Diversity in causes and characteristics of drug-induced deaths in an urban setting

Mortality risk and causes of death among people who use opioids in a take-home naloxone cohort

BACKGROUND

People who use opioids (PWUO) have an excess mortality from a range of causes. The cumulative effect of behavioral, social, and health risk factors complicates the interpretation of the effects of suitable interventions. This study explores mortality causes among a cohort of PWUO in the take-home naloxone (THN) program.

METHODS

This was a prospective cohort study of PWUO who received THN between 2015 and 2023. Participant data was linked with death registry data. Crude mortality rates and standardized mortality ratios (SMRs) were calculated for all causes, internal causes, and accidental opioid overdoses (AOOs). In addition to age and gender, risk factors like main route of administration, polydrug use, self-experienced overdoses, and using while alone were fitted in a Cox Regression model to explore factors associated with mortality.

RESULTS

The 2194 participants had a considerably higher mortality ratio for all causes investigated when compared to the general population (SMR=10.9, 95 % CI = 9.3,12.6). AOOs were the most prevalent cause of death (49 %). Those who reported frequent opioid use while alone had an elevated risk of dying of 2.6 (95 % CI = 1.1,6.4) compared to those who never used while alone.

CONCLUSIONS

Frequent opioid use while alone was associated with elevated mortality risk, supporting the importance of overdose prevention education with naloxone distribution, and additional efforts to improve environmental and social areas for safer drug-use practices among PWUO. The variety of mortality causes found in this study illustrates the need for multifaceted and targeted interventions for people at risk of overdosing.

Investigating the associations of age of initiation and other psychosocial factors of singular alcohol, tobacco and marijuana usage on polysubstance use: analysis of a population-based survey in Jamaica

OBJECTIVES

This study aimed to examine concurrent polysubstance use of alcohol, tobacco and marijuana and determine correlations with access to marijuana, friend and familial drug use habits, risk perception and the age of initiation associated with the singular use of these substances.

DESIGN

A secondary data analysis.

SETTING

Used the Jamaica National Drug Prevalence Survey 2016 dataset.

PARTICIPANTS

Involved the entire dataset comprising 4623 randomly selected respondents between 12 and 65 years old.

OUTCOME MEASURES

Primary outcome: concurrent polysubstance use recorded as using two or more of alcohol, tobacco and marijuana. Predictor variables include risk perception and age of initiation of singular alcohol, tobacco and marijuana use, ease of marijuana access and family and friend alcohol and illegal drug use.

RESULTS

Approximately 58%-66% of respondents commenced singular alcohol, tobacco or marijuana use under 17. Participants commencing marijuana use at 11 years and under and between 12 and 17 were 3.346 and 4.560 times more likely to report past month concurrent polysubstance use (p=0.030 and p<0.001). Respondents who did not believe that smoking tobacco sometimes (p=0.049), and smoking marijuana sometimes and often was harmful, had increased odds of concurrent polysubstance use (p=0.047 and p<0.001, respectively). Respondents who indicated access to marijuana as easy were significantly more likely to report past month concurrent polysubstance use compared with those who reported access as difficult (p=0.002). Participants who indicated that friends or family members get drunk and take illegal drugs were associated with 1.722 and 1.864 increased odds of reporting past month concurrent polysubstance use (p=0.004 and p=0.017, respectively).

CONCLUSIONS

Decreased perceived risk, childhood and adolescent age of initiation and easy access to marijuana were significantly associated with polysubstance use among Jamaicans. The influence of friends and family members' drug and alcohol use behaviours on individuals developing polysubstance use habits further endorses the need for interventions.

Exploring dog ownership in the lives of people with substance use disorder: a qualitative study

BACKGROUND

Recovery from substance use is commonly seen as a process of integrating social relationships and creating a sense of meaning in one's life. Dog owners describe a close relationship with their dog that impacts many aspects of their everyday life. Yet for individuals with substance use disorder (SUD), little is known about how dog ownership could affect their lives. The aim of this study was to explore how people living with SUD experience and describe their everyday life when owning a dog.

METHOD

Eight semi-structured in-depth individual interviews were conducted with people having personal experience of living with SUD and owning a dog. Data were gathered and analysed using qualitative content analysis.

RESULTS

The analysis yielded four categories, reflecting different aspects of dog ownership. Living with SUD and owning a dog was primarily something positive in their life. People increased their social connections personally and within society. They felt a belonging which gave a sense of agency and purpose, and they developed structure in their day and boundaries to their environment. Dog ownership, however, could hinder access to services which was found to be challenging for some participants.

CONCLUSIONS

The owning of a dog can lead to changes that parallel those of a recovery process. This finding adds to the research on the connection that dogs can provide and shows how pertinent this can be particularly for vulnerable persons such as those with SUD.

Record linkage studies of drug-related deaths among adults who were released from prison to the community: a scoping review

BACKGROUND

There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners.

METHODS

MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA.

RESULTS

A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74-27.66; I 2 = 83.83%) for the first 3-4 weeks (3 studies) and 15.58 (95%CI 7.05-34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13-11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique.

CONCLUSIONS

This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.

Increases in drug overdose deaths in Norway and the United States during the COVID-19 pandemic

INTRODUCTION

Little international comparative work exists describing pandemic-related spikes in overdose and related implications for drug and public health policy. We compared increases in overdose deaths during the pandemic in Norway and the United States, two countries in the top 10 for per-capita overdose mortality, yet with very different approaches to the pandemic, healthcare and drug policy.

METHODS

We examined monthly overdoses in 2020 versus baseline rates (the monthly average across 2017-2019). We compared excess overdose mortality to shifts in human mobility and social interaction, measured using cellphone-based mobility data, an indicator of the societal response to the pandemic.

RESULTS

Both the US and Norway saw large magnitude exacerbations in overdose mortality during the pandemic-related lockdowns, reaching 46.8% and 57.0% above baseline, respectively. Maximum increases occurred 2-3 months after peak reductions in mobility, suggesting lagged mechanisms. While overdose mortality returned to baseline relatively quickly in Norway, rates remained elevated in the US to the end of 2020.

CONCLUSIONS

Spikes in overdose mortality in both contexts may relate to disruptions in healthcare access and the drug supply becoming more potent. Norway's quicker return to baseline may reflect more robust access to harm reduction and addiction-related healthcare services. Nevertheless, it is notable that even in Norway - with universal access to high-quality services, low COVID-19 rates, and a highly effective public health infrastructure - a greater than 50% spike in overdose deaths was still seen at the onset of lockdown measures. This may have important implications for future pandemic and disaster planning.

Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program

BACKGROUND

In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use.

METHODS

This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included.

RESULTS

In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%).

CONCLUSION

People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

Poisoning with central stimulant drugs: an observational study from Oslo, Norway

Background

The use of central stimulant drugs causes significant morbidity. We describe poisonings with central stimulant drugs and compare the different central stimulants concerning combinations with other drugs, treatment, and clinical course. 

Methods

Patients presenting from 1 October 2013 to 31 March 2016 with poisoning related to the recreational use of central stimulant drugs were retrospectively included at a primary care emergency outpatient clinic and at a hospital emergency department in Oslo, Norway. Diagnosis of toxic agents was mainly based on the clinical assessment of the doctor treating the patient. Amphetamine and methamphetamine were co-categorized as amphetamine.

Results

Among the 1131 cases of acute poisoning with central stimulant drugs at the outpatient clinic, amphetamine was involved in 808 (71.4%), cocaine in 252 (22.3%) methylenedioxymethamphetamine (MDMA) in 104 (9.2%), and methylphenidate in 13 (1.1%). Among the 211 cases at the hospital, amphetamine was involved in 167 (79.1%), cocaine in 60 (28.4%), and MDMA in 38 (18.0%). Amphetamine was frequently combined with opioids (40.1% at the outpatient clinic and 41.9% at the hospital) and benzodiazepines (28.3% and 45.5%), while MDMA often was combined with ethanol (64.4% and 71.1%), as was cocaine (62.7% and 61.7%). Sedation was given in 5.2% and 38.4% of cases, naloxone in 9.4% and 37.0%, and flumazenil in 0.1% and 28.0%. In total, 16.5% of the cases at the outpatient clinic were transferred to a hospital for medical review and 8.5% to a psychiatric hospital. Among the hospital patients, 92.9% were admitted to intensive care.

Conclusion

Amphetamine was the most common central stimulant drug involved in acute poisoning in Oslo, often combined with opioids and benzodiazepines.

Increasing trend in accidental pharmaceutical opioid overdose deaths and diverging overdose death correlates following the opioid prescription policy liberalization in Norway 2010-2018

BACKGROUND

During the last decade, opioid prescription policies in Norway have been liberalised and pharmaceutical opioid (PO) dispensing has increased. Against this backdrop, we examined the trends in and the correlates of accidental overdose deaths attributable to PO in the period 2010-2018 in comparison with traditional heroin overdose deaths.

METHODS

Accidental overdose deaths attributable to PO or heroin were identified through the Norwegian Cause of Death Registry (n = 1267) and cross-linked with population and patient registries. Overdose death correlates were examined using multivariable logistic regression.

FINDINGS

The trend in accidental overdose deaths attributable to PO increased significantly from 2010 to 2018. Females, people aged 50 years or older, disability pension recipients and/or those with the highest net wealth had a greater risk of a PO vs. heroin overdose death, while those dying in public spaces, living in urban areas, having recent specialized drug treatment encounters, and/or criminal charge(s) had a lower risk. Among those with primary health care encounters, those with back problems and accidents and injuries had a greater risk of a PO vs. heroin overdose death, while those with a substance use disorder had a lower risk.

CONCLUSION

The increase in accidental overdose deaths attributable to PO coincides with the period of opioid prescription policy liberalization and an increase in PO consumption in Norway. The PO and heroin overdose deaths differed in terms of the associated sociodemographic characteristics, primary and secondary health care encounters, diagnoses, and criminal charges, indicating a need for additional interventions aimed at preventing PO overdose deaths specifically.

Increasing drug-related mortality rates over the last decade in Scotland are not just due to an ageing cohort: A retrospective longitudinal cohort study

BACKGROUND

In Europe, North America, and Australia, mortality due to drug-related (DR) causes amongst people who inject drugs (PWID) is a major issue. Our objective was to characterise temporal trends in DR mortality rates in a large cohort of PWID in Scotland over the past decade, all of whom had been diagnosed with hepatitis C virus (HCV) infection, and to investigate factors associated with DR mortality.

METHODS

Retrospective longitudinal cohort study linking Scotland's national HCV Diagnosis Database and deaths registry. The study cohort consisted of all individuals with likely injection drug use-related route of HCV acquisition, who had been diagnosed with HCV between 1991 and 2018, and were alive and aged under 65 years on 1 January 2009. We used Lexis expansion to adjust for ageing cohort effects and calculated the mortality rate from an underlying/contributing DR cause over the period 2009-2018. We fitted Poisson regression models to estimate the temporal trend adjusting for attained age, sex, referral setting, region, and viraemic status at baseline.

RESULTS

Amongst the study population (n = 35,065; 236,914 person-years), a total of 1900 DR deaths occurred; the DR mortality rate increased from 5.6/1000 [101 deaths] in 2009 to 12.4/1000 [342] person-years in 2018. Increasing trends were observed for all age-groups except 55-64 years. The overall DR mortality rate was highest for referrals for HCV testing from prison (11.0/1000) and hospital settings (10.0/1000). Mortality increased with calendar time period, with significantly raised adjusted rate ratios (RRs) from 2015 (RR=1.40, 95% CI:1.16-1.69) to 2018 (RR=2.23, 95% CI:1.88-2.64), compared with 2011-2012, for older age (35-44: RR=1.37, 95% CI:1.20-1.56; 45-54: RR=1.32, CI:1.14-1.53) compared with <35 years, for persons diagnosed with HCV since 2009 (RR=1.34, 95% CI:1.21-1.49), and for prison and hospital referrals (RRs of 1.30, 1.37) compared with GP referrals.

CONCLUSION

Increasing DR mortality rates in Scotland over the past decade are not just due to an ageing cohort. Harm reduction services will likely need to expand and adapt to reverse the recent upward trends in DR mortality in PWID.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis

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.

One Is Not Enough: Understanding and Modeling Polysubstance Use

Substance use disorder (SUD) is a chronic, relapsing disease with a highly multifaceted pathology that includes (but is not limited to) sensitivity to drug-associated cues, negative affect, and motivation to maintain drug consumption. SUDs are highly prevalent, with 35 million people meeting criteria for SUD. While drug use and addiction are highly studied, most investigations of SUDs examine drug use in isolation, rather than in the more prevalent context of comorbid substance histories. Indeed, 11.3% of individuals diagnosed with a SUD have concurrent alcohol and illicit drug use disorders. Furthermore, having a SUD with one substance increases susceptibility to developing dependence on additional substances. For example, the increased risk of developing heroin dependence is twofold for alcohol misusers, threefold for cannabis users, 15-fold for cocaine users, and 40-fold for prescription misusers. Given the prevalence and risk associated with polysubstance use and current public health crises, examining these disorders through the lens of co-use is essential for translatability and improved treatment efficacy. The escalating economic and social costs and continued rise in drug use has spurred interest in developing preclinical models that effectively model this phenomenon. Here, we review the current state of the field in understanding the behavioral and neural circuitry in the context of co-use with common pairings of alcohol, nicotine, cannabis, and other addictive substances. Moreover, we outline key considerations when developing polysubstance models, including challenges to developing preclinical models to provide insights and improve treatment outcomes.

Opportunities for Emergency Medical Services Intervention to Prevent Opioid Overdose Mortality

OBJECTIVES

The opioid crisis is a growing cause of mortality in the United States and may be mitigated by innovative approaches to identifying individuals at-risk of fatal opioid overdose. We examined Emergency Medical Services (EMS) utilization among a cohort of individuals who died from opioid overdose in order to identify potential opportunities for intervention. Methods: Individuals who died of unintentional opioid overdose in a large North Carolina county between 01/01/2014 and 12/31/2016 were studied in a retrospective cohort. Death records obtained from North Carolina Vital Records were linked to EMS patient care records obtained from the county EMS System in order to describe the EMS encounters of each decedent in the year preceding their death. Patient demographics and EMS encounters were assessed to identify encounter characteristics that may be targeted for intervention. Chi-square tests and odds ratios were used to evaluate and characterize the statistical significance of differences in EMS utilization. Results: Of the 218 individuals who died from unintentional opioid overdose in the study interval, 30% (n = 66) utilized EMS in the year before their death and 17% (n = 38) had at least one EMS encounter with documented drug or alcohol use (i.e. "drug-related encounter"). The mean age at death was 38 (range 19-74) years, 30% were female, 89% were White, and 8% were Black/African American. Factors associated with higher incidence of EMS utilization included age (P<.001), gender (P=.006), and race (P<.001). Decedents aged 56-65 had the highest EMS utilization (47%) and patients aged <25 and 25-35 had more drug-related EMS encounters (29% and 20%, respectively). The most common reasons for EMS utilization were "other medical" (27%), "non-traumatic pain" (20%), "traumatic injury" (16%), and "poisoning/drug ingestion" (14%). Drug or alcohol use was documented by EMS in 33% of all encounters and an opioid prescription was reported in 22% of encounters. Conclusions: Nearly one-third of individuals who died from accidental opioid overdose utilized EMS in the year before their death and nearly one-fifth had a drug-related encounter. EMS encounters may present an opportunity to identify individuals at-risk of opioid overdose and, ultimately, reduce overdose mortality.

Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances

BACKGROUND

Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths.

METHODS

The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson's chi-square test, Fisher's exact test and the Mann-Whitney U test to analyse group differences.

RESULTS

A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death.

CONCLUSIONS

The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.

Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances

Background

Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths.

Methods

The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson’s chi-square test, Fisher’s exact test and the Mann-Whitney U test to analyse group differences.

Results

A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death.

Conclusions

The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.

Mortality and causes of death among people suspected of driving under the influence and testing positive for multiple substances

Aims: Understanding the mortality of drug users using multiple substances is helpful in preventing the harmful effects of polydrug use. We examined overall and cause-specific mortality and differences in mortality based on social background among people suspected of driving under the influence and testing positive for multiple substances (DUIMS) compared with the general Finnish population. Methods: Register data from 785 DUIMS during 2003-2006 were studied, with a reference population (n = 25,381) drawn from the general Finnish population. The effect of DUIMS on all-cause and cause-specific mortality was estimated using a Poisson regression model. Results: DUIMS had an increased risk of death compared with the general population (MRR 5.3, 95% CI 4.2-6.6). The most common causes of death in DUIMS were poisonings (37.9%) and suicides (13.6%), whereas in the reference population these were cardiovascular diseases (30.8%) and cancer (26.6%). The cause-specific risk of death among DUIMS was higher in all observed causes of death, except for cancer. The effect of DUIMS on mortality was modified by age, employment status and marital status; DUIMS was associated with an elevated risk of death especially in younger age groups and in singles. Conclusions: DUIMS indicates higher mortality, and DUIMS' profiles in causes of death differ from the general population. Elevated risk for, for instance, suicidal, accidental and violent death among those using multiple substances highlights the need to also pay attention to causes of death other than poisoning/overdose.

Overdose mortality rates in Croatia and factors associated with self-reported drug overdose among persons who inject drugs in three Croatian cities

BACKGROUND

Drug overdose is the major cause of morbidity and mortality among persons who inject drugs (PWID). We assessed factors associated with the non-fatal drug overdose among PWID in three Croatian cities and national trends of overdose-related mortality (OM), and rates of uptake of opioid agonist drug treatment (OAT).

METHODS

We used a respondent-driven sampling method to recruit 830 PWID in Zagreb, Split and Rijeka in 2014/2015. Participants completed behavioural questionnaires that included questions about overdose history, and we used Poisson regression to assess factors associated with self-reported overdose. We used joinpoint regression to calculate national trends of OM from 2001 to 2015 and rates of uptake of drug treatment from 2005 to 2015.

RESULTS

Lifetime prevalence of self-reported drug overdose in our RDS sample was 45.2%, while 4.1% of PWID reported overdose in the past 12 months; PWID who injected more than one type of drug in the past 12 months (adjusted prevalence ratio [aPR] = 4.56, 95% confidence intervals [CI] = 1.35-15.38) compared to injecting only heroin, and those enrolled in OAT (aPR = 1.94, 95% CI = 1.01-3.74) were more likely to report overdose in the past 12 months. We observed an increase in annual percent change (APC) of the national OM rates from 2001 to 2007 (APC = 22.5%, 95% CI = 16.3-29.0) and a decline from 2007 to 2015 (APC = -8.0%, 95% CI = -5.3- -10.5). The national rates of drug treatment enrollment increased from 2005 to 2010 (APC = 12.0%, 95% CI = 10.3-13.8), mostly due to increase in provision of buprenorphine from 2005 to 2008 (APC = 130.4%, 95% CI = 102.1-162.7).

CONCLUSION

Injecting more than one type of drugs and enrollment in OAT while still injecting drugs was positively associated with non-fatal overdose in our sample. To further reduce OM in Croatia we suggest improvements in coverage and delivery of OAT and establishment of provision of naloxone for PWID.

Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health

Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.

Naloxone distribution and possession following a large-scale naloxone programme

AIMS

To examine uptake following a large-scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high-risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators.

DESIGN

(1) Distribution data (June 2014-August 2017) and date of implementation for each city and (2) a cross-sectional study among a sample of illicit substance users interviewed September 2017.

SETTING

Seven Norwegian cities.

PARTICIPANTS

A total of 497 recruited users of illegal opioids and/or central stimulants.

MEASUREMENTS

Primary outcomes: naloxone possession and use. Random-intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration).

FINDINGS

Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high-risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82-2.37], female gender (aOR = 1.97, 95% CI = 1.20-3.24) and drug-dealing (aOR = 2.36, 95% CI = 1.42-3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15-1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02-4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13-3.78), drug-dealing (aOR = 2.40, 95% CI = 1.27-4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04-4.38).

CONCLUSIONS

A large-scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high-risk individuals, with programme duration in each city as an important indicator for naloxone possession and use.

Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility

Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.

High risk of overdose death following release from prison: variations in mortality during a 15-year observation period

BACKGROUND AND AIMS

The time post-release from prison involves elevated mortality, especially overdose deaths. Variations in overdose mortality both by time since release from prison and time of release has not been investigated sufficiently. Our aims were to estimate and compare overdose death rates at time intervals after prison release and to estimate the effect on overdose death rates over calendar time.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

This 15-year cohort study includes all individuals (n = 91 090) released from prison (1 January 2000 to 31 December 2014) obtained from the Norwegian prison registry, linked to the Norwegian Cause of Death Registry (2000-14). All-cause and cause-specific mortality were examined during different time-periods following release: first week, second week, 3-4 weeks and 2-6 months, and by three different time intervals of release. We calculated crude mortality rates (CMRs) per 1000 person-years and estimated incidence rate ratios (IRR) by Poisson regression analysis adjusting for time intervals after prison release, release periods and time spent in prison.

FINDINGS

Overdose deaths accounted for 85% (n = 123) of all deaths during the first week following release (n = 145), with a peak during the 2 days immediately following release. Compared with week 1, the risk of overdose death was more than halved during week 2 [IRR = 0.43; 95% confidence interval (CI) = 0.31-0.59] and reduced to one-fifth in weeks 3-4 (IRR = 0.22; 95% CI = 0.16-0.31). The risk of overdose mortality during the first 6 months post-release was almost twofold higher in 2000-04 compared with 2005-09 (IRR = 0.53; 95% CI = 0.43-0.65) and 2010-14 (IRR = 0.47; 95% CI = 0.37-0.59). The risk of overdose death was highest for those incarcerated for 3-12 months compared with those who were incarcerated for shorter or longer periods, and recidivism was associated with risk of overdose death.

CONCLUSIONS

There is an elevated risk of death from drug overdose among individuals released from Norwegian prisons, peaking in the first week. The risk has reduced since 2000-04, but is greatest for those serving 3-12 months compared with shorter or longer periods.

Circumstances surrounding non-fatal opioid overdoses attended by ambulance services

INTRODUCTION AND AIMS

Opioid overdose fatalities are a significant concern globally. Non-fatal overdoses have been described as a strong predictor for future overdoses, and are often attended by the ambulance services. This paper explores characteristics associated with non-fatal overdoses and aims to identify possible trends among these events in an urban area in Norway.

DESIGN AND METHODS

This is a retrospective analysis of non-fatal overdoses from Bergen ambulance services from 2012 to 2013. Demographic, temporal and geographic data were explored.

RESULTS

During the two years, 463 non-fatal opioid overdoses were attended by ambulance services. Ambulance call-outs occurred primarily during the late afternoon and evening hours of weekdays. Summer months had more overdoses than other seasons, with a peak in August. Overdoses were nearly twice as likely to occur in a public location in August (risk ratio 1.92, P = 0.042). Ambulance response times were more likely to be longer to private locations, and these victims were more likely to be treated and left at the scene. There was no difference in arrival time for drug-related and non-drug related dispatch.

DISCUSSION AND CONCLUSIONS

The temporal patterns suggest that non-fatal overdoses occur during non-recreational time periods. The longer ambulance response time and disposition for private addresses indicate potential opportunities for peer interventions. Our analysis describes circumstances surrounding non-fatal overdoses and can be useful in guiding relevant, targeted prevention interventions. [Madah-Amiri D, Clausen T, Myrmel L, Brattebø G, Lobmaier P. Circumstances surrounding non-fatal opioid overdoses attended by ambulance services. Drug Alcohol Rev 2017;36:288-294].

Rapid widespread distribution of intranasal naloxone for overdose prevention

BACKGROUND

Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention.

METHODS

From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored.

RESULTS

There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths.

CONCLUSION

A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

Rusmisbruk, angst og depresjon etter 10 år: En prospektiv undersøkelse av stoffmisbrukere med og uten LAR-behandling

Substance abuse, anxiety and depression after 10 years: A prospective study of drug users in and outside OMT treatment

Aims

The national Opiate Maintenance Treatment (OMT) program in Norway started officially in 1998. The same year a treatment study was initiated, including the most used treatment measures for drug users in Norway. The main aim in the present study was to investigate the prevalence of live OMT patients in the total sample after 10 years, and to compare the outcome of primarily substance abuse, anxiety and depression among OMT patients versus non-OMT patients.

Design & Methods

Four hundred and seven patients, in Oslo and the nearby regions, who started in 16 different in- and outpatients programs, were followed from intake to treatment and during ten years (1998-2009). Patients in the sample were interviewed after one, two, seven and ten years, and they were divided into three different treatment groups: inpatient residency for grown-ups, outpatient psychiatric youth teams and youths living in collectives. Data was collected through use of EuropASI and HSCL-25 at all follow-ups.

Results

After ten years 15 % were deceased. Of the 333 persons left, 73 % (n=248) were interviewed after ten years. Forty percent (n=99) were then in OMT. After ten years there were no gender differences regarding attendance to OMT, but the OMT-group was older (30 vs .28 yrs, p<0.05), and they used more benzodiazepines (p<0.000) and cannabis (p<0.01) than the others. The OMT-group reported to a larger extent more anxiety and depression throughout the total observation period than the non OMT participants. Use of heroin and criminality were significantly reduced in both groups.

Conclusions

In spite of reduced use of heroin, the OMT patients seemed to have more difficulties in reducing the use of benzodiazepines and cannabis, whereas the anxiety and depression scores were high and stable through the total observation time.

Patients presenting with acute poisoning to an outpatient emergency clinic: a one-year observational study in Oslo, Norway

BACKGROUND

In Oslo, the majority of patients with acute poisoning are treated in primary care, at an emergency outpatient clinic with limited diagnostic and treatment resources. We describe the poisonings currently seen in this setting. We compare our findings with previous studies, with special concern for the appearance of new toxic agents, and changes in overall numbers and patterns of poisoning.

METHODS

Observational study. Patients above the age of 12 years presenting at Oslo Accident and Emergency Outpatient Clinic (Oslo Legevakt) with acute poisoning were included consecutively from October 2011 through September 2012. Physicians and nurses registered data on preset forms. Main outcome measures were toxic agents, age, sex, intention, referral and time of presentation.

RESULTS

There were 2923 episodes of acute poisoning in 2261 patients. Median age of the patients was 32 years, and 1430 (63%) were males. The most frequent toxic agents were ethanol in 1684 (58%) episodes, heroin in 542 (19 %), benzodiazepines in 521 (18%), amphetamine in 275 (9%), fire smoke in 192 (7%), gamma-hydroxybutyrate (GHB) in 144 (5%), and cannabis in 143 (5%). In 904 (31%) poisonings there were more than one toxic agent. In 493 episodes (17%), the patient was hospitalised, and in 60 episodes (2%) admitted to a psychiatric ward. Most poisonings, 2328 (80%), were accidental overdoses with substances of abuse, 276 (9%) were suicide attempts, and 312 (11%) were accidents. Among ethanol poisonings in patients above the age of 26 years, 685/934 (73%) were in males, and 339/934 (36%) presented during weekends. However, among ethanol poisonings in patients under the age of 26 years, 221/451 (49 ) were in females, and 297/451 (66%) presented during weekends.

CONCLUSIONS

The poisonings treated in this primary care setting were mostly due to accidental overdoses with ethanol or other substances of abuse. There is a disconcerting weekend drinking pattern among adolescents and young adults, with young females presenting as often as young males with ethanol poisoning.

Need and utility of a polyethylene glycol marker to ensure against urine falsification among heroin users

BACKGROUND

Deceptive methods of falsifying urine samples are of concern for anyone who relies on accurate urine toxicology results. A novel method to combat these efforts utilizes polyethylene glycol (PEG) markers administered orally prior to providing a urine sample. By using various PEG combinations to create a tracer capsule of unique composition, each urine sample can be matched to that individual. The goal of this study was to determine the effectiveness of using the PEG marker system among active heroin users screening for research studies.

METHODS

Upon each screening visit, participants (N=55) were randomized to provide an unobserved urine sample, or the PEG tracer procedure was used. LCMS analysis was used to distinguish the PEG combinations, and allowed us to provide a unique qualitative analysis of patterns of drug use (N=168, total urine specimens).

RESULTS

The unique composition of the tracer capsules was accurately detected in 83.5% of the urine specimens. Analyses of inconsistencies implicated a number of possible attempts at fraudulence (11.4%) and investigator/lab error (5.1%). Among this sample, the concurrent use of multiple classes of psychoactive drugs was more common than not, though concomitant drug use was often underreported.

CONCLUSION

Urine drug testing should be the minimum standard for obtaining information about drug use as self-report was unreliable even in a situation where there were no perceived adverse consequences for full disclosure. In cases where there are significant pressures for individuals to falsify these data, more protective collection methods such as the PEG marker system should be considered.

Drug-related causes of death: Socioeconomic and demographic characteristics of the deceased

AIM

The aim of this study was to describe subgroups of those who died from a drug-related cause of death employing demographic and socioeconomic data.

METHODS

A total of 1,628 persons with registered drug-related deaths in the Norwegian Cause of Death Registry between 2003 and 2009 were matched with research registers of data on demographic and socioeconomic factors during the five years prior to their deaths.

RESULTS

Three equal-sized clusters were identified: persons with very low socioeconomic status, disability pensioners and people on the edge of the workforce.

CONCLUSIONS

Socioeconomic situation prior to drug-related deaths was more heterogeneous than expected. Greater knowledge about the members of the disability pensioner and the edge of the workforce clusters must be established in order to make prevention efforts towards these groups more precise and goal oriented.

The message of the heroin overdoses

Drug use can be defined as a kind of self destruction, and it is directly linked to attitudes toward death and suicide occurring in a significant number of users of different narcotics. The aim of the authors was to look for the background of this relationship between drug and death and examine the origin, development, and motives behind heroin overdose based on an analysis of previous studies. It seems clear that pure heroin overdose increased gradually over the years. The fear of the police is the inhibitory factor of the overdose prevention and notification of emergency health care service. Signs of suicide could be the own home as the chosen location for heroin overdose and the presence of partners (“moment of death companion”). Interventions should include simple techniques such as first aid, naloxone administration, resuscitation, prevention of relapse of prisoners and social network extension involving maintenance programs. Orv. Hetil., 2015, 156(9), 352–357.