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Henson RM, Mullachery PH, Sánchez-Pájaro A, Cruz-Cruz C, Bilal U, Langellier B, Barrientos-Gutiérrez T. Spatial Heterogeneity in Fatal Overdose Rate Trends in Mexican Cities: 2005-2021. Am J Public Health 2024; 114:705-713. [PMID: 38723222 PMCID: PMC11153949 DOI: 10.2105/ajph.2024.307650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 05/18/2024]
Abstract
Objectives. To describe national and city-level fatal drug overdose trends between 2005 and 2021 in Mexico. Methods. We calculated fatal overdose rates at the city level in 3-year periods from 2005 to 2021 and annually at the national level for people aged 15 to 64 years in Mexico. We calculated rate differences and rate ratios for each city between periods. Results. The national fatal overdose rate was 0.53 overdose deaths per 100 000 population and was almost twice as high in urban than in nonurban areas. The national fatal overdose rate was stable over the period 2005 to 2014 and increased monotonically to a peak in 2021. Fatal overdose rates varied across cities. Cities with the 8 highest fatal overdose rates in the period were all in states along the US-Mexico border. Conclusions. Fatal overdoses have doubled over the past 15 years in Mexico. Overdose rates are particularly high and increasing in cities close to the US-Mexico border. Public Health Implications. There is a need for enhanced overdose surveillance data and coordinated harm reduction strategies, particularly in the northern border region of Mexico. (Am J Public Health. 2024;114(7):705-713. https://doi.org/10.2105/AJPH.2024.307650).
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Affiliation(s)
- Rosie Mae Henson
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Pricila H Mullachery
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Andrés Sánchez-Pájaro
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Copytzy Cruz-Cruz
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Usama Bilal
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Brent Langellier
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
| | - Tonatiuh Barrientos-Gutiérrez
- Rosie Mae Henson and Brent Langellier are with the Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Pricila H. Mullachery is with the Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA. Andrés Sánchez-Pájaro and Tonatiuh Barrientos-Gutiérrez are with the Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Mexico City, Mexico. Copytzy Cruz-Cruz is with the Servicios de Atención Psiquiátrica, Secretaría de Salud, Mexico City, Mexico. Usama Bilal is with the Urban Health Collaborative, Dornsife School of Public Health
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Walters JK, Lewis P, Dileo K. Evaluation of a Suspected Overdose Form for Timely Surveillance of Fatal Drug Overdoses, Multnomah County, OR, 2020-2021. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024; 30:586-592. [PMID: 38870376 DOI: 10.1097/phh.0000000000001942] [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: 06/15/2024]
Abstract
OBJECTIVES There is a significant delay in finalization of drug overdose deaths, and a need to more quickly identify suspected overdoses to improve public health response. The objective of our study was to describe creation of a suspect overdose form and evaluate its use. DESIGN Evaluation of a suspected overdose form used to record information related to death investigation with matching to state vital records. We calculated the toxicology turnaround time for matched records, and also calculated sensitivity, specificity, positive predictive value, and negative predictive value of the form compared to vital records as the gold standard. SETTING Multnomah County, Oregon, deaths investigated by the County Medical Examiner between January 2020 and December 2021. MAIN OUTCOME MEASURE Sensitivity of the suspected overdose form. RESULTS We analyzed 2818 matched death records in total during the study period. The average turnaround time for the 1673 records with toxicology results was 101 days. In 2020, sensitivity of the form was 74%, but this increased to nearly 95% in 2021. CONCLUSIONS Multnomah County's suspected evaluation form provides a timelier indicator of deaths suspected to be from drug overdose, has good sensitivity to detect true overdoses, and can help guide more rapid public health and public safety response activities.
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Affiliation(s)
- Jaime K Walters
- Author Affiliations: Community Epidemiology Services (Ms Walters), Health Officer Division (Dr Lewis and Ms Dileo), Multnomah County Health Department, Public Health Division, Portland, OR
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Henningfield JE, Grundmann O, Huestis MA, Smith KE. Kratom safety and toxicology in the public health context: research needs to better inform regulation. Front Pharmacol 2024; 15:1403140. [PMID: 38887550 PMCID: PMC11180979 DOI: 10.3389/fphar.2024.1403140] [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: 03/18/2024] [Accepted: 04/30/2024] [Indexed: 06/20/2024] Open
Abstract
Although kratom use has been part of life for centuries in Southeast Asia, the availability and use of kratom in the United States (US) increased substantially since the early 2000s when there was little information on kratom pharmacology, use patterns, and effects, all critical to guiding regulation and policy. Here we provide a synthesis of research with several hundred English-language papers published in the past 5 years drawing from basic research, epidemiological and surveillance data, and recent clinical research. This review of available literature aims to provide an integrated update regarding our current understanding of kratom's benefits, risks, pharmacology, and epidemiology, which may inform United States-based kratom regulation. Recent surveillance indicates there are likely several million past-year kratom consumers, though estimates vary widely. Even without precise prevalence data, kratom use is no longer a niche, with millions of United States adults using it for myriad reasons. Despite its botanical origins in the coffee tree family and its polypharmacy, kratom is popularly characterized as an opioid with presumed opioid-system-based risks for addiction or overdose. Neuropharmacology, toxicology, and epidemiology studies show that kratom is more accurately characterized as a substance with diverse and complex pharmacology. Taken together the work reviewed here provides a foundation for future scientific studies, as well as a guide for ongoing efforts to regulate kratom. This work also informs much-needed federal oversight, including by the United States Food and Drug Administration. We conclude with recommendations for kratom regulation and research priorities needed to address current policy and knowledge gaps around this increasingly used botanical product.
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Affiliation(s)
- Jack E. Henningfield
- Pinney Associates, Inc., Bethesda, MD, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Bethesda, MD, United States
| | - Oliver Grundmann
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, Gainesville, FL, United States
| | - Marilyn A. Huestis
- Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kirsten E. Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Rempel AML, Persons JE, Bengtson K, Nashelsky MB. Causes of Death in the Presence of Law Enforcement in Johnson County, Iowa, 2011-2020. Am J Public Health 2024; 114:642-650. [PMID: 38574318 PMCID: PMC11079845 DOI: 10.2105/ajph.2024.307616] [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: 04/06/2024]
Abstract
Objectives. To examine sudden and unexpected or trauma-related deaths that occurred in the presence of law enforcement in Johnson County, Iowa, between 2011 and 2020. Methods. We identified deaths in the presence of law enforcement using definitions from the National Association of Medical Examiners. We obtained data, including demographics, cause and manner of death, toxicology results, and circumstances and location of event leading to death, from comprehensive medical examiner investigative reports. Results. There were 165 deaths that occurred in the presence of law enforcement: 114 were from a known disease, and 51 were either trauma related or the sudden, unexpected initial presentation of a previously unrecognized disease. Three deaths occurred in the context of physical restraint by law enforcement. Suicide was the leading manner of death among trauma-related deaths; the means of suicide was predictable based on in-custody (hanging) or precustody (firearm) circumstances. Conclusions. Our findings highlight the potential role of medical examiners and coroners in improving completeness of data on reporting death in the presence of law enforcement to public health agencies. (Am J Public Health. 2024;114(6):642-650. https://doi.org/10.2105/AJPH.2024.307616).
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Affiliation(s)
- Anne M L Rempel
- Anne M. L. Rempel, Jane E. Persons, and Marcus B. Nashelsky are with the Department of Pathology, University of Iowa Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City. Anne M. L. Rempel is also with the University of California, San Francisco, Department of Emergency Medicine, Fresno, CA. Kate Bengtson and Marcus B. Nashelsky are also with the Johnson County, Iowa Medical Examiner Department, Iowa City
| | - Jane E Persons
- Anne M. L. Rempel, Jane E. Persons, and Marcus B. Nashelsky are with the Department of Pathology, University of Iowa Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City. Anne M. L. Rempel is also with the University of California, San Francisco, Department of Emergency Medicine, Fresno, CA. Kate Bengtson and Marcus B. Nashelsky are also with the Johnson County, Iowa Medical Examiner Department, Iowa City
| | - Kate Bengtson
- Anne M. L. Rempel, Jane E. Persons, and Marcus B. Nashelsky are with the Department of Pathology, University of Iowa Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City. Anne M. L. Rempel is also with the University of California, San Francisco, Department of Emergency Medicine, Fresno, CA. Kate Bengtson and Marcus B. Nashelsky are also with the Johnson County, Iowa Medical Examiner Department, Iowa City
| | - Marcus B Nashelsky
- Anne M. L. Rempel, Jane E. Persons, and Marcus B. Nashelsky are with the Department of Pathology, University of Iowa Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City. Anne M. L. Rempel is also with the University of California, San Francisco, Department of Emergency Medicine, Fresno, CA. Kate Bengtson and Marcus B. Nashelsky are also with the Johnson County, Iowa Medical Examiner Department, Iowa City
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Gill JR. The Canceling of Excited Delirium. Am J Forensic Med Pathol 2024; 45:98-102. [PMID: 38497613 DOI: 10.1097/paf.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- James R Gill
- From the Office of the Chief Medical Examiner, CT
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Chandra J, Charpignon ML, Bhaskar A, Therriault A, Chen YH, Mooney A, Dahleh MA, Kiang MV, Dominici F. Excess Fatal Overdoses in the United States During the COVID-19 Pandemic by Geography and Substance Type: March 2020-August 2021. Am J Public Health 2024; 114:599-609. [PMID: 38718338 PMCID: PMC11079842 DOI: 10.2105/ajph.2024.307618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 05/12/2024]
Abstract
Objectives. To assess heterogeneity in pandemic-period excess fatal overdoses in the United States, by location (state, county) and substance type. Methods. We used seasonal autoregressive integrated moving average (SARIMA) models to estimate counterfactual death counts in the scenario that no pandemic had occurred. Such estimates were subtracted from actual death counts to assess the magnitude of pandemic-period excess mortality between March 2020 and August 2021. Results. Nationwide, we estimated 25 668 (95% prediction interval [PI] = 2811, 48 524) excess overdose deaths. Specifically, 17 of 47 states and 197 of 592 counties analyzed had statistically significant excess overdose-related mortality. West Virginia, Louisiana, Tennessee, Kentucky, and New Mexico had the highest rates (20-37 per 100 000). Nationally, there were 5.7 (95% PI = 1.0, 10.4), 3.1 (95% PI = 2.1, 4.2), and 1.4 (95% PI = 0.5, 2.4) excess deaths per 100 000 involving synthetic opioids, psychostimulants, and alcohol, respectively. Conclusions. The steep increase in overdose-related mortality affected primarily the southern and western United States. We identified synthetic opioids and psychostimulants as the main contributors. Public Health Implications. Characterizing overdose-related excess mortality across locations and substance types is critical for optimal allocation of public health resources. (Am J Public Health. 2024;114(6):599-609. https://doi.org/10.2105/AJPH.2024.307618).
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Affiliation(s)
- Jay Chandra
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Marie-Laure Charpignon
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Anushka Bhaskar
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Andrew Therriault
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Yea-Hung Chen
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Alyssa Mooney
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Munther A Dahleh
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Mathew V Kiang
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
| | - Francesca Dominici
- Jay Chandra is with Harvard Medical School, Harvard University, Boston, MA. Marie-Laure Charpignon and Munther A. Dahleh are with the Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge. Anushka Bhaskar and Andrew Therriault are with the Department of Government, Harvard University, Cambridge. Yea-Hung Chen is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Alyssa Mooney is with the Institute for Health Policy Studies, University of California, San Francisco. Mathew V. Kiang is with the Department of Epidemiology and Population Health, Stanford University, Stanford, CA. Francesca Dominici is with the Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston
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Hancock A, McLemore J, Russell G. False-Positive Rate for Suspected Drug-Related Deaths Following Full Autopsy. Am J Forensic Med Pathol 2024:00000433-990000000-00172. [PMID: 38497621 DOI: 10.1097/paf.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
ABSTRACT The sharp increase in drug-related deaths has tempted medical examiner/coroner offices to perform external examinations with comprehensive toxicology testing instead of performing a standard autopsy. Compounding the problem of an increasing workload has been the decrease in available forensic pathologists. Opting for external examinations on suspected drug-related fatalities, however, is antithetical to current best practices. The purpose of this study was to review case files, autopsy reports, and toxicologic results of all deaths that were autopsied at the authors' facility and decide whether significant disease processes or injuries that would supersede the results of toxicologic testing and external examination findings alone were being missed.
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Affiliation(s)
- Addie Hancock
- From the Resident, Pathology, Wake Forest Baptist Medical Center
| | - Jerri McLemore
- Associate Professor, Wake Forest University School of Medicine
| | - Greg Russell
- Senior Biostatistician, Associate Director for Consulting, Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
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Deo VS, Bhullar MK, Gilson TP, Flannery DJ, Fulton SE. The Need to Rethink Harm Reduction for People Using Drugs Alone to Reduce Overdose Fatalities. Subst Use Misuse 2024; 59:450-458. [PMID: 37964569 DOI: 10.1080/10826084.2023.2280534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Background: During the ongoing opioid epidemic, Cuyahoga County (second largest in Ohio) reported overdose mortality rates (54/per 100,000) higher than the national average. Prior research demonstrates that people who use drugs often use alone but there is minimal research on people who died of overdose while using alone. The objective of this study is to examine sociodemographic, toxicologic, and injury characteristics, and emergency medical response to overdose decedents who died using drugs alone. Method: Data from the Cuyahoga County Medical Examiner's Office (2016-2020, N = 2944) on unintentional overdose deaths in adults was tabulated including socio-demographic, toxicologic, and injury-related information. Decedents using drugs alone were identified and compared to those not using alone via Chi-square and Fisher's exact tests. We further fit a multivariate logistic regression model to evaluate socio-demographic, toxicologic, and injury-related factors associated with increased odds of using alone. All results are reported with 95% confidence intervals. Result: Among decedents, 75% (n = 2205) were using drugs alone. Decedents using alone were more likely to be using drugs at home (p = 0.001) or be found dead at the scene (p < 0.001) and less likely to receive naloxone (p < 0.001) have other person/bystander, not using, present (p = 0.002). Using drugs at home (aOR = 1.61[1.19-2.20]) was associated with higher odds of using alone; and being married (aOR = 0.57[0.38-0.86]), having history of illicit drug use (aOR = 0.25[0.08-0.81]) and other person present, who was not using (aOR = 0.58[0.42-0.79]) were associated with lower odds of using alone. Conclusion: New harm reduction approaches targeting people using drugs alone are needed to reduce overdose deaths.
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Affiliation(s)
- Vaishali S Deo
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Thomas P Gilson
- Cuyahoga County Medical Examiner's Office, Cleveland, Ohio, USA
| | - Daniel J Flannery
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sarah E Fulton
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio, USA
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Gelberg KH, Chase R, Lindstrom M, Hochstatter KR, Larochelle L, Hunt T. Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study. Public Health Rep 2024; 139:72-78. [PMID: 36951207 PMCID: PMC10905759 DOI: 10.1177/00333549231161339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. METHODS The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. RESULTS Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. CONCLUSION Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.
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Affiliation(s)
| | - Rachel Chase
- HEALing Communities Study, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan Lindstrom
- HEALing Communities Study, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Lauren Larochelle
- Injury Surveillance Program, Massachusetts Department of Public Health, Boston, MA, USA
| | - Timothy Hunt
- Social Intervention Group, Columbia University School of Social Work, New York, NY, USA
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Roberts E, Copeland C, Humphreys K, Shover CL. Drug-related deaths among housed and homeless individuals in the UK and the USA: comparative retrospective cohort study. Br J Psychiatry 2023; 223:562-568. [PMID: 37665046 PMCID: PMC10727910 DOI: 10.1192/bjp.2023.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The UK and USA currently report their highest number of drug-related deaths since records began, with higher rates among individuals experiencing homelessness. AIMS Given that overdose prevention in homeless populations may require unique strategies, we evaluated whether substances implicated in death differed between (a) housed decedents and those experiencing homelessness and (b) between US and UK homeless populations. METHOD We conducted an internationally comparative retrospective cohort study utilising multilevel multinomial regression modelling of coronial/medical examiner-verified drug-related deaths from 1 January 2012 to 31 December 2021. UK data were available for England, Wales and Northern Ireland; US data were collated from eight county jurisdictions. Data were available on decedent age, sex, ethnicity, housing status and substances implicated in death. RESULTS Homeless individuals accounted for 16.3% of US decedents versus 3.4% in the UK. Opioids were implicated in 66.3 and 50.4% of all studied drug-related deaths in the UK and the USA respectively. UK homeless decedents had a significantly increased risk of having only opioids implicated in death compared with only non-opioids implicated (relative risk ratio RRR = 1.87, 95% CI 1.76-1.98, P < 0.001); conversely, US homeless decedents had a significantly decreased risk (RRR = 0.37, 95% CI 0.29-0.48, P < 0.001). Methamphetamine was implicated in two-thirds (66.7%) of deaths among US homeless decedents compared with 0.4% in the UK. CONCLUSIONS Both the rate and type of drug-related deaths differ significantly between homeless and housed populations in the UK and USA. The two countries also differ in drugs implicated in death. Targeted programmes for country-specific implicated drug profiles appear warranted.
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Affiliation(s)
- Emmert Roberts
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Caroline Copeland
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Keith Humphreys
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA; and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Chelsea L. Shover
- David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, University of California – Los Angeles (UCLA), Los Angeles, California, USA
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11
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Maskell PD, Elliott S, Desharnais B, Findell M, Jackson G. A model of evaluative opinion to encourage greater transparency and justification of interpretation in postmortem forensic toxicology. J Anal Toxicol 2023; 47:563-573. [PMID: 37566485 PMCID: PMC10503647 DOI: 10.1093/jat/bkad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 08/13/2023] Open
Abstract
Over the past decades, the calls to improve the robustness of interpretation in forensic science have increased in magnitude. Forensic toxicology has seen limited progress in this regard. In this work, we propose a transparent interpretive pathway for use in postmortem forensic toxicology cases. This process allows the selection of the interpretive methodology based on the amount of previous information that is available for the drug(s) in question. One approach is an assessment of various pharmacological and circumstantial considerations resulting in a toxicological significance score (TSS), which is particularly useful in situations where limited information about a drug is available. When there is a robust amount of case data available, then a probabilistic approach, through the evaluation of likelihood ratios by the forensic toxicologist and of prior probabilities by the fact finder, is utilized. This methodology provides a transparent means of making an interpretive decision on the role of a drug in the cause of death. This will allow the field of forensic toxicology to take a step forward in using best practice in evaluative reporting, a tool already used by many other forensic science disciplines.
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Affiliation(s)
- Peter D Maskell
- Scottish Police Authority Forensic Services, Glasgow G69 8AE, UK
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Simon Elliott
- Elliott Forensic Consulting, Birmingham, UK
- Department of Analytical, Environmental and Forensic Sciences, King’s College London, London SE1 9NH, UK
| | - Brigitte Desharnais
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais Street, Montréal, QC H2K 3S7, Canada
| | - Martin Findell
- Division of Psychology and Forensic Science, School of Applied Sciences, Abertay University, Dundee DD1 1HG, UK
| | - Graham Jackson
- Division of Psychology and Forensic Science, School of Applied Sciences, Abertay University, Dundee DD1 1HG, UK
- Advance Forensic Science, St. Andrews, Scotland, UK
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12
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Harruff RC, Yarid NA, Barbour WL, Martin YH. Medical examiner response to the drug overdose epidemic in King County Washington: "Real-time" surveillance, data science, and applied forensic epidemiology. J Forensic Sci 2023; 68:1632-1642. [PMID: 37417312 DOI: 10.1111/1556-4029.15329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/16/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with "real-time" fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.
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Affiliation(s)
| | - Nicole A Yarid
- King County Medical Examiner's Office, Seattle, Washington, USA
| | | | - Yang H Martin
- King County Medical Examiner's Office, Seattle, Washington, USA
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13
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Noriega I, Bhullar MK, Gilson TP, Flannery DJ, Deo V, Fulton S. A case study for local data surveillance in opioid overdose fatalities in Cuyahoga County, OH 2016-2020. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 8:100187. [PMID: 37711883 PMCID: PMC10498169 DOI: 10.1016/j.dadr.2023.100187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023]
Abstract
Introduction Fentanyl and fentanyl analogs have increased the overdose mortality rates in the United States, significantly impacting states like Ohio. We examined carfentanil overdose deaths, other contributing Cause of Death (COD) drugs, and drug seizure trends from 2016 to 2020 in Northeast Ohio. Materials and methods We studied death investigation data from the Cuyahoga County, Ohio Medical Examiner's Office (CCMEO) of all fatal accidental opioid overdoses as well as drug seizure data from Cuyahoga County Regional Forensic Science Laboratory (CCRFSL). We also compared decedents' race, gender, age, residential locality, drugs contributing to the COD in opioid cases, and for carfentanil, fentanyl, and cocaine seizures in Cuyahoga County from 2016 to 2020 (N = 2948). Results Decedents' had an average of three different drugs contributing to their COD. A bimodal carfentanil spike was observed in fatal accidental overdoses in Cuyahoga County for the years 2017 and 2019. Decedents in urban residency, who were Non-Hispanic, White and younger, significantly predicted the presence of carfentanil contributing to the COD. In 2020, decedents who were Black and older were significantly associated with cocaine contributing to the COD. Carfentanil and carfentanil-related overdoses were significantly correlated. Discussion The pervasiveness of illicitly manufactured fentanyl and fentanyl analog (e.g., carfentanil) mixtures with other drugs are changing the demographics of persons who fatally overdose in Cuyahoga County, OH. Significant trending shifts can also be observed for the presence of carfentanil in decedent and seizure county data. Conclusions Local data of drug-related overdose deaths and drug seizures from a medical examiner's office and affiliated forensic laboratory lab can be used for timely public health surveillance, and informing prevention, and intervention at the county level.
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Affiliation(s)
- Ivette Noriega
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, USA
| | - Manreet K. Bhullar
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Thomas P. Gilson
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Daniel J. Flannery
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, USA
| | - Vaishali Deo
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, USA
| | - Sarah Fulton
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, USA
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14
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Seth P, Baldwin GT, Davis NL, Jones CM. Clarifying CDC's Efforts to Quantify Overdose Deaths. Public Health Rep 2023; 138:721-726. [PMID: 36184930 PMCID: PMC10467501 DOI: 10.1177/00333549221123586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Puja Seth
- Epidemiology and Surveillance Branch, Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Grant T. Baldwin
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nicole L. Davis
- Overdose Mortality Team, Epidemiology and Surveillance Branch, Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christopher M. Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
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15
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Davis GG, Fligner CL. The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States. J Forensic Sci 2023; 68:1626-1631. [PMID: 37306311 DOI: 10.1111/1556-4029.15304] [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: 04/20/2023] [Revised: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.
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Affiliation(s)
- Gregory G Davis
- Forensic Division, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Jefferson County, Alabama, Birmingham, Alabama, USA
| | - Corinne L Fligner
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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16
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Utley S, Arunkumar P, Das T, Fierro MF, Fudenberg J, Harding BE, Hoffmann BA, Keyes KA, Lewis A, Maloney K, O'Neal BJ, Pinneri K, Rapkiewicz A, Sathyavagiswaran L, Weedn V, Williams T. National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths. Am J Forensic Med Pathol 2023:00000433-990000000-00107. [PMID: 37527356 DOI: 10.1097/paf.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
ABSTRACT Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.
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Affiliation(s)
- Suzanne Utley
- From the Associate Medical Examiner, District Twelve Medical Examiner's Office, Florida
| | - Ponni Arunkumar
- Chief Medical Examiner, Cook County Medical Examiner's Office, Chicago, IL
| | - Tara Das
- Vital Statistics Section, Texas Department of State Health Services, Austin TX
| | - Marcella F Fierro
- Retired Chief Medical Examiner, Office of the Chief Medical Examiner of Virginia, Richmond, VA
| | - John Fudenberg
- Executive Director, International Association of Coroners & Medical Examiners, Las Vegas, NV
| | - Brett E Harding
- Chief Deputy Coroner, Ada County Coroner's Office, Boise, ID
| | - Bryan A Hoffmann
- Fatality Management and Inspection Unit Coordinator, New Jersey Office of the Chief State Medical Examiner, Trenton, NJ
| | | | - Adele Lewis
- State Medical Examiner, Office of the State Chief Medical Examiner, Tennessee, Department of Health
| | - Katherine Maloney
- Deputy Chief Medical Examiner, Erie County Medical Examiner's Office, Buffalo, NY
| | | | - Kathryn Pinneri
- Director, Montgomery County Forensic Services Department, Conroe, TX
| | - Amy Rapkiewicz
- Deputy Chief Medical Examiner, Office of the Suffolk County Medical Examiner Department, Hauppauge, NY
| | - Lakshmanan Sathyavagiswaran
- Former Chief Medical Examiner-Coroner, Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, CA
| | - Victor Weedn
- Deputy Medical Examiner, DC Office of the Chief Medical Examiner, Washington, DC
| | - Tiffany Williams
- Senior Deputy Coroner, Orange County Sheriff-Coroner Department, Santa Ana, CA
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17
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Beer T, Eriksson A, Wingren CJ. Increased lung weight in fatal intoxications is not unique to opioid drugs. J Forensic Sci 2023; 68:518-523. [PMID: 36572955 DOI: 10.1111/1556-4029.15187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 01/02/2023]
Abstract
Fatal intoxications with opioids are known to be associated with an increased lung weight, as well as with brain and pulmonary edema and urinary retention. However, there is evidence to suggest that fatal intoxications with non-opioid substances are also associated with increased lung weight; however, the latter aspect has not been comprehensively analyzed. To determine to what extent opioid and non-opioid substances are associated with increased lung and brain weight, we studied these organs in cases where the cause of death was attributed to intoxication with a single agent. Using data from cases autopsied at the National Board of Forensic Medicine (NBFM) in Sweden from 2009 through 2019 where the cause of death was attributed to a single substance, we created models of combined lung weight and brain weight. The models used age and sex as predictors as well as nested varying effects for the specific intoxicant and category of intoxicant. Suicidal hanging with negative toxicology cases served as controls. The population majority was male among both intoxications (68%) and controls (83%). The most common single substance group was opioids. All tested substances were associated with heavier lungs than controls, with the largest effect in the opioid group. Our findings show that several substances are associated with increased lung weight and that among intoxication deaths there is no difference in expected brain weight between substances. Hence, heavy lungs, without a reasonable explanation, should prompt a broad toxicological screening.
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Affiliation(s)
- Torfinn Beer
- Department of Community Medicine and Rehabilitation/Forensic Medicine, Umeå University, Umeå, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation/Forensic Medicine, Umeå University, Umeå, Sweden
| | - Carl Johan Wingren
- Unit for Forensic Medicine, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
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18
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Lathrop SL, Wiest PW, Andrews SW, Elifritz J, Price JP, Mlady GW, Zumwalt RE, Gerrard CY, Poland VL, Nolte KB. Can computed tomography replace or supplement autopsy? J Forensic Sci 2023; 68:524-535. [PMID: 36752321 DOI: 10.1111/1556-4029.15217] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
Postmortem computed tomography (PMCT) has been integrated into the practice of many forensic pathologists. To evaluate the utility of PMCT in supplementing and/or supplanting medicolegal autopsy, we conducted a prospective double-blind comparison of abnormal findings reported by the autopsy pathologist with those reported by a radiologist reviewing the PMCT. We reviewed 890 cases: 167 with blunt force injury (BFI), 63 with pediatric trauma (under 5 years), 203 firearm injuries, and 457 drug poisoning deaths. Autopsy and radiology reports were coded using the Abbreviated Injury Scale and abnormal findings and cause of death (COD) were compared for congruence in consensus conferences with novel pathologists and radiologists. Overall sensitivity for recognizing abnormal findings was 71% for PMCT and 74.6% for autopsy. Sensitivities for PMCT/autopsy were 74%/73.1% for BFI, 61.5%/71.4% for pediatric trauma, 84.9%/83.7% for firearm injuries, and 56.5%/66.4% for drug poisoning deaths. COD assigned by reviewing PMCT/autopsy was correct in 88%/95.8% of BFI cases, 99%/99.5% of firearm fatalities, 82.5%/98.5% of pediatric trauma deaths, and 84%/100% of drug poisoning deaths of individuals younger than 50. Both autopsy and PMCT were imperfect in recognizing injuries. However, both methods identified the most important findings and are sufficient to establish COD in cases of BFI, pediatric trauma, firearm injuries and drug poisoning in individuals younger than 50. Ideally, all forensic pathologists would have access to a CT scanner and a consulting radiologist. This would allow a flexible approach that meets the diagnostic needs of each case and best serves decedents' families and other stakeholders.
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Affiliation(s)
- Sarah L Lathrop
- Office of the Medical Investigator, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Philip W Wiest
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Sam W Andrews
- Tarrant County Medical Examiner Office, Fort Worth, Texas, USA
| | - Jamie Elifritz
- Office of the Medical Investigator, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA.,Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Gary W Mlady
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Ross E Zumwalt
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chandra Y Gerrard
- Radiology Informatics/Information Technology, University of New Mexico Hospitals, Albuquerque, New Mexico, USA
| | - Valerie L Poland
- Office of the Medical Investigator, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Kurt B Nolte
- Office of the Medical Investigator, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA.,Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
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19
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Buprenorphine involvement in opioid overdose deaths: A retrospective analysis of postmortem toxicology in Marion County, Indiana, 2015-2021. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100131. [PMID: 36777895 PMCID: PMC9910498 DOI: 10.1016/j.dadr.2023.100131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Amidst an unprecedented overdose epidemic, the opioid partial agonist buprenorphine is a medication for opioid use disorder associated with reductions in overdose. Despite its efficacy, buprenorphine prescribing remains closely regulated, owing to concerns about misuse, and its possible role in overdoses. Methods A retrospective analysis of the Marion County, Indiana coroner's postmortem toxicology data for unintentional opioid-involved overdose deaths from 2015 through 2021. The county was chosen as a novel setting whose corner provided comprehensive overdose data. It contains Indianapolis, a large city in the US Midwest The 2,369 opioid-involved overdoses were analyzed for the presence of buprenorphine and its metabolite, as wel as potent substances associated with illicit drug use and overdose. Results Of the 2,369 postmortem toxicology records analyzed, 55 (2.3%) indicated presence of buprenorphine. Of buprenorphine-involved cases, 51 (92.7%) involved other potent substances such as fentanyl, heroin, cocaine, methadone, and amphetamines; 4 (7.3%) were attributed to buprenorphine and liver failure, diabetic ketoacidosis, or relatively less potent substances. Fentanyl was present in 28 cases (50.9%), benzodiazepines were present in 24 (43.6%). Black opioid decedents were considerably less likely to have buprenorphine in their toxicology than White decedents. Conclusions Buprenorphine was rarely detected in the postmortem toxicology of unintentional opioid overdoses in a major US city in the Midwest. In nearly all cases it was accompanied by other potent substances that more frequently cause fatal overdoses on their own. This study confirms findings from other geographic settings that the overdose mortality risks associated with buprenorphine are low.
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20
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Harruff R, Simpson CM, Gifford AL, Yarid N, Barbour WL, Heidere C. Evaluation of "Real-Time" Fatal Drug Overdose Surveillance by King County Medical Examiner's Office, Seattle, Washington. Am J Forensic Med Pathol 2023; 44:11-16. [PMID: 36165595 DOI: 10.1097/paf.0000000000000798] [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: 02/07/2023]
Abstract
ABSTRACT To address the challenges in monitoring the continuously accelerating drug overdose epidemic, the King County Medical Examiner's Office in Seattle, Washington, instituted a "real-time" fatal drug overdose surveillance project, depending on scene investigations, autopsy findings, and in-house testing of blood, urine, and drug evidence collected from death scenes. Validation of the project's rapid death certification methodology from 2019 through 2021 was performed at the following 3 levels: blood testing, urine testing, and death certification, and for the following 4 drugs: fentanyl, opiate, methamphetamine, and cocaine. For blood testing, sensitivity ranged from 90% to 99%, and specificity ranged from 86% to 97%. For urine testing, sensitivity ranged from 91% to 92%, and specificity ranged from 87% to 97%. The positive predictive value for cocaine was poor for both blood testing (57%) and urine testing (72%). Of 1034 deaths, 807 were certified as overdose by rapid methodology, and 803 (99.5%) were confirmed by formal toxicology results. Manners of death were changed from accident to natural in 3 of 1034 cases (0.29%). Results of this study indicate that the rapid overdose surveillance methodology described in this study offers benefits to families and provides useful, timely information for responding law enforcement and public health agencies.
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21
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Bitting J, O’Donnell J, Mattson CL. Notes from the Field: Overdose Deaths Involving Para-fluorofentanyl — United States, July 2020–June 2021. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:1239-1240. [PMID: 36173752 PMCID: PMC9533727 DOI: 10.15585/mmwr.mm7139a3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Živković V, Leković A, Nikolić S. Hyposphagma, positional asphyxia, and acute intoxication with psychoactive substances. J Forensic Sci 2022; 67:2492-2496. [DOI: 10.1111/1556-4029.15141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Vladimir Živković
- Institute of Forensic Medicine University of Belgrade – School of Medicine Belgrade Serbia
| | - Aleksa Leković
- Institute of Forensic Medicine University of Belgrade – School of Medicine Belgrade Serbia
| | - Slobodan Nikolić
- Institute of Forensic Medicine University of Belgrade – School of Medicine Belgrade Serbia
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23
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Bhullar MK, Gilson TP, Singer ME. Trends in opioid overdose fatalities in Cuyahoga County, Ohio: Multi-drug mixtures, the African-American community and carfentanil. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100069. [PMID: 36846577 PMCID: PMC9948855 DOI: 10.1016/j.dadr.2022.100069] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
Abstract
Background Ohio's age-adjusted opioid overdose fatality rate is double the national average. In an ever-evolving epidemic, it is crucial to monitor trends to inform public health interventions. Methods A retrospective study was conducted using the Medical Examiner's decedent case files for all accidental opioid-related adult overdose deaths in Cuyahoga County (Cleveland), Ohio in 2017. Characterization of trends was based on autopsy/toxicology and first responder reports, medical records and death scene investigations. Results Of 543 accidental opioid-related adult overdose fatalities, 64.1% died from 3+ drugs. The most common cause of death (COD) drugs included fentanyl (63.4%), heroin (44.4%), cocaine (37.0%) and carfentanil (35.0%). There were four times as many African American decedents as two years prior. Three or more COD drugs was >50% more common in those with fentanyl (Prevalence Ratio (PR) = 1.56[1.34-1.70]; p<.001) or carfentanil (PR = 1.51[1.33-1.70]; p<.001) as a COD drug, more common with a history of prescription drug abuse (PR = 1.16[1.02-1.33]; p=.025), but less common in divorced/widowed decedents (PR = 0.83[0.71-0.97]; p=.022). Carfentanil was nearly 4 times as prevalent in those with previous illicit drug use (PR = 3.88[1.09-13.70]; p=.025), and less common in those with previous medical history (PR = 0.72[0.55-0.94]; p=.016) or age 50+ (PR = 0.72[0.53-0.97]; p=.031). Conclusions Accidental opioid-related overdose fatalities in Cuyahoga County adults were dominated by 3+ COD drugs, with cocaine/fentanyl mixtures driving sharp increases in African American fatalities. Carfentanil was more prevalent in people fitting the profile of recreational drug use. This data can inform harm reduction interventions.
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Affiliation(s)
- Manreet K Bhullar
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, United States of America.,Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, United States of America
| | - Thomas P Gilson
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, United States of America
| | - Mendel E Singer
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, United States of America
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Hochstatter KR, Rastogi S, Klein K, Tait-Ozer C, El-Bassel N, Graham J. Predicting accidental drug overdose as the cause of fatality in near real-time using the Suspected Potential Overdose Tracker (SPOT): public health implications. BMC Public Health 2022; 22:1311. [PMID: 35804334 PMCID: PMC9263436 DOI: 10.1186/s12889-022-13700-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/03/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Effective responses to the worsening drug overdose epidemic require accurate and timely drug overdose surveillance data. The objectives of this paper are to describe the development, functionality, and accuracy of the Suspected Potential Overdose Tracker (SPOT) for predicting accidental drug overdose as the cause and manner of death in near real-time, and public health implications of adopting the tool. METHODS SPOT was developed to rapidly identify overdose deaths through a simple and duplicable process using data collected by death investigators. The tool assigns each death a ranking of 1 through 3 based on the likelihood of it being an unintentional drug overdose, with 1 representing the highest likelihood that the death will be confirmed as an unintentional drug overdose and 3 representing the lowest. We measured the accuracy of the tool for predicting overdose deaths by comparing potential overdose deaths in New York City from 2018-2020 that were identified using SPOT to finalized death certificates. We also calculated the proportion of death certificate-confirmed overdoses that were missed by the SPOT tool and the proportion of type 1 errors. RESULTS SPOT captured up to 77% of unintentional drug overdose deaths using data collected within 72 h of fatality. The tool predicted unintentional drug overdose from 2018 to 2020 with 93-97% accuracy for cases assigned a ranking of 1, 87-91% accuracy for cases assigned a ranking of 2, and 62-73% accuracy for cases assigned a ranking of 3. Among all unintentional overdose deaths in 2018, 2019, and 2020, 21%, 28%, and 33% were missed by the SPOT tool, respectively. During this timeframe, the proportion of type 1 errors ranged from 15%-23%. CONCLUSIONS SPOT may be used by health departments, epidemiologists, public health programs, and others to monitor overdose fatalities before death certificate data becomes available. Improved monitoring of overdose fatalities allows for rapid data-driven decision making, identification of gaps in public health and public safety overdose response, and evaluation and response to overdose prevention interventions, programs, and policies.
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Affiliation(s)
- Karli R Hochstatter
- Columbia University School of Social Work, New York, NY, USA.
- Friends Research Institute, Inc, Baltimore, MD, USA.
| | - Sonal Rastogi
- New York/New Jersey High Intensity Drug Trafficking Area, New York, NY, USA
- New York City Office of Chief Medical Examiner, New York, NY, USA
| | - Kathryn Klein
- New York/New Jersey High Intensity Drug Trafficking Area, New York, NY, USA
- New York City Office of Chief Medical Examiner, New York, NY, USA
| | - Cameron Tait-Ozer
- New York/New Jersey High Intensity Drug Trafficking Area, New York, NY, USA
- New York City Office of Chief Medical Examiner, New York, NY, USA
| | | | - Jason Graham
- New York City Office of Chief Medical Examiner, New York, NY, USA
- New York University Grossman School of Medicine, New York, NY, USA
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Mattson CL, Chowdhury F, Gilson TP. Notes from the Field: Trends in Gabapentin Detection and Involvement in Drug Overdose Deaths - 23 States and the District of Columbia, 2019-2020. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:664-666. [PMID: 35552367 PMCID: PMC9098248 DOI: 10.15585/mmwr.mm7119a3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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O'Donnell J, Gladden RM, Kariisa M, Mattson CL. Using death scene and toxicology evidence to define involvement of heroin, pharmaceutical morphine, illicitly manufactured fentanyl and pharmaceutical fentanyl in opioid overdose deaths, 38 states and the District of Columbia, January 2018-December 2019. Addiction 2022; 117:1483-1490. [PMID: 34882865 PMCID: PMC9798922 DOI: 10.1111/add.15768] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 11/05/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Tracking specific drugs contributing to drug overdose deaths is limited when relying on death certificate (DC) data alone. This study aimed to determine whether integrating DC data with medical examiner/coroner reports, including postmortem toxicology and death investigation findings, would enhance identification of (1) heroin and pharmaceutical morphine involvement in overdose deaths and (2) fentanyl source (illicitly manufactured versus pharmaceutical). DESIGN Retrospective analysis of heroin, pharmaceutical morphine, illicitly manufactured fentanyl (IMF) and pharmaceutical fentanyl involvement in fatal overdoses. DC and toxicology data were compared with enhanced definitions integrating overdose scene, witness and toxicology evidence. SETTING United States: 38 states and the District of Columbia, participating in Centers for Disease Control and Prevention (CDC)-funded opioid overdose death surveillance. CASES Opioid overdose decedents from funded jurisdictions; deaths during 1 January 2018-31 December 2019. MEASUREMENTS Using medical examiner/coroner report data, deaths with 6-acetylmorphine and/or morphine detected by postmortem toxicology were defined as confirmed, probable or suspected heroin deaths, or probable pharmaceutical morphine deaths. Fentanyl was defined as probable or suspected IMF or probable pharmaceutical fentanyl. FINDINGS The enhanced definition defined 18 393 deaths as confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths. Among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF and 1.0% as probable pharmaceutical fentanyl. Fentanyl source could not be determined for 9.7% of deaths. CONCLUSIONS Integrating drug overdose scene, witness and toxicology findings can improve identification of specific drugs contributing to overdose deaths and enhance overdose intervention targeting.
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Affiliation(s)
- Julie O'Donnell
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Overdose Prevention Atlanta GA USA
| | - R. Matt Gladden
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Overdose Prevention Atlanta GA USA
| | - Mbabazi Kariisa
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Overdose Prevention Atlanta GA USA
| | - Christine L. Mattson
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Division of Overdose Prevention Atlanta GA USA
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Argo A, Zerbo S, Buscemi R, Trignano C, Bertol E, Albano GD, Vaiano F. A Forensic Diagnostic Algorithm for Drug-Related Deaths: A Case Series. TOXICS 2022; 10:toxics10040152. [PMID: 35448413 PMCID: PMC9024928 DOI: 10.3390/toxics10040152] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/11/2022] [Accepted: 03/19/2022] [Indexed: 02/06/2023]
Abstract
The best evidence provided in the literature worldwide suggests the importance of harmonizing the investigation in drug-related fatalities. In this study, the application of a multidisciplinary approach in eight cases of drug-related deaths is presented. Although death scene findings could be highly suggestive of drug intoxication, external examination and toxicological screening test alone are insufficient. There are several variables, and it is not always easy to give the proper interpretation of the drug detection. A complete autopsy is necessary to correctly complete organ and tissues sampling for further histological and toxicological studies and obtain body fluids. The use of peripheral blood is recommended to avoid artifacts. The collection of many specimens is warranted to get more responses. The sampling aims to provide a picture of the distribution of the substance in the body. The sample and the selection of the drugs and the matrices to investigate are case-dependent. The presented diagnostic algorithm provides the coroner with all the elements to investigate drug-related deaths and cooperate with toxicologists. Toxicological forensic diagnosis is still extremely heterogeneous in regional and national contexts. Funding for method development, research, networking, facilities, and technologies improvement is mandatory to standardize the toxicological investigation.
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Affiliation(s)
- Antonina Argo
- PROMISE Department, University of Palermo, 90100 Palermo, Italy; (A.A.); (S.Z.); (R.B.)
| | - Stefania Zerbo
- Department of Biomedical Sciences, University of Sassari, 7100 Sassari, Italy;
| | - Roberto Buscemi
- Department of Biomedical Sciences, University of Sassari, 7100 Sassari, Italy;
| | - Claudia Trignano
- Department of Health Sciences, University of Florence, 50121 Florence, Italy; (E.B.); (F.V.)
| | - Elisabetta Bertol
- Department of Biomedical Sciences, University of Sassari, 7100 Sassari, Italy;
| | - Giuseppe Davide Albano
- PROMISE Department, University of Palermo, 90100 Palermo, Italy; (A.A.); (S.Z.); (R.B.)
- Correspondence: ; Tel.: +39-3312264328
| | - Fabio Vaiano
- Department of Biomedical Sciences, University of Sassari, 7100 Sassari, Italy;
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Lappas NT, Lappas CM. Heroin. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Milam AJ, Furr-Holden D, Wang L, Simon KM. Health Data Disparities in Opioid-Involved Overdose Deaths From 1999 to 2018 in the United States. Am J Public Health 2021; 111:1627-1635. [PMID: 34185576 PMCID: PMC8589046 DOI: 10.2105/ajph.2021.306322] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 01/09/2023]
Abstract
Objectives. To examine temporal trends in the classification of opioid-involved overdose deaths (OODs) and racial variation in the classification of specific types of opioids used. Methods. We analyzed OODs coded as other or unspecified narcotics from 1999 to 2018 in the United States using data from the National Vital Statistics System and the Centers for Disease Control and Prevention. Results. The total proportion of OODs from unspecified narcotics decreased from 32.4% in 1999 to 1.9% in 2018. The proportion of OODs from unspecified narcotics among African American persons was approximately 2-fold greater than that of non-Hispanic White persons until 2012. Similarly, the proportion of OODs from unspecified narcotics among Hispanic persons was greater than that of White persons until 2015. After we controlled for death investigation system, African American persons had a higher incidence rate of OODs from unspecified narcotics compared with White persons. Conclusions. There have been significant improvements in the specification OODs over the past 20 years, and there has been significant racial disparity in the classification of OODs until about 2015. The findings suggest a health data disparity; the excessive misclassification of OODs is likely attributable to the race/ethnicity of the decedent.
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Affiliation(s)
- Adam J Milam
- Adam J. Milam is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH. Debra Furr-Holden is with the Division of Public Health, College of Human Medicine, Michigan State University, Flint, and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health. Ling Wang is with Department of Medicine, College of Human Medicine, Michigan State University, East Lansing. Kevin M. Simon is with Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, and Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Debra Furr-Holden
- Adam J. Milam is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH. Debra Furr-Holden is with the Division of Public Health, College of Human Medicine, Michigan State University, Flint, and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health. Ling Wang is with Department of Medicine, College of Human Medicine, Michigan State University, East Lansing. Kevin M. Simon is with Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, and Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Ling Wang
- Adam J. Milam is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH. Debra Furr-Holden is with the Division of Public Health, College of Human Medicine, Michigan State University, Flint, and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health. Ling Wang is with Department of Medicine, College of Human Medicine, Michigan State University, East Lansing. Kevin M. Simon is with Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, and Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Kevin M Simon
- Adam J. Milam is with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH. Debra Furr-Holden is with the Division of Public Health, College of Human Medicine, Michigan State University, Flint, and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health. Ling Wang is with Department of Medicine, College of Human Medicine, Michigan State University, East Lansing. Kevin M. Simon is with Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, and Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Affiliation(s)
- Sally S Aiken
- Sally S. Aiken is a medical examiner with the Spokane County Medical Examiners' Office, Spokane, WA
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Vannice K, Hood J, Yarid N, Kay M, Harruff R, Duchin J. Accuracy of Medical Examiner's Assessment for Near-Real-Time Surveillance of Fatal Drug Overdoses, King County, Washington, March 2017-February 2018. Public Health Rep 2021; 137:463-470. [PMID: 33909524 PMCID: PMC9109540 DOI: 10.1177/00333549211008455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Up-to-date information on the occurrence of drug overdose is critical to guide public health response. The objective of our study was to evaluate a near-real-time fatal drug overdose surveillance system to improve timeliness of drug overdose monitoring. METHODS We analyzed data on deaths in the King County (Washington) Medical Examiner's Office (KCMEO) jurisdiction that occurred during March 1, 2017-February 28, 2018, and that had routine toxicology test results. Medical examiners (MEs) classified probable drug overdoses on the basis of information obtained through the death investigation and autopsy. We calculated sensitivity, positive predictive value, specificity, and negative predictive value of MEs' classification by using the final death certificate as the gold standard. RESULTS KCMEO investigated 2480 deaths; 1389 underwent routine toxicology testing, and 361 were toxicologically confirmed drug overdoses from opioid, stimulant, or euphoric drugs. Sensitivity of the probable overdose classification was 83%, positive predictive value was 89%, specificity was 96%, and negative predictive value was 94%. Probable overdoses were classified a median of 1 day after the event, whereas the final death certificate confirming an overdose was received by KCMEO an average of 63 days after the event. CONCLUSIONS King County MEs' probable overdose classification provides a near-real-time indicator of fatal drug overdoses, which can guide rapid local public health responses to the drug overdose epidemic.
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Affiliation(s)
- Kirsten Vannice
- Epidemiology Workforce Branch, Division of Scientific Education
and Professional Development, Epidemic Intelligence Service, Center for
Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and
Prevention, Atlanta, GA, USA, Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA,Kirsten Vannice, PhD, MHS, Centers for
Disease Control and Prevention, 2400 Century Center, Atlanta, GA 30345, USA;
| | - Julia Hood
- Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA
| | - Nicole Yarid
- Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA
| | - Meagan Kay
- Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA
| | - Richard Harruff
- Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA
| | - Jeff Duchin
- Prevention Division, Public Health–Seattle & King County,
Seattle, WA, USA
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Al-Matrouk A, Al-Hasan M, Naqi H, Al-Abkal N, Mohammed H, Haider M, Al-Shammeri D, Bojbarah H. Snapshot of narcotic drugs and psychoactive substances in Kuwait: analysis of illicit drugs use in Kuwait from 2015 to 2018. BMC Public Health 2021; 21:671. [PMID: 33827491 PMCID: PMC8028837 DOI: 10.1186/s12889-021-10705-z] [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: 06/01/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background The misuse of illicit substances is associated with increased morbidity and mortality; thus, substance abuse is a global health concern. The Arabian Gulf region is considered a crossing point and a consumer of illicit drugs. However, a lack of laboratory-based research has limited the scientific assessment of drug misuse in the Arabian Gulf region. Thus, an up-to-date analytical representation of the drug situation is warranted. Methods We investigated the type and quantity of detained narcotic drugs and psychotropic substances from 2015 to 2018, representing a population of approximately 4 million people, in addition to the number of abusers and mortality among abusers. In total, 6220 cases from the Narcotic and Psychotropic Laboratory and 17,755 cases from the Forensic Toxicology Laboratory were reviewed and analyzed. Substances were identified and documented using gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. Results Cannabis, including marijuana, was the most seized substance, followed by heroin, opium, and cocaine. Amphetamines, including methamphetamine, in the form of powder or pills, were seized in larger quantities than other psychoactive substances. The most consumed substances were, in order, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin. We identify the common drugs in postmortem specimens, according to sex, from suspected drug-related deaths. The most common single drug identified were heroin, benzodiazepines, and methamphetamine. Similarly, the multiple-drug cocktail of heroin–benzodiazepines, cannabis–benzodiazepines, and cannabis–amphetamines, were detected frequently. Conclusions The data shows that cannabis is the leading type of illicit substance seized. Deaths resulting from benzodiazepines and heroin abuse were the highest in the single drug category, while heroin-benzodiazepines combination deaths were the highest in the multiple-drug category. Methamphetamine was the most abused illicit drug in Kuwait. These findings revealed the illicit drug abuse situation in the State of Kuwait, in a region that suffers from the scarcity of information regarding illicit substances. Thus, providing valuable information for drug enforcement, forensic analyst, health workers on national and international levels. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10705-z.
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Affiliation(s)
- Abdullah Al-Matrouk
- Narcotic and Psychotropic Laboratory, General Department of Criminal Evidence, Ministry of Interior, Al-Dhajeej, Block 1, Al-Farwaniya City, Kuwait.
| | - Mohammed Al-Hasan
- Toxicology Laboratory, Department of Criminal Evidence, Ministry of Interior, Farwaniya city, Kuwait
| | - Husain Naqi
- Kuwait Police Academy for Security Sciences, Ministry of Interior, Al-Farwaniya City, Kuwait
| | - Neamat Al-Abkal
- Narcotic and Psychotropic Laboratory, General Department of Criminal Evidence, Ministry of Interior, Al-Dhajeej, Block 1, Al-Farwaniya City, Kuwait
| | - Hanan Mohammed
- Narcotic and Psychotropic Laboratory, General Department of Criminal Evidence, Ministry of Interior, Al-Dhajeej, Block 1, Al-Farwaniya City, Kuwait
| | - Meshaal Haider
- Toxicology Laboratory, Department of Criminal Evidence, Ministry of Interior, Farwaniya city, Kuwait
| | - Dalal Al-Shammeri
- Narcotic and Psychotropic Laboratory, General Department of Criminal Evidence, Ministry of Interior, Al-Dhajeej, Block 1, Al-Farwaniya City, Kuwait
| | - Haider Bojbarah
- Narcotic and Psychotropic Laboratory, General Department of Criminal Evidence, Ministry of Interior, Al-Dhajeej, Block 1, Al-Farwaniya City, Kuwait
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Rockett IR, Caine ED, Banerjee A, Ali B, Miller T, Connery HS, Lulla VO, Nolte KB, Larkin GL, Stack S, Hendricks B, McHugh RK, White FM, Greenfield SF, Bohnert AS, Cossman JS, D'Onofrio G, Nelson LS, Nestadt PS, Berry JH, Jia H. Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis. EClinicalMedicine 2021; 32:100741. [PMID: 33681743 PMCID: PMC7910714 DOI: 10.1016/j.eclinm.2021.100741] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).
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Affiliation(s)
- Ian R.H. Rockett
- Department of Epidemiology, West Virginia University School of Public Health, Morgantown, WV, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, United States
| | - Eric D. Caine
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, United States
| | - Aniruddha Banerjee
- Department of Geography, Indiana University-Purdue University at Indianapolis, Indianapolis, Indiana, United States
| | - Bina Ali
- Pacific Institute for Research and Evaluation, Calverton, Maryland, United States
| | - Ted Miller
- Pacific Institute for Research and Evaluation, Calverton, Maryland, United States
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Hilary S. Connery
- McLean Hospital, Belmont, Massachusetts, United States
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Vijay O. Lulla
- Department of Geography, Indiana University-Purdue University at Indianapolis, Indianapolis, Indiana, United States
| | - Kurt B. Nolte
- Department of Pathology and Radiology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States
| | - G. Luke Larkin
- Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Steven Stack
- Department of Criminal Justice, Wayne State University, Detroit, Michigan, United States
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, Michigan, United States
| | - Brian Hendricks
- Department of Epidemiology, West Virginia University School of Public Health, Morgantown, WV, United States
| | - R. Kathryn McHugh
- McLean Hospital, Belmont, Massachusetts, United States
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Franklin M.M. White
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shelly F. Greenfield
- McLean Hospital, Belmont, Massachusetts, United States
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Amy S.B. Bohnert
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, United States
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, United States
| | - Jeralynn S. Cossman
- College for Health, Community and Policy, University of Texas-San Antonio, San Antonio, Texas, United States
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Lewis S. Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Paul S. Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, West Virginia, United States
| | - Haomiao Jia
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States
- School of Nursing, Columbia University, New York, New York, United States
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34
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Tse R, Morrow P, Sage M, Stables S. Targeted and minimally invasive post-mortem examination with total body computed tomography not recommended in New Zealand. Forensic Sci Med Pathol 2020; 17:373-374. [PMID: 32897531 DOI: 10.1007/s12024-020-00303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Rexson Tse
- Northern Forensic Pathology Service of New Zealand, LabPLUS, Auckland City Hospital, Auckland, 1023, New Zealand.
| | - Paul Morrow
- Northern Forensic Pathology Service of New Zealand, LabPLUS, Auckland City Hospital, Auckland, 1023, New Zealand
| | - Martin Sage
- Canterbury District Health Board, Christchurch, 8011, South Island, New Zealand
| | - Simon Stables
- Northern Forensic Pathology Service of New Zealand, LabPLUS, Auckland City Hospital, Auckland, 1023, New Zealand
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