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Stephenson L, Van Den Heuvel C, Humphries M, Byard RW. Prescribed and Diverted Methadone Toxicity in South Australia: An Update. Am J Forensic Med Pathol 2024; 45:124-129. [PMID: 38064311 DOI: 10.1097/paf.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
ABSTRACT Methadone is one of the most common medications currently prescribed for the treatment of opioid use disorders (OUDs). While methadone maintenance programs (MMPs) have been highly successful in the management and treatment of OUDs resulting in a reduced number of fatalities, the risk of overdose/toxicity remains. The current study was undertaken to analyze trends in overdoses attributed to prescribed and diverted methadone in South Australia (SA) between 2000 and 2019. Over the 20-year period, 344 methadone-related deaths occurred in SA with a significant increase in deaths over the study period ( P = 0.03). The mean age of decedents was 42.5 years with a male to female ratio of 1.8:1, with approximately 20% of decedents enrolled in a MMP at the time of death. Overall, only 5.2% of cases demonstrated methadone diversion, which was associated with methadone prescribed for chronic pain and was most likely to be diverted from a friend/housemate or a partner. However, the source of methadone in more than half of cases was unknown, so this is likely a significant underestimate of actual MMP methadone diversion and total methadone diversion.
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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:metabo11030189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
- Correspondence:
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Errico S, Bedocchi D, Drommi M, Barranco R, Bonsignore A, Ventura F. Forensic pathological study of methadone-related deaths in the Genoa (Italy) district: A six-year study. J Forensic Leg Med 2021; 79:102149. [PMID: 33667794 DOI: 10.1016/j.jflm.2021.102149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Abstract
Methadone is a synthetic opioid, a pure agonist of the μ receptor. It is used for opioid maintenance therapy in heroin addiction. In recent years, Italian studies of incidence and prevalence have indicated an increase in the illegal sales of methadone and, consequently, an increase in deaths due to acute methadone intoxication as well. The present review is a prospective-observational study regarding epidemiological and toxicological analyses of methadone-related deaths recorded in the district of Genoa (Italy) from 2013 to 2018. The study includes a list of twenty-six people that have died from methadone toxicity: twenty-two males and four females. The concentration of methadone in the blood samples ranged from 181 to 4058.53 ng/mL, with an average of 964.29 ng/mL. Six subjects tested positive for methadone alone; twenty cases, however, presented drugs or substances in different concentrations in the blood samples. Illegal sales and consumption of methadone have a negative impact on the self-administration therapy of opioid addiction, inducing patients to increase their dosage or sell methadone in order to purchase illegal drugs. As shown in our study, this behaviour is associated with an increase in methadone-related deaths. Accordingly, careful monitoring of dosage administrated to patients is required in order to render the system safer.
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Affiliation(s)
- Stefano Errico
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Davide Bedocchi
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Martina Drommi
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Rosario Barranco
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Alessandro Bonsignore
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Francesco Ventura
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy.
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ABCB1, CYP2B6, and CYP3A4 genetic polymorphisms do not affect methadone maintenance treatment in HCV-positive patients. Arh Hig Rada Toksikol 2020; 71:353-358. [PMID: 33410778 PMCID: PMC7968507 DOI: 10.2478/aiht-2020-71-3378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 11/01/2020] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to determine the influence of ABCB1, CYP2B6, and CYP3A4 genetic polymorphisms on methadone metabolism in patients with hepatitis C virus (HCV) undergoing methadone maintenance treatment (MMT). The study included 35 participants undergoing MMT, who were divided in three groups: HCV-positive (N=12), HCV-negative (N=16), and HCV clinical remission (CR) (N=7). The concentrations of methadone and its main metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) were determined with gas chromatography-mass spectrometry. The patients were genotyped for ABCB1 rs1045642, CYP2B6 rs3745274, CYP3A4 rs2242480, and CYP3A4 rs2740574 polymorphisms. Differences between single nucleotide polymorphism (SNP) genotypes and methadone-to-EDDP ratio were analysed with one-way ANOVA, which showed no significant difference between the genes (p=0.3772 for ABCB1 rs1045642, p=0.6909 for CYP2B6 rs3745274, and p=0.6533 for CYP3A4 rs2242480). None of the four analysed SNP genotypes correlated with methadone-to-EDDP concentration ratio. A major influence on it in hepatitis C-positive patients turned out to be the stage of liver damage.
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Ključević Ž, Benzon B, Ključević N, Veršić Bratinčević M, Sutlović D. Liver damage indices as a tool for modifying methadone maintenance treatment: a cross-sectional study. Croat Med J 2019. [PMID: 30610772 PMCID: PMC6330771 DOI: 10.3325/cmj.2018.59.298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim To assess the effect of liver damage on methadone metabolism in opiate addicts undergoing methadone maintenance treatment (MMT). Methods This cross-sectional study recruited 74 patients treated at the outpatient clinic of Public Health Institute of Split-Dalmatia County from 2013-2016. Concentrations of methadone and its main inactive metabolite were measured in participants’ biological samples on regular check-ups. Urine samples obtained before oral methadone intake, and blood and urine samples obtained 90 minutes after methadone intake were analyzed using gas chromatography/mass spectrometry. Participants were divided into groups according to liver damage criteria: hepatitis C virus status (positive, negative, or clinical remission); aspartate aminotransferase to platelet ratio (APRI) index (<0.7 and ≥0.7); and fibrosis-4 score (<1.45, 1.45-3.25, >3.25). Results Metabolic ratio and methadone metabolite concentration in plasma decreased linearly with HCV infection status by the factor of 1.67 (P = 0.001) and 2.2 (P = 0.043), respectively. Metabolic ratio in plasma decreased in patients with APRI index ≥0.7 by the average factor of 2.12 (P = 0.01) and methadone metabolite concentration in plasma decreased by the factor of 6.16 (P = 0.009). Metabolic ratio in urine decreased with the severity of fibrosis-4 score by the average factor of 1.63 (P = 0.008), whereas methadone metabolite concentration decreased by the factor of 3.53 (P = 0.007). Conclusion Liver damage decreases methadone metabolism. Indices of liver function should be calculated regularly during MMT for methadone dose titration.
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Affiliation(s)
- Željko Ključević
- Željko Ključević, Public Health Institute of Split-Dalmatia County, Vukovarska 46, 21 000 Split, Croatia,
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