death. RESULTS The USA and Scotland both saw large relative increases and high absolute levels of drug-related deaths. The rest of the UK and Canada saw relative increases but much lower absolute levels in comparison. Alcohol-specific deaths showed less consistent trends that did not track other 'despair' causes, with older groups in Scotland seeing steep declines over time. Suicide deaths trended slowly upward in most countries. CONCLUSIONS In the UK, Scotland has suffered increases in drug-related mortality comparable with the USA, while Canada and other UK constituent nations did not see dramatic increases. Alcohol-specific and suicide mortalities generally follow different patterns to drug-related deaths across countries and over time, questioning the utility of a cohesive 'deaths of despair' narrative.
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Affiliation(s)
- Jennifer Beam Dowd
- Leverhulme Centre for Demographic Science, University of Oxford, Oxford, UK
- Nuffield College, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Colin Angus
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna Zajacova
- University of Western Ontario, London, Ontario, Canada
| | - Andrea M Tilstra
- Leverhulme Centre for Demographic Science, University of Oxford, Oxford, UK
- Nuffield College, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Bhatraju E, Liebschutz JM, Lodi S, Forman LS, Lira MC, Kim TW, Colasanti J, Del Rio C, Samet JH, Tsui JI. Post-traumatic stress disorder and risky opioid use among persons living with HIV and chronic pain. AIDS Care 2023; 35:1173-1180. [PMID: 33535800 PMCID: PMC8333265 DOI: 10.1080/09540121.2021.1876838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
Persons with HIV (PWH) experience chronic pain and Post-Traumatic Stress Disorder (PTSD) at higher rates than the general population, and more often receive opioid medications to treat chronic pain. A known association exists between PTSD and substance use disorders, but less is known about the relationship between PTSD and risky opioid use among PWH taking prescribed opioid medications. In this observational study of PWH on long-term opioid medications for pain we examined associations between PTSD symptom severity based on the Post Traumatic Stress Disorder Checklist for DSM-5 (PCL-5, response range 0-80) and the following outcomes: 1) risk for opioid misuse (COMM score ≥13); 2) risky alcohol use (AUDIT score ≥8); 3) concurrent benzodiazepine prescription; and 4) morphine equivalent dose. Among 166 patients, 38 (23%) had a PCL-5 score over 38, indicating high PTSD symptom burden. Higher PCL-5 score (per 10 point difference) was associated with increased odds of opioid misuse (aOR 1.55; 95%CI: 1.31-1.83) and risky drinking (aOR: 1.28;1.07-1.52). No significant association was observed between PCL-5 score and benzodiazepine prescriptions or morphine equivalent dose. These findings suggest that when addressing alcohol and opioid use in PWH on long term opioid therapy, attention to PTSD symptoms is especially important given the higher risk for risky alcohol and opioid use among patients with this common comorbid condition.
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Affiliation(s)
- Elenore Bhatraju
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Seattle, WA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Theresa W Kim
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Seattle, WA, USA
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Ou TS, Huber L, Macy JT, Bray BC, Lin HC. Stressful Life Events and Patterns of Polysubstance Use Among U.S. Late Middle-Aged and Older Adults: A Latent Class Analysis. J Appl Gerontol 2023; 42:1867-1876. [PMID: 36988206 DOI: 10.1177/07334648231165256] [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] [Indexed: 03/30/2023] Open
Abstract
The goals of this study were to identify patterns of polysubstance use and their associations with stressful life events among U.S. late middle-aged and older adults and examine whether gender moderates these associations. Adults aged 50 and older (N = 14,738) from the National Epidemiological Survey on Alcohol and Related Conditions-III were included. Latent class analysis was conducted to identify patterns of polysubstance use. Weighted multinomial logistic regression was estimated with a generalized structural equation model. Three different polysubstance use patterns (non-users/low substance users; cannabis and excessive alcohol users; painkiller and sedative/tranquilizer misusers) were identified. Higher levels of stressful life events were associated with patterns of polysubstance use. Gender moderated the association between stressful life events and co-misusing painkillers and sedatives/tranquilizers (p < 0.05). Substance use prevention efforts should consider aging adults' patterns of polysubstance use and associated stressful life events when designing and implementing gender-specific polysubstance use prevention interventions.
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Affiliation(s)
- Tzung-Shiang Ou
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Lesa Huber
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Jonathan T Macy
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Bethany C Bray
- Institute for Health Research and Policy, The University of Illinois at Chicago, Chicago, IL, USA
| | - Hsien-Chang Lin
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
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Castillo-Carniglia A, Rivera-Aguirre A, Santaella-Tenorio J, Fink DS, Crystal S, Ponicki W, Gruenewald P, Martins SS, Keyes KM, Cerdá M. Changes in Opioid and Benzodiazepine Poisoning Deaths After Cannabis Legalization in the US: A County-level Analysis, 2002-2020. Epidemiology 2023; 34:467-475. [PMID: 36943813 PMCID: PMC10712490 DOI: 10.1097/ede.0000000000001609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Cannabis legalization for medical and recreational purposes has been suggested as an effective strategy to reduce opioid and benzodiazepine use and deaths. We examined the county-level association between medical and recreational cannabis laws and poisoning deaths involving opioids and benzodiazepines in the US from 2002 to 2020. METHODS Our ecologic county-level, spatiotemporal study comprised 49 states. Exposures were state-level implementation of medical and recreational cannabis laws and state-level initiation of cannabis dispensary sales. Our main outcomes were poisoning deaths involving any opioid, any benzodiazepine, and opioids with benzodiazepines. Secondary analyses included overdoses involving natural and semi-synthetic opioids, synthetic opioids, and heroin. RESULTS Implementation of medical cannabis laws was associated with increased deaths involving opioids (rate ratio [RR] = 1.14; 95% credible interval [CrI] = 1.11, 1.18), benzodiazepines (RR = 1.19; 95% CrI = 1.12, 1.26), and opioids+benzodiazepines (RR = 1.22; 95% CrI = 1.15, 1.30). Medical cannabis legalizations allowing dispensaries was associated with fewer deaths involving opioids (RR = 0.88; 95% CrI = 0.85, 0.91) but not benzodiazepine deaths; results for recreational cannabis implementation and opioid deaths were similar (RR = 0.81; 95% CrI = 0.75, 0.88). Recreational cannabis laws allowing dispensary sales was associated with consistent reductions in opioid- (RR = 0.83; 95% CrI = 0.76, 0.91), benzodiazepine- (RR = 0.79; 95% CrI = 0.68, 0.92), and opioid+benzodiazepine-related poisonings (RR = 0.83; 95% CrI = 0.70, 0.98). CONCLUSIONS Implementation of medical cannabis laws was associated with higher rates of opioid- and benzodiazepine-related deaths, whereas laws permitting broader cannabis access, including implementation of recreational cannabis laws and medical and recreational dispensaries, were associated with lower rates. The estimated effects of the expanded availability of cannabis seem dependent on the type of law implemented and its provisions.
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Affiliation(s)
- Alvaro Castillo-Carniglia
- Society and Health Research Center and School of Public Health, Facultad de Ciencias Sociales y Artes, Universidad Mayor, Chile
- Millennium Nucleus for the Evaluation and Analysis of Drug Policies (nDP), Chile
- Millennium Nucleus on Sociomedicine (Sociomed), Chile
- Department of Population Health, New York University Grossman School of Medicine, NY
| | - Ariadne Rivera-Aguirre
- Millennium Nucleus for the Evaluation and Analysis of Drug Policies (nDP), Chile
- Department of Population Health, New York University Grossman School of Medicine, NY
| | | | | | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, NJ
| | - William Ponicki
- Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA
| | - Paul Gruenewald
- Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA
| | | | | | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, NY
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Walde J, Andersson L, Johnson B, Håkansson A. Drug prescriptions preceding opioid-related deaths-a register study in forensic autopsy patients. PLoS One 2023; 18:e0285583. [PMID: 37256903 DOI: 10.1371/journal.pone.0285583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND/AIM Opioid overdose deaths have increased in Sweden and other developed countries in recent decades, despite increased treatment efforts and harm-reduction interventions. Further knowledge in this field is needed if this trend is to be reversed. Previous research suggests that mental health and patterns of prescription of opioids and other prescription drugs are associated with increased opioid-related mortality. The present study therefore aimed to investigate what drugs were prescribed during the last six months of life to individuals with a history of illicit substance use who died with opioids present in their blood, the relationship between drugs prescribed and drugs found in blood at time of death, and if prescription of specific drugs was temporally associated with death. METHODS This was a retrospective, register-based observational study that utilized data from the National Board of Forensic Medicine, the Prescribed Drug Registry, regional health care services, and municipal social services. We used conditional logistic regression to find temporal associations between the prescription and dispensing of drugs and time of death. RESULTS Prescription and dispensing of alprazolam and diazepam were temporally associated with death. The most frequently dispensed drugs were zopiclone, pregabalin, methylphenidate, diazepam and oxycodone. Methadone, alprazolam, and buprenorphine were the drugs most often found in the blood. Opioids and tranquilizers in combination were found in a vast majority of deaths, and prescription data suggested that the use of these drugs was illicit in a majority of cases. CONCLUSION Prescription of certain drugs, especially alprazolam and diazepam, should be made with great caution to patients with a history of illicit substance use or concurrent use of opioids.
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Affiliation(s)
- Jonatan Walde
- Umeå University and Region Västerbotten, Umeå, Sweden
| | - Lisa Andersson
- Faculty of Health and Society, Department of Social Work, Malmö University, Malmö, Sweden
| | - Björn Johnson
- Faculty of Health and Society, Department of Social Work, Malmö University, Malmö, Sweden
- Lund University, School of Social Work, Lund, Sweden
| | - Anders Håkansson
- Department of Clinical Sciences Lund, Lund University, Psychiatry, Lund, Sweden
- Region Skåne, Malmö Addiction Center, Malmö, Sweden
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Hong JH, de Dios C, Badawi JC, Tonkin SS, Schmitz JM, Walss-Bass C, Meyer TD. Types of Traumatic Experiences in Drug Overdose-Related Deaths: An Exploratory Latent Class Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.30.23289256. [PMID: 37205511 PMCID: PMC10187323 DOI: 10.1101/2023.04.30.23289256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Aim Drug overdose related-deaths in the US are increasing, with over 100,000 deaths occurring in 2020, an increase of 30% from the previous year and the highest number recorded in a single year. It is widely known that experiences of trauma and substance use very often co-occur, but little is known about the role of trauma in the context of drug overdose-related deaths. Latent class analysis (LCA) was used to classify drug overdose-related deaths based on type of traumatic experiences and individual, social, and substance use characteristics. Methods Psychological autopsy data were obtained from the University of Texas Health Science Center at Houston (UTHealth) Brain Collection. A total of 31 drug overdose-related deaths collected from January 2016 through March 2022 were included in this study. LCA was used to identify latent factors via experience of four trauma categories (illness/accidents, sexual/interpersonal violence, death/trauma to another, other situations where life was in danger). Generalized linear modeling (GLM) was used to explore differences on demographic, social, substance use, and psychiatric variables between the latent classes in separate models. Results LCA identified 2 classes: C1 ( n =12; 39%) was characterized by higher incidence of overall trauma exposure as well as variation in trauma type; C2 ( n =19; 61%) had lower levels of overall trauma exposure with sexual/interpersonal violence as the most frequent. GLMs indicated that C1 membership was associated with higher incidence of polysubstance use, being married, and having suicidal ideation compared to C2 membership ( p s<0.05). Conclusion Among individuals who died by drug overdose, the exploratory LCA identified two distinct subgroups that differed in type of trauma experienced and substance use pattern, the first group having more "typical" characteristics of drug overdoses cases, the other group less typical. This suggests that those at risk of drug overdose may not always exhibit high-risk characteristics.
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Mandal P, Mittal S, Chadda RK. Polysubstance use in South Asia. Curr Opin Psychiatry 2023:00001504-990000000-00064. [PMID: 37185341 DOI: 10.1097/yco.0000000000000869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE OF REVIEW Polysubstance use is very common in the world, but there has been limited research in this area. South Asia is sandwiched between two of the world's largest heroin producing areas: the Golden Crescent and the Golden Triangle. The burden and prevalence of polysubstance use have not been estimated in this region of the world. We review the research findings on polysubstance use in different South Asian countries. The review also comments on the gaps in knowledge regarding polysubstance use in this region of the world. RECENT FINDINGS The available literature on polysubstance use from South Asia suggests its widespread presence in the region, ranging from 20 to 90%, more commonly among illicit opioid drug users and injection drug users. Most of the available data is from epidemiological studies. There are few studies on the adverse effects of polysubstance use, but the limited data clearly suggests an elevated risk of comorbid psychopathology and health problems. SUMMARY Polysubstance use still lacks a consensus definition. There is a need of more research on its prevalence, effects on health, and prevention and treatment.
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Affiliation(s)
- Piyali Mandal
- Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Lawson R, Čechová P, Zarrouk E, Javellaud J, Bazgier V, Otyepka M, Trouillas P, Picard N, Marquet P, Saint-Marcoux F, El Balkhi S. Metabolic interactions of benzodiazepines with oxycodone ex vivo and toxicity depending on usage patterns in an animal model. Br J Pharmacol 2023; 180:829-842. [PMID: 34855983 DOI: 10.1111/bph.15765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Opioids and benzodiazepines are frequently combined in medical as well as in non-medical contexts. At high doses, such combinations often result in serious health complications attributed to pharmacodynamics interactions. Here, we investigate the contribution of the metabolic interactions between oxycodone, diazepam and diclazepam (a designer benzodiazepine) in abuse/overdose conditions through ex vivo, in vivo and in silico approaches. EXPERIMENTAL APPROACH A preparation of pooled human liver microsomes was used to study oxycodone metabolism in the presence or absence of diazepam or diclazepam. In mice, diazepam or diclazepam was concomitantly administered with oxycodone to mimic acute intoxication. Diclazepam was introduced on Day 10 in mice continuously infused with oxycodone for 15 days to mimic chronic intoxication. In silico modelling was used to study the molecular interactions of the three drugs with CYP3A4 and 2D6. KEY RESULTS In mice, in acute conditions, both diazepam and diclazepam inhibited the metabolism of oxycodone. In chronic conditions and at pharmacologically equivalent doses, diclazepam drastically enhanced the production of oxymorphone. In silico, the affinity of benzodiazepines was higher than oxycodone for CYP3A4, inhibiting oxycodone metabolism through CYP3A4. Oxycodone metabolism is likely to be diverted towards CYP2D6. CONCLUSION AND IMPLICATIONS Acute doses of diazepam or diclazepam result in the accumulation of oxycodone, whereas chronic administration induces the accumulation of oxymorphone, the toxic metabolite. This suggests that overdoses of opioids in the presence of benzodiazepines are partly due to metabolic interactions, which in turn explain the patterns of toxicity dependent on usage. LINKED ARTICLES This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Affiliation(s)
- Roland Lawson
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France
| | - Petra Čechová
- Regional Center of Advanced Technologies and Materials, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, Olomouc, Czechia
| | - Eliès Zarrouk
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France
| | - James Javellaud
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France
| | - Václav Bazgier
- Department of Physical Chemistry, Faculty of Science, Palacký University Olomouc, Olomouc, Czechia
| | - Michal Otyepka
- Regional Center of Advanced Technologies and Materials, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, Olomouc, Czechia
| | - Patrick Trouillas
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France.,Regional Center of Advanced Technologies and Materials, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, Olomouc, Czechia
| | - Nicolas Picard
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, CHU Limoges, Limoges, France
| | - Pierre Marquet
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, CHU Limoges, Limoges, France
| | - Franck Saint-Marcoux
- University of Limoges, IPPRITT, Limoges, France.,INSERM, IPPRITT, U1248, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, CHU Limoges, Limoges, France
| | - Souleiman El Balkhi
- INSERM, IPPRITT, U1248, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, CHU Limoges, Limoges, France
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Chu E, Cocos G, Lee HJ, Go J, Lewis J, Apollonio DE. Trends in concomitant and single opioid and benzodiazepine exposures reported to the California Poison Control System following the Centers for Disease Control and Prevention release of opioid guidelines in 2016. Clin Toxicol (Phila) 2023; 61:305-311. [PMID: 36988441 DOI: 10.1080/15563650.2022.2158095] [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: 05/18/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 03/30/2023]
Abstract
INTRODUCTION In March 2016, the Centers for Disease Control and Prevention released the Guideline for Prescribing Opioids for Chronic Pain, intended for primary care clinicians. One recommendation advised against concurrent prescription of opioids and benzodiazepines. Although existing research suggests a reduction in co-prescribing of these drug classes by clinicians after guideline release, there are limited data assessing its possible effect on patient medical outcomes, such as overdoses. METHODS This retrospective observational study analyzed opioid and benzodiazepine exposures, alone or in combination, reported to the California Poison Control System from January 2012 to June 2021. Interrupted time series analyses identified the difference in monthly call volume between pre- and post-guideline release. For exposures resulting in serious medical outcomes, additional analyses assessed trends and identified associated variables. RESULTS There was no significant change in concomitant opioid and benzodiazepine exposures reported to California Poison Control System between pre- and post-guideline release. Compared to pre-guideline release, exposures to a single opioid or to a single benzodiazepine significantly decreased by 1.07 (95% CI: -1.62, -0.51) and 1.82 (95% CI: -2.33, -1.31) calls per month, respectively, after the guideline release. For exposure calls associated with serious medical outcomes, there was a significant increase of 0.11 (95% CI: 0.04, 0.18) and 0.2 (95% CI: 0.05, 0.34) calls per month for concomitant opioid and benzodiazepine and single opioid exposures, respectively, following guideline release. DISCUSSION The guideline release appeared to have a variable association with exposures to single opioid, single benzodiazepines, and concomitant opioid and benzodiazepine cases reported to California Poison Control System. Although exposures to opioids or benzodiazepines alone significantly decreased after guideline release, there was no significant change in concomitant exposures. Additionally, for exposures associated with serious medical outcomes, concomitant exposures, and single opioid exposures significantly increased following guideline release. CONCLUSION Our results suggest that the guideline was not associated with a corresponding decrease in the number of concomitant poisoning exposures reported to California Poison Control System. Additional interventions may be needed to reduce concomitant exposures to opioids and benzodiazepines.
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Affiliation(s)
- Emily Chu
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Gina Cocos
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Ho Jun Lee
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Jane Go
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Justin Lewis
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
- California Poison Control System, San Francisco, CA, USA
| | - Dorie E Apollonio
- School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA
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McHugh RK, Votaw VR, Trapani EW, McCarthy MD. Prevalence and correlates of the misuse of z-drugs and benzodiazepines in the National Survey on Drug Use and Health. Front Psychiatry 2023; 14:1129447. [PMID: 36970272 PMCID: PMC10033696 DOI: 10.3389/fpsyt.2023.1129447] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundBenzodiazepines and non-benzodiazepine hypnotics (z-drugs) are commonly prescribed for their anxiolytic and hypnotic properties, though they can also be misused. In studies examining the epidemiology of prescription drug misuse, these medication classes are commonly combined, rendering inadequate knowledge of their patterns of misuse. The objective of this study was to characterize the population prevalence, conditional dependence, and sociodemographic and clinical correlates of the misuse of benzodiazepines and z-drugs.MethodsData from the National Survey on Drug Use and Health from 2015 to 2019 were used to estimate population-level prevalence and characteristics of benzodiazepine and z-drug misuse. Groups were derived based on past-year misuse of benzodiazepines alone, z-drugs alone, or both drug types. Unadjusted regression analyses were used to compare groups on characteristics of interest.ResultsExposure to benzodiazepines and/or z-drugs via prescription or misuse was common; however, only 2% of the population was estimated to have misused a benzodiazepine in the past year, and less than 0.5% misused z-drugs. People who misused only z-drugs were generally older, more likely to have health insurance, more educated, and had less severe psychiatric symptoms. This group was also more likely to report misuse to cope with sleep difficulty. Although concurrent substance use was highly prevalent in all groups, people who misused z-drugs alone generally reported less concurrent substance use than the other groups.ConclusionThe misuse of z-drugs is less common than benzodiazepines, and people who misuse only z-drugs appear to generally have lower clinical severity. Nonetheless, a substantial subgroup of people exposed to z-drugs report concurrent, past-year use of other substances. Further research on z-drug misuse, including consideration of whether it should be grouped with other anxiolytic/hypnotic drugs, is needed.
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Affiliation(s)
- R. Kathryn McHugh
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- *Correspondence: R. Kathryn McHugh,
| | - Victoria R. Votaw
- Department of Psychology, University of New Mexico, Albuquerque, NM, United States
- Center on Alcohol, Substance Use, and Addictions, University of New Mexico, Albuquerque, NM, United States
| | - Emma W. Trapani
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
| | - Megan D. McCarthy
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
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郑 俊, 孟 适, 刘 王, 常 祥, 时 杰. [Appropriate Use and Abuse of Sedative-Hypnotic Drugs]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:231-239. [PMID: 36949678 PMCID: PMC10409172 DOI: 10.12182/20230260302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Indexed: 03/24/2023]
Abstract
The incidence of insomnia has been increasing in recent years. In addition, due to the impact of the COVID-19 pandemic, more and more people are experiencing a variety of insomniac problems, including having difficulty in sleep initation, waking up too early, and short sleep duration. Chronic insomnia may seriously affect patients' life and work, increase their risks of developing physical and mental illnesses, and cause crushing social and economic burdens. Sedative-hypnotics, including benzodiazepine agonists, melatonin receptor agonists, orexin receptor antagonists, and antidepressants with hypnotic effects, are widely used to treat most patients suffering from insomnia. However, there is the phenomenon of the non-medical use and abuse of sedative-hypnotic drugs, especially benzodiazepine receptor agonists. The abuse of sedative-hypnotic drugs may lead to mental and physical dependence, cognitive impairment, depression and anxiety, as well as an increased risks of falls and death. Therefore, drug regulatory authorities in China and other countries have issued relevant policies to reinforce regulation. Herein, we reviewed the prevalent use and safety of sedative-hypnotic drugs and proposed suggestions concerning their appropriate use. Both the efficacy and safety of sedative-hypnotic drugs should be carefully considered so that patients suffering from insomnia receive thorough and prompt treatment and the problem of potential abuse of sedative-hypnotic drugs is assessed in an objective and scientific manner. We also hope to provide references for the standardized clinical use of insomnia drugs.
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Affiliation(s)
- 俊玮 郑
- 北京大学中国药物依赖性研究所 (北京 100191)National Institute on Drug Dependence, Peking University, Beijing 100191, China
- 北京大学基础医学院 (北京 100191)School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - 适秋 孟
- 北京大学中国药物依赖性研究所 (北京 100191)National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - 王玥 刘
- 北京大学中国药物依赖性研究所 (北京 100191)National Institute on Drug Dependence, Peking University, Beijing 100191, China
- 北京大学基础医学院 (北京 100191)School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - 祥文 常
- 北京大学中国药物依赖性研究所 (北京 100191)National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - 杰 时
- 北京大学中国药物依赖性研究所 (北京 100191)National Institute on Drug Dependence, Peking University, Beijing 100191, China
- 北京大学基础医学院 (北京 100191)School of Basic Medical Sciences, Peking University, Beijing 100191, China
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Badour CL, Flores J, Hood CO, Jones AC, Brake CA, Tipsword JM, Penn CJ, McCann JP. Concurrent and proximal associations among PTSD symptoms, prescription opioid use, and co-use of other substances: Results from a daily monitoring study. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2023; 15:367-376. [PMID: 35901427 PMCID: PMC10157500 DOI: 10.1037/tra0001303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and nonmedical prescription opioid use (NMPOU) are linked. Much of the research documenting this association uses cross-sectional or longitudinal designs that describe patterns of use over extended intervals. The present study used a daily monitoring design to examine how daily fluctuations in PTSD symptoms predicted patterns of prescription opioid use (both medical and nonmedical) and co-use of other substances. This approach has distinct advantages for understanding proximal temporal relations between PTSD symptom variation and substance use patterns. METHOD Forty adults with clinical or subclinical PTSD and past-month NMPOU completed daily measures of PTSD symptoms, physical pain, prescription opioid use, and other substance use for 28 days using a smartphone application. RESULTS Same day co-use of prescription opioids and at least one other substance was common. Higher-than-typical PTSD symptoms on a given day (within-person) was associated with an increased likelihood of reporting NMPOU (overall and with co-use of one or more additional substances) on the same day. This association was specific to PTSD alterations in arousal and reactivity symptoms (Criteria E). Neither total PTSD symptoms nor individual PTSD symptom clusters prospectively predicted next-day prescription opioid use (overall or with co-use). Use of prescription opioids also did not predict next-day PTSD symptom severity. CONCLUSION This is the first study to demonstrate positive associations between day-to-day fluctuations in PTSD symptoms and NMPOU. Results from the current study also highlight the importance of examining polysubstance use patterns among individuals with PTSD who use prescription opioids. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Metabolic profiling of clonazolam in human liver microsomes and zebrafish models using liquid chromatography quadrupole Orbitrap mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1216:123583. [PMID: 36621072 DOI: 10.1016/j.jchromb.2022.123583] [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: 07/06/2022] [Revised: 11/08/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Clonazolam is a designer benzodiazepine with strong sedative and amnesic effects. As we all know, the detection of metabolites is the key to confirming the use of substances in the field of forensic toxicology. In order to better describe clonazolam metabolism completely, we performed the two different experiments exploiting the unique characteristics of the models used. In this study, in vivo and in vitro samples were analyzed with liquid chromatography-quadrupole/electrostatic field orbitrap mass spectrometry. The results showed that seven Phase I metabolites and one Phase II metabolite were detected in zebrafish model. The remaining Phase I and II metabolites were also found in the incubation solution of pooled human liver microsomes. The main types of metabolic reactions of clonazolam included hydroxylation, dealkylation, nitroreduction, dechlorination, N-Acetylation, and O-glucuronidation. In this paper, the main metabolites and metabolic pathways of clonazolam are clarified in detail in order to further improve the metabolic rule of clonazolam. Based on these results, to better detect and judge the abuse of clonazolam, we suggest that M1, its nitro reduction product, is used as its biomarker. The results of this study provide a theoretical basis for the pharmacokinetics and forensic medicine of clonazolam.
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45
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Lape EC, Powers JM, Hooker JE, Edwards RR, Ditre JW. Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing. THE JOURNAL OF PAIN 2023; 24:345-355. [PMID: 36243316 PMCID: PMC9898110 DOI: 10.1016/j.jpain.2022.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Abstract
Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts. PERSPECTIVE: This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.
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Affiliation(s)
- Emma C Lape
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Jessica M Powers
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Julia E Hooker
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, New York.
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Greenwald MK, Moses TEH, Lundahl LH, Roehrs TA. Anhedonia modulates benzodiazepine and opioid demand among persons in treatment for opioid use disorder. Front Psychiatry 2023; 14:1103739. [PMID: 36741122 PMCID: PMC9892948 DOI: 10.3389/fpsyt.2023.1103739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
Background Benzodiazepine (BZD) misuse is a significant public health problem, particularly in conjunction with opioid use, due to increased risks of overdose and death. One putative mechanism underlying BZD misuse is affective dysregulation, via exaggerated negative affect (e.g., anxiety, depression, stress-reactivity) and/or impaired positive affect (anhedonia). Similar to other misused substances, BZD consumption is sensitive to price and individual differences. Although purchase tasks and demand curve analysis can shed light on determinants of substance use, few studies have examined BZD demand, nor factors related to demand. Methods This ongoing study is examining simulated economic demand for alprazolam (among BZD lifetime misusers based on self-report and DSM-5 diagnosis; n = 23 total; 14 male, 9 female) and each participant's preferred-opioid/route using hypothetical purchase tasks among patients with opioid use disorder (n = 59 total; 38 male, 21 female) who are not clinically stable, i.e., defined as being early in treatment or in treatment longer but with recent substance use. Aims are to determine whether: (1) BZD misusers differ from never-misusers on preferred-opioid economic demand, affective dysregulation (using questionnaire and performance measures), insomnia/behavioral alertness, psychiatric diagnoses or medications, or urinalysis results; and (2) alprazolam demand among BZD misusers is related to affective dysregulation or other measures. Results Lifetime BZD misuse is significantly (p < 0.05) related to current major depressive disorder diagnosis, opioid-negative and methadone-negative urinalysis, higher trait anxiety, greater self-reported affective dysregulation, and younger age, but not preferred-opioid demand or insomnia/behavioral alertness. Alprazolam and opioid demand are each significantly positively related to higher anhedonia and, to a lesser extent, depression symptoms but no other measures of negative-affective dysregulation, psychiatric conditions or medications (including opioid agonist therapy or inpatient/outpatient treatment modality), or sleep-related problems. Conclusion Anhedonia (positive-affective deficit) robustly predicted increased BZD and opioid demand; these factors could modulate treatment response. Routine assessment and effective treatment of anhedonia in populations with concurrent opioid and sedative use disorder may improve treatment outcomes. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03696017, identifier NCT03696017.
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Affiliation(s)
- Mark K. Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Tabitha E. H. Moses
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Leslie H. Lundahl
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Timothy A. Roehrs
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
- Sleep Disorders Center, Henry Ford Health System, Detroit, MI, United States
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Glicksberg L, Dempsey SK, Casey BK. Heroin and fentanyl in Dallas County: A 5-year retrospective review of toxicological, seized drug, and demographical data. J Forensic Sci 2023; 68:222-232. [PMID: 36303261 DOI: 10.1111/1556-4029.15155] [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: 08/17/2022] [Revised: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 12/31/2022]
Abstract
The opioid epidemic resulted in an increase in identifications of fentanyl, fentanyl analogs, and heroin, among other opioids, in the toxicology and seized drug analysis fields over the past several years. The Dallas County Southwestern Institute of Forensic Sciences, comprised of the Toxicology Laboratory and Drug Analysis Laboratory, observed a rise in fentanyl-positive analyses in both laboratories. Fentanyl positivity increased from 1.1% to 3.4% in the Toxicology Laboratory over the five years of this study, whereas 6-monoacetylmorphine (6-MAM) positivity remained relatively stable at approximately 2%. Similarly, in the Drug Analysis Laboratory, the fentanyl positivity rate changed from 0.03% to 0.60%, whereas heroin identification remained stable at approximately 8-9%. Based on data obtained from toxicology submissions, a typical fentanyl or heroin user was a white male in their late 30s. The average concentration of fentanyl in postmortem cases, antemortem cases, and 6-MAM in postmortem specimens was 9.7 ng/ml, 5.5 ng/ml, and 68.4 ng/ml, respectively. Poly-drug use was evident, with benzodiazepines being the most commonly co-administered drug with fentanyl (49.4%). Multiple drugs were identified via analysis of clandestine tablets submitted to the Drug Analysis Laboratory, including fentanyl and/or heroin in combination with compounds such as cocaine, etizolam, and acetaminophen. The most frequently identified clandestine tablet was "M367," typically manufactured to contain acetaminophen and hydrocodone, but was found to contain fentanyl or heroin. The results from this study aid in the understanding of the current opioid trends in Dallas County and provides an opportunity for comparison to other populations and geographical regions.
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Affiliation(s)
- Lindsay Glicksberg
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
| | - Sara K Dempsey
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
| | - Brittany K Casey
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
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Black JC, Rockhill KM, Dart RC, Iwanicki J. Clustering patterns in polysubstance mortality in the United States in 2017: a multiple correspondence analysis of death certificate data. Ann Epidemiol 2023; 77:119-126. [PMID: 35378292 DOI: 10.1016/j.annepidem.2022.03.011] [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: 11/04/2021] [Revised: 02/25/2022] [Accepted: 03/24/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE The main goal of this analysis was to identify mortality patterns apparent when many drug classes are analyzed together. METHODS The Drug Involved Mortality database is a registry of drug terms mentioned on death certificates of all drug-related deaths in the United States. Means of total number of drugs involved and percentages of specific drug combinations were calculated. Dimensionality reduction using multiple correspondence analysis and hierarchical clustering identified clusters of drugs listed on death certificates. RESULTS An average of 2.4 specific drugs were listed on death certificates in 2017. For 9 of the top 10 drugs involved, over 80% of deaths involved at least one other drug. As expected, opioid drugs and psychostimulants clustered together, but other psychoactive substances (non-opioid analgesics, sedatives, antidepressants, antipsychotics) clustered together into multi-class groups. Other drugs (e.g., acetaminophen, oxymorphone) were frequently involved in polysubstance death, but did not cluster with any other specific drug. Deaths involving illicit drugs listed fewer drugs than deaths involving prescription drugs. CONCLUSIONS While individual drug substances might contribute to many deaths (e.g., fentanyl), polysubstance mortality is more common than single substance mortality. Multidimensional analyses integrating all drugs involved are useful to identify uncommon patterns of overdose and changing trends.
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Affiliation(s)
- Joshua C Black
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO.
| | - Karilynn M Rockhill
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Janetta Iwanicki
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO
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An J, Wang X, Song H, Zhao T, Ren H, Kang W, Dong Z, Niu L, Shi H. Simultaneous determination of four sedative-hypnotics in human urine based on dendritic structured magnetic nanomaterials. ARAB J CHEM 2022. [DOI: 10.1016/j.arabjc.2022.104363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Morford KL, Tetrault JM, Zhou B, Li F, Gleeson B, Edelman EJ, Stein MD, Barry DT, Madden L. The impact of benzodiazepine exposure on treatment retention in an open-access methadone program: A retrospective cohort study. Drug Alcohol Depend 2022; 241:109707. [PMID: 36423462 PMCID: PMC9777057 DOI: 10.1016/j.drugalcdep.2022.109707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure. METHODS We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders. RESULTS Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16). CONCLUSIONS In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines.
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Affiliation(s)
- Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
- APT Foundation, 1 Long Wharf Drive, New Haven, CT 06511, United States
| | - Jeanette M. Tetrault
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
- APT Foundation, 1 Long Wharf Drive, New Haven, CT 06511, United States
| | - Bin Zhou
- Yale Center for Analytic Sciences, Yale School of Public Health, P.O. Box 208034, New Haven, CT 06520, United States
| | - Fangyong Li
- Yale Center for Analytic Sciences, Yale School of Public Health, P.O. Box 208034, New Haven, CT 06520, United States
| | - Brynna Gleeson
- Vassar College, 124 Raymond Avenue, Poughkeepsie, NY 12604, United States
| | - E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Michael D. Stein
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Boston, MA 02118. United States
| | - Declan T. Barry
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States
- APT Foundation, 1 Long Wharf Drive, New Haven, CT 06511, United States
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States
| | - Lynn Madden
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
- APT Foundation, 1 Long Wharf Drive, New Haven, CT 06511, United States
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