Alcohol and Benzodiazepines in Fatal Poisonings

Exploring unified methods of killing and storing insect samples for forensic entomotoxicology using diazepam in Lucilia sericata (Meigen, 1826) (Diptera: Calliphoridae) larvae

Forensic entomologists use the maturity of necrophagous larvae to estimate the minimum post-mortem interval (PMImin), ideally taking account of effects that xenobiotics in the corpse may have on insect maturation. Forensic toxicologists may employ larvae to detect drugs in drug-related deaths when human samples are unavailable. Yet current pre-analytical practices of these two professions differ significantly, impeding the successful use of the same samples. Potential benefits of shared pre-analytical practices and opportunities for enhanced collaboration have yet to be fully explored. We employed Lucilia sericata (Meigen, 1826) (Diptera: Calliphoridae) larvae, raised in the presence of diazepam, to investigate the effects of two standard investigative practices on larvae for drug detection and for quantifying mass and length as proxies of age. Specimens were killed by either blanching or freezing and stored at -20℃ for either intermediate or long periods. Blanched larvae showed smaller changes in size and body integrity during storage, thereby producing the most reproducible estimates of PMImin. Consequently, data obtained from blanched larvae were used to evaluate the impact of diazepam on larval development. Diazepam exerted no significant effect on larval mass, and a weak effect on length. Diazepam recovery was significantly higher from blanched larvae, suggesting that freeze-killing causes drug loss. This model system demonstrates the value to forensic entomologists of the standard technique of blanching larvae, followed by storage at -20℃ for toxicological analysis. We recommend that forensic toxicologists consider blanching to kill larvae before storage at low temperatures, at least for certain drugs. This approach offers the dual benefit of high-quality specimens for both PMI estimation and drug detection.

Analytical Methods for Determining Psychoactive Substances in Various Matrices: A Review

Psychoactive substances pose significant challenges and dangers to society due to their impact on perception, mood, and behavior, leading to health and life disturbances. The consumption of these substances is largely influenced by their legal status, cultural norms, and religious beliefs. Continuous development and chemical modifications of psychoactive substances complicate their control, detection, and determination in the human body. This paper addresses the terminological distinctions between psychoactive and psychotropic substances and drugs. It provides a comprehensive review of analytical methods used to identify and quantify 25 psychoactive substances in various biological matrices, including blood, urine, saliva, hair, and nails. The analysis categorizes these substances into four primary groups: stimulants, neuroleptics, depressants, and hallucinogens. The study specifically focuses on chromatographic and spectrophotometric methods, as well as other novel analytical techniques. Methodology includes a review of scientific articles containing validation studies of these methods and innovative approaches to psychoactive substance determination. Articles were sourced from the PubMed database, with most research originating from the twenty first century. The paper discusses the limits of detection and quantitation for each method, along with current trends and challenges in the analytical determination of evolving psychoactive substances.

Beyond benzodiazepines: a meta-analysis and narrative synthesis of the efficacy and safety of alternative options for alcohol withdrawal syndrome management

PURPOSE

To compare the efficacy and safety of non-benzodiazepines (non-BZDs) to benzodiazepines (BZDs) in the treatment of alcohol withdrawal syndrome (AWS).

METHODS

For relevant literature, Google Scholar, PubMed, Embase, OVID MEDLINE, EBSCO, Cochrane Central Registry of Controlled Trials, Web of Science, and Scopus were searched. Randomized control trials (RCTs) were included, omitted were nonblinded trials, blinded trials that were not randomized, and open-label studies. The Effective Public Health Practice Project Quality Assessment was used to assess the trial's quality. A meta-analysis and a narrative synthesis were carried out.

RESULTS

Twenty non-BZDs and five BZDs were investigated in thirty RCTs. Meta-analysis favored gabapentin over chlordiazepoxide and lorazepam (d = 0.563, p < 0.001) and carbamazepine over oxazepam and lorazepam (d = 0.376, p = 0.029), for reducing Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale scores. Eleven non-BZDs fared better than BZDs for reducing CIWA-Ar, Total Severity Assessment, Selective Severity Assessment, Borg and Weinholdt, and Gross Rating Scale for Alcohol Withdrawal scores. Eight non-BZDs outmatched BZDs regarding autonomic, motor, awareness, and psychiatric symptoms. Sedation and fatigue were prevalent in BZDs, while seizures were prevalent in non-BZDs.

CONCLUSION

For AWS treatments, non-BZDs are superior to or equally effective as BZDs. Non-BZD adverse events warrant further investigation. Agents that inhibit gated ion channels are promising candidates.

PROTOCOL REGISTRATION

PROSPERO CRD42022384875.

Development and Validation of an Explainable Machine Learning-Based Prediction Model for Drug-Food Interactions from Chemical Structures

Possible drug-food constituent interactions (DFIs) could change the intended efficiency of particular therapeutics in medical practice. The increasing number of multiple-drug prescriptions leads to the rise of drug-drug interactions (DDIs) and DFIs. These adverse interactions lead to other implications, e.g., the decline in medicament's effect, the withdrawals of various medications, and harmful impacts on the patients' health. However, the importance of DFIs remains underestimated, as the number of studies on these topics is constrained. Recently, scientists have applied artificial intelligence-based models to study DFIs. However, there were still some limitations in data mining, input, and detailed annotations. This study proposed a novel prediction model to address the limitations of previous studies. In detail, we extracted 70,477 food compounds from the FooDB database and 13,580 drugs from the DrugBank database. We extracted 3780 features from each drug-food compound pair. The optimal model was eXtreme Gradient Boosting (XGBoost). We also validated the performance of our model on one external test set from a previous study which contained 1922 DFIs. Finally, we applied our model to recommend whether a drug should or should not be taken with some food compounds based on their interactions. The model can provide highly accurate and clinically relevant recommendations, especially for DFIs that may cause severe adverse events and even death. Our proposed model can contribute to developing more robust predictive models to help patients, under the supervision and consultants of physicians, avoid DFI adverse effects in combining drugs and foods for therapy.

Clinical effect of ethanol co-use in patients with acute drug toxicity involving the use of central nervous system depressant recreational drugs

BACKGROUND AND IMPORTANCE

Patients who use recreational drugs frequently co-ingest ethanol, which is considered a central nervous system (CNS) depressant. The clinical relevance of this in acute toxicity involving other CNS depressants is not well described.

OBJECTIVE

To assess the clinical impact of ethanol co-use in patients presenting to the emergency department (ED) with acute toxicity involving the use of CNS depressant drugs.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective multicentre study using data from the Euro-DEN Plus database from January 2014 to December 2019.

OUTCOMES MEASURE AND ANALYSIS

Comparison of epidemiologic and clinical characteristics, ED and hospital management of patients with CNS depressant intoxication with or without ethanol co-use.

MAIN RESULTS

Although 7644 (17.5%) of the 43 633 presentations were included, ethanol was co-ingested in 3811 (49.9%). In total 53.3% required medical treatment, 14 patients died. Patients with ethanol co-use more frequently presented with a Glasgow Coma Scale (GCS) ≤8 (34.1% vs. 22.4%; P  < 0.001), vomiting (8.1% vs. 4.6%; P  < 0.001), anxiety (12 % vs. 6.4%; P  < 0.001), agitation/aggression (22% vs. 14.7%; P  < 0.001), seizures (3.8% vs. 2.4%; P  < 0.001) and hypotension (7.5% vs. 4.6%; P  < 0.001). They more often required ambulance transport (85.5% vs. 76.5%; P  < 0.001), medical treatment (57.3% vs. 48.0%; P  < 0.001), hospitalization (27.7% vs. 18.9%; P  < 0.001), and admission to intensive care (12.2% vs. 4.0%; P  < 0.001). Subgroup analysis showed that GCS ≤8 was particularly common in patients who combined ethanol with opioids or gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL).

CONCLUSION

Co-use of ethanol with CNS-depressant drugs appears to increase the risk of adverse effects and is associated with a higher need for medical treatment, especially when ethanol is combined with opioids or GHB/GBL.

Real-time drug detection using a diathermic knife combined to rapid evaporative ionisation mass spectrometry

Fast, accurate and sensitive detection of drugs in human tissue is of crucial importance in an investigation of a suspicious death. Here, we aimed to screen cocaine, diazepam, methadone and morphine in post-mortem muscle samples without sample preparation and in quasi-real time using rapid evaporative ionisation mass spectrometry (REIMS). REIMS enables the online MS analysis of vapours generated from tissue dissection by a diathermic knife. Human muscle samples were soaked in solutions of 4 drugs at different concentrations and multiple incubation times to check the feasibility of REIMS for this innovative application. Muscle samples soaked in blank saline were used as a control. The classification model was able to distinguish between 30 μg g^-1 cocaine (m/z 304.2), 200 μg g^-1 morphine (m/z 286.2), 10 μg g^-1 methadone (m/z 310.2) and 10 μg g^-1 muscle of diazepam (m/z 285.1). REIMS tandem MS confirmed that the mass peaks that contributed to the class separation, originated from the drugs of interest. As a proof-of-concept, a forensic case muscle sample from a methadone overdose was investigated using REIMS. Here, using our classification model, the recognition software was able to detect methadone, demonstrating that the REIMS method opens new possibilities in forensic toxicology and during autopsy, leading to faster crime solving and decreased costs.

Significant decrease in the rate of fatal alcohol poisonings in Finland validated by blood alcohol concentration statistics

BACKGROUND

Alcohol may cause death directly by acute poisoning, as well as induce illnesses or accidents that lead to death. Our research question was whether the current decreasing trend in acute fatal alcohol poisonings in Finland is a real phenomenon or an artefact caused by possible changes in the process of determining the cause of death.

METHODS

All cases in the national post-mortem toxicology database in which the underlying cause of death was acute alcohol poisoning in 1987-2018 were investigated in terms of blood alcohol concentration (BAC), age and gender. The number of acute alcohol poisonings was compared to the number of deaths from alcohol induced illness in the post-mortem toxicology database.

RESULTS

A total of 12 126 acute alcohol poisoning cases were retrieved. Between 2004 and 2017 the number of acute alcohol poisonings decreased 60.1 %. At the same time the number of alcohol induced illnesses in the study material remained stable or decreased marginally. The median BAC in all acute alcohol poisonings was 3.2 g/kg. The annual median BAC values showed a small but significant decrease over the study period. The proportion of women in acute alcohol poisonings increased significantly over the study period, from 17.1%-22.3%. Women were on average 2.5 years older than men.

CONCLUSIONS

On grounds of the BAC statistics and supporting evidence, we conclude that the significant decrease in the number of fatal alcohol poisonings is true and likely reflects changes in the overall consumption of alcohol.

Relative toxicity of benzodiazepines and hypnotics commonly used for self-poisoning: An epidemiological study of fatal toxicity and case fatality

The relative toxicity of anxiolytic and hypnotic drugs commonly used for self-poisoning was assessed using data on suicides, prescriptions and non-fatal self-poisonings in England, 2005-2012. Data on suicide by self-poisoning were obtained from the Office for National Statistics, information on intentional non-fatal self-poisoning was derived from the Multicentre Study of Self-harm in England and data on prescriptions in general practice from the Clinical Practice Research Datalink. We used two indices of relative toxicity: fatal toxicity (the number of fatal self-poisonings relative to the number of individuals prescribed each drug) and case fatality (the number of fatal relative to non-fatal self-poisonings). Diazepam was the reference drug in all analyses. Temazepam was 10 times (95% confidence interval 5.48-18.99) and zopiclone/zolpidem nine times (95% confidence interval 5.01-16.65) more toxic in overdose than diazepam (fatal-toxicity index). Temazepam and zopiclone/zolpidem were 13 (95% confidence interval 6.97-24.41) and 12 (95% confidence interval 6.62-22.17) times more toxic than diazepam, respectively (case-fatality index). Differences in alcohol involvement between the drugs were unlikely to account for the findings. Overdoses of temazepam and zopiclone/zolpidem are considerably more likely to result in death than overdoses of diazepam. Practitioners need to exercise caution when prescribing these drugs, especially for individuals who may be at risk of self-harm, and also consider non-pharmacological options.

Time-dependent interacting effects of caffeine, diazepam, and ethanol on zebrafish behaviour

Zebrafish have become a popular animal model for behavioural pharmacology due to their small size, rapid development, and amenability to high throughput behavioural drug screens. Furthermore, water-soluble compounds can be administered via immersion of the fish in the drug solution, which provides a non-invasive drug delivery method. Numerous studies have demonstrated stimulant effects of alcohol. Diazepam and caffeine, on the other hand have been found to have inhibitory effect on locomotor activity in zebrafish. However, the time-dependent changes induced by these psychoactive drugs are rarely reported, and potential drug interactions have not been examined in zebrafish, despite the translational relevance of this question. In the current study, we examine time- and dose-dependent changes in zebrafish following exposure to caffeine, diazepam, and ethanol quantifying four different behavioural parameters over a 30min recording session. We subsequently analyze potential drug-drug interactions by co-administering the three drugs in different combinations. Our time-course and dose-response analyses for each of the three drugs represent so far the most detailed studies available serving as a foundation for future psychopharmacology experiments with zebrafish. Furthermore, we report significant interactions between the three drugs corroborating findings obtained with rodent models as well as in humans, providing translational relevance for the zebrafish model.

Sedative-hypnotics are widely abused by drivers apprehended for driving under the influence of drugs

BACKGROUND

Sedative-hypnotics are commonly encountered in drivers apprehended for driving under the influence of drugs (DUID). Previous research has mainly concentrated on the residual effects of the drugs.

METHODS

In this study, the extent of sleep medication use and abuse among drivers apprehended on suspicion of DUID was assessed. Additionally, the prevalence and concentrations of the drugs, concomitant use of other drugs of abuse, and the age and sex of the drivers positive for the most commonly prescribed sedative-hypnotics (temazepam, midazolam, nitrazepam, zopiclone, and zolpidem) in DUID cases in Finland in 2009 to 2011 were examined.

RESULTS

Sedative-hypnotics were found in 3155 samples of the 13,248 that were analyzed. Temazepam was present in over half of the cases (57.9%), along with other benzodiazepines such as midazolam (13.1%) and nitrazepam (7.0%) and the non-benzodiazepine hypnotics zopiclone (12.2%) and zolpidem (9.8%). The mean age of the drivers using the studied sedative-hypnotics was 33.5 years. Many of the drivers were polydrug users; concomitant stimulant use was found in nearly half of the cases. Cannabis and alcohol were also very common co-findings. In nearly 20% of the cases, the driver had taken more than 1 of the studied sedative-hypnotics; only 2.5% had no findings other than a single sedative-hypnotic in their blood. The drug use pattern of those positive for zopiclone and zolpidem was somewhat different from that of users of benzodiazepine sedative-hypnotics; their age was higher and the concomitant use of illegal stimulants was markedly less prevalent than among the users of temazepam, midazolam, and nitrazepam.

CONCLUSIONS

There were very few cases in our study population where the positive sedative-hypnotic finding could have been due to appropriate medical use. The extremely prevalent concomitant use of other psychoactive drugs and the high median serum concentrations of the studied sedative-hypnotics suggest their widespread abuse among apprehended drivers.

Coadministration of disulfiram and lorazepam in the treatment of alcohol dependence and co-occurring anxiety disorder: an open-label pilot study

BACKGROUND

Anxiety is common among persons with alcohol use disorder during early abstinence from alcohol. Although benzodiazepines are effective for short-term treatment of anxiety, they are rarely used beyond acute detoxification due to concerns about misuse or interactions with alcohol.

OBJECTIVES

We conducted an open-label trial to explore the effects of coadministering lorazepam and disulfiram to alcohol-dependent patients with anxiety disorder symptoms. The rationale for this model is to minimize the risks of the benzodiazepine, while also potentially enhancing adherence to disulfiram.

METHODS

Forty-one participants with DSM-IV alcohol dependence who also met syndromal criteria for anxiety disorder with or without co-occurring major depressive syndrome initiated treatment with lorazepam (starting dose 0.5 mg three times daily) and disulfiram (starting dose 500 mg three times weekly). Participants received 16 weeks of monitored pharmacotherapy with manualized medical management.

RESULTS

Adherence to treatment decreased steadily with time (85.4% at 4 weeks, 36.6% at 16 weeks). Participants showed significant increases in percent abstinent days during treatment and at 24 weeks follow-up. Large reductions in anxiety, depression, and craving were observed during treatment, and improvement remained significant at 24 weeks. Duration of adherence with disulfiram strongly predicted abstinence at 16 weeks. There was no evidence of misuse of lorazepam or dose escalation during the study.

CONCLUSION

Lorazepam can be safely used for short-term treatment of anxiety in combination with disulfiram treatment of alcohol use disorder. However, it is not clear that making lorazepam dispensing contingent on adherence to disulfiram enhances retention in disulfiram treatment.

Can cannabis be considered a substitute medication for alcohol?

AIMS

Substituting cannabis for alcohol may reduce drinking and related problems among alcohol-dependent individuals. Some even recommend prescribing medical cannabis to individuals attempting to reduce drinking. The primary aim of this review is to assess whether cannabis satisfies the seven previously published criteria for substitute medications for alcohol [e.g. 'reduces alcohol-related harms'; 'is safer in overdose than alcohol'; 'should offer significant health economic benefits'; see Chick and Nutt ((2012) Substitution therapy for alcoholism: time for a reappraisal? J Psychopharmacol 26:205-12)].

METHODS

Literature review.

RESULTS

All criteria appear either satisfied or partially satisfied, though studies relying on medical cannabis patients may be limited by selection bias and/or retrospective designs. Individual-level factors, such as severity of alcohol problems, may also moderate substitution.

CONCLUSIONS

There is no clear pattern of outcomes related to cannabis substitution. Most importantly, the recommendation to prescribe alcohol-dependent individuals cannabis to help reduce drinking is premature. Future studies should use longitudinal data to better understand the consequences of cannabis substitution.

Driving under the influence with blood alcohol concentrations over 0.4 g%

The aim of this study was to evaluate the characteristics of traffic offenders with unusually high blood-alcohol concentrations (BAC>0.4 g%) when arrested. The BAC that kills one person might be easily tolerated by another, depending on, among other things, the person's age, pattern of drinking, and the development of tolerance. The archives of two forensic laboratories, one in Sweden and the other in Wisconsin (USA), were searched to find traffic offenders with BACs>0.4 g%. The results were compared in relation to the person's age and gender, mean BAC and the weekday and time of day of the arrest. The mean age (±standard deviation) of N=158 Swedish offenders was 45±9.0 y, which was not significantly different from the 43±9.4 y in N=233 Wisconsin drivers (p>0.05). Overall there were more men (78%) than women (22%) arrested with BAC's>0.4 g%, although the proportion of women in Wisconsin (35%) was higher than in Sweden (9%) (p<0.001). The mean (median) and highest BAC did not differ between jurisdictions; 0.429 g% (0.422) and 0.546 g% in Sweden and 0.428 g% (0.421 g%) and 0.526 g% in Wisconsin. In Sweden 40% of the arrests occurred on Fridays and Saturdays, whereas in Wisconsin the arrests of people with such high BAC's were more evenly distributed throughout the week. Forty eight percent of the arrests in Sweden were made between 12 noon and 6 pm compared with 37% in Wisconsin. Neither the mean age of offenders nor their mean BAC seemed to depend on the weekday or time of day of the arrest. Attempting to drive with a BAC above 0.4 g% verifies the development of an appreciable tolerance to ethanol-induced cognitive and psychomotor impairment. Reaching such a high BAC probably requires continuous heavy drinking over several days as opposed to an evening's binge drinking.

Concentrations of alprazolam in blood from impaired drivers and forensic autopsies were not much different but showed a high prevalence of co-ingested illicit drugs

Alprazolam is a benzodiazepine anxiolytic widely prescribed for treatment of panic-disorder and social phobias, although this medication is also subject to abuse. In this paper, the concentrations of alprazolam in venous blood samples from impaired drivers were compared with femoral blood samples from forensic autopsies classified as intoxication or other causes of death (e.g. natural, trauma). After liquid-liquid extraction (n-butyl acetate) alprazolam was determined in blood by capillary gas chromatography with a nitrogen-phosphorous detector. The mean (median) and range of alprazolam concentrations in blood from impaired drivers (n = 773) were 0.08 mg/L (0.05 mg/L) and 0.02-3.9 mg/L, respectively. Many traffic offenders had co-ingested ethanol (13%), amphetamine (46%), cannabis (32%), or heroin (14%), as well as other drugs. In deaths attributed to drug intoxication, the mean (median) and range of alprazolam concentrations in blood (n = 438) were 0.10 mg/L (0.06 mg/L) and 0.02-1.6 mg/L, respectively, which were not much different from other causes of death (n = 278); 0.08 mg/L (0.05 mg/L) and 0.02-0.9 mg/L. Median concentrations of alprazolam in blood from living and deceased persons did not seem to depend on the number of co-ingested substances. The result of this pharmacoepidemiological study suggests that alprazolam is a fairly innocent drug when used as monotherapy, but toxicity problems arise when co-ingested with illicit drugs and/or psychoactive medication.

Methadone as social control: institutionalized stigma and the prospect of recovery

Methadone maintenance treatment (MMT) is an intervention used to treat opioid (heroin) dependence. Several investigators have found that MMT is effective in reducing heroin use and other behaviors; however, a disproportionate number of MMT clients leave treatment prematurely. Moreover, MMT outcome variables are often limited in terms of their measurement. Utilizing an integrated theoretical framework of social control and stigma, we focused on the experiences of methadone maintenance from the perspective of clients. We pooled interview data from four qualitative studies in two jurisdictions and found linkages between social control and institutional stigma that serve to reinforce "addict" identities, expose undeserving customers to the public gaze, and encourage clients to be passive recipients of treatment. We discuss the implications for recovery and suggest recommendations for change.

Patterns of benzodiazepine use in a Canadian population sample

Aim – The objective of this study was to identify clinical and demographic factors that may be associated with benzodiazepine treatment, to describe the reported reasons for use of these medications and to appraise the pattern of use in relation to standard guidelines in a general population sample. Methods – Telephone survey methods were employed to select a sample of 3345 people between the ages of 18 and 64. A computer assisted telephone interview, including the Mini Neuropsychiatric Diagnostic Interview (MINI), was administered. Estimates were weighted for design features and population demographics. Results – The overall prevalence of benzodiazepines use was 3.3% (95% confidence interval [CI] 2.6 to 4.1%). There was a higher frequency of medication use in women than men, among respondents who were widowed, separated or divorced, and those with lower levels of education. In relation to MINI diagnosis, diagnoses of Panic Disorder and Major Depression increased the probability of taking benzodiazepines. The reported main reason for use was “Sleep disorders” (68.9%), “Anxiety” (35.8%), “Depression” (27.8%) and “Pain management” (21.2%). More than 80% of subjects were taking benzodiazepines for more than one year. Conclusions – When compared to previous estimates, the lower frequency of benzodiazepines use suggests that there has been improvement in their evidence-based use at a population level. However our results once more confirm the difficulty stopping the use of these medications once they have been started. Further randomized control studies may help clinicians in having a better practical approach to rational benzodiazepine use.

Declaration of Interest: None.

Neuroimaging insights into the role of cortical GABA systems and the influence of nicotine on the recovery from alcohol dependence

This paper reviews evidence suggesting that nicotine and tobacco smoke profoundly modulate the effects of alcohol on γ-aminobutyric acid (GABA) neuronal function, specifically at the GABA(A)-benzodiazepine receptor (GABA(A)-BZR). The focus of this paper is on recent neuroimaging evidence in preclinical models as well as clinical experiments. First, we review findings implicating the role of alcohol at the GABA(A)-BZR and discuss the changes in GABA(A)-BZR availability during acute and prolonged alcohol withdrawal. Second, we discuss preclinical evidence that suggests nicotine affects GABA neuronal function indirectly by a primary action at neuronal nicotinic acetylcholine receptors. Third, we show how this evidence converges in studies that examine GABA levels and GABA(A)-BZRs in alcohol-dependent smokers and nonsmokers, suggesting that tobacco smoking attenuates the chemical changes that occur during alcohol withdrawal. Based on a comprehensive review of literature, we hypothesize that tobacco smoking minimizes the changes in GABA levels that typically occur during the acute cycles of drinking in alcohol-dependent individuals. Thus, during alcohol withdrawal, the continued tobacco smoking decreases the severity of the withdrawal-related changes in GABA chemistry. This article is part of a Special Issue entitled 'Trends in neuropharmacology: in memory of Erminio Costa'.

Drug poisoning deaths in Sweden show a predominance of ethanol in mono-intoxications, adverse drug-alcohol interactions and poly-drug use

Over a 10-year period (1998-2007) all deaths in Sweden classified by forensic pathologists as fatal drug poisonings (N = 6894) were retrieved from a toxicology database (TOXBASE) belonging to the National Board of Forensic Medicine. The deaths were further classified as suicides N = 2288 (33%), undetermined N = 2260 (33%) and accidental N = 2346 (34%). The average age (± SD) of all victims was 49.1 ± 15.9 years and men 47.4 ± 15.6 years were 5-year younger than women 52.2 ± 15.8 years (p < 0.01). Most of the deceased (78%) were poly-drug users although a single drug (mono-intoxications) was found in 22% of all poisoning deaths (p < 0.001). The number of drugs in blood samples varied from 1 to 12 with a median of 3-4 per case. Mono-intoxication deaths were mostly ethanol-related (N = 976) and the mean and median blood-alcohol concentration (BAC) was 3.06 g/L and 3.10 g/L, respectively. The BAC decreased as the number of additional drugs in blood increased from 2.15 g/L with one drug to 1.25 g/L with 6 or more drugs. The mean (median) concentrations of non-alcohol drugs in mono-intoxication deaths were morphine (N = 93) 0.5mg/L (0.2mg/L), amphetamine (N = 39) 2.0mg/L (1.2mg/L), dextropropoxyphene (N = 33) 3.9 mg/L (2.9 mg/L), dihydro-propiomazine (N = 32) 1.6 mg/L (1.0mg/L) and 7-amino-flunitrazepam (N = 28), 0.4 mg/L (0.3mg/L). Elevated blood morphine in these poisoning deaths mostly reflected abuse of heroin as verified by finding 6-monoacetyl morphine (6-MAM) in the blood samples. When investigating drug poisoning deaths a comprehensive toxicological analysis is essential although the results do not reveal the extent of prior exposure to drugs or the development of pharmacological tolerance. The concentrations of drugs determined in post-mortem blood are one element in the case. The autopsy report, the police investigation, the findings at the scene and eye-witness statements should all be carefully considered when the cause and manner of death are determined.

Loop 2 structure in glycine and GABA(A) receptors plays a key role in determining ethanol sensitivity

The present study tests the hypothesis that the structure of extracellular domain Loop 2 can markedly affect ethanol sensitivity in glycine receptors (GlyRs) and gamma-aminobutyric acid type A receptors (GABA(A)Rs). To test this, we mutated Loop 2 in the alpha1 subunit of GlyRs and in the gamma subunit of alpha1beta2gamma2GABA(A)Rs and measured the sensitivity of wild type and mutant receptors expressed in Xenopus oocytes to agonist, ethanol, and other agents using two-electrode voltage clamp. Replacing Loop 2 of alpha1GlyR subunits with Loop 2 from the deltaGABA(A)R (deltaL2), but not the gammaGABA(A)R subunit, reduced ethanol threshold and increased the degree of ethanol potentiation without altering general receptor function. Similarly, replacing Loop 2 of the gamma subunit of GABA(A)Rs with deltaL2 shifted the ethanol threshold from 50 mm in WT to 1 mm in the GABA(A) gamma-deltaL2 mutant. These findings indicate that the structure of Loop 2 can profoundly affect ethanol sensitivity in GlyRs and GABA(A)Rs. The deltaL2 mutations did not affect GlyR or GABA(A)R sensitivity, respectively, to Zn(2+) or diazepam, which suggests that these deltaL2-induced changes in ethanol sensitivity do not extend to all allosteric modulators and may be specific for ethanol or ethanol-like agents. To explore molecular mechanisms underlying these results, we threaded the WT and deltaL2 GlyR sequences onto the x-ray structure of the bacterial Gloeobacter violaceus pentameric ligand-gated ion channel homologue (GLIC). In addition to being the first GlyR model threaded on GLIC, the juxtaposition of the two structures led to a possible mechanistic explanation for the effects of ethanol on GlyR-based on changes in Loop 2 structure.

Prevalence of adverse drug combinations in a large post-mortem toxicology database

The prevalence of important adverse drug combinations was studied among the 37,367 cases included in the Finnish post-mortem toxicology database during 2000-2006. The new SFINX interaction database (Swedish, Finnish, INteraction X-referencing) was utilised to identify adverse drug combinations. Consequently, the 24 drugs chosen for the study generated 96 two-compound combinations possessing potentially severe interactions. The total number of hits for the combinations found in the post-mortem database was 267, which accounts for approximately 0.71% of all cases. The potential role of adverse drug interaction (ADI) in these cases was evaluated from the background information and death certificate. The possible ADI cases comprised 23% of all hits and 0.17% of all cases analysed. In cases with a pharmacodynamic mechanism, the most prominent combinations were medicines causing serotonin syndrome or a beta(1)-blocker with verapamil or diltiazem. In cases with a pharmacokinetic mechanism, half of the cases involved digoxin in combination with verapamil. In one third of the possible ADI cases, a forensic pathologist had noted the studied compounds as an underlying or contributing cause of death, although the agents' specific role in ADIs was rarely recognised.

Blood alcohol concentrations in apprehended drivers of cars and boats suspected to be impaired by the police

OBJECTIVE

According to the Norwegian Road Traffic Act, car drivers are not allowed to operate a vehicle with a blood alcohol concentration (BAC) above 0.2 g/kg. Depending on the size of the boat or ship, boat drivers/captains/first mates are not allowed to conduct the boat with a BAC above 0.8 g/kg when driving small boats (length less than 15 m) and above 1.5 g/kg when running larger vessels/ships. The new Sea Act of June 2005 states that captains/first mates cannot conduct a ship if he/she has a BAC above 0.2 g/kg. Our aim was to determine the current median BAC in a large population of car and boat drivers in Norway. Our other aim was to study if median BAC was higher in boat drivers than in car drivers who were suspected by the police to be impaired. Furthermore, we wanted to investigate if the BAC levels were differently distributed by gender or age within and between these two groups.

METHODS

The Norwegian Institute of Public Health analyzes blood samples from all car/boat drivers suspected of driving under the influence of alcohol and non-alcoholic drugs. In the present study, samples submitted between 01.05 and 01.09 in 2002-2004 were included. Drivers, who in addition tested positive for drugs or abuse substances other than ethanol were excluded.

RESULTS

There were 321 boat drivers and 3,061 car drivers who were suspected to be under the influence of ethanol only. The median BAC in boat drivers (1.76 g/kg [range 0.02-3.54]) was significantly higher compared to that in car drivers (1.54 g/kg [range 0.00-4.27]). In the car driver group, the mean BAC did not differ significantly between men and women. The median level of BAC was significantly higher in men than in women in the boat driver group (1.77 g/kg with CI 1.69-1.85 vs. 1.27 g/kg with CI 0.78-1.76).

CONCLUSIONS

Alcohol impairment of car drivers is known to be considered the most important contributing cause of car crash injuries. Driving a boat may demand the same degree of performance skills as driving a car. The median BAC in apprehended boat drivers was considerably high in the present study. The median BAC was also high in car drivers despite strict legislation. The population of drivers of cars in our study, however, is from previous studies known to contain a large proportion of heavy drinkers. Less is known about the drinking habits in boat drivers, and caution is needed in generalizing from our results. However, our results indicate the possible need for stricter legislation and more frequent police control that will hopefully prevent serious accidents caused by ethanol drinking at sea.

GABAA receptor subtypes: the "one glass of wine" receptors

This review discusses evidence for and apparent controversy about, gamma-aminobutyric acid type A (GABAA) receptor (GABAAR) subtypes that mediate alcohol effects experienced during social drinking. GABAARs that contain the beta3 and delta subunits were shown to be enhanced by alcohol concentrations that mirror the concentration dependence of alcohol responses in humans. A mutation (alpha6R100Q) previously found in alcohol nontolerant rats in the cerebellar GABAAR alpha6 subunit is sufficient for increased alcohol-induced ataxia in rats homozygous for this mutation (alpha6-100QQ) and further increases alcohol sensitivity of tonic GABA currents (mediated by alpha6betadelta receptors) in cerebellar granule cells of alpha6-100QQ rats and in recombinant alpha6R100Qbeta3delta receptors. This provided the first direct evidence that these types of receptors mediate behavioral effects of ethanol. Furthermore, the behavioral alcohol antagonist Ro15-4513 specifically reverses ethanol enhancement on alpha4/6beta3delta receptors. Unexpectedly, native and recombinant alpha4/6beta3delta receptors bind the behavioral alcohol antagonist Ro15-4513 with high affinity and this binding is competitive with EtOH, suggesting a specific and mutually exclusive (competitive) ethanol/Ro15-4513 site, which explains the puzzling activity of Ro15-4513 as a behavioral alcohol antagonist. Our conclusion from these findings is that alcohol/Ro15-4513-sensitive GABAAR subtypes are important alcohol targets and that alcohol at relevant concentrations is more specific than previously thought. In this review, we discuss technical difficulties in expressing recombinant delta subunit-containing receptors in oocytes and mammalian cells that may have contributed to negative results and confusion. Not only because we have reproduced detailed positive results numerous times, and we and many others have built extensively on basic findings, but also because we explain and combine many previously puzzling results into a coherent and highly plausible paradigm on how alcohol exerts an important part of its action in the brain, we are confident about our findings and conclusions. However, many important open questions remain to be answered.

Hypnotic use in a population-based sample of over thirty-five thousand interviewed Canadians

Background

As with most medications, benzodiazepine and similar sedative hypnotics (BDZ/SSH) can produce both beneficial and adverse effects. Pharmacoepidemiological studies have been limited in their capacity to evaluate the relationship between these medications and psychiatric diagnoses in non-clinical populations. The objective of this study was to provide a description of the pattern of use of BDZ/SSH medications in relation to both demographic and diagnostic data in a community population.

Methods

The source of data for this study was the Canadian Community Health Survey (CCHS 1.2), also known as the Canadian National Study of Mental Health and Well-being. This study was based on a nationally representative sample that included over 35 thousand subjects with a response rate of 77%. The survey interview included the latest version of the Composite International Diagnostic Interview (CIDI), which was developed for the World Health Organization's WHO Mental Health 2000 project. Current medication use was also recorded.

Results

As expected, BDZ/SSH use was more common in women than in men (4.2%, 95% CI 3.9 to 4.6 vs. 2.5%, 95% CI 2.2 to 2.8) and its frequency increased with age, 8.5% (95% CI 7.7 to 9.4) of those over the age of 65 compared to 2.4% (95% CI 2.2 to 2.7) of those aged 18 to 64 years. These medications were more frequently used in subjects with low levels of education (4.8%, 95% CI% 4.3 to 5.2) vs. high levels of education (2.4%, 95% CI 2.1 to 2.6) and low personal incomes (5.7%, 95% CI 5.2 to 6.3) vs. high personal incomes (2.3%, 95% CI 2.0 to 2.6). BDZ/SSH use was strongly associated with the presence of mood or anxiety disorders, but not with substance use disorders. Demographic differences persisted after statistical adjustment for diagnosis.

Conclusion

The observation that benzodiazepine use is more frequent in women, increases with age and is higher in low income and education groups supports previous findings. These results help to confirm that these differences are not accounted for by psychiatric diagnoses.

Sedative hypnotic use in Alberta

OBJECTIVE

Benzodiazepines and similar sedative-hypnotics (BDZ-SSHs) are associated with both beneficial and adverse effects. Pharmacoepidemiologic data describing the use of these medications in contemporary Canadian populations has not been readily available. Our objective was to examine the hypothesis that increasing use of antidepressant medications for anxiety and mood disorders during the past decade led to less frequent use of BDZ-SSH medications.

METHOD

We used data from an Alberta Mental Health Survey to describe the pattern of BDZ-SSH use and to estimate provincial and health region frequencies of use. We supplemented the data with pharmacy dispensing data from IMS Health.

RESULTS

The frequency of use was comparable to that reported in previous studies. Unexpectedly, in the survey data, we observed trends suggesting regional variation both in the frequency and pattern of use. Examination of prescription dispensing data confirmed this pattern. Clinical factors, including the use of other psychotropic medications and psychiatric diagnoses, were strongly associated with BDZ-SSH use. Among the drugs examined, zopiclone had the highest frequency of use. Prescription dispensing data confirmed that the frequency of zopiclone use in Alberta is higher than that in most other provinces.

CONCLUSIONS

This descriptive study generates several new research questions and provides benchmarks for future pharmacoepidemiologic monitoring.

Relation of postmortem blood alcohol and drug concentrations in fatal poisonings involving amitriptyline, propoxyphene and promazine

Drugs and alcohol often occur together in fatal poisonings, complicating the process of determining the cause of death. Especially when found in concentrations generally regarded as toxic but not lethal, the question arises whether the combination of sublethal amounts was the likely cause of death. In this study, we examined poisoning deaths involving amitriptyline, propoxyphene and promazine, which are, after benzodiazepines, the most frequently occurring drugs in Finnish alcohol-related poisonings. From the forensic toxicology database, covering the years 1995-2002, we extracted 332 fatal poisonings, calculated median blood alcohol and drug concentrations, constructed concentration-concentration and concentration-response curves and evaluated the significance of the presence of therapeutic amounts of benzodiazepines. Median amitriptyline and propoxyphene concentrations were lower in alcohol-related cases than in clean drug poisonings. Correspondingly, the median blood alcohol concentrations in all drug-related poisonings were 1.5-2.2 mg/g lower than that found in clean alcohol poisonings. Alcohol concentration proved to be a more sensitive indicator of alcohol-drug interaction than drug concentration. This result suggests that when alcohol is present, relatively small overdoses of the studied drugs may result in fatal poisoning. In this context, fatal drug and alcohol concentrations and the issue of determining the most important agent in fatal drug-alcohol intoxications are discussed.

Newer antidepressants: evaluation of fatal toxicity index and interaction with alcohol based on Finnish postmortem data

Finnish postmortem toxicology data from 1995 to 2002 was analyzed to obtain improved estimates of fatal toxicity indices for the newer antidepressants and to evaluate their interaction with alcohol. Altogether 284 fatal poisonings were attributed to 12 different newer antidepressants. Venlafaxine, mianserin, moclobemide, and mirtazapine were responsible for significantly more deaths than expected from their sales. Their fatal toxicity indices were higher than those of selective serotonin reuptake inhibitors (SSRIs) but lower than those of tricyclic antidepressants. In fatal poisonings involving alcohol in combination with venlafaxine, mianserin, moclobemide, or mirtazapine, the median blood alcohol concentration (BAC) ranged from 2.35 to 2.7 mg/g, whereas in those involving alcohol in combination with citalopram or fluoxetine the median BAC was 2.9 and 3.4 mg/g, respectively. The BAC was significantly lower in venlafaxine-related deaths than in those involving fluoxetine or citalopram. We conclude that among the newer antidepressants differences are present both in toxicity and in interaction potential with alcohol. The SSRIs appear to present a low risk of fatal poisoning when taken alone or in combination with alcohol, whereas venlafaxine is associated with an elevated risk.

Fatal intoxications in a Swedish forensic autopsy material during 1992-2002

Compilations of substances detected in fatal intoxications are important in order to observe changes in intoxication patterns, to monitor effects of preventive work and to discover new trends in drug usage. The aim of the present study was to describe the current pattern of substances detected in fatal intoxications in Sweden. Fatal intoxications investigated at the Department of Forensic Chemistry, Linköping, Sweden, during 1992-2002, were analysed. All suicides, uncertain cases and accidents where the cause of death were fatal intoxications (ICD-9: E950, E980 and E859) were included and substances detected in more than 50 fatal intoxications (in femoral blood) were listed. For each substance, a cut off value was set, above which concentrations were considered toxic. Fatal intoxications were detected by forensic-chemical analyses in 12% (6998/60,314) of the forensic autopsies during the study period. Among the suicides, an average of 3.8 substances were detected per case, the corresponding figure for uncertain cases and accidents were 3.5 and 4.1 substances, respectively. Ethanol was by far the most frequently detected substance, detected in 43% (3039) of the fatal intoxications, of which 32% (960) had toxic concentrations, followed by propoxyphene, detected in 27% (1863) of the fatal intoxications of which 74% (1370) had toxic concentrations. The number of cases where ethanol and propoxyphene were detected decreased during the study period. Moreover, other CNS-active drugs such as antidepressants, analgesics and anxiolytics were also frequently detected. The drugs with high proportions of cases with toxic concentrations detected were propoxyphene, amitriptyline, zolpidem, carisoprodol, alprazolam, thioridazine, methadone and ketobemidone. Selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCA) were detected in 12% (833) and 10% (665), respectively. A significantly (P <0.001) higher proportion of cases where TCA were detected had toxic concentrations when compared with cases where SSRI were detected (64% versus 31%).

Comparison of deramciclane to benzodiazepine agonists in behavioural activity of mice and in alcohol drinking of alcohol-preferring rats

Interactions between alcohol and traditional benzodiazepine anxiolytics hamper the treatment of alcoholism-related anxiety disorders. Serotonin 5-HT(2) receptor antagonists, such as deramciclane, are anxiolytic, and considering their pharmacological profile, they might benefit alcoholics with comorbid anxiety. We studied the effects of acute deramciclane (1, 3 and 10 mg/kg i.p.) on alcohol drinking of alcohol-preferring AA rats drinking 10% (vol/vol) ethanol solution in a 4-h limited-access paradigm. Thereafter, a 5-day repeated-treatment experiment was carried out, under corresponding test design, with deramciclane (3 mg/kg i.p.) as a test drug and midazolam (1 mg/kg i.p.) as a benzodiazepine reference compound. Deramciclane had no effect on alcohol consumption in either acute or repeated dosing study. Midazolam increased ethanol drinking, as expected, when administered on successive days. A modified functional observational battery (FOB) procedure was applied to study neurological, behavioural and autonomic effects induced by deramciclane (1-30 mg/kg po) and diazepam (1-30 mg/kg po) in mice at 30 min, 2 h and 4 h after dosing. Deramciclane had a mild dopamine D(2) receptor antagonism-like effect at the highest dose. The effects of diazepam were predictable, myorelaxation-induced motor impairment and anxiolysis-related hyperlocomotion in a novel environment being the characteristic features at the two highest doses. Deramciclane appears to be a safe and well-tolerated drug and we suggest that it might be useful in the treatment of anxiety in alcoholics.

Detection of the Adulteration of Traditional Alcoholic Beverages by the Separation and Determination of Alprazolam, Chloralhydrate and Diazepam Using Reversed-Phase High-Performance Liquid Chromatography

A simple, rapid and reliable reversed-phase high-performance liquid chromatographic method for the separation and determination of psycotropic substances viz., alprazolam, chloral hydrate and diazepam in traditional alcoholic beverages, such as toddy, has been developed. Separation was accomplished using a reversed-phase C18 column with water-methanol-acetic acid (35:65:0.1 v/v/v) as a mobile solvent and a photo-diode array detector at 210 nm. The limits of detection of alprazolam, chloral hydrate and diazepam were determined to be 0.8, 4.5 and 0.4 microg, respectively. The validity of the method was checked by analyzing nearly 200 samples collected from different outlets by enforcement authorities, and the extent of adulteration was determined.

Ethanol enhances alpha 4 beta 3 delta and alpha 6 beta 3 delta gamma-aminobutyric acid type A receptors at low concentrations known to affect humans

gamma-Aminobutyric acid type A receptors (GABARs) have long been implicated in mediating ethanol (EtOH) actions, but so far most of the reported recombinant GABAR combinations have shown EtOH responses only at fairly high concentrations (> or = 60 mM). We show that GABARs containing the delta-subunit, which are highly sensitive to gamma-aminobutyric acid, slowly inactivating, and thought to be located outside of synapses, are enhanced by EtOH at concentrations that are reached with moderate, social EtOH consumption. Reproducible ethanol enhancements occur at 3 mM, a concentration six times lower than the legal blood-alcohol intoxication (driving) limit in most states (0.08% wt/vol or 17.4 mM). GABARs responsive to these low EtOH concentrations require the GABAR delta-subunit, which is thought to be associated exclusively with alpha 4- and alpha 6-subunits in vivo, and the beta 3-subunit, which has recently been shown to be essential for the in vivo anesthetic actions of etomidate and propofol. GABARs containing beta 2-instead of beta 3-subunits in alpha 4 beta delta- and alpha 6 beta delta-receptor combinations are almost 10 times less sensitive to EtOH, with threshold enhancement at 30 mM. GABARs containing gamma 2-instead of delta-subunits with alpha 4 beta and alpha 6 beta are three times less sensitive to EtOH, with threshold responses at 100 mM, a concentration not usually reached with social EtOH consumption. These combined findings suggest that "extrasynaptic" delta-subunit-containing GABARs, but not their "synaptic" gamma-subunit-containing counterparts, are primary targets for EtOH.

alpha2-gamma-Aminobutyric acid (GABA)A receptors are the molecular substrates mediating precipitation of narcosis but not of sedation by the combined use of diazepam and alcohol in vivo

Classical benzodiazepines such as diazepam are widely used tranquillisers and hypnotics in various neuropsychiatric diseases including alcohol-related disorders. One of the major drawbacks of benzodiazepine therapy, however, is an exacerbation of the sedative and hypnotic effects associated with alcohol intake, even at low doses. Even though the gamma-aminobutyric acid (GABA)A receptor complex is a common target for the actions of both classes of drugs, the molecular mechanisms underlying the enhanced pharmacological properties of the combined use of benzodiazepines and alcohol remain to be identified. The present experiments aimed at clarifying which of the GABAA receptor subtypes mediate the augmented hypnotic-like and sedative effects of combined diazepam and alcohol using the righting reflex and motor activity assays, respectively, in histidine-to-arginine point mutated mice that possess diazepam-insensitive alpha1-, alpha2-, alpha3- or alpha5-GABAA receptors. The combination of diazepam (2 or 3 mg/kg) and ethanol (3 g/kg) induced loss of righting reflex with a significantly dose-dependent increase of the latency to its full recovery in wild-type, alpha1(H101R), alpha3(H126R) and alpha5(H105R) but not in alpha2(H101R) mice. A combined treatment with diazepam (1 mg/kg) and ethanol (2.5 g/kg) precipitated motor inhibition similarly in wild-type and alpha2(H101R) mice. Responsiveness of the alpha2(H101R) mice to ethanol alone was similar to that of wild-type mice. These results demonstrate that induction of loss of righting reflex by combined diazepam and alcohol is closely dependent on the activation of the alpha2-GABAA receptors by the benzodiazepine whereas precipitation of sedation involves GABAA receptors other than the alpha2-GABAA receptors.

Interaction of alcohol and drugs in fatal poisonings

In Finnish data from 1995-2000, 1006 fatal poisonings due to alcohol (ethanol), a single drug or both were statistically analysed in retrospect to evaluate the interaction between alcohol and drugs. In 53% of these cases, low concentrations of some common benzodiazepines were present. The median postmortem blood alcohol concentration (BAC) was 3.3 percent per thousand (w/w) in the 615 alcohol poisonings, but significantly lower, ranging from 1.3 to 1.7 percent per thousand, when promazine, doxepin, amitriptyline or propoxyphene were found together with alcohol. When levomepromazine, temazepam or zopiclone were present, the median BAC was also significantly lower, 2.5-2.7 percent per thousand. Citalopram and diltiazem did not exhibit a significant effect. The median BAC was significantly lower in cases with high concentrations than in those with low concentrations of a drug (excluding citalopram), suggesting a positive concentration-effect relationship. Fatal toxicity indices (FTIs) were calculated by relating the number of deaths caused by a drug to the corresponding sales figures. Promazine had an extremely high FTI, followed by levomepromazine, propoxyphene, doxepin and amitriptyline. The other drugs had relatively low FTIs. The results reflect not only the acute toxicity of a given drug-alcohol combination but also the manners of use and abuse of these drugs.