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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
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Prolonged ethanol administration prevents the development of tolerance to morphine-induced respiratory depression. Drug Alcohol Depend 2019; 205:107674. [PMID: 31715438 DOI: 10.1016/j.drugalcdep.2019.107674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Opioid users regularly consume other drugs such as alcohol (ethanol). Acute administration of ethanol can rapidly reverse tolerance to morphine-induced respiratory depression. However, alcohol consumption by opioid users is likely to occur over prolonged time periods. We have therefore sought to determine the effect of prolonged alcohol consumption on the development of tolerance to opioid respiratory depression. METHODS Mice were fed control or ethanol (5%) liquid diet for 16 days. On days 9-16 morphine tolerance was induced by administration of 3 priming injections of morphine followed by subcutaneous implantation of a morphine-filled osmotic mini-pump. Control mice received saline. Respiration was measured by plethysmography and the effect of an acute morphine challenge dose was measured on day 16 to assess the development of morphine tolerance. RESULTS Prolonged ethanol consumption for 14 days did not alter the respiratory depressant effect of an acute dose of morphine. Control mice treated with prolonged morphine developed tolerance to acute morphine respiratory depression whereas ethanol diet fed mice treated with prolonged morphine showed significant respiratory depression during morphine-pump treatment and remained sensitive to the respiratory depressant effect of the acute challenge dose of morphine. The ethanol consumption did not alter blood or brain levels of morphine, whilst conversely prolonged morphine treatment did not alter blood levels of ethanol. CONCLUSIONS Prolonged ethanol consumption prevents the development and maintenance of tolerance to the respiratory depressant effect of morphine. These data suggest that ethanol inhibition of tolerance will greatly increase the risk of fatal heroin overdose in humans.
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Marotta PL, Hunt T, Gilbert L, Wu E, Goddard-Eckrich D, El-Bassel N. Assessing Spatial Relationships between Prescription Drugs, Race, and Overdose in New York State from 2013 to 2015. J Psychoactive Drugs 2019; 51:360-370. [PMID: 31056042 PMCID: PMC6847245 DOI: 10.1080/02791072.2019.1599472] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 11/08/2018] [Indexed: 10/26/2022]
Abstract
Over the last decade, New York State has experienced one of the greatest increases in opioid overdose deaths in the United States, particularly from heroin and synthetic opioids. This study investigated spatial patterns in the distribution of county-level rates of overdose deaths in New York State and associations between prescriptions for opioid pain relievers, race, and overdose deaths from 2013-2015. Global and local Moran's I tests for spatial autocorrelation examined Bayesian smoothed rates of overdose for clusters of counties with high and low rates of overdose mortality. Getis Ord* analyses identified local hotspots of high and low clusters of overdose. Model performance indicators selected the best-fitting spatial regression model to examine associations between prescriptions for opioid pain relievers, race/ethnicity (non-Hispanic White, Black, and Hispanic) after adjusting for spatial dependence in the data. Socio-demographic characteristics of clusters were examined. Findings suggest rates of opioid overdose deaths are clustered in New York. Rates of prescription opioids were associated with rates of overdose from any opioid, prescription pain relievers, and synthetic opioids. Greater populations of African Americans were associated with greater rates of heroin overdose death rates. Findings from this study inform public health opioid overdose prevention interventions and policies.
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Affiliation(s)
- Phillip L Marotta
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
| | - Tim Hunt
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
| | - Louisa Gilbert
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
| | - Elwin Wu
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
| | - Dawn Goddard-Eckrich
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
| | - Nabila El-Bassel
- School of Social Work, Columbia University , New York , NY , USA
- Social Intervention Group, Columbia University , New York , NY , USA
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Kozlenkov A, Jaffe AE, Timashpolsky A, Apontes P, Rudchenko S, Barbu M, Byne W, Hurd YL, Horvath S, Dracheva S. DNA Methylation Profiling of Human Prefrontal Cortex Neurons in Heroin Users Shows Significant Difference between Genomic Contexts of Hyper- and Hypomethylation and a Younger Epigenetic Age. Genes (Basel) 2017; 8:genes8060152. [PMID: 28556790 PMCID: PMC5485516 DOI: 10.3390/genes8060152] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/21/2017] [Accepted: 05/25/2017] [Indexed: 12/30/2022] Open
Abstract
We employed Illumina 450 K Infinium microarrays to profile DNA methylation (DNAm) in neuronal nuclei separated by fluorescence-activated sorting from the postmortem orbitofrontal cortex (OFC) of heroin users who died from heroin overdose (N = 37), suicide completers (N = 22) with no evidence of heroin use and from control subjects who did not abuse illicit drugs and died of non-suicide causes (N = 28). We identified 1298 differentially methylated CpG sites (DMSs) between heroin users and controls, and 454 DMSs between suicide completers and controls (p < 0.001). DMSs and corresponding genes (DMGs) in heroin users showed significant differences in the preferential context of hyper and hypo DM. HyperDMSs were enriched in gene bodies and exons but depleted in promoters, whereas hypoDMSs were enriched in promoters and enhancers. In addition, hyperDMGs showed preference for genes expressed specifically by glutamatergic as opposed to GABAergic neurons and enrichment for axonogenesis- and synaptic-related gene ontology categories, whereas hypoDMGs were enriched for transcription factor activity- and gene expression regulation-related terms. Finally, we found that the DNAm-based “epigenetic age” of neurons from heroin users was younger than that in controls. Suicide-related results were more difficult to interpret. Collectively, these findings suggest that the observed DNAm differences could represent functionally significant marks of heroin-associated plasticity in the OFC.
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Affiliation(s)
- Alexey Kozlenkov
- James J. Peters VA Medical Center, Bronx, NY 10468, USA.
- The Friedman Brain Institute and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Andrew E Jaffe
- Lieber Institute for Brain Development, Johns Hopkins Medical Campus, Baltimore, MD 21205, USA.
- Department of Biostatistics and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
- Center for Computational Biology, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | | | - Pasha Apontes
- James J. Peters VA Medical Center, Bronx, NY 10468, USA.
| | | | - Mihaela Barbu
- Hospital for Special Surgery, New York, NY 10021, USA.
| | - William Byne
- James J. Peters VA Medical Center, Bronx, NY 10468, USA.
- The Friedman Brain Institute and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Yasmin L Hurd
- The Friedman Brain Institute and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Steve Horvath
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA.
- Department of Biostatistics, School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA.
| | - Stella Dracheva
- James J. Peters VA Medical Center, Bronx, NY 10468, USA.
- The Friedman Brain Institute and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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Abstract
Drug-related overdoses are now the leading injury-related death in the USA, and many of these deaths are associated with illicit opioids and prescription opiate pain medication. This study uses multiple sources of data to examine accidental opioid overdoses across 6 years, 2010 through 2015, in Marion County, IN, an urban jurisdiction in the USA. The primary sources of data are toxicology reports from the county coroner, which reveal that during this period, the most commonly detected opioid substance was heroin. During the study period, 918 deaths involved an opiod, and there were significant increases in accidental overdose deaths involving both heroin and fentanyl. In order to disentangle the nature and source of opioid overdose deaths, we also examine data from Indiana's prescription drug monitoring program and the law enforcement forensic services agency. Results suggest that there have been decreases in the number of opiate prescriptions dispensed and increases in law enforcement detection of both heroin and fentanyl. Consistent with recent literature, we suggest that increased regulation of prescription opiates reduced the likelihood of overdoses from these substances, but might have also had an iatrogenic effect of increasing deaths from heroin and fentanyl. We discuss several policy implications and recommendations for Indiana.
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Affiliation(s)
- Bradley Ray
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Kenna Quinet
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Timothy Dickinson
- School of Public & Environmental Affairs, Indiana University – Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Dennis P. Watson
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Alfarena Ballew
- Marion County (Indiana) Coroner’s Office, Indianapolis, IN USA
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Egervari G, Landry J, Callens J, Fullard JF, Roussos P, Keller E, Hurd YL. Striatal H3K27 Acetylation Linked to Glutamatergic Gene Dysregulation in Human Heroin Abusers Holds Promise as Therapeutic Target. Biol Psychiatry 2017; 81:585-594. [PMID: 27863698 PMCID: PMC5346335 DOI: 10.1016/j.biopsych.2016.09.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Opiate abuse and overdose reached epidemic levels in the United States. However, despite significant advances in animal and in vitro models, little knowledge has been directly accrued regarding the neurobiology of the opiate-addicted human brain. METHODS We used postmortem human brain specimens from a homogeneous European Caucasian population of heroin users for transcriptional and epigenetic profiling, as well as direct assessment of chromatin accessibility in the striatum, a brain region central to reward and emotion. A rat heroin self-administration model was used to obtain translational molecular and behavioral insights. RESULTS Our transcriptome approach revealed marked impairments related to glutamatergic neurotransmission and chromatin remodeling in the human striatum. A series of biochemical experiments tracked the specific location of the epigenetic disturbances to hyperacetylation of lysine 27 of histone H3, showing dynamic correlations with heroin use history and acute opiate toxicology. Targeted investigation of GRIA1, a glutamatergic gene implicated in drug-seeking behavior, verified the increased enrichment of lysine-27 acetylated histone H3 at discrete loci, accompanied by enhanced chromatin accessibility at hyperacetylated regions in the gene body. Analogous epigenetic impairments were detected in the striatum of heroin self-administering rats. Using this translational model, we showed that bromodomain inhibitor JQ1, which blocks the functional readout of acetylated lysines, reduced heroin self-administration and cue-induced drug-seeking behavior. CONCLUSIONS Overall, our data suggest that heroin-related histone H3 hyperacetylation contributes to glutamatergic transcriptional changes that underlie addiction behavior and identify JQ1 as a promising candidate for targeted clinical interventions in heroin use disorder.
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Affiliation(s)
- Gabor Egervari
- Department of Psychiatry, Friedman Brain Institute; Fishberg Department of Neuroscience, Friedman Brain Institute
| | - Joseph Landry
- Department of Psychiatry, Friedman Brain Institute; Fishberg Department of Neuroscience, Friedman Brain Institute
| | - James Callens
- Department of Psychiatry, Friedman Brain Institute; Fishberg Department of Neuroscience, Friedman Brain Institute
| | - John F Fullard
- Department of Psychiatry, Friedman Brain Institute; Department of Genetics and Genomic Science and Institute for Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York
| | - Panos Roussos
- Department of Psychiatry, Friedman Brain Institute; Department of Genetics and Genomic Science and Institute for Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York; Mental Illness Research, Education, and Clinical Center (VISN 3), James J. Peters VA Medical Center, Bronx, New York
| | - Eva Keller
- Department of Forensic Medicine, Semmelweis University, Budapest, Hungary
| | - Yasmin L Hurd
- Department of Psychiatry, Friedman Brain Institute; Fishberg Department of Neuroscience, Friedman Brain Institute.
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Lozano JG, Healy NL, Kimberley Molina D. The Prevalence of Paraphernalia Found at the Scene of Drug-Related Deaths. J Forensic Sci 2016; 62:691-694. [DOI: 10.1111/1556-4029.13329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 08/14/2016] [Accepted: 08/20/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jason G. Lozano
- Forensic Pathology Fellow; Bexar County Medical Examiner's Office; 7337 Louis Pasteur Drive San Antonio TX 78229-4565
| | - Nicole L. Healy
- Forensic Pathology Fellow; Bexar County Medical Examiner's Office; 7337 Louis Pasteur Drive San Antonio TX 78229-4565
| | - D. Kimberley Molina
- Forensic Pathology Fellow; Bexar County Medical Examiner's Office; 7337 Louis Pasteur Drive San Antonio TX 78229-4565
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Maynié-François C, Cheng DM, Samet JH, Lloyd-Travaglini C, Palfai T, Bernstein J, Saitz R. Unhealthy alcohol use in primary care patients who screen positive for drug use. Subst Abus 2016; 38:303-308. [PMID: 27482999 DOI: 10.1080/08897077.2016.1216920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Unhealthy alcohol use (UAU) is common among people who use other drugs; however, little information is available about UAU among patients who screen positive for drugs in primary care, where the clinical priority might be assumed to be drug use. This study aimed at describing the occurrence of UAU and its association with substance use-related outcomes in such patients. METHODS This cohort study is a secondary analysis of data from a randomized trial of brief intervention for primary care patients screening positive for drug use. UAU was assessed at baseline; the main independent variable was any heavy drinking day in the past month. Outcomes including drug use characteristics and substance use-related consequences were assessed at baseline and 6 months later. RESULTS Of 589 primary care patients with drug use, 48% had at least 1 past-month heavy drinking day. The self-identified main drug was marijuana for 64%, cocaine for 18%, and an opioid for 16%. Any heavy drinking at baseline was negatively associated with number of days use of the main drug at 6 months (incidence rate ratio [IRR] = 0.75, 95% confidence interval [CI]: 0.62-0.91), but positively associated with the use of more than 1 drug (IRR = 1.73, 95% CI: 1.17-2.55) and unsafe sex (odds ratio [OR] = 1.90, 95% CI: 1.21-2.98). CONCLUSION Unhealthy alcohol use is common among patients identified by screening in primary care as using other drugs. Unexpectedly, UAU was negatively associated with days of main drug use. But, as expected, it was positively associated with other drug use characteristics and substance use-related consequences. These findings suggest that attention should be given to alcohol use among primary care patients who use other drugs.
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Affiliation(s)
- Christine Maynié-François
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA
| | - Debbie M Cheng
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA.,b Department of Biostatistics , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Jeffrey H Samet
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA.,c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Christine Lloyd-Travaglini
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA.,d Data Coordinating Center, Boston University School of Public Health , Boston , Massachusetts , USA
| | - Tibor Palfai
- e Department of Psychology , Boston University , Boston , Massachusetts , USA
| | - Judith Bernstein
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Richard Saitz
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA.,c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
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Weimer MB, Chou R. Research gaps on methadone harms and comparative harms: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:366-76. [PMID: 24685460 DOI: 10.1016/j.jpain.2014.01.496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/10/2023]
Abstract
UNLABELLED Methadone-associated overdose deaths have dramatically increased. In order to inform an evidence-based clinical practice guideline to improve safety of methadone prescribing, the American Pain Society commissioned a systematic review on various aspects related to methadone safety. We searched Ovid MEDLINE, Cochrane Library, and PsycINFO databases through July 2012 to identify studies that addressed 1 or more of 17 Key Questions related to methadone safety; an update search was performed in 2014 for new studies related to methadone-related overdose and risks related to cardiac arrhythmias. A total of 168 studies met inclusion criteria for the review. The purpose of this article is to highlight critical research gaps in the literature related to methadone safety. These include lack of evidence on risk factors associated with methadone-overdose deaths and adverse events, limited evidence to evaluate the comparative mortality of methadone versus other opioids, insufficient evidence to fully understand the harms associated with methadone use during pregnancy, and insufficient evidence to determine effects of risk mitigation strategies such as electrocardiogram monitoring, strategies for managing patients with prolonged QTc intervals on screening, urine drug testing, alternative dosing regimens for initiation and titration of therapy, and timing of follow-up. Therefore, most guideline recommendations are based on weak evidence. More research is needed to guide safe methadone prescribing practices and decrease the adverse events associated with methadone. PERSPECTIVE This article summarizes critical research gaps in the literature related to methadone safety, based on a systematic review commissioned by the American Pain Society. Critical research gaps were identified in a number of areas, highlighting the need for additional research to guide safer prescribing and risk mitigation strategies.
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Affiliation(s)
- Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
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Chou R, Weimer MB, Dana T. Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:338-65. [PMID: 24685459 DOI: 10.1016/j.jpain.2014.01.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED The number of deaths associated with methadone use increased dramatically in parallel with marked increases in its use, particularly for treatment of chronic pain. To develop a clinical guideline on methadone prescribing to reduce potential harms, the American Pain Society commissioned a review of various aspects related to methadone safety. This article summarizes evidence related to unintentional overdose due to methadone and harms related to cardiac arrhythmia potential. We searched Ovid MEDLINE, the Cochrane Library, and PsycINFO databases through January 2014 for studies assessing harms associated with methadone use; we judged 70 studies to be relevant and to meet inclusion criteria. The majority of studies on overdose and cardiac arrhythmia risk are observational and provide weak evidence on which to base clinical guidelines. In patients prescribed methadone for treatment of opioid dependence, data suggest that mortality benefits related to reduction in illicit drug use outweigh harms. Despite epidemiologic data showing marked increases in the numbers of methadone-related deaths that have been primarily attributed to increased use of methadone for chronic pain, evidence on methadone and mortality risk in this population has been somewhat contradictory. There is some evidence that recent initiation of methadone, psychiatric admissions, and concomitant use of benzodiazepines are associated with a higher risk for overdose. Evidence on cardiac risks is primarily limited to case reports of torsades de pointes, primarily in patients on high doses of methadone, and to studies showing an association between methadone use and prolongation of QTc intervals. Research is needed to understand the effectiveness of dosing methods, electrocardiogram monitoring, and other risk mitigation strategies in patients prescribed methadone. PERSPECTIVE This systematic review synthesizes the evidence related to methadone use and risk for overdose and cardiac arrhythmia. Findings regarding the association between methadone use and QTc interval prolongation and risk factors for methadone-associated overdose suggest potential targets for risk mitigation strategies, though research is needed to determine the effectiveness of such strategies at reducing adverse outcomes.
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Affiliation(s)
- Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
| | - Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
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Darke S. Opioid overdose and the power of old myths: what we thought we knew, what we do know and why it matters. Drug Alcohol Rev 2014; 33:109-14. [PMID: 24589077 DOI: 10.1111/dar.12108] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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12
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Darke S, Farrell M. Would legalizing illicit opioids reduce overdose fatalities? Implications from a natural experiment. Addiction 2014; 109:1237-42. [PMID: 24456133 DOI: 10.1111/add.12456] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/18/2013] [Accepted: 12/06/2013] [Indexed: 11/29/2022]
Abstract
Overdose is the leading cause of premature mortality among heroin users. We examine whether the provision of regulated and quality-controlled heroin to users in specified doses would reduce heroin overdose rates. We also address this in the context of the epidemic of prescription opioid use and deaths seen in recent years in the United States and internationally. We explore the extent to which any change in legal access to heroin would affect overdose rates, and note that this depends upon the validity of the two main assumptions that variations in illicit drug purity and/or the presence of drug contaminants are major causes of overdose. Toxicological and demographic data from studies of heroin overdose deaths do not support these assumptions. The surge in the use of pharmaceutical opioids provides an example of the legal delivery of opioids of known dosage and free of contaminants, where overdose deaths can be examined to test these assumptions. Rates of fatal opioid overdose have escalated, with increased rates of prescribing of pharmaceutical opioids. On the basis of the experience with prescription opioids, unregulated legal heroin access would not reduce overdose rates.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Cerdá M, Ransome Y, Keyes KM, Koenen KC, Tardiff K, Vlahov D, Galea S. Revisiting the role of the urban environment in substance use: the case of analgesic overdose fatalities. Am J Public Health 2013; 103:2252-60. [PMID: 24134362 PMCID: PMC3828967 DOI: 10.2105/ajph.2013.301347] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose. METHODS In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006. RESULTS Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods. CONCLUSIONS Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.
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Affiliation(s)
- Magdalena Cerdá
- Magdalena Cerdá, Katherine M. Keyes, Karestan C. Koenen and Sandro Galea are with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Yusuf Ransome is with the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health. Kenneth Tardiff is with the Department of Psychiatry, Weill Cornell Medical College, New York, NY. David Vlahov is with the School of Nursing, University of California, San Francisco
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Strang J, Bird SM, Parmar MKB. Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. J Urban Health 2013; 90:983-96. [PMID: 23633090 PMCID: PMC3795186 DOI: 10.1007/s11524-013-9803-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.
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Affiliation(s)
- John Strang
- King’s College London, National Addiction Centre (Institute of Psychiatry and The Maudsley), London, SE5 8AF UK
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Cerdá M, Ransome Y, Keyes KM, Koenen KC, Tracy M, Tardiff KJ, Vlahov D, Galea S. Prescription opioid mortality trends in New York City, 1990-2006: examining the emergence of an epidemic. Drug Alcohol Depend 2013; 132:53-62. [PMID: 23357743 PMCID: PMC3748247 DOI: 10.1016/j.drugalcdep.2012.12.027] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/29/2012] [Accepted: 12/29/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990-2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas. METHODS We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990-2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas. RESULTS Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990-2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents. CONCLUSIONS The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts.
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Affiliation(s)
- Magdalena Cerdá
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA.
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Marasovic Susnjara I, Definis Gojanovic M, Vodopija D, Capkun V, Smoljanovic A. Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia. Croat Med J 2011; 52:629-36. [PMID: 21990081 PMCID: PMC3195972 DOI: 10.3325/cmj.2011.52.629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aim To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County. Methods We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed. Results There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P = 0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P = 0.008). The most common site of death was the deceased person’s home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides. Conclusion The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate.
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Feldman N, Chatton A, Khan R, Khazaal Y, Zullino D. Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2011; 6:22. [PMID: 21849027 PMCID: PMC3191344 DOI: 10.1186/1747-597x-6-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 08/17/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite the importance of heavy drinking and alcohol dependence among patients with opiate and cocaine dependence, few studies have evaluated specific interventions within this group. The aim of the present study was to evaluate the impact of screening with the Alcohol Use Disorders Identification Test (AUDIT) and of brief intervention (BI) on alcohol use in a sample of patients treated for opioid or cocaine dependence in a specialized outpatient clinic. METHODS Adult outpatients treated for opioid or cocaine dependence in Switzerland were screened for excessive alcohol drinking and dependence with the AUDIT. Patients with AUDIT scores that indicated excessive drinking or dependence were randomized into two groups--treatment as usual or treatment as usual together with BI--and assessed at 3 months and 9 months. RESULTS Findings revealed a high rate (44%) of problematic alcohol use (excessive drinking and dependence) among patients with opiate and cocaine dependence. The number of drinks per week decreased significantly between T0 (inclusion) and T3 (month 3). A decrease in average AUDIT scores was observed between T0 and T3 and between T0 and T9 (month 9). No statistically significant difference between treatment groups was observed. CONCLUSIONS In a substance abuse specialized setting, screening for alcohol use with the AUDIT, followed by feedback on the score, and use of alcohol BI are both possibly useful strategies to induce changes in problematic alcohol use. Definitive conclusions cannot, however, be drawn from the study because of limitations such as lack of a naturalistic group. An important result of the study is the excellent internal consistency of AUDIT in a population treated for opiate or cocaine dependence.
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Perez-Alvarez S, Iglesias-Guimarais V, Solesio ME, Melero-Fernandez de Mera RM, Yuste VJ, Galindo MF, Jordán J. Methadone induces CAD degradation and AIF-mediated necrotic-like cell death in neuroblastoma cells. Pharmacol Res 2010; 63:352-60. [PMID: 21145398 DOI: 10.1016/j.phrs.2010.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 12/01/2010] [Accepted: 12/02/2010] [Indexed: 10/18/2022]
Abstract
Methadone (d,l-methadone hydrochloride) is a full-opioid agonist, originally developed as a substitution for heroin or other opiates abusers. Nowadays methadone is also being applied as long-lasting analgesics in cancer, and it is proposed as a promising agent for leukemia therapy. Previously, we have demonstrated that high concentrations of methadone (0.5mM) induced necrotic-like cell death in SH-SY5Y cells. The pathway involved is caspase-independent but involves impairment of mitochondrial ATP synthesis and mitochondrial cytochrome c release. However, the downstream mitochondrial pathways remained unclear. Here, we studied the participation of apoptosis inducing factor (AIF) in methadone-induced cell death. Methadone resulted in a translocation of AIF from mitochondria to the nucleus. Translocation was inhibited by cyclosporine A, but not by lack of Bax protein. Therefore the effect seems mediated by the formation of the mitochondrial transition pore, but is apparently independent of Bax. Furthermore, methadone-treated SH-SY5Y nuclei show characteristics that are typical for stage I nuclear condensation. Methadone did not induce degradation of DNA into oligonucleosomal fragments or into high molecular weight DNA fragments. Absence of DNA fragmentation coincided with a considerable decrease in the levels of the caspase-actived endonuclase DNase and its chaperone-inhibitor ICAD. In conclusion, our results provide mechanistic insights into the molecular mechanisms that underlie methadone-induced cell death. This knowledge may prove useful to develop novel strategies to prevent toxic side-effects of methadone thereby sustaining its use as therapeutical agent against tumors.
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Affiliation(s)
- Sergio Perez-Alvarez
- Departamento de Ciencias Médicas, Facultad de Medicina, Universidad Castilla-La Mancha, Albacete, Spain
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Sternfeld I, Perras N, Culross PL. Development of a coroner-based surveillance system for drug-related deaths in Los Angeles county. J Urban Health 2010; 87:656-69. [PMID: 20440654 PMCID: PMC2900566 DOI: 10.1007/s11524-010-9455-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Existing data sources do not provide comprehensive and timely information to adequately monitor drug-related mortality in Los Angeles County. To fill this gap, a surveillance system using coroner data was developed to examine patterns in drug-related deaths. The coroner provided data on all injury deaths in Los Angeles County. A list of keywords that indicate a death was caused by drug use was developed. The cause of death variables in the coroner data were searched for mentions of one of the keywords; if a keyword was detected, that death was classified as drug related. The effectiveness of the keyword list in classifying drug-related deaths was evaluated by matching records in the coroner death data to records in the state death files. Then, the drug-related deaths identified using the keywords were compared to drug-related deaths in the state mortality files identified using International Classification of Death codes. Toxicological test results were used to categorize drug-related deaths based on the type and legality of the drug(s) ingested. Mortality rates were calculated for each category of drug and legal status and for different demographic groups. Compared to the gold standard state mortality files, the coroner data had a sensitivity of 95.6% for identifying drug-related deaths. Over three quarters of all drug-related deaths tested positive for opiates and/or stimulants. Males, Whites, and 35-54-year-olds each accounted for more than half of all drug-related deaths. The surveillance of drug-related deaths using coroner data has several advantages: data are available in a timely fashion, the data include information about the specific substances each victim ingested, and the data can be broken down to compare mortality among specific subpopulations.
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Affiliation(s)
- Isabelle Sternfeld
- Injury & Violence Prevention Program, Los Angeles County Department of Public Health, 3530 Wilshire Blvd., Ste. 800, Los Angeles, CA, 90010, USA.
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Darke S, Duflou J, Torok M. The comparative toxicology and major organ pathology of fatal methadone and heroin toxicity cases. Drug Alcohol Depend 2010; 106:1-6. [PMID: 19720472 DOI: 10.1016/j.drugalcdep.2009.07.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 07/16/2009] [Accepted: 07/16/2009] [Indexed: 11/16/2022]
Abstract
In order to determine the comparative toxicology and systemic disease of cases of death due to methadone and heroin toxicity, 1193 coronial cases of opioid overdose that occurred in New South Wales, Australia between 1 January 1998 and 31 December 2007 were inspected. These comprised 193 cases in which cause of death involved methadone toxicity (METH) and 1000 cases in which cause of death involved heroin toxicity in the absence of methadone (HER). METH cases were significantly more likely to have benzodiazepines (63.7% vs. 32.2%), and less likely to have alcohol (23.6% vs. 42.7%) detected. METH cases were significantly more likely to be diagnosed with pre-existing systemic pathology (94.3% vs. 79.9%), and multiple organ system pathology (68.8% vs. 41.4%). Specifically, METH cases were more likely to have cardiac (58.9% vs. 34.5%), pulmonary (53.6% vs. 30.9%), hepatic (80.7% vs. 62.8%) and renal (25.0% vs. 9.5%) disease. Given the notable differences in toxicology and disease patterns, great caution appears warranted in prescribing benzodiazepines to methadone users, and regular physical examinations of methadone treatment patients would appear clinically warranted.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
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Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction 2009; 104:2067-74. [PMID: 19922572 DOI: 10.1111/j.1360-0443.2009.02724.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Traditionally, the opiate antagonist naloxone has been administered parenterally; however, intranasal (i.n.) administration has the potential to reduce the risk of needlestick injury. This is important when working with populations known to have a high prevalence of blood-borne viruses. Preliminary research suggests that i.n. administration might be effective, but suboptimal naloxone solutions were used. This study compared the effectiveness of concentrated (2 mg/ml) i.n. naloxone to intramuscular (i.m.) naloxone for suspected opiate overdose. METHODS This randomized controlled trial included patients treated for suspected opiate overdose in the pre-hospital setting. Patients received 2 mg of either i.n. or i.m. naloxone. The primary outcome was the proportion of patients who responded within 10 minutes of naloxone treatment. Secondary outcomes included time to adequate response and requirement for supplementary naloxone. Data were analysed using multivariate statistical techniques. RESULTS A total of 172 patients were enrolled into the study. Median age was 29 years and 74% were male. Rates of response within 10 minutes were similar: i.n. naloxone (60/83, 72.3%) compared with i.m. naloxone (69/89, 77.5%) [difference: -5.2%, 95% confidence interval (CI) -18.2 to 7.7]. No difference was observed in mean response time (i.n.: 8.0, i.m.: 7.9 minutes; difference 0.1, 95% CI -1.3 to 1.5). Supplementary naloxone was administered to fewer patients who received i.m. naloxone (i.n.: 18.1%; i.m.: 4.5%) (difference: 13.6%, 95% CI 4.2-22.9). CONCLUSIONS Concentrated intranasal naloxone reversed heroin overdose successfully in 82% of patients. Time to adequate response was the same for both routes, suggesting that the i.n. route of administration is of similar effectiveness to the i.m. route as a first-line treatment for heroin overdose.
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Affiliation(s)
- Debra Kerr
- Victoria University, School of Nursing and Midwifery, St Albans, Victoria, Australia.
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Ciccarone D, Unick GJ, Kraus A. Impact of South American heroin on the US heroin market 1993-2004. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2009; 20:392-401. [PMID: 19201184 PMCID: PMC2719678 DOI: 10.1016/j.drugpo.2008.12.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 11/19/2008] [Accepted: 12/04/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The past two decades have seen an increase in heroin-related morbidity and mortality in the United States. We report on trends in US heroin retail price and purity, including the effect of entry of Colombian-sourced heroin on the US heroin market. METHODS The average standardized price ($/mg-pure) and purity (% by weight) of heroin from 1993 to 2004 was from obtained from US Drug Enforcement Agency retail purchase data for 20 metropolitan statistical areas. Univariate statistics, robust Ordinary Least Squares regression and mixed fixed and random effect growth curve models were used to predict the price and purity data in each metropolitan statistical area over time. RESULTS Over the 12 study years, heroin price decreased 62%. The median percentage of all heroin samples that are of South American origin increased an absolute 7% per year. Multivariate models suggest percent South American heroin is a significant predictor of lower heroin price and higher purity adjusting for time and demographics. CONCLUSION These analyses reveal trends to historically low-cost heroin in many US cities. These changes correspond to the entrance into and rapid domination of the US heroin market by Colombian-sourced heroin. The implications of these changes are discussed.
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Affiliation(s)
- Daniel Ciccarone
- University of California San Francisco, Department of Family and Community Medicine, San Francisco, CA 94143-0900, USA.
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Ciccarone D. Heroin in brown, black and white: structural factors and medical consequences in the US heroin market. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2009; 20:277-82. [PMID: 18945606 PMCID: PMC2704563 DOI: 10.1016/j.drugpo.2008.08.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 08/12/2008] [Accepted: 08/14/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Heroin coming into the United States historically comes from three widely dispersed geographical regions: Southwest Asia, Southeast Asia and Mexico. A fourth source of US-bound heroin, from Colombia, originated in the early 1990s. The fact that the four heroin sources produce differing morphologies and qualities of heroin has not been critically examined. In addition, it is not well established how the contemporary competing dynamics of interdiction, or restriction of heroin flows across international boundaries, and neoliberal, e.g., global expansion of free trade, policies are affecting heroin markets. This paper will highlight changes in the US heroin market, including source trends, the political economy of the now dominant source and the resultant effects on the heroin risk environment by US region. METHODS Using a structural and historical framework this paper examines two decades of secondary data sources, including government and drug control agency documents, on heroin flows together with published work on the political and economic dynamics in Latin America. RESULTS Co-occurring neoliberal economic reforms may have contributed to paradoxical effects of US/Colombian interdiction efforts. Since entering the US market, heroin from Colombia has been distributed at a much higher quality and lower retail price. An increasingly exclusive market has developed with Mexican and Colombian heroin gaining market share and displacing Asian heroin. These trends have had dramatic effects on the risk environment for heroin consumers. An intriguing factor is that different global sources of heroin produce substantially different products. Plausible associations exist between heroin source/form and drug use behaviours and harms. For example, cold water-soluble powdered heroin (sources: Asia, Colombia) may be associated with higher HIV prevalence in the US, while low-solubility "black tar" heroin (BTH; source: Mexico) is historically used in areas with reduced HIV prevalence. BTH is associated with soft tissue infections caused by Clostridium bacteria. CONCLUSION Source and type of heroin are structural factors in the risk environment of heroin users: source dictates distribution and type predicts practice. How specific types of heroin are used and with what risk is therefore distributed geographically. Continued flux in the heroin market and its effects on the risk environment for drug users deserves further attention.
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Affiliation(s)
- Daniel Ciccarone
- Department of Family and Community Medicine, University of California San Francisco, 500 Parnassus Avenue, MU-3E Box 0900, San Francisco, CA 94143-0900, USA.
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Wunsch MJ, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: a description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict 2009; 18:5-14. [PMID: 19219660 DOI: 10.1080/10550490802544938] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35-54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers.
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Affiliation(s)
- Martha J Wunsch
- Edward Via Virginia College of Osteopathic Medicine, Blacksburg, Virginia, USA.
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van Gaalen FA, Compier EA, Fogteloo AJ. Sudden hearing loss after a methadone overdose. Eur Arch Otorhinolaryngol 2009; 266:773-4. [DOI: 10.1007/s00405-009-0935-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 02/18/2009] [Indexed: 11/24/2022]
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Ompad DC, Fuller CM, Chan CA, Frye V, Vlahov D, Galea S. Correlates of illicit methadone use in New York City: a cross-sectional study. BMC Public Health 2008; 8:375. [PMID: 18957116 PMCID: PMC2588458 DOI: 10.1186/1471-2458-8-375] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 10/28/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite growing concern about illicit methadone use in the US and other countries, there is little data about the prevalence and correlates of methadone use in large urban areas. We assessed the prevalence and examined correlates of lifetime and recent illicit methadone use in New York City (NYC). METHODS 1,415 heroin, crack, and cocaine users aged 15-40 years were recruited in NYC between 2000 and 2004 to complete interviewer-administered questionnaires. RESULTS In multivariable logistic regression, non-injection drug users who used illicit methadone were more likely to be heroin dependent, less than daily methamphetamine users and to have a heroin using sex partner in the last two months. Injection drug users who used illicit methadone were more likely to use heroin daily, share injection paraphernalia and less likely to have been in a detoxification program and to have not used marijuana in the last six months. CONCLUSION The results overall suggest that illicit (or street) methadone use is likely not a primary drug of choice, but is instead more common in concert with other illicit drug use.
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Affiliation(s)
- Danielle C Ompad
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, USA.
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Affiliation(s)
- Michael Soyka
- Private Hospital Meiringen PO Box 612, 3860 Meiringen, Switzerland.
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Fairbairn N, Wood E, Stoltz JA, Li K, Montaner J, Kerr T. Crystal methamphetamine use associated with non-fatal overdose among a cohort of injection drug users in Vancouver. Public Health 2008; 122:70-8. [PMID: 17645904 DOI: 10.1016/j.puhe.2007.02.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Revised: 09/07/2006] [Accepted: 02/23/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the prevalence and correlates of non-fatal overdose among a polysubstance-using cohort of injection drug users (IDU) in Vancouver. STUDY DESIGN/METHODS We evaluated factors associated with non-fatal overdose among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) using univariate statistics. Self-reports of the awareness of drugs taken and drug potency, polysubstance use, and assistance received at the time of non-fatal overdose were also recorded. RESULTS From 1 December 2003 to 1 June 2005, 551 participants who were active injectors were followed. In total, 37 (6.7%) individuals reported experiencing a non-fatal overdose in the previous 6 months. Factors positively associated with non-fatal overdose included public injecting (odds ratio (OR)=4.74, 95% confidence interval (CI) 2.35-9.37, P<0.001), crystal methamphetamine use (OR=4.11) and injection (OR=3.63), morphine injection (OR=3.55), non-injection opiate use (OR=3.30), frequent heroin injection (OR=2.28) and sex trade work (OR=2.12). Factors negatively associated with non-fatal overdose included participation in methadone maintenance therapy (OR=0.31) and injecting alone (OR=0.36). Sixty-two percent of individuals were unaware of drug potency, 64.9% of IDU were taking other drugs at the time of overdosing, with crack being the main drug (37.0%). Fifty-four percent were assisted by ambulance personnel, 56.8% were taken to accident and emergency or hospital, 38.1% left accident and emergency or hospital before being released, and 35.1% were given Naloxone. CONCLUSION Structural interventions are needed that seek to modify the social and contextual risks for overdose, increased access to treatment programmes, and trials of novel interventions for crystal methamphetamine users.
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Affiliation(s)
- Nadia Fairbairn
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC Canada, V6Z 146
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Bauer SM, Loipl R, Jagsch R, Gruber D, Risser D, Thau K, Fischer G. Mortality in opioid-maintained patients after release from an addiction clinic. Eur Addict Res 2008; 14:82-91. [PMID: 18334818 DOI: 10.1159/000113722] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM To investigate the mortality rate in a cohort of 269 opioid-dependent patients and the outcome of survivors meeting DSM-IV criteria for opioid dependence. DESIGN Retrospective cohort study. PARTICIPANTS Patients enrolled in synthetic opioid maintenance therapy during a time frame from 1998 to 1999 originally at the Addiction Clinic and then discharged to general practitioners. METHODS Structured interviews (Europ-ASI), urinalysis at time of interview as well as autopsy findings from deceased patients. RESULTS After six mailings, information from 147 (54.6%) patients was gained. 85 patients (31.6%) were interviewed. From these 76.5% (n = 65) were still enrolled in maintenance therapy, 18.8% (n = 16) were drug-free and 4.7% (n = 4) relapsed. From 29 fatalities, 37.9% died of intoxication with illicit substances, 34.5% related to AIDS and 27.6% of somatic complications. The Standardized Mortality Ratio (SMR) was 29.13 (95% CI = 19.27-44.04). A higher lifetime frequency of hospitalization, less working days and a lack of social relationships were factors associated with high mortality. CONCLUSIONS The study confirms the high mortality rate in this patient group and supports the importance of maintenance therapy. Although great efforts were undertaken in locating patients, about 45% of the target group could not be located.
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Affiliation(s)
- Susanne M Bauer
- Department of Psychiatry and Psychotherapy, Division of Biological Psychiatry, Medical University of Vienna, Vienna, Austria
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Vlahov D, O'Driscoll P, Mehta SH, Ompad DC, Gern R, Galai N, Kirk GD. Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users. Addiction 2007; 102:771-7. [PMID: 17506154 DOI: 10.1111/j.1360-0443.2007.01767.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined. OBJECTIVE To estimate the frequency and risk factors for use of street methadone. METHODS Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression. RESULTS Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment. CONCLUSION The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.
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Affiliation(s)
- D Vlahov
- New York Academy of Medicine, New York, NY 10029, USA.
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Abstract
Methadone maintenance treatment (MMT) for opioid dependency has consistently shown important heath, social and legal benefits. What started as a small experimental program in Lexington, Kentucky has grown and expanded substantially over 35 years. Its practice is now well established both in specialized centers and in the broader community. In society, methadone deaths represent an important issue of public safety: methadone diversion to and ingestion by nontolerant individuals outside of treatment. Within treatment, methadone deaths occur most commonly in the early stabilization period (due to issue of tolerance), in periods of transition, or among certain individuals who abuse other substances (opioids, benzodiazepines, or alcohol). Research suggests moderately high methadone dosages help improve patient retention. Results from pharmacodynamic, kinetic and stereospecific studies continue to support the importance of individualizing dose. For some patients, much larger doses may be necessary to fully achieve all pharmacotherapy goals of treatment. Practitioners must be cautious however as certain patients on higher dosages are predisposed to torsade de pointes and increased mortality. Policymakers have a responsibility in their decision-making to balance the quality of life benefits for patients within MMT with the risks of increased mortality both for individuals within treatment and the general public.
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Affiliation(s)
- Mark Latowsky
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
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Bernstein KT, Bucciarelli A, Piper TM, Gross C, Tardiff K, Galea S. Cocaine- and opiate-related fatal overdose in New York City, 1990-2000. BMC Public Health 2007; 7:31. [PMID: 17349051 PMCID: PMC1839087 DOI: 10.1186/1471-2458-7-31] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 03/09/2007] [Indexed: 11/10/2022] Open
Abstract
Background In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990–2000. Methods Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990–2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression. Results Overall, among decedents ages 15–64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62–0.82), Black (OR = 4.73, 95% CI 4.08–5.49) or Hispanic (OR = 1.51, 95% CI 1.29–1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06–1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44–0.56) and older age (55–64) (OR = 2.53 95% CI 1.70–3.75)). Conclusion As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.
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Affiliation(s)
- Kyle T Bernstein
- Department of Emergency Medicine, School of Medicine, New York University. 462 First Ave, 3Floor, Room A345, NY, NY 10003. USA
| | - Angela Bucciarelli
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Ave, NY, NY 10029, USA
| | - Tinka Markham Piper
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Ave, NY, NY 10029, USA
| | - Charles Gross
- Department of Psychiatry, Weill Medical College, Cornell University, 525 E. 68th St, NY, NY 10021 USA
| | - Ken Tardiff
- Department of Psychiatry, Weill Medical College, Cornell University, 525 E. 68th St, NY, NY 10021 USA
| | - Sandro Galea
- Department of Epidemiology, School of Public Health, University of Michigan. 1214 South University, Ann Arbor, Michigan, 48104-2548, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health. 722 168th St, New York, New York 10032, USA
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Soyka M, Apelt SM, Lieb M, Wittchen HU. One-year mortality rates of patients receiving methadone and buprenorphine maintenance therapy: a nationally representative cohort study in 2694 patients. J Clin Psychopharmacol 2006; 26:657-60. [PMID: 17110826 DOI: 10.1097/01.jcp.0000245561.99036.49] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Mortality rates in drug-dependent patients in substitution treatment remain a matter of debate. Although several retrospective toxicological or forensic postmortem studies on this issue have been conducted, few prospective studies have addressed this problem. In a nationally representative sample of 2694 opioid dependent patients in substitution treatment either with methadone or buprenorphine at baseline were monitored over a 12-month period (response rate, 91%). A total number of 1629 (60.4%) were still in treatment after 12 months. The overall mortality rate was 1.04%. In total, 28 patients of the initial sample deceased within the 1-year follow-up period. Eleven (0.4%) of these deaths are due to a fatal intoxication. Three patients (0.1%) died of human immunodeficiency virus/acquired immunodeficiency syndrome, and 3 (0.1%) committed suicide. Thirteen of these patients (4 with overdose/polyintoxication) were not in substitution treatment at the time of death. Other reasons included accidents and deaths due to other medical conditions. Only in one case the reason could not be ascertained. The mortality rate was similar in methadone as compared with buprenorphine patients. Taking into account the high comorbidity of opioid dependent patients and the severity of dependence, the mortality rate of approximately 1% confirms that maintenance treatment could be regarded as a fairly safe treatment.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, Munich, Germany.
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Abstract
AIMS To determine levels of systemic disease among cases of death due to opioid toxicity. DESIGN Analysis of coronial cases. SETTING Sydney, Australia. CASES A total of 841 cases of death due to opioid toxicity (1 January 1998-31 December 2002). FINDINGS Ventricular hypertrophy was present in 5.9% of cases and severe coronary artery atherosclerosis in 5.7%. Severe coronary pathology was more pronounced among older cases. Pre-existing bronchopneumonia was present in 13.2% of cases. Hepatic pathology was the most common type of pathology, and was far more marked among older cases. Cirrhosis was present in 25.3% of those aged > 44 years. Levels of renal pathology were comparatively low, but were related significantly to increasing age. Systemic disease in more than one organ system was present in 24.4% of cases, and was related to increasing age (44% of those aged > 44 years). The only pathology for which gender was an independent predictor among opioid cases was ventricular hypertrophy, more common in males. CONCLUSIONS Systemic disease, most prominently liver disease, is common among fatal opioid toxicity cases, and may be a factor in understanding the dynamics and age demographics of opioid-related death.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia.
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Horvath MC, Hurd YL, Rajs J, Keller E. Variations in respiratory distress characterize the acute agonal period during heroin overdose death: Relevance to postmortem mRNA studies. Brain Res Bull 2006; 70:251-9. [PMID: 16861111 DOI: 10.1016/j.brainresbull.2006.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Revised: 05/19/2006] [Accepted: 05/23/2006] [Indexed: 11/19/2022]
Abstract
AIMS To determine whether there are factors during apparent rapid heroin overdose death that affect agonal state and thus brain pH (index of hypoxia) that can influence neurobiological systems linked to drug abuse. DESIGN AND METHODS Brain specimens and autopsy/medical reports were investigated in subjects dying from heroin overdose (n=70) and compared to normal controls (n=45) as well as suicide victims (n=31) with a documented rapid cause of death. Detailed autopsy material was characterized as to positive and negative respiratory distress in relation to brain pH; drug toxicity and other demographic information was also evaluated. In situ hybridization histochemistry was used to study mRNA expression levels of dopamine (e.g., D2 receptor, dopamine transporter) and opioid (e.g., proenkephalin) related markers in various structures in relation to brain pH. FINDINGS Brain pH was generally reduced in heroin overdose cases versus normal and suicide subjects. There was, however, significant variation in heroin overdose deaths related to differences in respiratory distress that differentially altered brain pH levels. Various factors such as vomit inhalation, resuscitation, pulmonary embolism and suffocation contributed to positive respiratory distress. Elevated brain pH was observed in heroin overdose with positive alcohol toxicity suggesting potentiated alcohol-induced rapidity of heroin deaths. mRNA expression levels of the dopamine-related genes and proenkephalin were positively correlated with brain pH. CONCLUSIONS Respiratory distress contributes to variations in the acute agonal state during heroin overdose death that differentially alters brain pH levels and significantly impacts mRNA levels. Such findings should be considered for postmortem molecular/neurochemical neurobiological studies of opiate abusers.
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Affiliation(s)
- Monika Cs Horvath
- Department of Forensic Medicine, Semmelweis University, 1091 Budapest, Ulloi Str 93, Hungary
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Abstract
The prevalence of overdose deaths from opioids is still generally increasing throughout the world. Heroin is still the predominant illicit opioid of interest to toxicology laboratories because of its continuing widespread availability and its ability to elicit respiratory depression and coma. In many countries methadone continues to play a major role in cases of drug toxicity because of its large-scale use to treat opioid dependency and its high potency and long duration of action. Increasingly, buprenorphine is being used as an alternative pharmacotherapy, and although apparently safer than methadone, it still has an inherent risk of toxicity when used with CNS depressants such as benzodiazepines or when injected. Morphine continues to be the dominant analgesic; however, oxycodone, hydromorphone, hydrocodone, and fentanyl are increasingly being used and will require increasing efforts by toxicology laboratories to ensure that these substances are adequately covered by testing programs.
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Affiliation(s)
- Olaf H Drummer
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Victoria, Australia.
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37
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Mueller MR, Shah NG, Landen MG. Unintentional prescription drug overdose deaths in New Mexico, 1994-2003. Am J Prev Med 2006; 30:423-9. [PMID: 16627130 DOI: 10.1016/j.amepre.2005.12.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 11/28/2005] [Accepted: 12/21/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND New Mexico has the highest rate of drug-induced mortality in the United States. The contribution of prescription drugs to the total overdose death rate has not been adequately described. METHODS A total of 1,906 unintentional drug overdose deaths occurring in 1994 to 2003 in New Mexico were analyzed. Unintentional drug overdose death was defined as death caused by prescription, illicit, or a combination of drugs, as determined by a pathologist. Deaths were investigated annually by the medical examiner and data were analyzed in 2004-2005. Rates and trends of total and prescription drug overdose death were calculated, decedent characteristics were analyzed, and common drug combinations causing death were described. RESULTS The rate of unintentional prescription drug overdose death increased by 179% (1.9 to 5.3/100,000) from 1994 to 2003. A high percentage of prescription drug overdose decedents were white non-Hispanic (63.2%) and female (43.9%). These decedents were older and less frequently had alcohol listed as an additional cause of death than decedents of other drug overdose categories. Of all deaths caused by prescription drug(s) (n =765), 590 (77.1%) were caused by opioid painkillers, 263 (34.4%) by tranquilizers, and 196 (25.6%) by antidepressants. CONCLUSIONS The rate of prescription drug overdose death in New Mexico increased significantly over the 10-year study period. Comprehensive surveillance of drug overdose deaths is recommended to describe their occurrence in the context of both medical and diverted use of prescription drugs. Understanding decedent profiles and the potential risk factors for prescription drug overdose death is crucial for effective drug overdose prevention education among healthcare providers.
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Affiliation(s)
- Mark R Mueller
- Centers for Disease Control and Prevention, Office of Workforce and Career Development, Atlanta, Georgia, USA
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Abstract
This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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39
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The political economy of heroin: Regional markets, practices and consequences. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2005. [DOI: 10.1016/j.drugpo.2005.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Shah N, Lathrop SL, Landen MG. Unintentional methadone-related overdose death in New Mexico (USA) and implications for surveillance, 1998-2002. Addiction 2005; 100:176-88. [PMID: 15679747 DOI: 10.1111/j.1360-0443.2004.00956.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To determine death rates from methadone over time, to characterize methadone-related death and to discuss public health surveillance of methadone-related death. DESIGN We analyzed medical examiner data for all unintentional drug overdose deaths in New Mexico, USA, between 1998 and 2002. MEASUREMENTS Age-adjusted death rates for methadone-related death, logistic regression models for likelihood of methadone-related death among all unintentional drug overdose deaths and bivariate comparisons within methadone-related death. FINDINGS Of 1120 drug overdose deaths during this period, there were 143 (12.8%) methadone-related deaths; the death rate decreased over the time period, averaging 1.6 per 100,000. Of 143 methadone-related deaths, 22.4% were due to methadone alone, 23.8% were due to methadone/prescription drugs (no illicit drugs), 50.3% were due to methadone/illicit drugs and 3.5% were due to methadone/alcohol. These groups were significantly different in demographics, health history and circumstances of death. Of 79 decedents (55.2%) with a known source of methadone, 68 obtained methadone through a physician prescription (31 for methadone maintenance treatment (MMT), 27 for managing pain and 10 had unknown reason for prescription). CONCLUSIONS Methadone-related death rates and the proportion of methadone-related death among all drug overdose deaths decreased in New Mexico from 1998 to 2002. It is important for surveillance of methadone-related death to assess multiple drug causes, not just underlying cause. Also, methadone for pain management must be examined alongside MMT and when possible, methadone co-intoxication should be described in the context of other drugs causing death.
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Affiliation(s)
- Nina Shah
- Epidemiology and Response Division, New Mexico Department of Health, Santa Fe, NM 87502-6110, USA.
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Corkery JM, Schifano F, Ghodse AH, Oyefeso A. The effects of methadone and its role in fatalities. Hum Psychopharmacol 2004; 19:565-76. [PMID: 15378662 DOI: 10.1002/hup.630] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methadone is a synthetic opioid, used both as an analgesic in severe pain relief and now mainly in the treatment of opiate dependence. Such use of the drug has increased as its advantages have become widely recognized. There are undesirable outcomes from its greater use, including a substantial market in diverted methadone and a high number of deaths where the drug has been implicated. It is important to understand how and why methadone causes death so that such fatalities can be minimized, and to disseminate such information. This paper presents an overview of the chief effects of methadone on the human body, considering its metabolism, drug interactions and tolerance. The principal mechanisms by which methadone causes death are discussed: respiratory depression, aspiration of vomit, pulmonary oedema, bronchopneumonia, cardiac problems and renal failure. Many such deaths are preventable, if drug interactions and polydrug use are avoided, its longer period of metabolism and individuals' tolerance levels are considered. It is hoped that this paper will (a) help guide health professionals in their management and treatment of patients participating in methadone treatment programmes, and (b) provide some basic information for those dealing with individuals who have consumed methadone.
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Affiliation(s)
- John M Corkery
- National Programme on Substance Abuse Deaths, Department of Mental Health-Addictive Behaviour, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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