The source of methadone in overdose deaths in Western Virginia in 2004

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis

BACKGROUND

Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT).

METHODS

We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT.

RESULTS

Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths.

DISCUSSION

Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

INTRODUCTION

This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.

METHODS

The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.

RESULTS

The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.

CONCLUSIONS

The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

The Influence of Co-Occurring Substance Use on the Effectiveness of Opiate Treatment Programs According to Intervention Type

This systematic review describes the influence of co-occurring substance use on the effectiveness of opiate treatment programs. MEDLINE/PubMed, Embase, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from database inception to November 28, 2018, to identify eligible opioid treatment studies in the United States that assessed the relationship between co-occurring substance use and treatment outcome (i.e., opioid abstinence and treatment retention). A total of 34 eligible studies were included. Overall, co-occurring substance use was associated with negative treatment outcomes regardless of intervention type. However, patterns varied by substance and intervention type. In particular, co-occurring use of cocaine or marijuana with opioids was associated with reduced treatment retention and opioid abstinence regardless of intervention type. Co-occurring use of amphetamines, compared with no use or reduced use of amphetamines, decreased treatment retention. Co-occurring use of alcohol was both positively and negatively associated with treatment outcomes. One study reported a significant positive association between sedative use and opioid abstinence. Generally, findings suggest that combined interventions reported better health outcomes compared with pharmacological or behavioral intervention studies alone. The findings of this review emphasize the need to comprehensively study and address co-occurring substance use to improve opiate treatment programs.

American Indian and Non-Hispanic White Midlife Mortality Is Associated With Medicaid Spending: An Oklahoma Ecological Study (1999-2016)

Objective: A one third reduction of premature deaths from non-communicable diseases by 2030 is a target of the United Nations Sustainable Development Goal for Health. Unlike in other developed nations, premature mortality in the United States (US) is increasing. The state of Oklahoma suffers some of the greatest rates in the US of both all-cause mortality and overdose deaths. Medicaid opioids are associated with overdose death at the patient level, but the impact of this exposure on population all-cause mortality is unknown. The objective of this study was to look for an association between Medicaid spending, as proxy measure for Medicaid opioid exposure, and all-cause mortality rates in the 45–54-year-old American Indian/Alaska Native (AI/AN45-54) and non-Hispanic white (NHW45-54) populations.

Methods: All-cause mortality rates were collected from the US Centers for Disease Control & Prevention Wonder Detailed Mortality database. Annual per capita (APC) Medicaid spending, and APC Medicare opioid claims, smoking, obesity, and poverty data were also collected from existing databases. County-level multiple linear regression (MLR) analyses were performed. American Indian mortality misclassification at death is known to be common, and sparse populations are present in certain counties; therefore, the two populations were examined as a combined population (AI/NHW45-54), with results being compared to NHW45-54 alone.

Results: State-level simple linear regressions of AI/NHW45-54 mortality and APC Medicaid spending show strong, linear correlations: females, coefficient 0.168, (R² 0.956; P < 0.0001; CI95 0.15, 0.19); and males, coefficient 0.139 (R² 0.746; P < 0.0001; CI95 0.10, 0.18). County-level regression models reveal that AI/NHW45-54 mortality is strongly associated with APC Medicaid spending, adjusting for Medicare opioid claims, smoking, obesity, and poverty. In females: [R² 0.545; (F)P < 0.0001; Medicaid spending coefficient 0.137; P < 0.004; 95% CI 0.05, 0.23]. In males: [R² 0.719; (F)P < 0.0001; Medicaid spending coefficient 0.330; P < 0.001; 95% CI 0.21, 0.45].

Conclusions: In Oklahoma, per capita Medicaid spending is a very strong risk factor for all-cause mortality in the combined AI/NHW45-54 population, after controlling for Medicare opioid claims, smoking, obesity, and poverty.

Medication-assisted therapies for opioid use disorders in patients with chronic pain

Opioids have been used to treat pain and invoke pleasure for centuries. Modern scientific advancements have led to more potent, synthetic opioids. While certainly more effective in treating pain, they can also be much more addictive. Over the years the scientific community has developed a clearer understanding of the role opioid receptors play in causing and treating opioid use disorders (OUD) and we now know that OUD can develop in individuals taking opioids for "legitimate" pain. Current guidelines suggest that all prescribers (especially those prescribing opioids) be capable treating OUD. Pharmacological advances have led to a wide array of safe and effective treatment options to address OUDs. This paper will discuss the history of opioid development, what is known about the transition from analgesic uses to addiction and modern evidenced based treatment strategies to address OUDs.

The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015

OBJECTIVES

Opioid-related overdoses are commonly attributed to prescription opioids. We examined data on opioid-related overdose decedents in Massachusetts. For each decedent, we determined which opioid medications had been prescribed and dispensed and which opioids were detected in postmortem medical examiner toxicology specimens.

METHODS

Among opioid-related overdose decedents in Massachusetts during 2013-2015, we analyzed individually linked postmortem opioid toxicology reports and prescription drug monitoring program records to determine instances of overdose in which a decedent had a prescription active on the date of death for the opioid(s) detected in the toxicology report. We also calculated the proportion of overdoses for which prescribed opioid medications were not detected in decedents' toxicology reports.

RESULTS

Of 2916 decedents with complete toxicology reports, 1789 (61.4%) had heroin and 1322 (45.3%) had fentanyl detected in postmortem toxicology reports. Of the 491 (16.8%) decedents with ≥1 opioid prescription active on the date of death, prescribed opioids were commonly not detected in toxicology reports, specifically: buprenorphine (56 of 97; 57.7%), oxycodone (93 of 176; 52.8%), and methadone prescribed for opioid use disorder (36 of 112; 32.1%). Only 39 (1.3%) decedents had an active prescription for each opioid detected in toxicology reports on the date of death.

CONCLUSION

Linking overdose toxicology reports to prescription drug monitoring program records can help attribute overdoses to prescribed opioids, diverted prescription opioids, heroin, and illicitly made fentanyl.

Prescription Opioids Are Associated With Population Mortality in US Deep South Middle-Age Non-hispanic Whites: An Ecological Time Series Study

Objective: The US Burden of Disease Collaborators reported that between 1990 and 2016, the top 10 states with increasing probability of death between the ages of 20 and 55 years were all in the South. A recent study of annual surveillance data found that increasing all-cause mortality rates were occurring in middle-age non-Hispanic whites. The vast proportion of all-cause mortality consists of medical causes, not external causes (i.e., overdose, mental illness, suicide, homicide, or motor vehicle crashes). It has been hypothesized by researchers that the ongoing opioid epidemic has an etiologic role in the trend of increasing medical death, but ecological studies looking for an association have not been published. The objective of this study was to test the hypothesis that hydrocodone and oxycodone sales are temporally associated and correlated with annual NHW45-54 medical-cause mortality rates in the Deep South region comprised of Alabama, Arkansas, Louisiana, Mississippi, Oklahoma, and South Carolina.

Methods: Mortality and opioid sales data were obtained from the Centers for Disease Control and Prevention Wonder Detailed Mortality and University of Wisconsin State Health Access Data Assistance Center databases, respectively. Annual, state and regional NHW45-54 medical-cause mortality and opioid sales data were analyzed using Spearman rank correlation (rs) testing, after first and second differencing, in order to achieve stationarity and control for trend similarities.

Results: Sales of prescription opioids follow very similar temporal patterns across these six states, with simultaneous increases in 2007 and 2013. With few exceptions, annual opioids sales trends were correlated state-to-state. Two prominent spikes are evident in the aggregated opioid sales trends of the six states, with both sales spikes preceding same-directional fluctuations in medical-cause mortality by ~1 year. After a 1 year adjustment of second-differenced data, population hydrocodone exposure was correlated with female NHW45-54 population medical-cause mortality [rs₍₁₃₎ = 0.540; P = 0.038]; and oxycodone exposure correlated with male NHW45-54 population medical-cause mortality [rs₍₁₃₎ = 0.607; P = 0.016].

Conclusions: State sales of prescription hydrocodone and oxycodone in the six states studied follow non-random, systematic trajectories. A strong correlation and temporal association exists between prescription opioid sales and medical-cause mortality in this Deep South NHW45-54 population.

Methadone Maintenance Treatment: A 15-year Retrospective Study in Split-Dalmatia County, Croatia

BACKGROUND

The aim of this retrospective study is to use existing epidemiological data on patients in methadone maintenance treatment in Split-Dalmatia County from 2001 to 2015 to evaluate the substitution treatment system and policy of opiate addicts treatment, the epidemiological trend, and risk of overdose mortality. In addition, we would like to highlight the problem of poor control of methadone therapy and thus the possibility of selling methadone. The result is a greater number of deaths caused by methadone in people who were not in methadone therapy.

METHODS

The research included data collected from 3189 patients who had been in the drug abuse treatment program in Split-Dalmatia County during 2001-2015 and data gathered from autopsy examinations of patients in Split-Dalmatia County with emphasis on data for 186 overdosed patients during research period.

RESULTS

The total number of patients in the methadone treatment program in Split-Dalmatia County during the research period, except in 2005 and 2006, has been stable, while the number of new opiate patients, being in first-time treatment, decreased by 62.5%. The number of addicts who were in a long-term maintenance program has increased by 198%, whereas the number of addicts who were in a short-term detoxification treatment has decreased by 96.4%. According to results obtained from performed autopsies, 186 death cases were determined as overdoses. Methadone was found in 56 of those cases and was declared as the cause of death in 39 cases (70%). Of the total number of autopsied patients with diagnosed methadone overdose, only 23 (59%) had been recorded to receive methadone therapy in Public Health Institute of Split-Dalmatia County database.

CONCLUSIONS

The results of this study show the favorable epidemiological trend because of the decreasing number of new opiate patients in treatment. The retention of opiate patients in substitution therapy indicates the effectiveness of methadone maintenance programs. Our research did not determine any influence of methadone substitution therapy on an increasing risk of specific (overdose) mortality.

Sociodemographic factors, prescription history and opioid overdose deaths: a statewide analysis using linked PDMP and mortality data

BACKGROUND

Opioid overdose deaths have continued to rise in Tennessee (TN) with fentanyl emerging as a major contributor. Current data are needed to identify at-risk populations to guide prevention strategies. We conducted a large statewide observational study among TN adult decedents (2013-2016) to evaluate the association of sociodemographic factors and prescribing patterns with opioid overdose deaths.

METHODS

Among drug overdose decedents identified using death certificate data (n = 5483), we used logistic regression to estimate adjusted odds ratios and 95% confidence intervals for characteristics associated with prescription opioid (PO) (excluding fentanyl), fentanyl, and heroin alone overdoses. Among decedents linked to TN's Prescription Drug Monitoring Database using deterministic algorithms, we obtained prescription history in the year before death (n = 3971), which was evaluated by type of overdose using descriptive statistics.

RESULTS

Younger, non-White decedents had lower odds of PO overdose, while females and benzodiazepines as a contributing cause were associated with increased odds of PO overdose. Younger age, Non-Hispanic Black race/ethnicity, greater than high school education, and cocaine/other stimulants as a contributing cause were associated with increased odds of fentanyl or heroin overdoses. Over 55% of PO, 39.2% of fentanyl, and 20.7% of heroin overdoses had an active opioid prescription at death. For PO, fentanyl, and heroin decedents, respectively, 46.0%, 30.5%, and 26.2% had an active prescription for benzodiazepines at death.

CONCLUSIONS

Prescription opioid overdose deaths were associated with different sociodemographic profiles and prescribing history compared to fentanyl and heroin overdose deaths in TN. Data can guide prevention strategies to reduce opioid overdose mortality.

The source and diversion of pharmaceutical drugs for non-medical use: A systematic review and meta-analysis

BACKGROUND

The non-medical use (NMU) of pharmaceutical drugs is an increasing public health concern. This systematic review consolidates current knowledge about how pharmaceutical drugs are obtained for NMU and the processes and people involved in diversion.

METHODS

Peer-reviewed and grey literature databases were searched for empirical studies published between 1996 and 2017 that examined the source or diversion of pharmaceutical opioids, sedatives or stimulants for NMU in countries with reported misuse problems. Pooled prevalence meta-analyses using random effects models were used to estimate the prevalence of medical and non-medical sourcing reported by end-users, and gifting, selling and trading by various populations.

RESULTS

This review synthesizes the findings of 54 cross-sectional studies via meta-analyses, with a remaining 95 studies examined through narrative review. Pharmaceutical drugs are primarily sourced for NMU from friends and family (57%, 95% CI 53%-62%, I² = 98.5, n = 30) and despite perceptions of healthcare professionals to the contrary, illegitimate practices such as doctor shopping are uncommon (7%, 95% CI 6%-10%, I² = 97.4, n = 29). Those at risk of diversion include patients displaying aberrant medication behaviors, people with substance use issues and students in fraternity/sorority environments. Sourcing via dealers is also common (32%, 95% CI 23%-41%, I² = 99.8, n = 25) and particularly so among people who use illicit drugs (47%, 95% CI 35%-60%, I² = 99.1, n = 15). There is little to no organized criminal involvement in the pharmaceutical black market.

CONCLUSION

Pharmaceutical drugs for NMU are primarily sourced by end-users through social networks. Future research should examine how dealers source pharmaceutical drugs.

Using Controlled Substance Receipt Patterns to Predict Prescription Overdose Death

BACKGROUND

This study evaluates complete state data from controlled substance prescribing trends in the prescription monitoring program (PMP) database and their association with the risk of prescription drug overdose death.

SUMMARY

Maine PMP records of individuals who died of prescription overdose deaths between 2006 and 2010 were selected (n = 690). For each subject, an age, gender, and residence matched cohort of PMP users in a 50: 1 ratio was identified (n = 34,500). Key Messages: Prescription opioids contributed to 480 of 690 prescription deaths, many co-ingestions were noted, and OR for overdose death increased with milligram of morphine equivalent (MME)/day >100. The majority who were prescribed MME >100 per day received a prescription within 90 days of overdose matching the toxicology cause of death.

CONCLUSIONS

Medication profiles available through state PMP can identify dosing of prescriptions associated with drug overdose death.

Medications without a patient: potential lethal implications of pharmaceuticals left behind

BACKGROUND

Little has been published on the sources of medications used in suicide by self-poisoning.

AIMS

To examine data on self-poisoning occurring through the use of medications returned to the next of kin after the death of a family member or friend ("returned medication") and to examine public policies relevant to this issue.

METHOD

A review of charts at the Office of the Chief Coroner of Ontario for deaths by self-poisoning suicide in the City of Toronto occurring between 1998 and 2010 was conducted. Information regarding the source of medication used in self-poisoning was extracted. Federal, provincial, and local policies were also examined to determine whether there are guidelines governing returning medication to next of kin.

RESULTS

Of 567 suicide deaths by self-poisoning in Toronto over 13 years, there were eight cases in which returned medication was used in suicide by self-poisoning. No policies prohibiting this type of medication return were identified.

CONCLUSION

Suicide by self-poisoning using returned medications is an important consideration that may not yet be fully appreciated, and has relevance for suicide prevention policies.

Factors associated with illicit methadone injecting in a Canadian setting

BACKGROUND AND OBJECTIVES

While methadone is well established as an evidence-based treatment for opioid use disorder, safety concerns persist regarding its diversion. The authors examine the prevalence of and risk factors associated with injection of methadone in an urban population.

METHODS

Between December 2005 and November 2013, data were derived from two open prospective studies of persons who inject drugs (PWID) in Vancouver, Canada. Generalized estimating equations (GEE) logistic regression was used to determine factors independently associated with illicit methadone injecting.

RESULTS

During the study, 1911 individuals (34% women) were recruited; 134 (7%) participants reported methadone injecting at least once. In multivariable analysis, Caucasian ethnicity [adjusted odds ratio (AOR) = 1.90, 95% confidence interval (CI) = 1.20-3.00]; homelessness (AOR = 1.46, 95% CI = 1.09-1.95); drug dealing (AOR = 2.10, 95% CI = 1.50-2.93); ≥daily heroin injection (AOR = 1.57, 95% CI = 1.08-2.26); ≥daily crack smoking (AOR = 2.06, 95% CI = 1.44-2.95); being a victim of violence (AOR = 1.48, 95% CI = 1.04-2.12); and non-fatal overdose (AOR = 1.67, 95% CI = 1.67 (1.00-2.79) were independently and positively associated with methadone injection; female gender (AOR = 0.47, 95% CI = 0.30-0.75) was negatively associated.

DISCUSSION AND CONCLUSIONS

The diversion of methadone for illicit injection in this urban setting was associated with several markers of addiction severity and other health and social vulnerabilities.

SCIENTIFIC SIGNIFICANCE

These findings underscore the need to ensure methadone accessibility while limiting diversion-related risk.

Research gaps on methadone harms and comparative harms: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline

Methadone-associated overdose deaths have dramatically increased. In order to inform an evidence-based clinical practice guideline to improve safety of methadone prescribing, the American Pain Society commissioned a systematic review on various aspects related to methadone safety. We searched Ovid MEDLINE, Cochrane Library, and PsycINFO databases through July 2012 to identify studies that addressed 1 or more of 17 Key Questions related to methadone safety; an update search was performed in 2014 for new studies related to methadone-related overdose and risks related to cardiac arrhythmias. A total of 168 studies met inclusion criteria for the review. The purpose of this article is to highlight critical research gaps in the literature related to methadone safety. These include lack of evidence on risk factors associated with methadone-overdose deaths and adverse events, limited evidence to evaluate the comparative mortality of methadone versus other opioids, insufficient evidence to fully understand the harms associated with methadone use during pregnancy, and insufficient evidence to determine effects of risk mitigation strategies such as electrocardiogram monitoring, strategies for managing patients with prolonged QTc intervals on screening, urine drug testing, alternative dosing regimens for initiation and titration of therapy, and timing of follow-up. Therefore, most guideline recommendations are based on weak evidence. More research is needed to guide safe methadone prescribing practices and decrease the adverse events associated with methadone.

PERSPECTIVE

This article summarizes critical research gaps in the literature related to methadone safety, based on a systematic review commissioned by the American Pain Society. Critical research gaps were identified in a number of areas, highlighting the need for additional research to guide safer prescribing and risk mitigation strategies.

Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society

Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence.

PERSPECTIVE

This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.

Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline

The number of deaths associated with methadone use increased dramatically in parallel with marked increases in its use, particularly for treatment of chronic pain. To develop a clinical guideline on methadone prescribing to reduce potential harms, the American Pain Society commissioned a review of various aspects related to methadone safety. This article summarizes evidence related to unintentional overdose due to methadone and harms related to cardiac arrhythmia potential. We searched Ovid MEDLINE, the Cochrane Library, and PsycINFO databases through January 2014 for studies assessing harms associated with methadone use; we judged 70 studies to be relevant and to meet inclusion criteria. The majority of studies on overdose and cardiac arrhythmia risk are observational and provide weak evidence on which to base clinical guidelines. In patients prescribed methadone for treatment of opioid dependence, data suggest that mortality benefits related to reduction in illicit drug use outweigh harms. Despite epidemiologic data showing marked increases in the numbers of methadone-related deaths that have been primarily attributed to increased use of methadone for chronic pain, evidence on methadone and mortality risk in this population has been somewhat contradictory. There is some evidence that recent initiation of methadone, psychiatric admissions, and concomitant use of benzodiazepines are associated with a higher risk for overdose. Evidence on cardiac risks is primarily limited to case reports of torsades de pointes, primarily in patients on high doses of methadone, and to studies showing an association between methadone use and prolongation of QTc intervals. Research is needed to understand the effectiveness of dosing methods, electrocardiogram monitoring, and other risk mitigation strategies in patients prescribed methadone.

PERSPECTIVE

This systematic review synthesizes the evidence related to methadone use and risk for overdose and cardiac arrhythmia. Findings regarding the association between methadone use and QTc interval prolongation and risk factors for methadone-associated overdose suggest potential targets for risk mitigation strategies, though research is needed to determine the effectiveness of such strategies at reducing adverse outcomes.

Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review

We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-related mortality and mortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population, making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations.

Opioid-related mortality and filled prescriptions for buprenorphine and methadone

INTRODUCTION AND AIMS

To assess opioid-related mortality and correlation with filled prescriptions for buprenorphine and methadone.

DESIGN AND METHODS

A register study, including data from the Swedish Forensic Pathology and Forensic Toxicology databases 2003-2010, the Prescribed Drug Register and the National Patient Register.

RESULTS

A total of 1301 deaths, assessed as related to buprenorphine, methadone or heroin, or a combination of them, were studied. The largest number of fatalities was related to intake of heroin (n = 776), followed by methadone (n = 342) and buprenorphine (n = 168). The total annual number of fatal cases related to the studied drugs more than doubled (116 to 255) during the study period. There were increases in mortality related to both buprenorphine and methadone: from 1 to 49 cases for buprenorphine, and from 19 to 81 cases for methadone. Only one-fifth of the fatal cases had a filled prescription for the maintenance drug assessed as the cause of death.

DISCUSSION AND CONCLUSION

This study showed that most fatalities were not related to filled prescriptions of maintenance drugs, and a substantial illicit use of buprenorphine and methadone resulting in deaths was revealed. To prevent opioid toxicity deaths it is important to make efforts not only to reduce drug diversion from maintenance programs, but also to improve the control of drug trafficking and other illegal sources.

Prevalence and correlates for nonmedical use of prescription opioids among urban and rural residents

BACKGROUND

In the United States, rural areas have reported an increase in overdose deaths secondary to nonmedical use of prescription opioids. Little is known about the differences in nonmedical use of prescription opioids among urban and rural adults.

METHODS

Using the 2008-2009 National Survey on Drug Use and Health, we examined the prevalence of nonmedical use of prescription opioids in urban and rural counties and determined bivariate and multivariate associations, stratified by county. We also compared type of opioids, stratified by county.

RESULTS

Among 75,964 respondents, the prevalence of nonmedical use of prescriptions opioids was similar among residents in urban and rural counties (4.7% vs. 4.3%, p=0.15). Urban and rural residents with severe psychological distress and nonmedical use of other prescription medications were more likely to report nonmedical use of opioids. Urban residents whose first use of illicit drugs was between the age of 18 and 25 and who reported alcohol use were more likely to report nonmedical use. Black and Hispanic urban residents were less likely to use prescription opioids nonmedically compared to white urban residents. Rural residents were more likely than urban residents to use acetaminophen with propoxyphene (61.1% vs. 55.8%, p=0.02), methadone (14.8% vs. 9.1%, p=0.003) and acetaminophen with codeine (3.5% vs. 1.9%, p=0.05).

CONCLUSIONS

Prevalence and risk factors related to nonmedical use of opioids are similar between urban and rural residents; however rural residents report propoxyphene, codeine, and methadone use more than their urban counterparts. Prevention and treatment interventions may need to be tailored for specific communities.