Drug poisoning deaths in Sweden show a predominance of ethanol in mono-intoxications, adverse drug-alcohol interactions and poly-drug use

Fatal Intoxications with Zopiclone-A Cause for Concern?

INTRODUCTION

Zopiclone, a controlled substance prescribed for insomnia, has become a common toxicological finding in forensic autopsy cases. This study investigated the role and extent of zopiclone use in fatal intoxications in Sweden.

METHODS

All forensic autopsy cases positive for zopiclone in femoral blood during 2012-2020 were selected. Among these cases, fatalities caused by intoxication according to the cause of death certificates issued by the forensic pathologist were identified. Intoxications where zopiclone contributed to the cause of death were included in the study. The Swedish Prescribed Drug Register was utilized to examine whether the included cases were prescribed zopiclone or not.

RESULTS

In total 7320 fatal intoxications underwent a forensic autopsy during the study period, 573 of them were caused by zopiclone. Among the zopiclone fatalities, 87% (n = 494) had a prescription for zopiclone, and 8% (n = 43) were monointoxications. Most fatalities, 62% (n = 354) were suicides, and zopiclone was involved in about 17% (n = 354) of all intoxication suicides in Sweden. Women were significantly (p < 0.01) overrepresented in suicides with zopiclone, comprising 56% (n = 291) of fatalities. The median age was 55 years among zopiclone intoxications compared with 44 years amongst all fatal intoxications.

CONCLUSION

This study demonstrates that the toxicity of zopiclone can be lethal both in combination with other substances and on its own. Most individuals dying in fatal zopiclone intoxications were prescribed zopiclone, which potentially indicates that a more restrictive prescribing rate could prevent future intoxication deaths, especially when caring for patients with an increased suicide risk.

The role of alcohol and patterns of alcohol-related deaths in Republic of North Macedonia within the period 2007-2020

Excessive alcohol consumption is one of the most important factors in a substantial number of violent deaths. The aim of our study was to investigate alcohol-related deaths in the Republic of North Macedonia in the period from 2007 to 2020, in order to study the influence of elevated blood alcohol levels in violent deaths. Five hundred sixty-four post-mortem blood samples from alcohol-related death cases-natural deaths and violent deaths (suicides, accidents, and homicides)-were analyzed, and the results were evaluated according to sex, age, and cause of death. Among 564 cases, traffic accidents were the leading cause of violent death (54.3% of the cases) followed by suicides (19.9% of the cases). In the examined post-mortem samples, BAC values ranged from 0.15-6.20 g/L. The average age was 45 ± 16 years for the male and 49 ± 19 years for the female group. The biggest proportion of high BAC values was found in the group of accidents specifically road traffic accidents and accidental intoxication as well as in the group of bolus deaths. The analysis of BAC in the cases of violent deaths in the Republic of North Macedonia confirmed that consumption of alcohol is strongly related to violent deaths. The data obtained from this study could raise caution and give aid in a national strategy for the prevention of alcohol-related violent deaths.

Post-mortem toxicological analysis of cocaine: main biological samples and analytical methods

This scoping review intends to identify the most used analytical methods and biological samples in the post-mortem forensic toxicological analysis of cocaine and its metabolites. A scoping review was performed based on the question "What are the analytical methods and types of biological samples most frequently used to identify and quantify cocaine in post-mortem forensic toxicology?" The studies were selected from five databases and, after exclusions, the data were tabulated, analyzed, and reported. Twenty-one articles published between 2012 and 2022 were filtered from five different databases to be studied. The collected data indicate that the most used biological samples were blood and hair. The most used sample preparation technique was solid phase extraction, while the most mentioned chromatography method was liquid chromatography with mass spectrometry. This review presents and discusses the state of the art regarding methods for the detection sensitivity spectrum, why limits of quantification are so important for these methods, and what are the most suitable biological samples to be utilized in each case. Cocaine and metabolites are important in forensic toxicologic post-mortem analysis. However, there is little concern in the development of miniaturized and automated sample preparation in this field. Besides, there is not enough understanding of post-mortem redistribution, tolerance, drug-drug interactions, and pre-existing medical conditions.

Ethanol inhibits dopamine uptake via organic cation transporter 3: Implications for ethanol and cocaine co-abuse

Concurrent cocaine and alcohol use is among the most frequent drug combination, and among the most dangerous in terms of deleterious outcomes. Cocaine increases extracellular monoamines by blocking dopamine (DA), norepinephrine (NE) and serotonin (5-HT) transporters (DAT, NET and SERT, respectively). Likewise, ethanol also increases extracellular monoamines, however evidence suggests that ethanol does so independently of DAT, NET and SERT. Organic cation transporter 3 (OCT3) is an emergent key player in the regulation of monoamine signaling. Using a battery of in vitro, in vivo electrochemical, and behavioral approaches, as well as wild-type and constitutive OCT3 knockout mice, we show that ethanol's actions to inhibit monoamine uptake are dependent on OCT3. These findings provide a novel mechanistic basis whereby ethanol enhances the neurochemical and behavioral effects of cocaine and encourage further research into OCT3 as a target for therapeutic intervention in the treatment of ethanol and ethanol/cocaine use disorders.

Potential drug-drug interactions in acute poisonings managed in the intensive care unit: Occurrence, risk factors and relationship to patient severity on admission

Beyond the direct toxicity resulting from each drug in the poisoned patient, additional toxicities may result from drug-drug interactions (DDIs). We aimed to determine the frequency of potential DDIs in the poisoned patient and investigate whether DDIs are associated with severity. We conducted a 1-year cohort study in a toxicological ICU. DDIs were identified using an electronic interaction-checker tool. Among our 354 ICU poisoned patients, 134 (38%) presented at least one potential DDI between acute poisoning drugs and 180 (51%) at least one potential DDI between acute poisoning and long-term treatment drugs. Using multivariate analyses, previous suicide attempt was associated with the presence of potential DDIs between acute poisoning drugs in suicide attempt patients (P = 0.014). Chronic alcoholism (P = 0.005) and tobacco smoking (P = 0.022) were associated with the presence of potential DDIs between acute poisoning and long-term treatment drugs in recreational drug users. Presence of potential DDIs between acute poisoning and long-term treatment drugs was associated with catecholamine infusion (P = 0.022) in suicidal self-exposure patients. Presence of potential pharmacodynamic DDIs between acute poisoning and long-term treatment drugs was associated with aspiration pneumonia onset in recreational drug users (P = 0.03). ICU poisoned patients present a high rate of potential DDIs that may influence the outcome.

Trends in fatal and nonfatal overdose by race among people who inject drugs in Baltimore, Maryland from 1998 to 2019

OBJECTIVE

The objective of this study was to examine trends in fatal and nonfatal overdose in a community-based sample of current and former people who inject drugs (PWID).

METHODS

Data from 4826 current and former PWID from the AIDS Linked to the IntraVenous Experience (ALIVE) observational cohort study in Baltimore, Maryland, were used to characterize fatal and nonfatal overdose rates from 1998 to 2019. Poisson regression was used to examine factors associated with nonfatal overdose and differences by race among 1052 PWID between 2014 and 2019.

RESULTS

Fatal overdose rates reached a high of 13 per 1000 person-years in 2018. Among 1052 current and former PWID, of whom 75% were Black and one-third were female, the nonfatal overdose rate of 529 per 1000 person-years in 2019 was 8 times higher than 2014 (incidence rate ratio [IRR]=7.76, 95% CI: 3.35, 18.0). The annual adjusted increase in nonfatal overdose rate was 53% among Black PWID (IRR=1.53, 95% CI: 1.34, 1.75), compared to 14% among White PWID (IRR=1.14, 95% CI: 0.88, 1.46). Urban residence, opioid use, depressive symptoms, and hepatitis C infection were positively associated with nonfatal overdose among Black PWID. Recent injection drug use and tranquilizer use was associated with increased overdose among Black and White PWID.

CONCLUSIONS

Rates of fatal and nonfatal overdose were high and increased from 2014 to 2019 among current and former PWID, with the most dramatic increases in nonfatal overdose observed among Black PWID. These findings highlight the urgent need for additional resources to reduce the differential harms associated with opioids by race.

Prevalence of new psychoactive substances (NPS) in Brazil based on oral fluid analysis of samples collected at electronic music festivals and parties

BACKGROUND

New psychoactive substances (NPS) use is a worldwide public health issue. Knowing the prevalence of NPS guides public health and legal policies to address the problem. The objective of this study was to identify NPS in Brazil through the analysis of oral fluid (OF) samples collected at parties and electronic music festivals.

METHODS

Anonymous questionnaires and oral fluid samples were collected from volunteers (≥18 years) who reported the consumption of at least one illicit psychoactive substance in the last 24 h. Oral fluid sample collections occurred at eleven parties and two electronic music festivals over 16 months (2018-2020). Questionnaire answers were matched to oral fluid toxicological results.

RESULTS

Of 462 oral fluid samples, 39.2 % were positive for at least one NPS by liquid chromatography‒tandem mass spectrometry (LC-MS/MS). The most prevalent NPS was ketamine (29.4 %), followed by methylone (6.1 %) and N-ethylpentylone (4.1 %); however, MDMA was the most commonly identified (88.5 %) illicit psychoactive substance. More than one drug was identified in 79.9 % of samples, with two (34.2 %) and three (23.4 %) substances most commonly observed. Only 5 % of volunteers reported recent NPS consumption.

CONCLUSION

MDMA is still the most common party and electronic music festival drug, although NPS were identified in more than one-third of oral fluid samples.

Summary statistics for drugs and alcohol concentration recovered in post-mortem femoral blood in Western Switzerland

In post-mortem investigations of fatal intoxication, it is challenging to determine which drug(s) were responsible for the death, and which drugs did not. This study aims to provide post-mortem femoral blood drug levels in lethal intoxication and in post-mortem control cases, where the cause of death was other than intoxication. The reference values could assist in the interpretation of toxicological results in the routine casework. To this end, all post-mortem toxicological results in femoral blood from 2011 to 2017 in Western Switzerland were considered. A full autopsy with systematic toxicological analysis (STA) was conducted in all cases. Results take into account the cause of death classified into one of four categories (as published by Druid and colleagues): I) certified intoxication by one substance alone, IIa) certified intoxication by more than one substance, IIb) certified other causes of death with incapacitation due to drugs, and III) certified other causes of death without incapacitation due to drugs. This study includes 1 990 post-mortem cases where femoral blood was analysed. The material comprised 619 women (31%) and 1 371 men (69%) with a median age of 50 years. The concentrations of the 32 most frequently recorded substances as well as alcohol are discussed. These include 6 opioids and opiates, 3 antidepressants, 6 neuroleptics and hypnotics, 1 barbiturate, 11 benzodiazepines (and related drugs), 2 amphetamine-type stimulants, cocaine, paracetamol, and tetrahydrocannabinol (THC). The most common substances that caused intoxication alone were morphine, methadone, ethanol, tramadol, and cocaine. The post-mortem concentration ranges for all substance are categorized as I, IIa, IIb, or III. Statistical post-mortem reference concentrations for drugs are discussed and compared with previously published concentrations. This study shows that recording and classifying cases is time-consuming, but it is rewarding in a long-term perspective to achieve a more reliable information about fatal and non-fatal blood concentrations.

Designer benzodiazepines versus prescription benzodiazepines: can structural relation predict the next step?

Designer benzodiazepines are a part of the recently discovered abuse synthetic drugs called Novel Psychoactive Substances (NPS) which need to be controlled due to their constantly growing market. Most of them are derived from the medically approved benzodiazepines used nowadays yet, may possess stronger effects, more toxicity, and longer durations of action. Some differences have also been observed in their detection and characteristics, in addition to the variations discovered in postmortem redistribution and drug stability. All these major alterations in features can result from only minor structural modifications. For example, a classic benzodiazepine (BZD) like diazepam only lacks one fluorine atom which exists in its derivatized designer drug, diclazepam, making substantial differences in activity. For this reason, it is essential to study the designer drugs in order to identify their dangers and distinguish them thus rule out their abuse and control the spread of such drugs. This review would highlight the distinct characteristics of some of the most commonly abused designer benzodiazepine analogies in relation to their original prescription BZD compounds.

Beliefs about Perioperative Opioid and Alcohol Use among Elective Surgical Patients Who Report Unhealthy Drinking: A Qualitative Study

OBJECTIVES

Elective surgical patients with unhealthy alcohol use have unique pain management needs and addiction risk factors that are relevant to surgical preparation and recovery. This descriptive qualitative study sought to better understand patients' beliefs and behaviors related to opioid use, alcohol use, and pain management in the perioperative context.

DESIGN

We conducted individual semi-structured interviews between July 2017 and March 2018.

SETTING

A large Midwestern academic health system.

SUBJECTS

Participants were elective surgical patients meeting unhealthy alcohol use criteria, recruited from the health system's preoperative anesthesia clinic.

METHOD

Semi-structured interview guides explored beliefs and behaviors relating to alcohol and opioid use, health status, and surgical care. Interview recordings were transcribed and coded for thematic analysis.

RESULTS

Among 20 elective surgical patients (25% female), we identified three key themes regarding alcohol use, opioid use, and their co-use before and after surgery. First, desires and intentions to use opioids for postoperative pain management varied widely, even before opioids were prescribed. Second, some participants described alcohol as a preferred pain management strategy. Third, participants held a range of beliefs about the risks and benefits of alcohol and opioid co-use.

CONCLUSION

Appropriate assessment of beliefs and intentions regarding opioid and alcohol use could help identify patients most vulnerable to new opioid problems and unhealthy alcohol use in the context of perioperative surgical pain. These findings have important implications for perioperative pain management.

Quantifying enhanced risk from alcohol and other factors in polysubstance-related deaths

BACKGROUND

To quantify how alcohol, polysubstance use and other factors influence opioid concentrations in drug-related deaths in West Virginia (WV), United States.

METHODS

Multiple linear regression models were employed to identify relationships among alcohol, other factors, and the concentrations of four commonly identified opioids (fentanyl, hydrocodone, oxycodone, methadone), accounting for demographic, toxicological and comorbid characteristics in WV drug-related deaths from 2005 to 2018.

RESULTS

Alcohol concentrations of 0.08% or above were associated with significant reductions in blood concentrations of fentanyl (27.5%), hydrocodone (30.5%) and methadone (32.4%). Significantly lower predicted concentrations of all opioids studied were associated with multiple opioid vs. single opioid presence, with predicted concentration reductions ranging from 13.7% for fentanyl to 65-66% for hydrocodone and oxycodone. Benzodiazepine presence was associated with small, non-statistically significant changes in opioid concentrations, while stimulant presence was associated with statistically significant reductions in hydrocodone and oxycodone concentrations.

CONCLUSIONS

Co-ingestion of alcohol, multiple opioids or stimulants were associated with significantly decreased predicted concentrations of commonly identified opioids in drug deaths. Further evidence is provided for enhanced risks from polysubstance use with opioids, which has important public health implications.

Significant decrease in the rate of fatal alcohol poisonings in Finland validated by blood alcohol concentration statistics

BACKGROUND

Alcohol may cause death directly by acute poisoning, as well as induce illnesses or accidents that lead to death. Our research question was whether the current decreasing trend in acute fatal alcohol poisonings in Finland is a real phenomenon or an artefact caused by possible changes in the process of determining the cause of death.

METHODS

All cases in the national post-mortem toxicology database in which the underlying cause of death was acute alcohol poisoning in 1987-2018 were investigated in terms of blood alcohol concentration (BAC), age and gender. The number of acute alcohol poisonings was compared to the number of deaths from alcohol induced illness in the post-mortem toxicology database.

RESULTS

A total of 12 126 acute alcohol poisoning cases were retrieved. Between 2004 and 2017 the number of acute alcohol poisonings decreased 60.1 %. At the same time the number of alcohol induced illnesses in the study material remained stable or decreased marginally. The median BAC in all acute alcohol poisonings was 3.2 g/kg. The annual median BAC values showed a small but significant decrease over the study period. The proportion of women in acute alcohol poisonings increased significantly over the study period, from 17.1%-22.3%. Women were on average 2.5 years older than men.

CONCLUSIONS

On grounds of the BAC statistics and supporting evidence, we conclude that the significant decrease in the number of fatal alcohol poisonings is true and likely reflects changes in the overall consumption of alcohol.

The Role of Drugs in Alcohol Poisoning and Blackout Events: A Latent Class Analysis of a Residential Treatment Sample

BACKGROUND

Alcohol can lead to fatal and nonfatal overdose (OD) through its neurobiological inhibitory effects when used alone or with other drugs. Little research has examined alcohol OD characteristics in the context of concomitant drug use.

METHODS

This study utilized alcohol OD data (defined as alcohol poisoning, passing out, or blacking out) collected in a large residential addiction treatment facility (N = 660). Latent class analysis identified classes of alcohol OD events based on concomitant drug use at the time of OD. We evaluated correlates of alcohol OD classes, including depression, emergency medical services, and hospitalization, using latent class regression.

RESULTS

Only 20% of alcohol ODs involved alcohol alone. Marijuana was the most commonly used drug during the most recent alcohol OD (43.2%), followed by sedatives (27.9%), cocaine or crack (25.9%), prescription opioids (26.1%), and heroin (20%). The final latent class model included 3 classes: no/low drug involvement (61%), moderate drug involvement (33%), and high drug involvement (6%). Relative to the no/low drug involvement class, participants admitted to the hospital were 6.4-fold more likely to be in the high drug involvement class (95% CI: 2.4 to 16.6) and 2.9-fold more likely to be in the moderate drug involvement class (95% CI: 1.2 to 7.2). Participants receiving emergency medical services were more likely to be in the high drug involvement class (aOR: 2.2, 95% CI: 2.2, 1.1 to 4.5) and less likely to be in the moderate drug involvement class (aOR 0.39, 95% CI: 0.2 to 0.96).

CONCLUSIONS

Combining drug classes with alcohol prior to OD was common and associated with a higher likelihood of hospitalization. Overdose prevention efforts should address acute risks of alcohol ingestion with other drugs.

Positive drug test trends in fatally-injured drivers in the United States from 2007 to 2017

Background

The last two decades have seen tremendous changes in the U.S. environment surrounding drugs. Driving under the influence of drugs is a growing public health hazard. The present study examined trends in drug involvement in fatally-injured drivers in the U.S.

Methods

Data were drawn from the 2007–2017 Fatality Analysis Reporting System. Cochran–Armitage tests were performed to assess the statistical significance of changes in the yearly prevalence of positive drug tests in fatally-injured drivers over time. In addition, analyses were stratified by sex, race, and age.

Results

The yearly prevalence of positive drug tests in fatally-injured drivers increased significantly from 20.7% in 2007 to 30.7% in 2017, with results showing a higher prevalence among males, those aged 21–44, and Whites. The gap between Blacks and Whites narrowed in 2017. There was a decline in the yearly prevalence in all age groups between 2016 and 2017, although the decrease in the 21–44 age group was much smaller than other age groups. Among drivers who tested positive for drugs, 34.6% had a blood alcohol concentration (BAC) above the threshold of per se evidence for impaired driving, and 63% had a BAC below the threshold.

Conclusions

Our results indicate that the overall yearly prevalence of fatally-injured drivers who tested positive for drugs increased significantly from 2007 to 2017, with similar results found for subgroups. Findings further highlight that drugged driving remains a public health priority, and more action is needed to stem this disturbing trend.

Forensic appraisal of death due to acute alcohol poisoning: three case reports and a literature review

Death due to acute alcohol poisoning lacks specific anatomical characteristics, compared with other deaths due to drug poisoning. We report three forensic cases of death from acute alcohol poisoning due to inhibition of the respiratory centre and eventual asphyxia. Blood alcohol concentrations in the three fatalities were 5.28, 3.33 and 3.78 mg/mL, respectively. Lethal doses and blood alcohol concentrations showed differences between individuals. Detailed auxiliary tests besides autopsy were undertaken. These cases show that forensic scientists should exclude other causes of death, combine the autopsy with auxiliary tests, and then make an appraisal.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Forensic Drug Profile: Cocaethylene

This article is intended as a brief review or primer about cocaethylene (CE), a pharmacologically active substance formed in the body when a person co-ingests ethanol and cocaine. Reference books widely used in forensic toxicology contain scant information about CE, even though this cocaine metabolite is commonly encountered in routine casework. CE and cocaine are equi-effective at blocking the reuptake of dopamine at receptor sites, thus reinforcing the stimulant effects of the neurotransmitter. In some animal species, the LD50 of CE was lower than for cocaine. CE is also considered more toxic to the heart and liver compared with the parent drug cocaine. The plasma elimination half-life of CE is ~2 h compared with ~1 h for cocaine. The concentrations of CE in blood after drinking alcohol and taking cocaine are difficult to predict and will depend on the timing of administration and the amounts of the two precursor drugs ingested. After an acute single dose of cocaine and ethanol, the concentration–time profile of CE runs on a lower level to that of cocaine, although CE is detectable in blood for several hours longer. A strong case can be made for adding together the concentrations of cocaine and CE in forensic blood samples when toxicological results are interpreted in relation to acute intoxication and the risk of an overdose death.

Challenges in investigation of diabetes-related aviation fatalities-an analysis of 1491 subsequent aviation fatalities in USA during 2011-2016

Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau's database between years 2011-2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (~ 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.

Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice

Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.

Non-medical use of psychoactive prescription drugs is associated with fatal poisoning

AIMS

The aims of this study were to estimate the prevalence and predictors of non-medical substance use, and to assess the association between non-medical substance use and fatal poisoning or history of drug abuse in Finland.

DESIGN AND SETTING

Retrospective cohort study of all medico-legally investigated death cases in Finland. The postmortem toxicology database was linked together with the register on reimbursed prescription medicines.

PARTICIPANTS AND CASES

All postmortem cases between 2011 and 2013 positive for one or more of the following drugs: oxycodone, fentanyl, tramadol, clonazepam, gabapentin, pregabalin, tizanidine, olanzapine, quetiapine, risperidone, alprazolam, zolpidem, mirtazapine and bupropion, n = 2974.

MEASUREMENTS

Non-medical use of substance was the outcome variable. Predictors were the following: gender, residence at the time of death, place of death, blood alcohol concentration, age, drug abuse, number of prescriptions of any psychoactive drugs in last year and proportion of prescriptions issued by psychiatrist in last year.

FINDINGS

In 50.4% of the studied cases, at least one drug was detected without a prescription. Clonazepam, alprazolam and tramadol were the most prevalent non-medical findings in these cases (6.6, 6.1 and 5.6%, respectively). The risk of non-medical use of prescription drugs was especially high in cases with history of drug abuse (88.5%) and in fatal poisonings (71.0%). The proportion of non-medical use of the studied substances varied between 5.9% [95% confidence interval (CI) = 3.1-10.1%)] for risperidone and 55.7% for fentanyl (95% CI = 44.1-66.9%). Valid prescription for one or more of any psychoactive drug was associated with lower odds for non-medical use of the studied substances. Additionally, the higher the proportion of psychoactive drugs prescribed by a psychiatrist, the lower the probability of non-medical use.

CONCLUSIONS

Non-prescribed psychoactive drugs are found commonly at postmortem in drug poisoning deaths in Finland, with history of drug abuse being a major contributing factor.

High-intensity drinking and nonmedical use of prescription drugs: Results from a national survey of 12th grade students

BACKGROUND

Nearly 10% of U.S. 12th graders report high-intensity drinking (10+ or 15+ drinks in a row), but the extent to which these drinkers also engage in nonmedical use of prescription drugs (NMUPD) is largely unknown. This study examined the associations between different thresholds of past two-week high-intensity drinking and past-month NMUPD among U.S. 12th graders.

METHODS

The sample consisted of eleven nationally representative cross-sections of 12th graders in the Monitoring the Future study (2005-2015) who answered questions on past two-week drinking behaviors and past-month nonmedical use of prescription opioids, sedative, stimulants, and tranquilizers (N=26,502 respondents).

RESULTS

High-intensity drinking during the past two-weeks was associated with an increased risk of past-month NMUPD. The odds of NMUPD were four times larger among 12th graders who indicated drinking 15 or more drinks on at least one occasion (AOR=4.43, 95% CI=3.18, 5.01) relative to those who had 0-4 drinks during the past two-weeks, after adjusting for relevant covariates. These associations were similar across different classes of prescription drugs and tended to be stronger among non-white respondents. A sub-analysis revealed simultaneous co-ingestion of alcohol and NMUPD was more prevalent among high-intensity drinkers.

CONCLUSIONS

More than 1 in every 4 U.S 12th graders who engage in high-intensity drinking (15+ drinks in a row) also report NMUPD. Given the greater likelihood of simultaneous co-ingestion of alcohol and prescription drugs among high-intensity drinkers, adolescent substance use interventions need to address the risks associated with mixing alcohol and prescription drugs.

The Appearance, Taste, and Concentrations of Zolpidem Dissolved in Still Water and Carbonated Beverages

Zolpidem is a sedative that could be used to drug victims, but its suitability to dissolve in drinks is unknown. In this small study, we added either crushed or whole tablets of zolpidem hemitartrate to carbonated beverages or still water to observe how this affected the taste and appearance. Also, concentrations were measured by ultra-high performance liquid chromatography tandem mass spectrometry at different time intervals. Two crushed tablets (20 mg) in cider (250 mL) lead to a maximum concentration of 84 mg/L zolpidem base after 30 min, while the corresponding concentration after adding fifteen tablets (150 mg) was 467 mg/L. There was little change in taste, but froth and turbidity were observed when adding high doses to carbonated beverages. Carbonated beverages spiked with 20 mg of crushed zolpidem hemitartrate tablets reached concentrations that could cause impairment. Spiking with 150 mg could possibly be lethal if several mouthfuls were ingested.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

Converging Patterns of Alcohol Use and Related Outcomes Among Females and Males in the United States, 2002 to 2012

BACKGROUND

Females in the United States consume less alcohol and cause and experience fewer alcohol-related harms than males. However, recent research suggests such gaps might be narrowing. The purpose of this study was to explore changes in alcohol use and associated outcomes among females and males in the United States between 2002 and 2012.

METHODS

Data from the National Survey on Drug Use and Health were used to assess the prevalence and trends for females and males aged 12+ in lifetime abstinence, age of onset, current drinking, binge drinking, drinking and driving, reaching DSM-IV criteria for an alcohol use disorder, combining alcohol with other drugs such as marijuana, and other variables. Of particular interest was whether differences between females and males narrowed during the decade under study.

RESULTS

Differences in the drinking patterns of females and males aged 12+ narrowed between 2002 and 2012 for current drinking, number of drinking days per month, past year DSM-IV alcohol abuse, and past-year driving under the influence of alcohol. In addition, convergence was noted in 1 or more age subgroups for the prevalence of binge drinking and DSM-IV alcohol dependence and mean age at drinking onset. Divergence in drinking habits did not occur for any measure in any age subgroups with the exception of a greater increase in the prevalence of combining alcohol with marijuana among young adult male drinkers than female drinkers aged 18 to 25.

CONCLUSIONS

Between 2002 and 2012, differences in alcohol consumption and related outcomes narrowed for females and males. Reasons for converging patterns of alcohol use are unclear and do not appear to be easily explainable by recent trends in employment status, pregnancy status, or marital status. More research is needed to identify the psychosocial and environmental contributors to these changes and to assess implications for prevention and treatment efforts.

Sedative-hypnotics are widely abused by drivers apprehended for driving under the influence of drugs

BACKGROUND

Sedative-hypnotics are commonly encountered in drivers apprehended for driving under the influence of drugs (DUID). Previous research has mainly concentrated on the residual effects of the drugs.

METHODS

In this study, the extent of sleep medication use and abuse among drivers apprehended on suspicion of DUID was assessed. Additionally, the prevalence and concentrations of the drugs, concomitant use of other drugs of abuse, and the age and sex of the drivers positive for the most commonly prescribed sedative-hypnotics (temazepam, midazolam, nitrazepam, zopiclone, and zolpidem) in DUID cases in Finland in 2009 to 2011 were examined.

RESULTS

Sedative-hypnotics were found in 3155 samples of the 13,248 that were analyzed. Temazepam was present in over half of the cases (57.9%), along with other benzodiazepines such as midazolam (13.1%) and nitrazepam (7.0%) and the non-benzodiazepine hypnotics zopiclone (12.2%) and zolpidem (9.8%). The mean age of the drivers using the studied sedative-hypnotics was 33.5 years. Many of the drivers were polydrug users; concomitant stimulant use was found in nearly half of the cases. Cannabis and alcohol were also very common co-findings. In nearly 20% of the cases, the driver had taken more than 1 of the studied sedative-hypnotics; only 2.5% had no findings other than a single sedative-hypnotic in their blood. The drug use pattern of those positive for zopiclone and zolpidem was somewhat different from that of users of benzodiazepine sedative-hypnotics; their age was higher and the concomitant use of illegal stimulants was markedly less prevalent than among the users of temazepam, midazolam, and nitrazepam.

CONCLUSIONS

There were very few cases in our study population where the positive sedative-hypnotic finding could have been due to appropriate medical use. The extremely prevalent concomitant use of other psychoactive drugs and the high median serum concentrations of the studied sedative-hypnotics suggest their widespread abuse among apprehended drivers.

Deaths by poisoning in Norway 2003-2012

CONTEXT

Poisoning is an important category of avoidable deaths in Norway and an important public health issue. Close monitoring of any development in this field is essential for effective preventive measures.

OBJECTIVE

To assess the pattern and trends of poisoning mortality in Norway from 2003 to 2012 based on official mortality data.

MATERIALS AND METHODS

This is a population-based registry study. We analyzed the underlying external cause of death data, in order to assess poisoning deaths (ICD-10) by accidents (X40-X49); intentional self-harm (suicide) (X60-X69); assault (homicide) (X85-X90); and poisoning of undetermined intent (Y10-Y19). We compared poisoning deaths to other injury mechanisms and used multiple injury cause data to identify substances involved in poisoning deaths. Poisson regression was applied to estimate the trend.

RESULTS

Poisoning was the second leading mechanism of injury deaths in Norway from 2003 to 2012, causing between 424 and 496 deaths each year. The rates of poisoning deaths varied between 8 and 11 per 100,000 inhabitants, with a peak in 2004. About 3366 of the 4620 poisoning deaths in the decade were accidental. Opioids were the most common causative agents. Heroin caused 150 deaths in 2004. The numbers fell to 63 in 2012 but showed great yearly variations. Deaths by methadone increased from 24 in 2003 to 61 in 2012.

DISCUSSION

Poisoning mortality rates declined from 2003 to 2012. Interpretation of the data, however, should be done with caution, and comparison with other countries may be biased due to differences in data production procedures. Evaluation of the effect of preventive measures to reduce mortality should be emphasized.

CONCLUSION

Poisonings remain a significant cause of mortality by injury in Norway. Emphasis should be placed on following the trends closely, especially regarding methadone deaths.

Alcohol-Induced Blackouts as Predictors of Other Drinking Related Harms Among Emerging Young Adults

BACKGROUND

Alcohol-related blackouts are periods of amnesia that reflect the failure of the brain to record memories of what transpires while drinking. This paper examined the incidence, predictors, and behavioral correlates of blackouts among emerging adults and examined whether questions about blackouts could serve as better markers of risk for other alcohol related harms than questions about levels of consumption.

METHODS

In 2012 to 2013, 1,463 (68%) of 2,140 respondents 1-year past high school reported having consumed alcohol. They were asked whether, in the past 6 months because of drinking, they forgot where they were or what they did. The survey also explored demographics, substance use behaviors, and other alcohol-related problems in the past 6 months. Chi-square and logistic regression analyses explored bivariate and multivariate predictors of blackouts and other alcohol-related problems.

RESULTS

Twenty percent of respondents who ever drank alcohol reported a blackout in the past 6 months. Blackouts were more prevalent among females and those who, in the past 30 days, used multiple drugs, more frequently binged, were drunk, smoked, had lower body weight, and lived in college dorms. After controlling for drinking levels, having a blackout was the strongest independent predictor of most other alcohol problems examined, including in the past 6 months because of drinking, missing class or work, getting behind in work or school, doing something respondents later regretted, arguing with friends, experiencing an overdose, and total number of alcohol problems reported. It was also an independent predictor of hangovers, damaging property, getting hurt, and trouble with police.

CONCLUSIONS

Because blackouts indicate drinking at levels that result in significant cognitive and behavioral impairment, questions about blackouts could serve as important, simple screeners for the risk of experiencing other alcohol related harms. Additional work on this subject is warranted.

Demographics and post-mortem toxicology findings in deaths among people arrested multiple times for use of illicit drugs and/or impaired driving

BACKGROUND

Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem.

METHODS

This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma.

RESULTS

Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids.

CONCLUSIONS

This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes.

Multi-drug intoxication fatality involving atorvastatin: A case report

Mixed antihypertensive drug intoxication poses a significant risk for patient mortality. In tandem to antihypertensives, hypolipidemic medicines (especially statins) are often prescribed. Among their well-known adverse effects belongs rhabdomyolysis. We report a case of fatal multi-drug overdose in a 65-year-old female alcoholic. The patient was unconscious at admission. Empty blister packs indicated the abuse of 250 tablets of urapidil, 42 tablets of verapamil/trandolapril, 50 tablets of moxonidin, 80 tablets of atorvastatin and 80 tablets of diacerein. Standard measures (gastric lavage, activated charcoal, mechanical ventilation, massive doses of vasopressors, volume expansion, diuretics and alkalinization) failed to provide sufficient drug elimination and hemodynamic support and the sufferer deceased on the fourth day. Dramatic elevations of serum myoglobin (34,020 μg/L) and creatine kinase (219 μkat/L) were accompanied by rise in cardiac troponin I and creatinine. Gas chromatography revealed ethanol 1.17 g/kg (blood) and 2.81 g/kg (urine). Thin layer chromatography and gas chromatography of gastric content and urine verified verapamil, moxonidin and urapidil fragment (diacerein method was unavailable). Atorvastatin and trandolapril concentrations (LC-MS(n)) equaled 277.7 μg/L and 57.5 μg/L, resp. (serum) and 8.15 μg/L and 602.3 μg/L, resp. (urine). Histology confirmed precipitates of myoglobin with acute necrosis of proximal renal tubules in association with striated muscle rhabdomyolysis and myocardial dystrophy. Cardiogenic-distributive shock in conjunction with acute renal failure due to the combined self-poisoning with vasoactive agents and atorvastatin were determined to be this decedent's immediate cause of death. The manner of death was assigned to be suicidal.

Parent and Metabolite Opioid Drug Concentrations in Unintentional Deaths Involving Opioid and Benzodiazepine Combinations

Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored.

Efficacy of drug screening in forensic autopsy: retrospective investigation of routine toxicological findings

Toxicological analysis is indispensable in forensic autopsy laboratories, but often depends on the limitations of individual institutions. The present study reviewed routine drug screening data of forensic autopsy cases (n=2996) during an 18.5-year period (January 1996-June 2014) at our institute to examine the efficacy of the procedures and findings in autopsy diagnosis and interpretation. Drug screening was performed using on-site immunoassay screening devices and gas chromatography/mass spectrometry (GC/MS) in all cases, followed by re-examination using GC/MS and liquid chromatography/tandem mass spectrometry (LC/MS/MS) at a cooperating institute in specific cases in the last 4 years. GC/MS detected drugs in 486 cases (16.2%), including amphetamines (n=160), major tranquilizers (n=72), minor tranquilizers (n=294), antidepressants (n=21), cold remedies (n=77), and other drugs (n=19). Among these cases, fatal intoxication (n=123) involved amphetamines (n=73), major tranquilizers (n=37), minor tranquilizers (n=86), antidepressants (n=3), and cold remedies (n=9); most cases involved self-administration, alleged suicide and accidental overdose, while homicide was not included. These drugs were also identified in other manners of death, including homicide (n=40/372), suicide (n=34/226), accidental falls (n=27/129), and natural death (n=72/514). In these cases, on-site immunoassay screening of drugs of abuse showed negative findings in 2440 cases (81.4% in all cases), while GC/MS detected other drugs in 218 cases (7.3% in all cases), including several antipsychotic drugs, acetaminophen and salicylic acid. Further analysis using LC/MS/MS detected low concentrations of benzodiazepines in 32 cases, and also anti-diabetic and hypertensive drugs in a case of fatal abuse. These observations indicate the efficacy of systematic routine toxicological analysis to investigate not only the cause of death but also the background of fatalities in forensic autopsy. The provision of extensive drug screening is needed for forensic and social risk management, considering the marked diversity of medical and illicit drugs.

Acute Alcohol Toxicity

Acute alcohol (ethanol) toxicity is a definition that encompasses both the metabolic toxicity of alcohol and the association of alcohol with traumatic deaths, suicide, and criminal activities. As with any postmortem measurement, there must be control of postmortem sampling, storage of specimens, and appropriate analysis to ensure that there is not artifactual alcohol production or incorrect measurement of other postmortem alcohols. It is almost unheard of for acute alcohol toxicity to cause death secondary to metabolic effects in a naïve individual, although there has been a recent trend in social media dares that have led to deaths due to isolated episodes of extreme alcohol consumption. However, in most cases, there will be evidence for chronic alcohol misuse at the postmortem examination.

Long-term mortality and causes of death among hospitalized Swedish drug users

AIM

To study long-term mortality and causes of death in a cohort of drug users in relation to main type of drug use and HIV-status.

METHODS

A total of 1640 hospitalized drug users in Stockholm was followed up from 1985 to the end of 2007. The mortality was compared with the general Swedish population and hazard ratios (HR) for the main risk indicators were calculated. The causes of death were studied, using information from death certificates.

RESULTS

630 persons died during the observation period. The Standard Mortality Ratio (SMR) was 16.1 (males 13.8, females 18.5). The crude mortality rate was 2.0 % (males 2.2% and females 1.5%). The mortality rate was higher in heroin users than among amphetamine users, HR 1.96, controlled for age and other risk factors. The mortality rate among individuals infected with the human immunodeficiency virus (HIV) was high (4.9 %), HR 2.64, compared with HIV-negative individuals. Most of the deaths were from other causes than acquired immune deficiency syndrome. One-third of deaths (227) were caused by heroin intoxication. The number of deaths from HIV-related causes decreased after 1996, when highly active anti-retroviral therapy was introduced. In all, there were 92 HIV-related deaths. Deaths from natural causes increased during the observation period. The SMR was highest for cardiovascular and gastrointestinal diseases. The results indicate a correlation between amphetamine use and death from cerebral haemorrhage. A high proportion of natural deaths were alcohol-related.

CONCLUSIONS

The death rate among illicit drug users was persistently high. Alcohol consumption was a contributing factor to premature death.

Fatal poisonings in Finland during the years 2004-2009

Fatal alcohol and drug poisonings in Finland during the years 2004-2009 were studied. Cases were divided into those that occurred outside the hospitals (the majority of cases) and those that occurred within the hospitals (the minority of cases). Differences and similarities between the two groups were analysed. The postmortem toxicological investigation of all sudden and unexpected deaths in Finland is centralised at the Department of Forensic Medicine, University of Helsinki. We examined each fatal poisoning separately and verified the cause and place of death as well as the age and sex of the deceased. Fatal poisonings, including suicides, have remained unchanged for many years from the same high level, that is, about 1200 cases annually (22/100,000 inhabitants). The number of patients dying in hospitals due to poisoning has also remained stable (55-70 patients/year). However, the toxic agents involved in such poisonings have changed and deaths due to opioids are now being more numerous. The number of fatal unintentional drug poisonings rose significantly from 191 to 341 (3-6/100,000 inhabitants, p < 0.001) during the study years, and the difference between poisonings caused by drugs or alcohol also changed significantly (p < 0.001). Diminishing substantially, the number of all fatal poisonings will be challenging because of the high percentage of suicides. However, a reduction in unintentional drug overdoses, which are presently on the rise, should be possible.

Evaluation of poisoning deaths in the Cukurova Region, Turkey, 2007-2011

Complications of substances detected in poisoning deaths are important in order to observe changes in poisoning patterns and to monitor effects of preventive work. The aim of the present study was to describe the characteristics of substances investigated and detected in poisoning deaths by Adana Group Authority of the Council of Forensic Medicine, Department of Forensic Chemistry, Cukurova, Turkey, between 2007 and 2011 retrospectively. A total of 7681 examinations were performed, of which, 7% (n = 564) determined positive for at least one compound investigated. Ages of the cases ranged from 1 to 97 years (mean ± SD: 36.10 ±19.16). Carbon monoxide (CO) poisonings were found most frequently with an incidence of 27.0%, followed by prescription medications with 25.0%. Illegal drug poisonings were present in 20.0% of blood and urine samples analyzed. Pesticides, mostly endosulfan, were found in 13.0% of the 564 cases investigated. In the blood samples analyzed, methyl and ethyl alcohol were detected in 14.0% and volatile substances in 1.0%. Overall, this study has managed to contribute substantial additional information regarding the epidemiology of poisoning in Cukurova region, Southern Turkey. The results confirm other epidemiological data that indicate CO as the major cause of poisoning deaths in Turkey.