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Liou H, Gentry MT, Leung JG, Mara KC, Staab JP, Rummans TA. Trends in Stimulant and Sedative/Hypnotic Dispensing: An Exploratory Study. J Atten Disord 2023; 27:1512-1519. [PMID: 37496458 DOI: 10.1177/10870547231187167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To investigate patterns and trends of co-prescriptions of stimulants and sedatives within the last 6 years at a tertiary care center. METHOD Patients 18 years of age and older who were dispensed at least one stimulant prescription from an institutional pharmacy between 1/1/2015 and 7/1/2021 were included. Prescription data for any co-prescribed sedative/hypnotic were collected. RESULTS Both the number of stimulant dispenses and the number of patients with stimulant dispenses increased significantly with yearly incidence rate ratios of 1.115 (95% CI [1.110, 1.119]) and 1.090 (95% CI [1.084, 1.096]), respectively. The number of patients with a stimulant dispensed who also had a benzodiazepine or "Z-drug" sedative-hypnotic dispensed at any point in the search timeframe increased significantly with incidence rate ratios of 1.077 and 1.092, respectively. The number of stimulant dispenses, number of patients with stimulant dispenses, and number of patients with a stimulant dispensed who also had both a benzodiazepine and Z-drug dispensed at any point in the search timeframe increased significantly more in Non-White than in White patients. CONCLUSIONS The results confirm previous findings of increases in dispensing of stimulants over the past 6 years and report increased polypharmacy of stimulants and sedative-hypnotics.
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Affiliation(s)
| | | | | | | | | | - Teresa A Rummans
- Mayo Clinic, Rochester, MN, USA
- Mayo Clinic, Jacksonville, FL, USA
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2
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Abstract
BACKGROUND The benzodiazepine drug alprazolam, a fast-acting tranquiliser, cannot be prescribed on the National Health Service in the United Kingdom. Illicit alprazolam supply and consumption have increased. Concern about increasing numbers of alprazolam-related fatalities started circulating in 2018. However, statistics on this issue are very limited. This study examined patterns in such mortality in Scotland. METHODS Statistics on deaths where alprazolam was mentioned in the 'cause of death' were obtained from official mortality registers. Anonymised Scottish case-level data were obtained. Data were examined in respect of the characteristics of decedents and deaths using descriptive statistics. RESULTS Scotland registered 370 deaths in 2004-2020; 366 of these occurred in 2015-2020: most involved males (77.1%); mean age 39.0 (SD 12.6) years. The principal underlying cause of death was accidental poisoning: opiates/opioids (77.9%); sedatives/hypnotics (15.0%). Two deaths involved alprazolam alone. Main drug groups implicated: opiates/opioids (94.8%), 'other benzodiazepines' (67.2%), gabapentinoids (42.9%), stimulants (30.1%), antidepressants (15.0%). Two-thirds (64.2%) involved combinations of central nervous system (CNS) depressants. DISCUSSION Alprazolam-related deaths are likely due to an increasing illicit supply. The fall in deaths in 2019-2020 is partially due to increased use of designer benzodiazepines. Treatment for alprazolam dependence is growing. Clinicians need to be aware of continuing recreational alprazolam use. When such consumption occurs with CNS depressants, overdose and death risks increase. CONCLUSIONS More awareness of alprazolam contributing to deaths, especially in conjunction with other CNS depressants, is needed by consumers and clinicians. Improved monitoring of illicit supplies could identify emerging issues of medicines' abuse.
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Affiliation(s)
- John Martin Corkery
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,John Martin Corkery, Psychopharmacology,
Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and
Medical Sciences, University of Hertfordshire, Health Research Building, College
Lane Campus, Hertfordshire AL10 9AB, UK.
| | - Amira Guirguis
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,Swansea University Medical School,
Swansea University, Swansea, UK
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK
| | - Giovanni Martinotti
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK,Department of Neuroscience, Imaging and
Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences,
University of Hertfordshire, Hertfordshire, UK
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Giorgetti A, Sommer MJ, Wilde M, Perdekamp MG, Auwärter V. A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues. Forensic Toxicol 2021; 40:180-188. [DOI: 10.1007/s11419-021-00591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose
Designer benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam.
Methods
A complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned.
Results
Flualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2–323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3).
Conclusions
Our results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.
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Sparrow EL, James S, Hussain K, Beers SA, Cragg MS, Bogdanov YD. Activation of GABA(A) receptors inhibits T cell proliferation. PLoS One 2021; 16:e0251632. [PMID: 34014994 PMCID: PMC8136847 DOI: 10.1371/journal.pone.0251632] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/29/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The major sites for fast synaptic inhibition in the central nervous system (CNS) are ion channels activated by γ-aminobutyric acid (GABA). These receptors are referred as GABA(A) receptors (GABA(A)R). Recent evidence indicates a role of GABA(A)R in modulating the immune response. This work aimed to discern the role of GABA and GABA(A)Rs in human and mouse T cell activity. METHODS Mouse splenocytes or human peripheral blood mononuclear cells (PBMCs) were activated with anti-CD3 antibodies and the proliferation of both CD8+ and CD4+ T cells assessed through flow cytometry. Subsequently, the effects on T cell proliferation of either GABA(A)R modulation by diazepam that is also capable of activating mitochondrial based translocator protein (TSPO), alprazolam and allopregnanolone or inhibition by bicucculine methiodide (BMI) and (1,2,5,6-Tetrahydropyridin-4-yl)methylphosphinic acid (TPMPA) were assessed. RESULTS Positive modulation of GABA(A)Rs either by benzodiazepines or the neurosteroid allopregnanolone inhibits both mouse and human T cell proliferation. GABAergic inhibition of T cell proliferation by benzodiazepines could be rescued by GABA(A)R blocking. Our data suggest that benzodiazepines influence T cell proliferation through both TSPO and GABA(A)Rs activation. CONCLUSIONS We conclude that activation of GABA(A)Rs provides immunosuppression by inhibiting T cell proliferation.
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Affiliation(s)
- Emma L. Sparrow
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
| | - Sonya James
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
| | - Khiyam Hussain
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
| | - Stephen A. Beers
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
| | - Mark S. Cragg
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
| | - Yury D. Bogdanov
- Antibody and Vaccine Group, Centre for Cancer Immunology, MP127, University of Southampton Faculty of Medicine, Southampton, Hants, United Kingdom
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Zarkowski PA, Van-Den-Ende AR, Groen JA. Prevalence and socioeconomic factors in the prescription of concurrent amphetamine and alprazolam. Int J Psychiatry Med 2021; 56:116-127. [PMID: 32954921 DOI: 10.1177/0091217420960619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Goals were to determine the prevalence of concurrent prescription of amphetamine and alprazolam, and examine variation by socioeconomic factors. METHODS Washington State's Prescription Monitoring Program was reviewed for calendar years 2013 through 2017. Individuals receiving more than 180 days of amphetamine, alprazolam or both were tabulated for each zip code. Prescription rates were compared between zip codes with variation in rural/urban setting and fraction of low and high income households using a multiple regression. RESULTS One in 3920 individuals in the general population of Washington State were taking a combination of alprazolam and amphetamine. The statewide prevalence of this combination increased 40.2% between 2013 and 2017. The prevalence of the combination in each zip code is significantly positively correlated with the fraction of high income households, p < 0.001, and urban area, p < 0.05. In contrast, the prevalence of amphetamine increased with both the fraction of high income, p < 0.001, and low income households, p < 0.01, with an incremental increase over twice as large with fraction of high income (b = 232 (25)) than low income households (b = 102 (38)). In contrast, alprazolam decreased in prevalence with the fraction of high income households, p < 0.05. CONCLUSIONS The prevalence of concurrent prescription of alprazolam and amphetamine correlates with local socioeconomic factors, including greater household income, instead of the prevalence of FDA indications, including anxiety disorders or ADHD. More clinical studies are required to establish efficacy and guidelines for safe use to mitigate the increased risk of accidents in patients taking concurrent amphetamine and alprazolam.
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Affiliation(s)
- Paul A Zarkowski
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Alex R Van-Den-Ende
- College of Osteopathic Medicine, Pacific Northwest University of Health Sciences, Yakima, WA, USA
| | - Jacob A Groen
- College of Osteopathic Medicine, Pacific Northwest University of Health Sciences, Yakima, WA, USA
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6
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Feola A, Carfora A, Mascolo P, Petrella R, Della Pietra B, Campobasso CP. Alprazolam-associated death: suicide or unintentional overdose? AUST J FORENSIC SCI 2021. [DOI: 10.1080/00450618.2021.1892190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Alessandro Feola
- Department of Experimental Medicine – Institute of Legal Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Anna Carfora
- Department of Experimental Medicine, Forensic Toxicology Unit, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Pasquale Mascolo
- Department of Experimental Medicine – Institute of Legal Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Raffaella Petrella
- Department of Experimental Medicine, Forensic Toxicology Unit, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Bruno Della Pietra
- Department of Experimental Medicine – Institute of Legal Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Carlo Pietro Campobasso
- Department of Experimental Medicine – Institute of Legal Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
- Department of Experimental Medicine, Forensic Toxicology Unit, University of Campania “L. Vanvitelli”, Naples, Italy
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The importance of sample size with regard to the robustness of postmortem reference values. Forensic Sci Int 2020; 311:110292. [PMID: 32330811 DOI: 10.1016/j.forsciint.2020.110292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/22/2022]
Abstract
Evaluating postmortem toxicological results is a challenging task due to multiple factors affecting blood concentrations after death. In order to improve the diagnostic accuracy in cases of suspected fatal intoxication different compilations of postmortem reference drug concentrations are often used. However, it is not clear what constitutes a reliable postmortem reference value. The current study presents reference concentrations for 13 substances from seven substance groups according to a standardized protocol. The reference concentrations were gathered from 3767 autopsy cases and subdivided into intoxications by one substance only (Group A, n=611), multi-substance intoxications (Group B, n=1355) and postmortem controls, in which incapacitation by drugs were excluded (Group C, n=1801). In particular, this study presents statistical information about the precision and conformity change with various sample sizes. Based on the present data >10 detections are usually needed, for the substances examined, to differentiate between intoxication cases and controls. Repeated samplings show that the median of small samples (N=≤5) has a high variation (normalized interquartile range 138-75%) and that a high number of detections (N=>20) in each group are needed to reduce the variation.
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8
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Zarkowski PA. Relative prevalence of 10 types of pharmacodynamic interactions in psychiatric treatment. Int J Psychiatry Med 2020; 55:82-104. [PMID: 31470752 DOI: 10.1177/0091217419870669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the relative prevalence and factors affecting the prescription of medication combinations with a theoretical efficacy limiting pharmacodynamic interaction, defined as two medications with opposing indications and side effects or antagonistic action at the primary receptor of mechanism of action. METHOD One hundred sixteen combinations were identified for 10 types of pharmacodynamic interactions. PubMed was searched for each combination to assess the quality of evidence either supporting clinical use or verifying reduced efficacy. Micromedex was searched to determine the presence of warnings to prescribers of reduced efficacy. The prevalence in clinical practice was determined by computer review of the Genoa Healthcare database for all prescribers at 10 participating community mental health centers. The expected prevalence was calculated as the product of the probability of each medication prescribed alone and was compared with the actual prevalence of the combination using the test of proportions. RESULTS The frequency of prescription of eight combinations met the Bonferroni corrected level of significance of p < 0.001. Four were combinations of amphetamine and D2 antagonists and each were prescribed less often than chance, p = 0.0001 consistent with epidemiological studies and multiple animal studies verifying an efficacy limiting interaction. Despite epidemiological studies indicating increased risk of accidents, alprazolam and amphetamine were prescribed more often than chance, p = 0.0001. Micromedex generated warnings for efficacy limiting interactions for five other combinations, but with no subsequent change in prescription frequency. CONCLUSIONS Neither presence of medical evidence nor warnings from Micromedex consistently affect the prescription of combinations with pharmacodynamic efficacy limiting interactions.
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Affiliation(s)
- Paul A Zarkowski
- Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington, Seattle, WA, USA
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9
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Yamamoto K, Fukushima S, Mishima Y, Hashimoto M, Yamakawa K, Fujioka K, Iijima K, Yano I. Pharmacokinetic assessment of alprazolam-induced neonatal abstinence syndrome using physiologically based pharmacokinetic model. Drug Metab Pharmacokinet 2019; 34:400-402. [PMID: 31699653 DOI: 10.1016/j.dmpk.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 11/26/2022]
Abstract
Sustained benzodiazepine use during pregnancy can induce neonatal abstinence syndrome (NAS). In this study, the association between NAS and plasma alprazolam concentration was examined using the measured neonatal concentrations in the time series as well as simulated plasma concentrations of pregnant woman and neonate by physiologically based pharmacokinetic (PBPK) modeling. A neonate born to a mother taking alprazolam daily throughout pregnancy exhibited symptoms such as apnea and vomiting from 9 h to 4 days after birth. Finnegan score was 7 at birth and decreased to 0 by day 4. Apnea improved by 24 h post-delivery and gastrointestinal symptoms disappeared by day 4. The plasma alprazolam concentration in the neonate was 15.2 ng/mL immediately after birth and gradually decreased over 3 days. Measured neonate and estimated maternal plasma alprazolam concentrations were within the 90% prediction intervals of each concentration by PBPK simulation using "pregnancy" and "pediatrics" population parameters including in Simcyp population-based ADME simulator. In conclusion, NAS symptoms such as apnea and digestive events disappeared in parallel with the decrease of the neonate's plasma alprazolam concentrations. Moreover, PBPK modeling and simulation is a useful methodology for toxicological assessment in special characteristics populations lacking specific experimental data.
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Affiliation(s)
| | - Sachiyo Fukushima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yui Mishima
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Mari Hashimoto
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Kei Yamakawa
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Kazumichi Fujioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ikuko Yano
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
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Huang Z, Xu Z, Wang H, Zhao ZQ, Rao Y. Influence of ethanol on the metabolism of alprazolam. Expert Opin Drug Metab Toxicol 2018; 14:551-559. [DOI: 10.1080/17425255.2018.1483338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Zhibin Huang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Zhiru Xu
- State Key Lab. of New Drug and Pharmaceutical Process, Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Shanghai, China
| | - Hao Wang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - ZQ Zhao
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Yulan Rao
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China
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11
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Jouanjus E, Guernec G, Lapeyre-Mestre M. Medical prescriptions falsified by the patients: a 12-year national monitoring to assess prescription drug diversion. Fundam Clin Pharmacol 2018; 32:306-322. [PMID: 29436015 DOI: 10.1111/fcp.12356] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/23/2018] [Accepted: 02/07/2018] [Indexed: 01/29/2023]
Abstract
Diversion of prescription drugs is difficult to assess in quality and quantity. This study aimed to characterize diversion of prescription drugs in France through a comparative analysis of falsified prescriptions collected during three periods from 2001 to 2012. The data recorded in a national program which records all falsified prescriptions presented to community pharmacies were studied. Included data regarded: subjects, prescription forms, and drugs. Description of the dataset in three periods (2001-2004, 2005-2008, and 2009-2012) was completed with clustering analyses to characterize profiles of prescriptions and subjects associated with the most reported drugs. The 4469 falsified prescriptions concerned most often females (51.6%). Average age was 46.5 years. Zolpidem, bromazepam, and buprenorphine were the most frequent drugs. Alone, 13 drugs (1.7%, 13/772) represented more than 40% of the total reports (3055/7272). They were associated with three diversion profiles: (i) buprenorphine, flunitrazepam, and morphine were mentioned on overlapping secure prescription forms presented by young men; (ii) alprazolam, bromazepam, zolpidem, codeine/acetaminophen were mentioned on simple prescription forms presented by experienced women; and (iii) acetaminophen and lorazepam were mentioned on modified prescription forms presented by elderly subjects. Clonazepam, clorazepate, dextropropoxyphene, zopiclone moved between those profiles. The patterns of falsified prescriptions provided in this study contribute to enhance the scientific knowledge on the most diverted prescription drugs. The latter follow distinct trajectories across time depending on their pharmacology (including their abuse/addiction potential) and on their regulation's history. The close and continuous analysis of falsified prescriptions is an excellent way to monitor prescription drug diversion.
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Affiliation(s)
- Emilie Jouanjus
- Pharmacoepidemiology Research Unit, INSERM 1027, University of Toulouse, 37, Allées Jules Guesde, 31000, Toulouse, France.,Department of Medical and Clinical Pharmacology, Addictovigilance Center, Toulouse University Hospital, 37, Allées Jules Guesde, 31000, Toulouse, France
| | - Grégory Guernec
- INSERM, UMR 1027, 37, Allées Jules Guesde, 31000, Toulouse, France.,UMR1027, University of Toulouse III, 31000, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Pharmacoepidemiology Research Unit, INSERM 1027, University of Toulouse, 37, Allées Jules Guesde, 31000, Toulouse, France.,Department of Medical and Clinical Pharmacology, Addictovigilance Center, Toulouse University Hospital, 37, Allées Jules Guesde, 31000, Toulouse, France
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12
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Jones AW. Postmortem toxicology findings from medicolegal investigations of drug-related deaths among the rich and famous. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Post-mortem concentrations of drugs determined in femoral blood in single-drug fatalities compared with multi-drug poisoning deaths. Forensic Sci Int 2016; 267:96-103. [DOI: 10.1016/j.forsciint.2016.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/26/2016] [Accepted: 08/05/2016] [Indexed: 11/17/2022]
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14
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Skov L, Holm KMD, Johansen SS, Linnet K. Postmortem Brain and Blood Reference Concentrations of Alprazolam, Bromazepam, Chlordiazepoxide, Diazepam, and their Metabolites and a Review of the Literature. J Anal Toxicol 2016; 40:529-36. [DOI: 10.1093/jat/bkw059] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/24/2016] [Indexed: 12/20/2022] Open
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Circumstances and toxicology of sudden or unnatural deaths involving alprazolam. Drug Alcohol Depend 2014; 138:61-6. [PMID: 24629629 DOI: 10.1016/j.drugalcdep.2014.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/27/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND There has been a great deal of clinical concern regarding alprazolam abuse. This paper reported on alprazolam positive cases of sudden or unnatural deaths presenting to the New South Wales Department of Forensic Medicine (DOFM), 1/1/1997-31/12/2012. METHODS Case series. RESULTS 412 cases were identified. There was a large increase in the annual number of cases, from 3 in 1997 to 86 in 2012. By 2012, 4.5% of all DOFM case presentations involved alprazolam. The mean age was 41.3 years, and 66.5% were male. Circumstances of death were: accidental drug toxicity (57.0%), deliberate drug toxicity (10.4%), suicide by means other than drug overdose (12.6%), disease (10.0%), accident (5.1%), homicide (2.4%). The major factor driving the increase in cases was accidental drug toxicity involving alprazolam, rising from 0 in 1997 to 58 in 2012. A history of drug/alcohol problems was noted in 80.4%, and 56.6% were injecting drug users. The median alprazolam concentration was 0.08 mg/L (range 0.005-2.10mg/L), with 37.4% of cases having concentrations of ≥ 0.1 mg/L. In 94.9% of cases, drugs other than alprazolam and its metabolites were present, including all accidental overdoses. The most commonly detected drugs were opioids (64.6%), other benzodiazepines (44.4%) and alcohol (34.5%). A third (31.8%) of cases were HCV positive. CONCLUSIONS Cases involving alprazolam increased markedly, driven mostly by toxicity deaths amongst people with known drug and alcohol problems. Caution in prescribing alprazolam would appear appropriate, particularly to those with known drug dependence.
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