Drug-related deaths between 2002 and 2013 with accent to methadone and benzodiazepines

Understanding circadian dynamics: current progress and future directions for chronobiology in drug discovery

INTRODUCTION

Most mammalian physiology is orchestrated by the circadian clock, including drug transport and metabolism. As a result, efficacy and toxicity of many drugs are influenced by the timing of their administration, which has led to the establishment of the field of chronopharmacology.

AREAS COVERED

In this review, the authors provide an overview of the current knowledge about the time-of-day dependent aspects of drug metabolism and the importance of chronopharmacological strategies for drug development. They also discuss the factors influencing rhythmic drug pharmacokinetic including sex, metabolic diseases, feeding rhythms, and microbiota, that are often overlooked in the context of chronopharmacology. This article summarizes the involved molecular mechanisms and functions and explains why these parameters should be considered in the process of drug discovery.

EXPERT OPINION

Although chronomodulated treatments have shown promising results, particularly for cancer, the practice is still underdeveloped due to the associated high cost and time investments. However, implementing this strategy at the preclinical stage could offer a new opportunity to translate preclinical discoveries into successful clinical treatments.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.

Correlates of Non-fatal, Opioid Overdose among Women Who Use Opioids in Dar es Salaam, Tanzania

BACKGROUND

As opioid overdoses and deaths increase globally, little is known about these dimensions in Sub-Saharan Africa. In this paper, we explore factors associated with opioid overdose experiences among a sample of women who use opioids in Dar es Salaam, Tanzania.

METHODS

We conducted a cross-sectional survey with 200 women who use opioids in Dar es Salaam, Tanzania, recruited via respondent-driven sampling. We fitted unadjusted and adjusted log-binomial regression models with robust standard errors to examine associations between participant characteristics and reporting ever had an opioid overdose in terms of prevalence ratios.

RESULTS

Thirty-four percent (n = 68) of participants reported having ever had an opioid overdose. In the final adjusted model, having ever attempted to stop using heroin (adj. PR = 1.46, 95% CI: 1.01-2.12), sleeping outside in the past 6 months (adj. PR = 1.93, 95% CI: 1.29-2.91), injecting drugs (adj. PR = 1.78, 95% CI: 1.19-2.66), alcohol use (adj. PR = 1.56, 95% CI: 1.09-2.23), and having moderately severe to severe depression (adj. PR = 3.10, 95% CI: 1.07-8.97) were all found to be significantly associated with having ever had an opioid overdose.

CONCLUSIONS

We demonstrate factors associated with opioid overdose among women who use drugs in Tanzania that may not be addressed with injection-focused harm reduction efforts. Our findings suggest the need for overdose surveillance efforts and further work to characterize overdose risks in this context in order to design relevant, targeted interventions to prevent opioid overdose in sub-Saharan Africa.

Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.

What are the Predictive Factors for the Treatment Outcomes in Multi Drug Poisoning Including Antidepressants/Antipsychotic Drugs?

Background

There have been studies on the outcome of acute intoxication with antidepressants or antipsychotics. We performed outcome prediction analysis in acute poisoning patients with antidepressants/antipsychotics with or without combination with other drugs.

Materials and Methods

A cross-sectional study was performed in Khorshid (PBUH) University Hospital affiliated with Isfahan University of Medical Sciences from March 2016 to May 2017. Patients with acute poisoning ingested antidepressants and antipsychotics with or without other drugs were included in the study. The outcome was categorized as survived without complications and complications/death. Binary regression analysis was performed for outcome prediction.

Results

The data from 239 patients were analyzed. Most of the patients were female (68.2%), 5.9% of patients admitted to the Intensive Care Unit. About 94.99% of patients survived without complications. There was a significant difference between patients with and without complications with respect to the level of consciousness, hypotension, seizure, electrocardiography findings, pulse rate after 24 hours (h) of admission, and need to endotracheal intubation (P < 0.0001). Binary logistic regression analysis showed admission level of consciousness (stupor/coma) (odds ratio [OR] =8.07; P = 0,005), hypotension (OR = 12.16; P = 0.001), seizure (OR = 11.15; P = 0.009), tachycardia after 24 h of admission (OR = 22.50; P = 0.003), and need for endotracheal intubation (OR = 10.47; P = 0.002) were determinant factors in outcome prediction.

Conclusions

Stupor/coma and hypotension were the predictive factors for outcome. Patients with seizure and tachycardia after 24 h of admission; and those intubated and received mechanical ventilation had a higher chance of complications.

Forensic Toxicology Perspectives of Methadone-associated Deaths in Tehran, Iran, a 7-year Overview

Methadone has a long history of pain relief and successful substitute for maintenance treatment in heroin and narcotic addiction. The aim of the study was to assess the trends of methadone-associated deaths in Tehran, Iran, in 2009-2015, from a forensic toxicology point of view. All methadone-associated deaths during this 7-year study period were evaluated according to demographic parameters and forensic toxicology analysis results. Results showed that 1274 cases of methadone-associated deaths were investigated during the study period. The incidence rate of methadone-associated deaths had risen 7.7 times in 2015 in comparison with 2009 (p < 0.05). The majority of cases were men (90.35%), aged from 20 to 40 years. About 80% of cases had shown positive results for other drugs and poisons in combination with methadone. Methamphetamine and tramadol were the most drugs detected in post-mortem samples. Death rates among methadone users in Tehran, Iran, increased year by year during 2009-2015. These findings raise the attention to the concomitant use of drugs with the need for changes in regulation and regulatory policy to restrict access and use of controlled drugs.

Cardiovascular effects of methadone and concomitant use of diazepam during methadone maintenance treatment induction: low concentration risk

BACKGROUND

The aim is to evaluate the role of diazepam concentrations in development of low-concentration-methadone-associated QTc prolongation in patients with opioid use disorder during methadone maintenance treatment (MMT) induction.

RESEARCH DESIGN AND METHODS

Individuals with addiction disorder on MMT were studied before the beginning of MMT and after one and six months of MMT. Serum concentrations of methadone, diazepam, electrolytes and ECG were analyzed.

RESULTS

Thirty patients were enrolled. The mean methadone concentration at time points was 177 ± 119 ng/ml and 343 ± 182 ng/ml, while the mean diazepam concentration was 561 ± 437 ng/ml and 1045 ± 933 ng/ml. The QTc interval before the introduction of MMT, after 1 and 6 months of MMT were 412 ± 27 ms, 425 ± 18 ms and 424 ± 15 ms, respectively, showing statistically significant increase in the length of QTc interval after 1 and 6 months of MMT. Statistically significant correlation between the concentration of methadone and QTc interval length at observed time points (R² = 0.239, p = 0.018; R² = 0.513, p = 0.006) was shown, and it remained so if the concentration of diazepam was included (R² = 0.347, p = 0.026, R² = 0.513, p = 0.009).

CONCLUSIONS

The prolongation of QTc below the risk threshold in low methadone therapeutic doses has been recorded and concomitant use of diazepam could be a co-factor in such issue.

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland

BACKGROUND

Overdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented.

METHODS

Data on self-reported overdose and receipt of naloxone during the preceding year for 2013-2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included.

RESULTS

Participants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types.

CONCLUSION

These data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.

Methadone related deaths compared to all prescription related deaths

BACKGROUND

Methadone is increasingly implicated in unintentional overdose deaths. Despite major interventions, rates continue to remain high. One primary intervention, Prescription Drug Monitoring Programs (PDMP) are limited in their ability to impact this epidemic due to federal law restricting Opioid Treatment Programs (OTPs) from sharing data to PDMPs, despite being a major source of Methadone dispensing.

METHODS

This retrospective, observational study analyzed all prescription-related deaths occurring in San Diego County during the year 2013 with a specific focus on methadone-related deaths. All patients designated by medical examiner to have died by unintentional prescription were then referenced in the California PDMP, the Controlled Substance Utilization Review and Evaluation System (CURES).

RESULTS

As a whole, patients who died had a high number of average prescriptions, 21, and averaged 4.5 different providers, and three different pharmacies. Methadone-related deaths (MRD) accounted for 46 out of the 254 total patient deaths (18.1%). Methadone prescriptions were found in 14 patients with PDMP reports, 10 of who had methadone on toxicology report. Notably, 100% of methadone prescribed by primary care specialists. MRD patients were less likely to have toxicology reports matching PDMP data compared to other related drug deaths (20.6 vs. 61.2%, p<0.0001). Of the 46 methadone deaths, only 10 (29.4%) had prescriptions for methadone recorded in the database. Out of the 51 patients with only one drug recorded at death, methadone was most common (n=12; 23.5%). While all deaths had a notably high rate of chronic prescriptions at death (68.8% compared to 2% for all patients in CURES), there was no significant difference between MRD and other drug-related deaths (73.5 vs. 67.8%, p=0.68, respectively). MRD patients were less likely than other drug patients to have matching PDMP data without any illicit substance or alcohol (14.7 vs. 41.4%, p=0.003, respectively).

CONCLUSION

Methadone is a long-acting opioid that carries a higher risk profile than other opioids. In San Diego, the great majority of MRD had no data on methadone in the statewide PDMP database, bringing to question the restriction of OTP clinics from uploading information into the database. A risk-benefit analysis should be made to consider changing laws that would allow for OTP to input data into PDMP. OTP should make it standard of care to check PDMP data on their patients. Methadone prescribed for pain management should be limited to the most compliant patients.