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Brandt J, Bressi J, Lê ML, Neal D, Cadogan C, Witt-Doerring J, Witt-Doerring M, Wright S. Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review. EClinicalMedicine 2024; 70:102507. [PMID: 38516102 PMCID: PMC10955669 DOI: 10.1016/j.eclinm.2024.102507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/03/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
Background Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion. Methods A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing. Findings 113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents. Interpretation Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering. Funding The authors received no funding for this work.
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Affiliation(s)
- Jaden Brandt
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
| | - Jolene Bressi
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Wegman's School of Pharmacy, St. John Fisher University, Rochester, NY, USA
| | - Mê-Linh Lê
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
- Neil John Maclean Health Sciences Library, University of Manitoba, MB, Canada
| | - Dejanee Neal
- Wegman's School of Pharmacy, St. John Fisher University, Rochester, NY, USA
| | - Cathal Cadogan
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Josef Witt-Doerring
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Witt-Doerring Psychiatry, Heber City, UT, USA
| | - Marissa Witt-Doerring
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Witt-Doerring Psychiatry, Heber City, UT, USA
| | - Steven Wright
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Wright Medical Consulting, Ashland, OR, USA
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Al-Asmari AI, Alharbi H, Al-Zahrani AE, Zughaibi TA. Heroin-Related Fatalities in Jeddah, Saudi Arabia, between 2008 and 2018. TOXICS 2023; 11:248. [PMID: 36977013 PMCID: PMC10099738 DOI: 10.3390/toxics11030248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 06/18/2023]
Abstract
To date, epidemiological studies have not evaluated heroin-related deaths in the Middle East and North African regions, especially Saudi Arabia. All heroin-related postmortem cases reported at the Jeddah Poison Control Center (JPCC) over a 10-year period (21 January 2008 to 31 July 2018) were reviewed. In addition, liquid chromatography electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) was utilized to determine the 6-monoacetylmorphine (6-MAM), 6-acetylcodeine (6-AC), morphine (MOR), and codeine contents in unhydrolyzed postmortem specimens. Ninety-seven heroin-related deaths were assessed in this study, and they represented 2% of the total postmortem cases at the JPCC (median age, 38; 98% male). In the blood, urine, vitreous humor, and bile samples, the median morphine concentrations were 280 ng/mL, 1400 ng/mL, 90 ng/mL, and 2200 ng/mL, respectively; 6-MAM was detected in 60%, 100%, 99%, and 59% of the samples, respectively; and 6-AC was detected in 24%, 68%, 50%, and 30% of the samples, respectively. The highest number of deaths (33% of total cases) was observed in the 21-30 age group. In addition, 61% of cases were classified as "rapid deaths," while 24% were classified as "delayed deaths." The majority (76%) of deaths were accidental; 7% were from suicide; 5% were from homicide; and 11% were undetermined. This is the first epidemiological study to investigate heroin-related fatalities in Saudi Arabia and the Middle East and North African region. The rate of heroin-related deaths in Jeddah remained stable but increased slightly at the end of the study period. Most patients were heroin-dependent abusers and from the middle-aged group. The availability of urine, vitreous humor, and bile specimens provided valuable information regarding the opioids that were administered and the survival time following heroin injection.
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Affiliation(s)
- Ahmed I. Al-Asmari
- Laboratory Department, Ministry of Health, King Abdul-Aziz Hospital, Jeddah 21442, Saudi Arabia
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hassan Alharbi
- Poison Control and Forensic Chemistry Center, Ministry of Health, Jeddah 21176, Saudi Arabia
| | | | - Torki A. Zughaibi
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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Sharma S, Mittal N, Banik BK. Chemistry and Therapeutic Aspect of Triazole: Insight into the Structure-activity Relationship. Curr Pharm Des 2023; 29:2702-2720. [PMID: 37916492 DOI: 10.2174/0113816128271288231023045049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/18/2023] [Indexed: 11/03/2023]
Abstract
The triazole ring is a highly significant heterocycle that occurs naturally in many commodities and is a common feature in pharmaceuticals. Recently, heterocyclic compounds and their derivatives have been getting a lot of attention in medicinal chemistry because they have a lot of pharmacological and biological potential. For example, a lot of drugs have nitrogen-containing heterocyclic moieties. The triazole ring is often used as a bio-isostere of the oxadiazole nucleus. The oxygen atom in the oxadiazole nucleus is replaced by nitrogen in the triazole analogue. This article explores the pharmacological properties of the triazole moiety, including but not limited to antibacterial, analgesic, anticonvulsant, anthelmintic, anti-inflammatory, antitubercular, antimalarial, antioxidant, antiviral, and other properties. Additionally, we discuss the diverse multi- target pharmacological activities exhibited by triazole-based compounds. Based on a literature review, it is evident that triazole-based chemicals hold significant potential for various applications.
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Affiliation(s)
- Shikha Sharma
- Department of Pharmaceutical Science, Lords University, Alwar 301028, India
| | - Nitin Mittal
- Department of Pharmaceutical Science, Lords University, Alwar 301028, India
| | - Bimal Krishna Banik
- Department of Mathematics and Natural Sciences, College of Sciences and Human Studies, Prince Mohammad Bin Fahd University, Al Khobar, Kingdom of Saudi Arabia
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Abstract
BACKGROUND The benzodiazepine drug alprazolam, a fast-acting tranquiliser, cannot be prescribed on the National Health Service in the United Kingdom. Illicit alprazolam supply and consumption have increased. Concern about increasing numbers of alprazolam-related fatalities started circulating in 2018. However, statistics on this issue are very limited. This study examined patterns in such mortality in Scotland. METHODS Statistics on deaths where alprazolam was mentioned in the 'cause of death' were obtained from official mortality registers. Anonymised Scottish case-level data were obtained. Data were examined in respect of the characteristics of decedents and deaths using descriptive statistics. RESULTS Scotland registered 370 deaths in 2004-2020; 366 of these occurred in 2015-2020: most involved males (77.1%); mean age 39.0 (SD 12.6) years. The principal underlying cause of death was accidental poisoning: opiates/opioids (77.9%); sedatives/hypnotics (15.0%). Two deaths involved alprazolam alone. Main drug groups implicated: opiates/opioids (94.8%), 'other benzodiazepines' (67.2%), gabapentinoids (42.9%), stimulants (30.1%), antidepressants (15.0%). Two-thirds (64.2%) involved combinations of central nervous system (CNS) depressants. DISCUSSION Alprazolam-related deaths are likely due to an increasing illicit supply. The fall in deaths in 2019-2020 is partially due to increased use of designer benzodiazepines. Treatment for alprazolam dependence is growing. Clinicians need to be aware of continuing recreational alprazolam use. When such consumption occurs with CNS depressants, overdose and death risks increase. CONCLUSIONS More awareness of alprazolam contributing to deaths, especially in conjunction with other CNS depressants, is needed by consumers and clinicians. Improved monitoring of illicit supplies could identify emerging issues of medicines' abuse.
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Affiliation(s)
- John Martin Corkery
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,John Martin Corkery, Psychopharmacology,
Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and
Medical Sciences, University of Hertfordshire, Health Research Building, College
Lane Campus, Hertfordshire AL10 9AB, UK.
| | - Amira Guirguis
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,Swansea University Medical School,
Swansea University, Swansea, UK
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK
| | - Giovanni Martinotti
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,Department of Neuroscience, Imaging and
Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK
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Giorgetti A, Sommer MJ, Wilde M, Perdekamp MG, Auwärter V. A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues. Forensic Toxicol 2021; 40:180-188. [DOI: 10.1007/s11419-021-00591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose
Designer benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam.
Methods
A complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned.
Results
Flualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2–323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3).
Conclusions
Our results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.
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Kumar S, Khokra SL, Yadav A. Triazole analogues as potential pharmacological agents: a brief review. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2021; 7:106. [PMID: 34056014 PMCID: PMC8148872 DOI: 10.1186/s43094-021-00241-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/03/2021] [Indexed: 02/01/2023] Open
Abstract
Background A large number of studies have recently reported that, because of their significant biological and pharmacological properties, heterocyclic compounds and their derivatives have attracted a strong interest in medicinal chemistry. The triazole nucleus is one of the most important heterocycles which has a feature of natural products as well as medicinal agents. Heterocyclic nitrogen is abundantly present in most medicinal compounds. The derivatization of triazole ring is based on the phenomenon of bio-isosteres in which substituted the oxygen atom of oxadiazole nucleus with nitrogen triazole analogue. Main text This review focuses on recent synthetic procedure of triazole moiety, which comprises of various pharmacological activities such as antimicrobial, anticonvulsant, anti-inflammatory, analgesic, antitubercular, anthelmintic, antioxidant, antimalarial, antiviral, etc.. Conclusion This review highlights the current status of triazole compounds as different multi-target pharmacological activities. From the literature survey, triazole is the most widely used compound in different potential activities.
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Affiliation(s)
- Sachin Kumar
- Institute of Pharmaceutical Sciences, Kurukshetra University, Kurukshetra, Haryana 136119 India
| | - Sukhbir Lal Khokra
- Institute of Pharmaceutical Sciences, Kurukshetra University, Kurukshetra, Haryana 136119 India
| | - Akash Yadav
- Institute of Pharmaceutical Sciences, Kurukshetra University, Kurukshetra, Haryana 136119 India
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Rasimas JJ, Kivovich V, Sachdeva KK, Donovan JW. Antagonizing the errors of history: bedside experience with flumazenil. TOXICOLOGY COMMUNICATIONS 2020. [DOI: 10.1080/24734306.2020.1752551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Joseph James Rasimas
- PinnacleHealth Toxicology Center, Harrisburg, PA, USA
- Department of Emergency Medicine, Penn State College of Medicine, Hershey, PA, USA
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - Violetta Kivovich
- Department of Internal Medicine, New York Presbyterian Hospital –Weill Cornell Medical Center, New York, NY, USA
| | | | - Joseph Ward Donovan
- PinnacleHealth Toxicology Center, Harrisburg, PA, USA
- Department of Emergency Medicine, Penn State College of Medicine, Hershey, PA, USA
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8
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The importance of sample size with regard to the robustness of postmortem reference values. Forensic Sci Int 2020; 311:110292. [PMID: 32330811 DOI: 10.1016/j.forsciint.2020.110292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/22/2022]
Abstract
Evaluating postmortem toxicological results is a challenging task due to multiple factors affecting blood concentrations after death. In order to improve the diagnostic accuracy in cases of suspected fatal intoxication different compilations of postmortem reference drug concentrations are often used. However, it is not clear what constitutes a reliable postmortem reference value. The current study presents reference concentrations for 13 substances from seven substance groups according to a standardized protocol. The reference concentrations were gathered from 3767 autopsy cases and subdivided into intoxications by one substance only (Group A, n=611), multi-substance intoxications (Group B, n=1355) and postmortem controls, in which incapacitation by drugs were excluded (Group C, n=1801). In particular, this study presents statistical information about the precision and conformity change with various sample sizes. Based on the present data >10 detections are usually needed, for the substances examined, to differentiate between intoxication cases and controls. Repeated samplings show that the median of small samples (N=≤5) has a high variation (normalized interquartile range 138-75%) and that a high number of detections (N=>20) in each group are needed to reduce the variation.
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Townsend EA, Platt DM, Rowlett JK, Roma PG, Freeman KB. Reinforcing effectiveness of midazolam, ethanol, and sucrose: behavioral economic comparison of a mixture relative to its component solutions. Behav Pharmacol 2017; 28:386-393. [PMID: 28537943 PMCID: PMC5648065 DOI: 10.1097/fbp.0000000000000308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Benzodiazepines (BZs) are relatively safe when administered alone. However, these drugs can produce severe side effects when coadministered with ethanol. Despite these adverse consequences, rates of concurrent BZ and ethanol misuse are increasing, and it is unclear whether this behavior is maintained by an enhanced reinforcing effect of the mixture. To address this issue, the current study compared the reinforcing effectiveness of sucrose solutions mixed with midazolam, ethanol, or both. Eight male rats were trained to orally self-administer solutions of either sucrose (S), sucrose+midazolam (SM), sucrose+ethanol (SE), or sucrose+midazolam+ethanol (SME). The response requirement was increased between sessions until the number of reinforcers earned was zero and the relationship between response requirement and reinforcers earned was analyzed using the exponential model of demand. Although baseline intake was similar across drug conditions, consumption of SM was least affected by increases in cost, indicating that it possessed the highest reinforcing effectiveness (i.e. least elastic). The reinforcing effectiveness of S, SE, and SME did not differ significantly. The finding that the reinforcing effectiveness of the SME was less than that of SM does not support the supposition that BZ and ethanol coadministration is maintained by a higher reinforcing effectiveness of the mixture.
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Affiliation(s)
- E. Andrew Townsend
- Division of Neurobiology and Behavior Research, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, United States
- Graduate Program in Neuroscience, University of Mississippi Medical Center, Jackson, MS, United States
| | - Donna M. Platt
- Division of Neurobiology and Behavior Research, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, United States
| | - James K. Rowlett
- Division of Neurobiology and Behavior Research, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, United States
| | - Peter G. Roma
- Institutes for Behavior Resources, Baltimore, MD 21218, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kevin B. Freeman
- Division of Neurobiology and Behavior Research, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, United States
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Skov L, Holm KMD, Johansen SS, Linnet K. Postmortem Brain and Blood Reference Concentrations of Alprazolam, Bromazepam, Chlordiazepoxide, Diazepam, and their Metabolites and a Review of the Literature. J Anal Toxicol 2016; 40:529-36. [DOI: 10.1093/jat/bkw059] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/24/2016] [Indexed: 12/20/2022] Open
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Shah NA, Abate MA, Smith MJ, Kaplan JA, Kraner JC, Clay DJ. Characteristics of Alprazolam-Related Deaths Compiled by a Centralized State Medical Examiner. Am J Addict 2015; 21 Suppl 1:S27-34. [DOI: 10.1111/j.1521-0391.2012.00298.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Circumstances and toxicology of sudden or unnatural deaths involving alprazolam. Drug Alcohol Depend 2014; 138:61-6. [PMID: 24629629 DOI: 10.1016/j.drugalcdep.2014.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/27/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND There has been a great deal of clinical concern regarding alprazolam abuse. This paper reported on alprazolam positive cases of sudden or unnatural deaths presenting to the New South Wales Department of Forensic Medicine (DOFM), 1/1/1997-31/12/2012. METHODS Case series. RESULTS 412 cases were identified. There was a large increase in the annual number of cases, from 3 in 1997 to 86 in 2012. By 2012, 4.5% of all DOFM case presentations involved alprazolam. The mean age was 41.3 years, and 66.5% were male. Circumstances of death were: accidental drug toxicity (57.0%), deliberate drug toxicity (10.4%), suicide by means other than drug overdose (12.6%), disease (10.0%), accident (5.1%), homicide (2.4%). The major factor driving the increase in cases was accidental drug toxicity involving alprazolam, rising from 0 in 1997 to 58 in 2012. A history of drug/alcohol problems was noted in 80.4%, and 56.6% were injecting drug users. The median alprazolam concentration was 0.08 mg/L (range 0.005-2.10mg/L), with 37.4% of cases having concentrations of ≥ 0.1 mg/L. In 94.9% of cases, drugs other than alprazolam and its metabolites were present, including all accidental overdoses. The most commonly detected drugs were opioids (64.6%), other benzodiazepines (44.4%) and alcohol (34.5%). A third (31.8%) of cases were HCV positive. CONCLUSIONS Cases involving alprazolam increased markedly, driven mostly by toxicity deaths amongst people with known drug and alcohol problems. Caution in prescribing alprazolam would appear appropriate, particularly to those with known drug dependence.
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Sedative and hypnotic drugs—Fatal and non-fatal reference blood concentrations. Forensic Sci Int 2014; 236:138-45. [DOI: 10.1016/j.forsciint.2014.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 12/30/2013] [Accepted: 01/05/2014] [Indexed: 11/20/2022]
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Rintoul AC, Dobbin MDH, Nielsen S, Degenhardt L, Drummer OH. Recent increase in detection of alprazolam in Victorian heroin‐related deaths. Med J Aust 2013; 198:206-9. [DOI: 10.5694/mja12.10986] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 10/28/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Angela C Rintoul
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
| | - Malcolm D H Dobbin
- Mental Health, Drugs and Regions Division, Department of Health, Victoria, Melbourne, VIC
| | | | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
| | - Olaf H Drummer
- Department of Forensic Medicine, Monash University, Melbourne, VIC
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Jones AW, Holmgren A. Concentrations of alprazolam in blood from impaired drivers and forensic autopsies were not much different but showed a high prevalence of co-ingested illicit drugs. J Psychopharmacol 2013; 27:276-81. [PMID: 23257168 DOI: 10.1177/0269881112471155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Alprazolam is a benzodiazepine anxiolytic widely prescribed for treatment of panic-disorder and social phobias, although this medication is also subject to abuse. In this paper, the concentrations of alprazolam in venous blood samples from impaired drivers were compared with femoral blood samples from forensic autopsies classified as intoxication or other causes of death (e.g. natural, trauma). After liquid-liquid extraction (n-butyl acetate) alprazolam was determined in blood by capillary gas chromatography with a nitrogen-phosphorous detector. The mean (median) and range of alprazolam concentrations in blood from impaired drivers (n = 773) were 0.08 mg/L (0.05 mg/L) and 0.02-3.9 mg/L, respectively. Many traffic offenders had co-ingested ethanol (13%), amphetamine (46%), cannabis (32%), or heroin (14%), as well as other drugs. In deaths attributed to drug intoxication, the mean (median) and range of alprazolam concentrations in blood (n = 438) were 0.10 mg/L (0.06 mg/L) and 0.02-1.6 mg/L, respectively, which were not much different from other causes of death (n = 278); 0.08 mg/L (0.05 mg/L) and 0.02-0.9 mg/L. Median concentrations of alprazolam in blood from living and deceased persons did not seem to depend on the number of co-ingested substances. The result of this pharmacoepidemiological study suggests that alprazolam is a fairly innocent drug when used as monotherapy, but toxicity problems arise when co-ingested with illicit drugs and/or psychoactive medication.
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Affiliation(s)
- Alan Wayne Jones
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden.
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Levita L, Hoskin R, Champi S. Avoidance of harm and anxiety: A role for the nucleus accumbens. Neuroimage 2012; 62:189-98. [DOI: 10.1016/j.neuroimage.2012.04.059] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 03/08/2012] [Accepted: 04/29/2012] [Indexed: 02/08/2023] Open
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Survey of methadone-drug interactions among patients of methadone maintenance treatment program in Taiwan. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2012; 7:11. [PMID: 22429858 PMCID: PMC3373376 DOI: 10.1186/1747-597x-7-11] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 03/20/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although methadone has been used for the maintenance treatment of opioid dependence for decades, it was not introduced in China or Taiwan until 2000s. Methadone-drug interactions (MDIs) have been shown to cause many adverse effects. However, such effects have not been scrutinized in the ethnic Chinese community. METHODS The study was performed in two major hospitals in southern Taiwan. A total of 178 non-HIV patients aged ≥ 20 years who had participated in the Methadone Maintenance Treatment Program (MMTP) ≥ 1 month were recruited. An MDI is defined as concurrent use of drug(s) with methadone that may result in an increase or decrease of effectiveness and/or adverse effect of methadone. To determine the prevalence and clinical characteristics of MDIs, credible data sources, including the National Health Insurance (NHI) database, face-to-face interviews, medical records, and methadone computer databases, were linked for analysis. Socio-demographic and clinical factors associated with MDIs and co-medications were also examined. RESULTS 128 (72%) MMTP patients took at least one medication. Clinically significant MDIs included withdrawal symptoms, which were found among MMTP patients co-administered with buprenorphine or tramadol; severe QTc prolongation effect, which might be associated with use of haloperidol or droperidol; and additive CNS and respiratory depression, which could result from use of methadone in combination with chlorpromazine or thioridazine. Past amphetamine use, co-infection with hepatitis C, and a longer retention in the MMTP were associated with increased odds of co-medication. Among patients with co-medication use, significant correlates of MDIs included the male gender and length of co-medication in the MMTP. CONCLUSIONS The results demonstrate clinical evidence of significant MDIs among MMTP patients. Clinicians should check the past medical history of MMTP clients carefully before prescribing medicines. Because combinations of methadone with other psychotropic or opioid medications can affect treatment outcomes or precipitate withdrawal symptoms, clinicians should be cautious when prescribing these medications to MMTP patients and monitor the therapeutic effects and adverse drug reactions. Although it is difficult to interconnect medical data from different sources for the sake of privacy protection, the incumbent agency should develop pharmacovigilant measures to prevent the MDIs from occurring. Physicians are also advised to check more carefully on the medication history of their MMTP patients.
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Kharb R, Sharma PC, Yar MS. Pharmacological significance of triazole scaffold. J Enzyme Inhib Med Chem 2010; 26:1-21. [PMID: 20583859 DOI: 10.3109/14756360903524304] [Citation(s) in RCA: 333] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The triazole nucleus is one of the most important and well known heterocycles which is a common and integral feature of a variety of natural products and medicinal agents. Triazole nucleus is present as a core structural component in an array of drug categories such as antimicrobial, anti-inflammatory, analgesic, antiepileptic, antiviral, antineoplastic, antihypertensive, antimalarial, local anaesthetic, antianxiety, antidepressant, antihistaminic, antioxidant, antitubercular, anti-Parkinson's, antidiabetic, antiobesity and immunomodulatory agents, etc. The broad and potent activity of triazole and their derivatives has established them as pharmacologically significant scaffolds. The basic heterocyclic rings present in the various medicinal agents are 1,2,3-triazole and 1,2,4-triazole. A large volume of research has been carried out on triazole and their derivatives, which has proved the pharmacological importance of this heterocyclic nucleus. The present paper is an attempt to review the pharmacological activities reported for triazole derivatives in the current literature with an update of recent research findings on this nuclei.
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Affiliation(s)
- Rajeev Kharb
- Sanjivani College of Pharmaceutical Sciences, Khetri, India
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Wunsch MJ, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: a description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict 2009; 18:5-14. [PMID: 19219660 DOI: 10.1080/10550490802544938] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35-54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers.
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Affiliation(s)
- Martha J Wunsch
- Edward Via Virginia College of Osteopathic Medicine, Blacksburg, Virginia, USA.
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Charlson F, Degenhardt L, McLaren J, Hall W, Lynskey M. A systematic review of research examining benzodiazepine-related mortality. Pharmacoepidemiol Drug Saf 2009; 18:93-103. [PMID: 19125401 DOI: 10.1002/pds.1694] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE This paper will review literature examining the association of benzodiazepine use and mortality. METHODS An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards. RESULTS Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug. CONCLUSION On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.
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Affiliation(s)
- Fiona Charlson
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
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Diazepam alters cocaine self-administration, but not cocaine-stimulated locomotion or nucleus accumbens dopamine. Pharmacol Biochem Behav 2008; 91:202-7. [PMID: 18691612 DOI: 10.1016/j.pbb.2008.07.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 07/07/2008] [Accepted: 07/11/2008] [Indexed: 11/23/2022]
Abstract
Cocaine is known to enhance nucleus accumbens dopamine (NAcc DA), to serve as a positive reinforcer and to produce negative effects, such as anxiety. The influence of diazepam on cocaine intake, cocaine-stimulated behavioral activity and NAcc DA was investigated using self-administration and experimenter-administered intravenous (i.v.) cocaine. In Experiment 1, rats were pretreated with diazepam (0.25 mg/kg) or saline (0.1 ml) 30 min prior to 20 daily 1-hour cocaine (0.75 mg/kg/injection) self-administration sessions. Cocaine intake increased for all animals across sessions, but was highest in diazepam-pretreated animals. Diazepam rats also self-administered their first cocaine injection of each session faster than controls. Experiment 2 utilized in vivo microdialysis to assess NAcc DA levels before and after experimenter-administered i.v. cocaine injections (0.75 mg/kg/injection x 2; 10-min interval) in diazepam- and saline-pretreated rats. Group differences were not revealed across basal and cocaine-stimulated NAcc DA assessments, indicating that diazepam did not decrease NAcc DA during cocaine self-administration. Findings that diazepam enhances cocaine self-administration and decreases cocaine response latency support the notion that cocaine-induced anxiety limits voluntary cocaine intake. It is further suggested that individual variations in cocaine-induced aversive effects may determine whether cocaine use is avoided or repeated.
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Peters RJ, Meshack AF, Kelder SH, Webb P, Smith D, Garner K. Alprazolam (Xanax) use among southern youth: beliefs and social norms concerning dangerous rides on "handlebars". JOURNAL OF DRUG EDUCATION 2007; 37:417-428. [PMID: 18351180 DOI: 10.2190/de.37.4.e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
While the epidemiologic trends concerning alprazolam (Xanax) are unknown, the use of benzodiazepines, in general, has increased in popularity among youth within recent years. To shed light on the drug problem, the current pilot study used a qualitative approach to investigate relevant beliefs, norms, and perceived addiction associated with alprazolam initiation among 46 youth who were attending an inpatient drug treatment program during the spring of 2004. Overwhelmingly, most participants stated that addiction to alprazolam occurs as early as initial consumption. Most youth in the study stated that their friends felt it was normal to use alprazolam. In addition, their control beliefs revealed that if someone wanted to stop it would be difficult because of the widespread use in their communities and family social reinforcement involved with its use. In this study, a majority of students stated that medical professionals such as doctors and pharmacists were the greatest facilitator of alprazolam acquisition. Implications for these results are discussed.
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Affiliation(s)
- Ronald J Peters
- The University of Texas Health Science Center at Houston, 77030, USA.
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Sanchez M. Pertinence clinique de l’utilisation de benzodiazépines. Presse Med 2006; 35:563-4. [PMID: 16614593 DOI: 10.1016/s0755-4982(06)74639-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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