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Rigg KK, Kusiak ES, Rigg LK. Motivations for Misusing Opioids Among African Americans. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:240-249. [PMID: 38258821 DOI: 10.1177/29767342231214118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND A wide range of opioid misuse motives have been documented in the literature, including to relieve physical pain, feel good/get high, relax, manage feelings/emotions, sleep, and moderate the effects of other substances. Despite a rise in opioid misuse among African Americans over the last 2 decades, their motivations for misuse remain unclear. Much of the research on opioid misuse motivations either rely on samples with little racial diversity or do not stratify their findings by race. As a result, less is known about the specific reasons why African Americans engage in opioid misuse. The objective of this study, therefore, was to identify and explain the most common motives for misusing opioids among African Americans. Qualitative interview data are also presented to explain/contextualize the most prevalent motivations. METHODS This study used data from the Florida Minority Health Survey, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of African Americans. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. RESULTS Analyses revealed that while some (33.9%) misused opioids for purposes of recreation/sensation seeking (eg, feel good/get high), the majority (66.1%) were attempting to self-treat perceived medical symptoms (eg, physical pain, anxiety/trauma, withdrawals, insomnia). CONCLUSIONS This study contributes to a better understanding of why some African Americans engage in opioid misuse and findings highlight the need for interventions to be trauma informed and address unmanaged physical pain among African Americans. Given that most studies on motivations are quantitative in nature, the study contributes to the literature by capturing the voices of African Americans who use drugs.
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Affiliation(s)
- Khary K Rigg
- Department of Mental Health Law & Policy, University of South Florida, Tampa, FL, USA
| | - Ethan S Kusiak
- Department of Mental Health Law & Policy, University of South Florida, Tampa, FL, USA
| | - Lindi K Rigg
- School of Psychology and Counseling, Regent University, Virginia Beach, VA, USA
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Boun SS, Omonaiye O, Yaya S. Prevalence and health consequences of nonmedical use of tramadol in Africa: A systematic scoping review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002784. [PMID: 38236813 PMCID: PMC10796000 DOI: 10.1371/journal.pgph.0002784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/04/2023] [Indexed: 01/22/2024]
Abstract
Tramadol is a widely prescribed painkiller around the world. As a synthetic opioid, it offers a valuable substitute for morphine and its derivatives in African countries. However, the adverse health effects of tramadol use resulting from illicit trafficking, like those caused by fentanyl and methadone in North America, have not been well-documented in Africa. This scoping review aims to shed light on the nature and scope of the nonmedical use (NMU) of tramadol in Africa and its associated health consequences. To carry out our scoping review, we used Arksey and O'Malley's (2005) five-step approach for exploratory analysis and followed Joanna Briggs Institute guidelines for scoping reviews to ensure systematic and replicable studies. We then searched six databases: Medline, Global Health (EBSCO), Scopus, Web of Science, the African Journals online database, and for grey literature via Google Scholar without any time restriction. The articles were imported into Covidence and reviewed by two independent researchers. Eighty-three studies on NMU of tramadol's prevalence or health consequences were selected from 532 titles/abstracts screened, including 60 cross-sectional and six qualitative studies from 10 African countries. Findings from the included studies highlighted five distinct groups significantly affected by the NMU of tramadol. These groups include: 1) young adults/active populations with varying degrees of prevalence ranging from 1.9% to 77.04%, 2) professionals, where drivers exhibit a relatively high prevalence of tramadol NMU, ranging from 7.2% to 35.1%, and commercial motorcyclists, with a prevalence of 76%, 3) patients, who have a high rate of tramadol NMUs, with prevalence rates ranging from 77.1% to 92%, 4) academics, with a considerable rate of tramadol misuse among substance-using undergraduates (74.2%) and substance-using high school students (83.3%), and 5) other individuals impacted in various ways. The health consequences are classified into four distinct types: intoxication, dependence syndrome, withdrawal syndrome and other symptoms. Despite providing a comprehensive global overview of the phenomenon described in the African literature, this systematic scoping review's main limitations stem from the relatively limited exploration of various consequences of the NMU of tramadol, notably those of a social and economic nature. Our review shows that tramadol misuse affects diverse populations in Africa. The prevalence of misuse varies within sub-populations, indicating the complexity of the issue. Professional and academic groups have different rates of misuse across regions. This highlights the need for targeted interventions to address unique challenges contributing to tramadol misuse. Future studies should focus on the social and economic costs of abuse on households to better understand the impact on well-being. Systematic review registration: Open Science Framework: https://osf.io/ykt25/.
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Affiliation(s)
- Saidou Sabi Boun
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
| | - Olumuyiwa Omonaiye
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Australia
- Deakin University Centre for Quality and Patient Safety Research–Eastern Health Partnership, Box Hill, Victoria, Australia
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, Imperial College London, London, United Kingdom
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Onohuean H, Oosthuizen F. Multinational appraisal of the epidemiological distribution of opioid fatalities: a systematic review and meta-analysis. Front Psychiatry 2024; 14:1290461. [PMID: 38250280 PMCID: PMC10796457 DOI: 10.3389/fpsyt.2023.1290461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/09/2023] [Indexed: 01/23/2024] Open
Abstract
Background The global or multinational scientific evidence on the distribution of opioid fatality is unknown. Hence, the current study collects epidemiological characteristics to shed light on the ongoing global or multinational opioid crisis and to promote the development of public health prevention/management strategies. Method All documents on PRISMA standards were retrieved via electronic databases. Results Among the 47 articles relevant to our studies, which depict a total population size of 10,191 individuals, the prevalence of opioid fatal overdose was 15,022 (14.74%). Among the 47 articles, 14 of them reported the gender of the participants, with 22,125 (15.79%) male individuals and 7,235 (5.17%) female individuals, and the age distribution of the participants that was most affected by the overdose was as follows: 29,272 (31.13%) belonged to the 18-34-year-old age group and 25,316 (26.92%) belonged to the less than 18-year-old age group. Eighteen studies qualified for the meta-analysis of the multinational prevalence of fatal opioid overdose, depicting an overall pooled prevalence estimate of 19.66%, with 95% CIs (0.13-0.29), I2 = 99.76% determined using the random-effects model, and Q statistic of 7198.77 (p < 0.0001). The Egger test models of publication bias revealed an insubstantial level of bias (p = 0.015). The subgroup analysis of the study design (cohort or other) revealed that others have the highest prevalence estimate of 34.37, 95% CIs (0.1600-0.5901), I2 = 97.04%, and a sample size of less than 1,000 shows the highest prevalence of 34.66, 95% CIs (0.2039-0.5234), I2 = 97.82%, compared to that of more than 1,000 with a prevalence of 12.28, 95% CIs (0.0675-0.2131), I2 = 99.85%. The meta-regression analysis revealed that sample size (less-than or greater-than 1,000), (p = 0.0098; R2 = 3.83%) is significantly associated with the observed heterogeneity. Conclusion Research-based findings of fatal opioid overdose are grossly lacking in middle- and low-income nations. We established that there is a need for opioid fatality surveillance systems in developing nations.
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Affiliation(s)
- Hope Onohuean
- Biopharmaceutics Unit, Department of Pharmacology and Toxicology, Kampala International University Western Campus, Ishaka-Bushenyi, Uganda
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Frasia Oosthuizen
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Monroe SC, Radke AK. Opioid withdrawal: role in addiction and neural mechanisms. Psychopharmacology (Berl) 2023; 240:1417-1433. [PMID: 37162529 PMCID: PMC11166123 DOI: 10.1007/s00213-023-06370-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/19/2023] [Indexed: 05/11/2023]
Abstract
Withdrawal from opioids involves a negative affective state that promotes maintenance of drug-seeking behavior and relapse. As such, understanding the neurobiological mechanisms underlying withdrawal from opioid drugs is critical as scientists and clinicians seek to develop new treatments and therapies. In this review, we focus on the neural systems known to mediate the affective and somatic signs and symptoms of opioid withdrawal, including the mesolimbic dopaminergic system, basolateral amygdala, extended amygdala, and brain and hormonal stress systems. Evidence from preclinical studies suggests that these systems are altered following opioid exposure and that these changes mediate behavioral signs of negative affect such as aversion and anxiety during withdrawal. Adaptations in these systems also parallel the behavioral and psychological features of opioid use disorder (OUD), highlighting the important role of withdrawal in the development of addictive behavior. Implications for relapse and treatment are discussed as well as promising avenues for future research, with the hope of promoting continued progress toward characterizing neural contributors to opioid withdrawal and compulsive opioid use.
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Affiliation(s)
- Sean C Monroe
- Department of Psychology and Center for Neuroscience and Behavior, Miami University, 90 N Patterson Ave, Oxford, OH, USA
| | - Anna K Radke
- Department of Psychology and Center for Neuroscience and Behavior, Miami University, 90 N Patterson Ave, Oxford, OH, USA.
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Dessoki HH, Abedlrasoul HA, Dawoud ME, Mohamed AM, Soltan MR. Oxytocin level among patients with opioid use disorder and its correlation with personality traits and perceived childhood trauma. MIDDLE EAST CURRENT PSYCHIATRY 2023. [DOI: 10.1186/s43045-023-00289-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Abstract
Background
Personality traits and perceived childhood maltreatment are of the predictors of substance use disorder development. Many studies have discussed oxytocin effect on personality traits and its relation with childhood trauma and how both affect the addictive process. The main aim was to compare oxytocin level between patients with opioid use disorder and controls and the potential association of oxytocin level with the basic dimensions of personality traits and perceived childhood adverse experiences in patients group. Forty male patients with opioid use disorder and 40 healthy controls matched in age and gender were assessed and compared regarding serum oxytocin level by ELISA, personality traits using Temperament and character inventory - revised (TCI- R) scale, and childhood adverse events using childhood trauma questionnaire.
Results
A significant difference between the patient group and the control group regarding the serum oxytocin level was found. Negative correlation with p-value <0.05 between oxytocin level and each of novelty seeking, and harm avoidance, in addition to a positive correlation between oxytocin level and each of reward dependence, self-directedness, and cooperativeness items of (TCR-R), among cases were found. Cases did not show statistically significant difference in oxytocin level between different Childhood Trauma Questionnaire (CTQ) items.
Conclusions
The interaction between serum oxytocin levels, personality traits, and childhood trauma has to be considered in management with heroin-dependent patients as it plays a crucial role.
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Amini K, Long T, Jafari Varjoshani N, Rabie Siahkali S. A comparison of risk factors for relapse in opiate-related and stimulant-related substance use disorders: A cross-sectional multicenter study. J Nurs Scholarsh 2023; 55:566-576. [PMID: 36596703 DOI: 10.1111/jnu.12872] [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: 06/21/2022] [Revised: 12/13/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Recognizing the specific factors in relapse disorders related to each substance can help improve treatment methods and adopt more effective preventive strategies. This study aimed to compare the situational factors associated with relapse in opiate-related disorders with stimulant-related disorders (SRDs) of those referred to substance misuse treatment centers. DESIGN This study was a cross-section type. METHODS The study participants were 150 clients with SRDs and 150 with opiate-related disorders. Samples were selected using two stages random sampling method. Data were collected through a demographic questionnaire and the Inventory of Drug-Taking Situations (IDTS). RESULTS The mean score of IDTS in the two groups was significantly different (X̄1 = 45.93 ± 11.12 vs. X̄2 = 48.34 ± 15.07; t = 3.32, p < 0.01). The mean scores of 'unpleasant emotions,' 'physical discomfort,' 'conflict with others,' and 'social pressure to use and urge/temptations' subscales were significantly higher in the stimulant group than in the opiate group (p < 0.05). However, the mean of the testing' personal control' subscale was higher in the opiate group than in the stimulant group (p < 0.05). CONCLUSION This study reveals that despite some similarities, relapse-related situational factors in opiates and stimulants differ. Some situational factors, such as social pressure and coping with unpleasant emotions, play a more critical role in relapse to both stimulant and opiate groups.
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Affiliation(s)
- Kourosh Amini
- Department of Psychiatric Nursing, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Nasrin Jafari Varjoshani
- Department of Community Health Nursing, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
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Roussin A, Soeiro T, Fouque C, Jouanjus E, Frauger E, Fouilhé N, Mallaret M, Micallef J, Lapeyre-Mestre M. Increase of high-risk tramadol use and harmful consequences in France from 2013-2018: evidence from the triangulation of addictovigilance data. Br J Clin Pharmacol 2022; 88:3789-3802. [PMID: 35318713 PMCID: PMC9545570 DOI: 10.1111/bcp.15323] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 03/03/2022] [Accepted: 03/13/2022] [Indexed: 12/11/2022] Open
Abstract
Aims The aim of this paper is to assess recent developments in non‐medical tramadol use, tramadol use disorder, illegal procurement and deaths. Methods This study used repeated cross‐sectional analysis of data collected nationwide from 2013 to 2018. Analysis was conducted through multisource monitoring of the French Addictovigilance Network of: (1) validated reports of high‐risk tramadol use, (2) record systems collecting information from toxicology experts investigating analgesic‐related deaths (DTA) and deaths related to substance abuse (DRAMES), and pharmacists for forged prescriptions (OSIAP), and (3) survey of drug users, with investigation of patterns of use while visiting addiction‐specialised institutions (OPPIDUM). Results Despite a plateauing level of tramadol exposure in the French population, the proportion of tramadol reports increased 1.7‐fold (187 cases in 2018, 3.2% (95% confidence interval [CI]: 2.74–3.63%), versus 1.9% (95% CI: 1.49–2.42% in 2013). Trends were similar in OSIAP: 11.9% of forged prescriptions in 2018 (95% CI: 10.56–13.45%); 1.7‐fold increase; in OPPIDUM: 0.76% (95% CI: 0.55–1.02); 2.2‐fold increase; and DRAMES: 3.2% of drug abuse‐related deaths in 2018 (95% CI: 1.89–5.16) versus 1.7% in 2013 (95% CI: 0.65–3.84). Tramadol was the primary opioid in analgesic‐related deaths in DTA (45% in 2018). Two profiles of high‐risk tramadol users were identified: (1) patients treated for pain or with tramadol persistence when pain disappeared (mainly women; mean age 44 years), and (2) individuals with non‐medical use for psychoactive effects (mainly men; mean age 36 years). Conclusion The triangulation of the data obtained through addictovigilance monitoring evidenced a recent increase in high‐risk tramadol use. These findings have a practical impact on the limitation of the maximal duration of tramadol prescriptions.
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Affiliation(s)
- Anne Roussin
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,Pharmacologie en Population Cohortes et Biobanques, Centre d'Investigation Clinique 1436, Université de Toulouse, France
| | - Thomas Soeiro
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France
| | - Charlotte Fouque
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France
| | - Emilie Jouanjus
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,CERPOP, Université de Toulouse, INSERM, France
| | - Elisabeth Frauger
- Aix-Marseille Université, Assistance publique-Hôpitaux de Marseille, Inserm, Inst Neurosci System, UMR 1106, Service de pharmacologie clinique et Pharmacovigilance, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
| | - Nathalie Fouilhé
- Département de Pharmacologie Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire Grenoble Alpes, France
| | - Michel Mallaret
- Département de Pharmacologie Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire Grenoble Alpes, France
| | - Joëlle Micallef
- Aix-Marseille Université, Assistance publique-Hôpitaux de Marseille, Inserm, Inst Neurosci System, UMR 1106, Service de pharmacologie clinique et Pharmacovigilance, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
| | - Maryse Lapeyre-Mestre
- Département de Pharmacologie Clinique et Médicale, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Centre Hospitalier Universitaire de Toulouse, France.,Pharmacologie en Population Cohortes et Biobanques, Centre d'Investigation Clinique 1436, Université de Toulouse, France
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Diouf A, Aghoutane Y, Burhan H, Sen F, Bouchikhi B, El Bari N. Tramadol sensing in non-invasive biological fluids using a voltammetric electronic tongue and an electrochemical sensor based on biomimetic recognition. Int J Pharm 2020; 593:120114. [PMID: 33253800 DOI: 10.1016/j.ijpharm.2020.120114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 02/01/2023]
Abstract
Tramadol (TRA) is a weak opioid analgesic, prescribed to relieve mild to moderately severe pain. However, side effects of TRA overdoses, including vomiting, depression, tachycardia, convulsions, morbidity and mortality are often reported. In this study, an electrochemical sensor based on molecularly imprinted conductive polymer was firstly developed for the quantitative and non-invasive detection of TRA. Secondly, a voltammetric electronic tongue (VE-Tongue) combined with chemometric methods was used for the qualitative analysis. The MIP sensor was constructed by self-assembling a poly-aniline layer coated with silver nanoparticles (PANI-AgNPs) on a screen-printed gold electrode (Au-SPE). Then, 2-amino-thiophenol was polymerised in the presence of TRA. The electronic device exhibits, under optimal conditions, responses proportional to TRA concentrations (0.01-100 µg/mL) with detection and quantification limits of 9.42 µg/mL and 28.55 µg/mL, respectively. Moreover, its selectivity was proven by insignificant interferences of substances (paracetamol and citric acid). Spiked saliva and urine samples were used for the sensor practical application with a significant recovery above 90% and standard deviations below 4.5%. Besides, urine samples' analyses using VE-Tongue and pattern recognition methods show good discrimination, classification, and prediction results with scores above 95%. Correspondingly, both electro-analytical devices could be viable for monitoring drugs in biological matrices.
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Affiliation(s)
- Alassane Diouf
- Biosensors and Nanotechnology Group, Department of Biology, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, 50003 Meknes, Morocco; Sensor Electronic & Instrumentation Group, Department of Physics, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, Meknes, Morocco
| | - Youssra Aghoutane
- Biosensors and Nanotechnology Group, Department of Biology, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, 50003 Meknes, Morocco; Sensor Electronic & Instrumentation Group, Department of Physics, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, Meknes, Morocco
| | - Hakan Burhan
- Department of Biochemistry, Kutahya Dumlupinar University, Kütahya, Turkey
| | - Fatih Sen
- Department of Biochemistry, Kutahya Dumlupinar University, Kütahya, Turkey
| | - Benachir Bouchikhi
- Sensor Electronic & Instrumentation Group, Department of Physics, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, Meknes, Morocco
| | - Nezha El Bari
- Biosensors and Nanotechnology Group, Department of Biology, Faculty of Sciences, Moulay Ismaïl University of Meknes, B.P. 11201, Zitoune, 50003 Meknes, Morocco.
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Risk and Protective Factors of Tramadol Abuse in the Gaza Strip: The Perspective of Tramadol Abusers and Psychiatrists. Int J Ment Health Addict 2020. [DOI: 10.1007/s11469-020-00301-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Ibrahim MA, Ibrahim HM, Mohamed AA, Tammam HG. Vitamin E supplementation ameliorates the hepatotoxicity induced by Tramadol: toxicological, histological and immunohistochemical study. Toxicol Mech Methods 2019; 30:177-188. [DOI: 10.1080/15376516.2019.1681043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Mahrous A. Ibrahim
- Forensic Medicine and Clinical Toxicology, College of Medicine, Jouf University, Aljouf, KSA
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Hussein M. Ibrahim
- Department of Anatomy and Embryology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Alaa A. Mohamed
- Department of Medical Biochemistry, College of Medicine, Jouf University, Aljouf, KSA
- Department of medical biochemistry, Faculty of Medicine, Beni- Suif University, Ben Suif, Egypt
| | - Hany G. Tammam
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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