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Mariottini C, Häkkinen M, Kriikku P, Ojanperä I. Buprenorphine deaths confirmed by toxicology reveal a low proportion of opioid agonist treatment before death in Finland. Int J Legal Med 2024:10.1007/s00414-024-03273-5. [PMID: 38910139 DOI: 10.1007/s00414-024-03273-5] [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: 01/20/2024] [Accepted: 06/13/2024] [Indexed: 06/25/2024]
Abstract
We studied opioid agonist treatment (OAT) status before buprenorphine-related death in Finland, where buprenorphine is the principal OAT medicine and also the most misused opioid, through a retrospective population-based study using medico-legal cause-of-death investigation and OAT patient records. The study included all death cases (N = 570) between 2018 and 2020 with a buprenorphine or norbuprenorphine finding in post-mortem toxicology and with known drug misuse history or concomitant findings of illicit drugs. Of the deceased, 10% had received OAT in the year before death. Less than 1% of individuals < 25 years had received OAT, whereas the proportion in individuals ≥ 25 years was 13% (p < 0.001). There were significantly more females and more fatal poisonings (p < 0.001) among those < 25 years than among those ≥ 25 years. OAT medication at the time of death was sublingual buprenorphine-naloxone in 74% and subcutaneous buprenorphine in 23%. Except for significantly fewer benzodiazepine findings among those receiving OAT, minimal differences were found in terms of age, gender, cause and manner of death, or concomitant substance use between the deceased in and outside of OAT. Concomitant misuse of benzodiazepines, psychostimulants, alcohol, and gabapentinoids was frequent both in and outside of OAT and likely contributed to the death. These results suggest that access to OAT especially for young people and treatment of multiple addictions should be improved. Comprehensive information from medico-legal cause-of-death investigation as a starting point, combined with subsequent ante-mortem patient records, proved to be a successful approach to shed light on the Finnish scene of buprenorphine mortality.
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Affiliation(s)
- Claudia Mariottini
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland.
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland.
| | - Margareeta Häkkinen
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
- A-Clinic Ltd, Kuortaneenkatu 2, Helsinki, 00510, Finland
| | - Pirkko Kriikku
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
| | - Ilkka Ojanperä
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
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Mariottini C, Kriikku P, Ojanperä I. Concomitant drugs with buprenorphine user deaths. Drug Alcohol Depend 2021; 218:108345. [PMID: 33127184 DOI: 10.1016/j.drugalcdep.2020.108345] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Buprenorphine is abused in several countries notwithstanding its benefits as an analgesic and as an opioid agonist treatment medication. Benzodiazepines and alcohol have previously been associated with buprenorphine toxicity. This study elucidates the role of emerging concomitant drugs in different groups of buprenorphine user deaths. METHODS All cases in the Finnish national post-mortem toxicology database from 2016-2019 in which buprenorphine or norbuprenorphine was a laboratory finding in any post-mortem specimen and age at death of 15-64 years were investigated for cause and manner of death, concurrent drug and alcohol findings, age, and gender. RESULTS There were 792 deaths with a buprenorphine finding, of which buprenorphine was implicated in poisoning without other opioids in 271 cases (34 %). In this group of buprenorphine poisoning deaths, concomitant benzodiazepines were found in 94 % (clonazepam 53 %), illicit drugs in 63 %, gabapentinoids in 50 % (pregabalin 41 %), alcohol in 41 %, antidepressants in 32 %, and antipsychotics in 28 % of cases; only three deaths showed no benzodiazepines, alcohol, or gabapentinoids. Polydrug use was common regardless of the cause of death. In the age group 15 to 24 years, concomitant use of benzodiazepines and illicit drugs, and buprenorphine poisoning were more prevalent than in the age group 25-64 years. CONCLUSIONS The unprecedentedly high concomitant use of benzodiazepines in buprenorphine user deaths obscures other possible pharmacological risk factors for buprenorphine poisoning that could be relevant for prevention. Higher mortality in the younger age group suggests particularly unsafe drug use patterns that should be addressed.
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Affiliation(s)
- Claudia Mariottini
- Department of Forensic Medicine, University of Helsinki, P.O. Box 40, 00014 Helsinki, Finland; Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
| | - Pirkko Kriikku
- Department of Forensic Medicine, University of Helsinki, P.O. Box 40, 00014 Helsinki, Finland; Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
| | - Ilkka Ojanperä
- Department of Forensic Medicine, University of Helsinki, P.O. Box 40, 00014 Helsinki, Finland; Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland.
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Abstract
BACKGROUND People with substance use disorders have a well-known increased risk for taking their own life. Previous research has mainly focused on suicide in mental health services, whereas there is limited knowledge regarding suicide after contact with substance misuse services. AIMS The aim of the current study was to describe the utilisation of both mental health services and substance misuse services among people who have died by suicide within a year of contact with substance misuse services. METHOD We used an explanatory observational design, where all suicide deaths in the period from 2009 to 2016 were retrieved from the Norwegian Cause of Death Registry and linked with the Norwegian Patient Registry. The people who had been in contact with substance misuse services within a year before their death were included in the sample (n = 419). The analysis was stratified by gender, and variables with significant differences between men and women were entered into a multivariate logistic regression model. RESULTS More women (73.5%) than men (60.6%) had contact with mental health services in their last year (P = 0.01). In the adjusted logistic regression model, poisoning was more common among women (adjusted odds ratio (AOR) = 1.81, 95% CI 1.09-3.02) and women were more likely to be diagnosed with a sedative, hypnotic or anxiolytic use disorder (F14) in their last year (AOR = 2.77, 95% CI 1.37-5.68). CONCLUSIONS This study highlights gender differences for suicide in substance misuse services, and the importance of collaboration and cooperation between substance misuse services and mental health services.
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Affiliation(s)
- Martin Ø Myhre
- National Centre for Suicide Research and Prevention, University of Oslo, Norway
| | - Anine T Kildahl
- National Centre for Suicide Research and Prevention, University of Oslo, Norway
| | - Fredrik A Walby
- National Centre for Suicide Research and Prevention, University of Oslo, Norway
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Karjalainen K, Haukka J, Kuussaari K, Hautala S, Hakkarainen P. Mortality and causes of death among people suspected of driving under the influence and testing positive for multiple substances. Scand J Public Health 2019; 48:809-816. [PMID: 31856686 DOI: 10.1177/1403494819894166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: Understanding the mortality of drug users using multiple substances is helpful in preventing the harmful effects of polydrug use. We examined overall and cause-specific mortality and differences in mortality based on social background among people suspected of driving under the influence and testing positive for multiple substances (DUIMS) compared with the general Finnish population. Methods: Register data from 785 DUIMS during 2003-2006 were studied, with a reference population (n = 25,381) drawn from the general Finnish population. The effect of DUIMS on all-cause and cause-specific mortality was estimated using a Poisson regression model. Results: DUIMS had an increased risk of death compared with the general population (MRR 5.3, 95% CI 4.2-6.6). The most common causes of death in DUIMS were poisonings (37.9%) and suicides (13.6%), whereas in the reference population these were cardiovascular diseases (30.8%) and cancer (26.6%). The cause-specific risk of death among DUIMS was higher in all observed causes of death, except for cancer. The effect of DUIMS on mortality was modified by age, employment status and marital status; DUIMS was associated with an elevated risk of death especially in younger age groups and in singles. Conclusions: DUIMS indicates higher mortality, and DUIMS' profiles in causes of death differ from the general population. Elevated risk for, for instance, suicidal, accidental and violent death among those using multiple substances highlights the need to also pay attention to causes of death other than poisoning/overdose.
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Affiliation(s)
- Karoliina Karjalainen
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Finland
| | - Jari Haukka
- Department of Public Health, Clinicum, University of Helsinki, Finland
| | - Kristiina Kuussaari
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Finland
| | - Sanna Hautala
- Faculty of Social Sciences, University of Lapland, Finland
| | - Pekka Hakkarainen
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Finland
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Selin J, Perälä R, Stenius K, Partanen A, Rosenqvist P, Alho H. Opioid substitution treatment in Finland and other Nordic countries: Established treatment, varying practices. NORDIC STUDIES ON ALCOHOL AND DRUGS 2017. [DOI: 10.1515/nsad-2015-0028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jani Selin
- The Tobacco, Gambling and Addiction Unit National Institute for Health and Welfare
| | - Riikka Perälä
- Department of Social Research, University of Helsinki
| | - Kerstin Stenius
- The Alcohol and Drugs Unit National Institute for Health and Welfare
| | - Airi Partanen
- The Tobacco, Gambling and Addiction Unit National Institute for Health and Welfare
| | | | - Hannu Alho
- The Tobacco, Gambling and Addiction Unit National Institute for Health and Welfare
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Rönkä S, Katainen A. Non-medical use of prescription drugs among illicit drug users: A case study on an online drug forum. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 39:62-68. [DOI: 10.1016/j.drugpo.2016.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 08/26/2016] [Accepted: 08/29/2016] [Indexed: 12/24/2022]
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Derbel I, Ghorbel A, Akrout FM, Zahaf A. Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia. Afr Health Sci 2016; 16:1067-1077. [PMID: 28479900 DOI: 10.4314/ahs.v16i4.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Illicit use of high dosage buprenorphine has been well documented in several countries, including Tunisia. OBJECTIVES The aim of this survey is to assess the buprenorphine withdrawal syndrome time course, and how it may be affected by the population characteristics among subjects admitted to a rehabilitation center in Tunisia. METHODS A prospective research has permitted study of the socio-demographic characteristics and assessment of buprenorphine withdrawal syndrome among 32 subjects admitted for buprenorphine dependence by using the clinical opiate withdrawal scale. An ANOVA was conducted to examine the effect of different factors on the withdrawal scores. RESULTS 32 subjects were included. Among them 30 were males, 27 had been injecting buprenorphine, 16 were poly-drug abusers and 2 had a history of mental disorders. Buprenorphine withdrawal syndrome was of a mild intensity and had a delayed onset. Withdrawal mean scores varied between 0 and 9, and maximum values were reached at day 21. These scores varied significantly over time (p<0,001). The sex v time interaction and the mode of consumption of buprenorphine had significant effects on the withdrawal scores (p<0,001). The poly-drug consumption and the history of mental disorders did not have any significant effect on the withdrawal scores. CONCLUSION This study has permitted description of buprenorphine withdrawal syndrome among patients going through a detoxification treatment at a rehabilitation center. Understanding this syndrome would help elaborate effective and suitable buprenorphine dependence management plans.
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Affiliation(s)
- Ines Derbel
- Faculty of Pharmacy, University of Monastir, Tunisia
| | - Asma Ghorbel
- Faculty of Pharmacy, University of Monastir, Tunisia
- Hygiene Laboratory Hedi Chaker Hospital, South of Tunisia
- Research Laboratory Toxicology and Environment RL12SP07
| | - Férièle Messadi Akrout
- Faculty of Pharmacy, University of Monastir, Tunisia
- Hygiene Laboratory Hedi Chaker Hospital, South of Tunisia
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Abstract
As a result of the prescription opioid epidemic in the United States, there has been an increasing need for effective treatment interventions, both pharmacological and nonpharmacological. Buprenorphine has emerged as a critical component of the treatment of opioid use disorder, yet its adoption has not been without some concerns. This article first reviews the pharmacology, clinical use, and US legislative action related to buprenorphine, followed by a discussion of the misuse and diversion of buprenorphine in the United States as well as internationally. We then explore the impact of buprenorphine abuse as well as discussing strategies for its reduction, including changes in policy, prescription and pharmacy monitoring, and continuing medical education for guiding and improving clinical practice.
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Manninen M, Pankakoski M, Gissler M, Suvisaari J. Adolescents in a residential school for behavior disorders have an elevated mortality risk in young adulthood. Child Adolesc Psychiatry Ment Health 2015; 9:46. [PMID: 26388934 PMCID: PMC4574605 DOI: 10.1186/s13034-015-0078-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/18/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Conduct problems during adolescence are associated with an elevated mortality risk. This study investigated the mortality rate, causes of death, and changes over time in a Finnish residential school (RS) population. METHODS All adolescents (N = 885, M/F = 594/291, age mean 15.2 years at baseline) residing in the RS system in 1991, 1996, 2001, and 2006 and matched controls were included in a register-based study with a follow-up time of up to 22 years. RESULTS The all-cause mortality rate for people with an RS background was 6.7 % compared to 1.0 % in the controls (Hazard Ratio HR = 6.95, 95 % 4.66-10.37, p < 0.001). 8.1 % of the RS boys had died compared to 2.2 % of the girls (HR = 2.2, p = 0.02). The HR for substance-related death was 24.31 (95 % CI 9.3-65.53, P < 0.001), for suicide 7.23 (95 % CI 3.24-16.11, P < 0.001) and for other external causes 5.45 (95 % CI 2.41-12.36, P < 0.001) compared to controls. Mortality peaked among RS boys at approximately 25 years, whereas for girls it peaked after 30 years. CONCLUSIONS Adolescents with severe disruptive behavior problems have a seven-fold risk for premature adult-age death compared to matched controls. The most common causes for death were avoidable, substance-related followed by suicide. Effective treatment of mental and substance use related problems during and after the placement is needed to reduce mortality.
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Affiliation(s)
- Marko Manninen
- National Institute for Health and Welfare, Mannerheimintie 166, 00300 Helsinki, Finland
| | - Maiju Pankakoski
- National Institute for Health and Welfare, Mannerheimintie 166, 00300 Helsinki, Finland
| | - Mika Gissler
- National Institute for Health and Welfare, Mannerheimintie 166, 00300 Helsinki, Finland
| | - Jaana Suvisaari
- National Institute for Health and Welfare, Mannerheimintie 166, 00300 Helsinki, Finland
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A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world. J Addict Med 2015; 8:315-26. [PMID: 25221984 DOI: 10.1097/adm.0000000000000045] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse, and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse, and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication nonadherence, are discussed, and gaps in knowledge are identified. Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability and medications with no known abuse. The objective was to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion.
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