Surveillance of prescription drug-related mortality using death certificate data

Sense of control and likelihood of prescription drug misuse 10-years later among middle-aged and older adults

Objectives: Sense of control (i.e. one's beliefs about their ability to influence life circumstances) has been linked to various psychological outcomes. However, it is unknown if sense of control is protective against prescription drug misuse (PDM). The present study sought to evaluate if sense of control is associated with reduced odds of PDM 9 to 10 years later among a sample of middle-aged and older adults.Methods: Data were evaluated from participants (M = 54 years, SD = 10.86; N = 2,108) of the second and third waves of the Midlife in the United States study. Logistic regression models were used to assess whether baseline sense of control (Wave 2) predicted odds of PDM 9 to 10 years later (Wave 3).Results: Findings revealed that greater sense of control at baseline was related to reduced odds of subsequent PDM (OR = 0.78; 95% CI: 0.64, 0.95), adjusting for baseline PDM, sociodemographic characteristics, health behaviors, psychological factors, number of prescription medications, and health. When assessing the subscales of sense of control separately, constraints (OR = 1.19; 95% CI: 1.00, 1.42), but not mastery (OR = 0.96; 95% CI: 0.80, 1.12), was predictive of odds of subsequent PDM. Further, being female was associated with greater odds of PDM (OR = 1.46; 95% CI: 1.02, 2.09), but did not moderate the association between sense of control and PDM.Conclusions: Sense of control may be a novel and viable target for interventions (e.g. using mobile phone apps) aimed at mitigating prescription drug misuse.

Opioid-related Mortality in United States Death Certificate Data: A Quantitative Bias Analysis With Expert Elicitation of Bias Parameters

BACKGROUND

Opioid-related mortality is an important public health problem in the United States. Incidence estimates rely on death certificate data generated by health care providers and medical examiners. Opioid overdoses may be underreported when other causes of death appear plausible. We applied physician-elicited death certificate bias parameters to quantitative bias analyses assessing potential age-related differential misclassification in US opioid-related mortality estimates.

METHODS

We obtained cause-of-death data (US, 2017) from the National Center for Health Statistics and calculated crude opioid-related outpatient death counts by age category (25-54, 55-64, 65+). We elicited beliefs from 10 primary care physicians on sensitivity of opioid-related death classification from death certificates. We summarized elicited sensitivity estimates, calculated plausible specificity values, and applied resulting parameters in a probabilistic bias analysis.

RESULTS

Physicians estimated wide sensitivity ranges for classification of opioid-related mortality by death certificates, with lower estimated sensitivities among older age groups. Probabilistic bias analyses adjusting for physician-estimated misclassification indicated 3.1 times more (95% uncertainty interval: 1.2-23.5) opioid-related deaths than the observed death count in the 65+ age group. All age groups had substantial increases in bias-adjusted death counts.

CONCLUSIONS

We developed and implemented a feasible method of eliciting physician expert opinion on bias parameters for sensitivity of a medical record-based death indicator and applied findings in quantitative bias analyses adjusting for differential misclassification. Our findings are consistent with the hypothesis that opioid-related mortality rates may be substantially underestimated, particularly among older adults, due to misclassification in cause-of-death data from death certificates.

Physical and mental illness comorbidity among individuals with frequent self-harm episodes: A mixed-methods study

Background

Research has indicated an increased risk of self-harm repetition and suicide among individuals with frequent self-harm episodes. Co-occurring physical and mental illness further increases the risk of self-harm and suicide. However, the association between this co-occurrence and frequent self-harm episodes is not well understood. The objectives of the study were (a) to examine the sociodemographic and clinical profile of individuals with frequent self-harm (regardless of suicidal intent) episodes and, (b) the association between physical and mental illness comorbidity, self-harm repetition, highly lethal self-harm methods, and suicide intent.

Methods

The study included consecutive patients with five or more self-harm presentations to Emergency Departments across three general hospitals in the Republic of Ireland. The study included file reviews (n = 183) and semi-structured interviews (n = 36). Multivariate logistic regression models and independent samples t-tests were used to test the association between the sociodemographic and physical and mental disorders comorbidity on highly lethal self-harm methods and suicidal intent, respectively. Thematic analysis was applied to identify themes related to physical and mental illness comorbidity and frequent self-harm repetition.

Findings

The majority of individuals with frequent self-harm episodes were female (59.6%), single (56.1%), and unemployed (57.4%). The predominant current self-harm method was drug overdose (60%). Almost 90% of the participants had history of a mental or behavioral disorder, and 56.8% had recent physical illness. The most common psychiatric diagnoses were alcohol use disorders (51.1%), borderline personality disorder (44.0%), and major depressive disorder (37.8%). Male gender (OR = 2.89) and alcohol abuse (OR = 2.64) predicted the risk of a highly lethal self-harm method. Suicide intent was significantly higher among those with a diagnosis of major depressive disorder (t = 2.43; p = 0.020). Major qualitative themes were (a) the functional meaning of self-harm (b) self-harm comorbidity (c) family psychiatric history and (d) contacts with mental health services. Participants described experiencing an uncontrollable self-harm urge, and self-harm was referred to as a way to get relief from emotional pain or self-punishment to cope with anger and stressors.

Conclusion

Physical and mental illness comorbidity was high among individuals with frequent self-harm episodes. Male gender and alcohol abuse were associated with highly lethal self-harm methods. The mental and physical illness comorbidity of individuals with frequent self-harm episodes should be addressed via a biopsychosocial assessment and subsequent indicated treatment interventions.

Hospitalizations and deaths related to adverse drug events worldwide: Systematic review of studies with national coverage

PURPOSE

Adverse drug events are related to negative outcomes in healthcare, including hospitalization, increased duration of hospital stay and death. The aim of this study was to conduct a systematic review to evaluate hospitalizations and deaths related to adverse drug events worldwide, reported in studies with national coverage.

METHODS

The protocol was registered in PROSPERO (CRD42020157008). We performed a systematic search on Medline, Embase, CINAHL, LILACS, and the Cochrane Library (until March 2020) using pre-specified terms. We included published studies that reported data on hospitalizations and/or deaths related to adverse drug events from a national perspective and the use of secondary data as a source of information. Two reviewers independently extracted and synthesized data. The quality of the studies was assessed using an adapted version of the Joanna Briggs Institute critical appraisal checklist for prevalence studies. Narrative summaries of findings were undertaken.

RESULTS

Among 59,336 citations, 62 studies were included for data extraction and synthesis. Among these studies, 41 studies included the outcome of hospitalization, 16 included the death outcome, and five included both outcomes. Administrative databases regarding discharges and registries of vital statistics were the most common sources of information. The relative frequency of hospitalizations ranged from 0.03% to 7.3%, and from 9.7 to 383.0/100,000 population, whereas mortality rate ranged from 0.1 to 7.88/100,000 population.

CONCLUSION

Our study highlights information about adverse drug events using large administrative databases in a national scenario and provides an overview of databases and methods implemented to detect adverse drug events.

Medication-related problems and adverse drug reactions in Ethiopia: A systematic review

Medication-related problems (MRPs) are an important healthcare problem. This study aimed at reviewing the published literature in Ethiopia to estimate the prevalence of MRPs and to summarize associated factors. A comprehensive systematic search was conducted in PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and Google databases from inception to April 2020. Articles that addressed MRPs were eligible for inclusion. Article screening, data extraction, and study quality analysis were performed independently by two reviewers. Studies targeting specific disease condition were considered as specific, while the remaining were nonspecific. The prevalence of MRPs was then computed in medians and interquartile ranges (IQR), while associated factors were summarized in a table. Of the thirty-two studies included in this review, the majority of them (n = 24) targeted MRPs, while the remaining studies (n = 8) investigated adverse drug reactions (ADRs). Studies varied in the study design, study population, and definition of MRPs and ADRs used. The overall median prevalence was 70.8% (IQR = 61.0-80.2) with a range of 16.0% to 88.7%. The median prevalence of MRPs in specific and nonspecific patients was 71.2% (IQR = 60.7-71.2) and 69.3% (IQR = 60.7-82.0), respectively. In addition, a median of 36.6% (IQR = 10.0-85.7) of patients experienced ADRs. Indication-related and effectiveness-related MRPs were commonly reported in both specific and nonspecific patients, while noncompliance MRPs were more prevalent among specific patients than nonspecific patients. Increasing age, presence of co-morbidity, and an increasing number of drugs were the commonly identified contributing factors of MRPs. The review showed that more than two-thirds of the study participants developed MRPs. Hence, an integrated approach should be designed to improve the optimal use of pharmacotherapy to reduce the burden of MRPs. Further, future research should be undertaken to prepare cost-effective and efficient prevention mechanisms to reduce or halt the development of MRPs.

Predictors of Mortality in the Older Population: The Role of Polypharmacy and Other Medication and Chronic Disease-Related Factors

BACKGROUND

Polypharmacy has been associated with increased mortality but the contribution of different medication-related factors to this is unknown.

AIMS

The aim of this study was to identify demographic and medication-related predictors of mortality in the older population. Given the intrinsic link between polypharmacy and multimorbidity, the secondary aim was to examine if the medicines or underlying diseases predicted mortality.

METHODS

Patients aged ≥ 65 years from an outpatient multimorbidity clinic were included. Medication-related factors included the medicines count, high-risk medicines, inappropriate medicines duplication, and potential drug-drug and drug-disease interactions. Logistic regression was used to identify mortality predictors within a year of clinic discharge from the outpatient clinic. Patients attend the clinic until medications and comorbidity management have been optimised, at which point they are discharged from the clinic, and their General Practitioner provides ongoing care.

RESULTS

A total of 584 patients were included (median age 80.0 years) and 9.9% (n = 58) died within a year of discharge. Demographics, namely age (adjusted odds ratio [aOR] 1.05; 95% CI 1.01-1.09; p = 0.018) and being male (aOR 5.10; 95% CI 2.63-9.88; p < 0.001); chronic disease, namely heart failure (aOR 3.36; 95% CI 1.78-6.35; p < 0.001); and medication-related factors, namely the number of sedative and anticholinergic medicines (aOR 1.66; 95% CI 1.19-2.33; p = 0.003) predicted mortality in the study population.

CONCLUSION

Whilst polypharmacy has been defined using the number of medicines in the literature, a combination of demographics, chronic disease and medications predicted mortality in our study. This provides guidance for the development of future tools and guidelines regarding the inclusion of key factors for identifying high-risk patients at risk of adverse health outcomes such as mortality.

Pseudo-colouring an ECG enables lay people to detect QT-interval prolongation regardless of heart rate

Drug-induced long QT syndrome (diLQTS), characterized by a prolongation of the QT-interval on the electrocardiogram (ECG), is a serious adverse drug reaction that can cause the life-threatening arrhythmia Torsade de Points (TdP). Self-monitoring for diLQTS could therefore save lives, but detecting it on the ECG is difficult, particularly at high and low heart rates. In this paper, we evaluate whether using a pseudo-colouring visualisation technique and changing the coordinate system (Cartesian vs. Polar) can support lay people in identifying QT-prolongation at varying heart rates. Four visualisation techniques were evaluated using a counterbalanced repeated measures design including Cartesian no-colouring, Cartesian pseudo-colouring, Polar no-colouring and Polar pseudo-colouring. We used a multi-reader, multi-case (MRMC) receiver operating characteristic (ROC) study design within a psychophysical paradigm, along with eye-tracking technology. Forty-three lay participants read forty ECGs (TdP risk n = 20, no risk n = 20), classifying each QT-interval as normal/abnormal, and rating their confidence on a 6-point scale. The results show that introducing pseudo-colouring to the ECG significantly increased accurate detection of QT-interval prolongation regardless of heart rate, T-wave morphology and coordinate system. Pseudo-colour also helped to reduce reaction times and increased satisfaction when reading the ECGs. Eye movement analysis indicated that pseudo-colour helped to focus visual attention on the areas of the ECG crucial to detecting QT-prolongation. The study indicates that pseudo-colouring enables lay people to visually identify drug-induced QT-prolongation regardless of heart rate, with implications for the more rapid identification and management of diLQTS.

Mortality Secondary to Unintentional Poisoning after Inpatient Rehabilitation among Individuals with Moderate to Severe Traumatic Brain Injury

Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death from unintentional poisoning (UP) being 11 times higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared with the characteristics of those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following TBI and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were the result of UP, 76% were the result of OC, and 20.5% were from an unknown cause. Among the UP deaths, 90% involved drugs (of these, 67% involved narcotic drugs and 14% involved psychostimulants), and 8% involved alcohol. Age-adjusted risk for UP death was associated with: white/non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow-up, better Functional Independence Measure^TM (FIM) scores, history of arrest, moderate disability (vs. severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die from UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.

Racial differences in overdose events and polydrug detection in Indianapolis, Indiana

BACKGROUND

We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana).

METHODS

Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose.

RESULTS

From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ² = 4.0, p < .05, Cramer's V=.05). Toxicology data illustrate changing polydrug combinations, with Black decedents more likely to test positive for fentanyl-cocaine polydrug use in recent years.

CONCLUSIONS

Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Prescription drug suicide in non-abusers: A 6-year forensic survey

BACKGROUND

Prescription drug suicide merits study to guide the development of strategies to reduce suicide risk. We examined prescription drug suicide specifically in non-abusers of prescription drugs; this is a relatively unexplored subject.

METHODS

Six-year data on prescription drug suicide in non-abusers were extracted from the records of the Department of Forensic Medicine at the All India Institute of Medical Sciences, New Delhi. These records contained information obtained from the scene of the suicide, from interviews with relatives of the deceased, and from forensic toxicological analyses at two laboratories.

RESULTS

There were 27 (8%) cases of prescription drug suicide in non-abusers out of 338 cases of suicidal poisoning. The mean age of this sample was 26 years. The sample was 74% male. Nearly half of the cases (44%) were students. A combination of dextropropoxyphene with dicyclomine, with or without paracetamol, was used by 41% of cases. Overdose was achieved through the ingestion of 10-40 (median, 30) tablets or by the injection of 2-3 (median, 2) vials of medication. In 52% of cases, it appeared that the drugs had been procured over the counter.

CONCLUSIONS

It is reassuring that the absolute number of prescription drug suicides in non-abusers was small; the findings, however, are important because they could serve as a baseline for assessing time trends in future studies. For the present, we suggest that prescription drugs of potential abuse, especially those containing opioids and antispasmodics, should be prescribed and dispensed judiciously, especially to youth.

Fentanyl related overdose in Indianapolis: Estimating trends using multilevel Bayesian models

INTRODUCTION

The opioid epidemic has been largely attributed to changes in prescribing practices over the past 20 years. Although current overdose trends appear driven by the opioid fentanyl, heroin has remained the focus of overdose fatality assessments. We obtained full toxicology screens on lethal overdose cases in a major US city, allowing more accurate assessment of the time-course of fentanyl-related deaths.

METHODS

We used coroner data from Marion County, Indiana comprising 1583 overdose deaths recorded between January 1, 2010 and April 30, 2017. Bayesian multilevel models were fitted to predict likelihood of lethal fentanyl-related overdose using information about the victim's age, race, sex, zip code, and date of death.

RESULTS

Three hundred and seventy-seven (23.8%) overdose deaths contained fentanyl across the seven-year period. Rates rose exponentially over time, beginning well below 15% from 2010 through 2013 before rising to approximately 50% by 2017. At the beginning of the study period, rates of fentanyl overdose were lowest among Black persons but increased more rapidly, eventually surpassing Whites. Currently, White females are at particularly low risk of fentanyl overdose whereas Black females are at high risk. Rates were highest for younger and middle-aged groups. Over time, fentanyl was more likely detected without the presence of other opioids.

CONCLUSIONS

Fentanyl has increasingly been detected in fatal overdose deaths in Marion County. Policy and program responses must focus on education for those at highest risk of fentanyl exposure and death. These responses should also be tailored to meet the unique needs of high-risk demographics.

[Recommendation of ICD-10 codes for surveillance of adverse drug reactions and drug intoxication]

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization. It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Associations between variables were evaluated using Pearson's chi-squared test and multiple correspondence analysis. Six hundred and ninety-one (691) codes were identified related to adverse drug reactions (52.1%) and drug poisoning (47.9%). A total of 687 (99.4%) and 511 (73.9%) codes were validated in 1st and 2nd validation, respectively. There were statistically significant differences (p <0.05) between adverse reactions and drug poisoning in the variables used to characterize the reference list. The association between drug and hospital admission and death was statistically significant when stratified by type of adverse event (p <0.001). Three groupings of codes were identified in multiple correspondence analysis where there are associations between categories of response assessed. The reference list can be a useful tool in pharmacovigilance actions in Brazil.

Non-medical use of psychoactive prescription drugs is associated with fatal poisoning

AIMS

The aims of this study were to estimate the prevalence and predictors of non-medical substance use, and to assess the association between non-medical substance use and fatal poisoning or history of drug abuse in Finland.

DESIGN AND SETTING

Retrospective cohort study of all medico-legally investigated death cases in Finland. The postmortem toxicology database was linked together with the register on reimbursed prescription medicines.

PARTICIPANTS AND CASES

All postmortem cases between 2011 and 2013 positive for one or more of the following drugs: oxycodone, fentanyl, tramadol, clonazepam, gabapentin, pregabalin, tizanidine, olanzapine, quetiapine, risperidone, alprazolam, zolpidem, mirtazapine and bupropion, n = 2974.

MEASUREMENTS

Non-medical use of substance was the outcome variable. Predictors were the following: gender, residence at the time of death, place of death, blood alcohol concentration, age, drug abuse, number of prescriptions of any psychoactive drugs in last year and proportion of prescriptions issued by psychiatrist in last year.

FINDINGS

In 50.4% of the studied cases, at least one drug was detected without a prescription. Clonazepam, alprazolam and tramadol were the most prevalent non-medical findings in these cases (6.6, 6.1 and 5.6%, respectively). The risk of non-medical use of prescription drugs was especially high in cases with history of drug abuse (88.5%) and in fatal poisonings (71.0%). The proportion of non-medical use of the studied substances varied between 5.9% [95% confidence interval (CI) = 3.1-10.1%)] for risperidone and 55.7% for fentanyl (95% CI = 44.1-66.9%). Valid prescription for one or more of any psychoactive drug was associated with lower odds for non-medical use of the studied substances. Additionally, the higher the proportion of psychoactive drugs prescribed by a psychiatrist, the lower the probability of non-medical use.

CONCLUSIONS

Non-prescribed psychoactive drugs are found commonly at postmortem in drug poisoning deaths in Finland, with history of drug abuse being a major contributing factor.

Examining Fatal Opioid Overdoses in Marion County, Indiana

Drug-related overdoses are now the leading injury-related death in the USA, and many of these deaths are associated with illicit opioids and prescription opiate pain medication. This study uses multiple sources of data to examine accidental opioid overdoses across 6 years, 2010 through 2015, in Marion County, IN, an urban jurisdiction in the USA. The primary sources of data are toxicology reports from the county coroner, which reveal that during this period, the most commonly detected opioid substance was heroin. During the study period, 918 deaths involved an opiod, and there were significant increases in accidental overdose deaths involving both heroin and fentanyl. In order to disentangle the nature and source of opioid overdose deaths, we also examine data from Indiana's prescription drug monitoring program and the law enforcement forensic services agency. Results suggest that there have been decreases in the number of opiate prescriptions dispensed and increases in law enforcement detection of both heroin and fentanyl. Consistent with recent literature, we suggest that increased regulation of prescription opiates reduced the likelihood of overdoses from these substances, but might have also had an iatrogenic effect of increasing deaths from heroin and fentanyl. We discuss several policy implications and recommendations for Indiana.

Pharmacovigilance is... Vigilance

The world changes continuously and pharmacovigilance as a new discipline also must change. There are new fields opening with novel challenges whilst we are still perfecting ways to manage and improve the basic challenges such as inadequate data for decision making and under-reporting. Traditional medicines, vaccines, poisoning and medication error are all aspects of the safety of medicines that we have monitored for decades, though without perhaps paying enough attention to their special aspects. There are many new stakeholders taking serious interest in pharmacovigilance outside the regulatory sphere and they often focus on improving individual patient care, rather than the more traditional concentration on broad public health. The same stakeholders are also drawing attention to other iatrogenic outcomes that should be recognised, evaluated and their outcomes compared and contrasted with medication, such as harm from medical devices. The vigilance methods used for medication are very much applicable to all these new fields, though more and different expertise will be needed to evaluate outcomes.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

OBJECTIVE

To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.

DESIGN

Case-cohort study.

SETTING

Veterans Health Administration (VHA), 2004-09.

PARTICIPANTS

US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics.

MAIN OUTCOME MEASURE

Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.

RESULTS

During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.

CONCLUSIONS

Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.

ICD-10 codes used to identify adverse drug events in administrative data: a systematic review

BACKGROUND

Adverse drug events, the unintended and harmful effects of medications, are important outcome measures in health services research. Yet no universally accepted set of International Classification of Diseases (ICD) revision 10 codes or coding algorithms exists to ensure their consistent identification in administrative data. Our objective was to synthesize a comprehensive set of ICD-10 codes used to identify adverse drug events.

METHODS

We developed a systematic search strategy and applied it to five electronic reference databases. We searched relevant medical journals, conference proceedings, electronic grey literature and bibliographies of relevant studies, and contacted content experts for unpublished studies. One author reviewed the titles and abstracts for inclusion and exclusion criteria. Two authors reviewed eligible full-text articles and abstracted data in duplicate. Data were synthesized in a qualitative manner.

RESULTS

Of 4241 titles identified, 41 were included. We found a total of 827 ICD-10 codes that have been used in the medical literature to identify adverse drug events. The median number of codes used to search for adverse drug events was 190 (IQR 156-289) with a large degree of variability between studies in the numbers and types of codes used. Authors commonly used external injury (Y40.0-59.9) and disease manifestation codes. Only two papers reported on the sensitivity of their code set.

CONCLUSIONS

Substantial variability exists in the methods used to identify adverse drug events in administrative data. Our work may serve as a point of reference for future research and consensus building in this area.

Methadone-related overdose deaths in rural Virginia: 1997 to 2003

AIM

Nonmedical use of prescription drugs and poisoning overdose deaths related to prescription drugs are increasing. This article presents an in-depth description of decedents from rural southwestern Virginia, where methadone was identified on toxicology.

METHODS

Cases for this study were derived from a population-based review of 893 drug-related deaths occurring from 1997 to 2003 in the Office of the Medical Examiner, Western District of Virginia.

RESULTS

Deaths in which methadone was identified on toxicology in rural southwestern Virginia increased rapidly over the 7-year study period. In the majority of cases, the cause of death was polydrug toxicity, and the manner of death was classified as accident. A majority of decedents did not have prescriptions for drugs identified on toxicology. The mean concentration of methadone for all cases was 495 mg/L, and there was no significant difference between concentrations where methadone was found alone or in combination with other drugs. There was a significant difference in methadone concentrations for those with prescriptions (645 mg/L vs 449 mg/L) when compared with those without.

CONCLUSIONS

Cases where methadone was identified on toxicology increased significantly over the time studied. Efforts to prevent these deaths include the use of State Prescription Monitoring Programs, Universal Precautions, and Guidelines from the Federation of State Medical Boards.

Drug Poisoning Deaths according to Ethnicity in Utah

This study characterizes drug-related deaths according to ethnicity in Utah during 2005-2010, based on data from the Utah Violent Death Reporting System (UTVDRS). Hispanics made up 12.1% (12.5% male and 11.7% female) of deaths. The most frequently identified drugs among decedents were opiates, then illicit drugs, benzodiazepines, over-the-counter medication, and antidepressants. Death rates for each drug were significantly greater in non-Hispanics than Hispanics. Most decedents used a combination of drugs. For each combination, rates were significantly greater for non-Hispanics than Hispanics, with an exception for opiates and illicit drugs combined, where there was no significant difference. Approximately 79% of non-Hispanics and 65% of Hispanics had one or more of the selected problems (e.g., mental, physical, or crisis related). Rates for each combination of problems were significantly greater in non-Hispanics, with the exception of crisis. Hispanics were less affected by the rise in prescription drug abuse. Hispanic decedents had a greater proportion of illegal drugs, consistent with it being more difficult to obtain prescription drugs. Hispanic decedents were less likely to have physical and mental health problems, which may be related to a smaller chance of diagnosis of such problems through the healthcare system.

Using multiple cause-of-death data to improve surveillance of drug-related mortality

CONTEXT

Many states and local areas are affected by the national epidemic of drug-related mortality, which recently has shown signs of a rising "licit-to-illicit drug" death ratio. Appropriate local public health surveillance can help monitor and control this epidemic.

OBJECTIVE

Using our state as an example, we sought to illustrate how to describe the changes in drug death rates, causes, and circumstances. In contrast to most other surveillance reports, our approach includes both drug-induced and drug-related deaths as well as both demographic and socioeconomic characteristics of decedents.

DESIGN

Cross-sectional study.

SETTING

All residents of the state of Wisconsin.

PARTICIPANTS

Decedents from 1999 to 2008.

MAIN OUTCOME MEASURE

Annual numbers and population-based rates of deaths due to drugs, including both identified and unidentified drugs. Information was obtained from death certificates with any of approximately 270 underlying, immediate, or contributing cause-of-death codes from the International Classification of Diseases, 10th Revision.

RESULTS

Drug-related death rates increased during much of the 10-year study period, and the male-to-female death ratio rose. The median age at death from drug-related causes was 43 years. Opioid analgesic poisoning surpassed cocaine and heroin poisoning as the most frequent type of fatal drug poisoning. Of all 4828 deaths from drug-related causes--virtually all of which were certified by a county medical examiner or coroner--3410 (71%) were unintentional and 1053 (22%) were suicides. The unintentional-to-suicide death rate ratio grew from 1.6 to 3.5 during the study period. Methadone-related deaths increased from 10 in 1999 to 118 in 2008 (1080%), while benzodiazepine-related deaths rose from 23 to 106 (361%).

CONCLUSIONS

Although premature deaths from drug use and abuse continue to rise, even surpassing deaths due to motor vehicle crash in some states, "multiple causes of death" information from death certificates is available to monitor their occurrence and nature and to inform selection of prevention strategies.

Understanding the etiology of prescription opioid abuse: implications for prevention and treatment

Although studies on the initiation of substance abuse abound, the body of literature on prescription opioid abuse (POA) etiology is small. Little is known about why and how the onset of POA occurs, especially among high-risk populations. In this study we aimed to fill this important knowledge gap by exploring the POA initiation experiences of 90 prescription opioid abusers currently in treatment and their narrative accounts of the circumstances surrounding their POA onset. This research was conducted within a storyline framework, which operates on the premise that the path to drug abuse represents a biography or a process rather than a static condition. Audiotapes of in-depth interviews were transcribed, coded, and thematically analyzed. Analyses revealed the presence of four trajectories leading to POA. This study adds to the limited research on POA etiology by not only illuminating the psychosocial factors that contribute to POA onset, but also by situating initiation experiences within broader life processes. The study findings provide crucial insights to policymakers and interventionists in identifying who is at risk for POA, and more important, when and how to intervene most efficaciously.

Comparison of opioid-related deaths by work-related injury

OBJECTIVE

To infer whether work-related injuries may impact opioid-related deaths.

METHODS

Descriptive comparisons were done using data from the Utah Department of Health, the Office of Medical Examiners, and the Labor Commission on all Utah residents who died from opioid-related deaths from 2008 to 2009.

RESULTS

The majority of decedents (145 of 254, 57%) had at least one prior work-related injury. Demographics were similar regardless of work injury status. However, lack of high school diploma (18% vs. 7%, P < 0.001), prevalence of mental illness (50% vs. 15%, P < 0.001), tobacco (61% vs. 12%, P < 0.001), alcohol (87% vs. 28%, P < 0.001), and illicit drug (50% vs. 4%, P < 0.001) use were all substantially higher than the background population.

CONCLUSION

A detailed history and screening for mental illness and substance abuse, including tobacco use, among injured workers may be helpful in avoiding potential opioid-related deaths.

Clostridium difficile in foods and animals: history and measures to reduce exposure

Many articles have summarized the changing epidemiology of Clostridium difficile infections (CDI) in humans, but the emerging presence of C. difficile in foods and animals and possible measures to reduce human exposure to this important pathogen have been infrequently addressed. CDIs have traditionally been assumed to be restricted to health-care settings. However, recent molecular studies indicate that this is no longer the case; animals and foods might be involved in the changing epidemiology of CDIs in humans; and genome sequencing is disproving person-to-person transmission in hospitals. Although zoonotic and foodborne transmission have not been confirmed, it is evident that susceptible people can be inadvertently exposed to C. difficile from foods, animals, or their environment. Strains of epidemic clones present in humans are common in companion and food animals, raw meats, poultry products, vegetables, and ready-to-eat foods, including salads. In order to develop science-based prevention strategies, it is critical to understand how C. difficile reaches foods and humans. This review contextualizes the current understanding of CDIs in humans, animals, and foods. Based on available information, we propose a list of educational measures that could reduce the exposure of susceptible people to C. difficile. Enhanced educational efforts and behavior change targeting medical and non-medical personnel are needed.

Using poison center exposure calls to predict methadone poisoning deaths

Purpose

There are more drug overdose deaths in the Untied States than motor vehicle fatalities. Yet the US vital statistics reporting system is of limited value because the data are delayed by four years. Poison centers report data within an hour of the event, but previous studies suggested a small proportion of poisoning deaths are reported to poison centers (PC). In an era of improved electronic surveillance capabilities, exposure calls to PCs may be an alternate indicator of trends in overdose mortality.

Methods

We used PC call counts for methadone that were reported to the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System in 2006 and 2007. US death certificate data were used to identify deaths due to methadone. Linear regression was used to quantify the relationship of deaths and poison center calls.

Results

Compared to decedents, poison center callers tended to be younger, more often female, at home and less likely to require medical attention. A strong association was found with PC calls and methadone mortality (b = 0.88, se = 0.42, t = 9.5, df = 1, p<0.0001, R² = 0.77). These findings were robust to large changes in a sensitivity analysis assessing the impact of underreporting of methadone overdose deaths.

Conclusions

Our results suggest that calls to poison centers for methadone are correlated with poisoning mortality as identified on death certificates. Calls received by poison centers may be used for timely surveillance of mortality due to methadone. In the midst of the prescription opioid overdose epidemic, electronic surveillance tools that report in real-time are powerful public health tools.

Perfil da mortalidade por intoxicação com medicamentos no Brasil, 1996-2005: retrato de uma década

A ocorrência de óbitos por intoxicação com medicamentos tem sido considerada um dos agravos de saúde pública. O estudo descreve o perfil epidemiológico da mortalidade por intoxicação com medicamentos na população do Brasil entre 1996 e 2005. Realizou-se um estudo descritivo com dados do Sistema de Informações sobre Mortalidade do Ministério da Saúde. Selecionaram-se os óbitos segundo a Classificação Internacional de Doenças (CID-10). Foram identificados 4.403 óbitos ocorridos em homens (53,9%), solteiros (53,7%) e faixa etária de 20-39 anos (44,0%). A maioria dos óbitos foi por autointoxicação intencional por anticonvulsivantes, sedativos, antiparkinsonianos e psicotrópicos. A taxa padronizada de mortalidade foi maior na região Centro-Oeste e os Anos Potenciais de Vida Perdidos aumentou durante o período estudado em 15,50%. O estudo apresentou as características e variações na mortalidade por intoxicação com medicamentos no Brasil que pode ser um reflexo do padrão de consumo dos medicamentos no país atrelado à necessidade de aprimoramento das políticas de vigilância sanitária.

Zebrafish: a model for the study of addiction genetics

Drug abuse and dependence are multifaceted disorders with complex genetic underpinnings. Identifying specific genetic correlates is challenging and may be more readily accomplished by defining endophenotypes specific for addictive disorders. Symptoms and syndromes, including acute drug response, consumption, preference, and withdrawal, are potential endophenotypes characterizing addiction that have been investigated using model organisms. We present a review of major genes involved in serotonergic, dopaminergic, GABAergic, and adrenoreceptor signaling that are considered to be directly involved in nicotine, opioid, cannabinoid, and ethanol use and dependence. The zebrafish genome encodes likely homologs of the vast majority of these loci. We also review the known expression patterns of these genes in zebrafish. The information presented in this review provides support for the use of zebrafish as a viable model for studying genetic factors related to drug addiction. Expansion of investigations into drug response using model organisms holds the potential to advance our understanding of drug response and addiction in humans.

Parental grief after a child's drug death compared to other death causes: investigating a greatly neglected bereavement population

This comparative survey contrasted 571 parents who lost children to various death causes: 48 to drug-related deaths and overdoses, 462 to suicide, 24 to natural death cases, and 37 to mostly accidental death cases. Groups were compared in terms of grief difficulties, mental health problems, posttraumatic stress, and stigmatization. Results did not show any appreciable differences in these respects between the suicide bereaved parents and those losing children to drug-related deaths. However, when the suicide and drug-related death survivors were specifically contrasted against accidental and natural death loss cases, a consistent pattern emerged showing the former group was consistently more troubled by grief and mental health problems than the latter two sub-groups. These differences remained when controls of time since the loss and gender differences were employed as covariates. These findings suggest that the powerful and intense stigma against drug use and mental illness, shared among the public-at-large, imposes challenges in healing of immense proportion for these parents as they find less compassionate responses from their significant others, following their losses.

Abuse risks and routes of administration of different prescription opioid compounds and formulations

BACKGROUND

Evaluation of tamper resistant formulations (TRFs) and classwide Risk Evaluation and Mitigation Strategies (REMS) for prescription opioid analgesics will require baseline descriptions of abuse patterns of existing opioid analgesics, including the relative risk of abuse of existing prescription opioids and characteristic patterns of abuse by alternate routes of administration (ROAs). This article presents, for one population at high risk for abuse of prescription opioids, the unadjusted relative risk of abuse of hydrocodone, immediate release (IR) and extended release (ER) oxycodone, methadone, IR and ER morphine, hydromorphone, IR and ER fentanyl, IR and ER oxymorphone. How relative risks change when adjusted for prescription volume of the products was examined along with patterns of abuse via ROAs for the products.

METHODS

Using data on prescription opioid abuse and ROAs used from 2009 Addiction Severity Index-Multimedia Version (ASI-MV®) Connect assessments of 59,792 patients entering treatment for substance use disorders at 464 treatment facilities in 34 states and prescription volume data from SDI Health LLC, unadjusted and adjusted risk for abuse were estimated using log-binomial regression models. A random effects binary logistic regression model estimated the predicted probabilities of abusing a product by one of five ROAs, intended ROA (i.e., swallowing whole), snorting, injection, chewing, and other.

RESULTS

Unadjusted relative risk of abuse for the 11 compound/formulations determined hydrocodone and IR oxycodone to be most highly abused while IR oxymorphone and IR fentanyl were least often abused. Adjusting for prescription volume suggested hydrocodone and IR oxycodone were least often abused on a prescription-by-prescription basis. Methadone and morphine, especially IR morphine, showed increases in relative risk of abuse. Examination of the data without methadone revealed ER oxycodone as the drug with greatest risk after adjusting for prescription volume. Specific ROA patterns were identified for the compounds/formulations, with morphine and hydromorphone most likely to be injected.

CONCLUSIONS

Unadjusted risks observed here were consistent with rankings of prescription opioid abuse obtained by others using different populations/methods. Adjusted risk estimates suggest that some, less widely prescribed analgesics are more often abused than prescription volume would predict. The compounds/formulations investigated evidenced unique ROA patterns. Baseline abuse patterns will be important for future evaluations of TRFs and REMS.

Mortality associated with illegal drug use among adults in the United States

OBJECTIVES

To examine all-cause and cause-specific mortality over a 15-year follow-up period in relation to at-baseline reported lifetime use of illegal drugs from five classes (marijuana, cocaine, heroin, hallucinogens, and inhalants) among adults in the United States (US) household population.

METHODS

The study involved 20,983 sample adults who responded to the 1991 National Health Interview Survey Drug and Alcohol Use supplemental questionnaire and also met the eligibility criteria for mortality follow-up. Cox proportional hazards models were estimated to examine the relationships.

RESULTS

Adults who at baseline reported lifetime heroin use were at significantly higher risk of all-cause death over the follow-up period (hazard rate ratio or HR = 2.02; 95% confidence interval or CI 1.26-3.23), compared with those who did not report using drugs from any of the five classes, even after adjusting for age, sex, race, education, marital status, cigarette smoking status, and alcohol use status. Those who at baseline reported lifetime cocaine (no heroin) use had a significantly higher rate of death associated with human immunodeficiency virus diseases over the follow-up period than nonusers of drugs from any of the five classes. Several limitations of the analysis are discussed.

CONCLUSIONS

Further research is needed to understand and track the elevated mortality associated with illegal drug use and the correlates of drug-poisoning deaths.

Drug and dietary interactions of warfarin and novel oral anticoagulants: an update

Clinicians and patients around the world have been intrigued by the concept of developing an oral anticoagulant with a broad therapeutic window and few drug and dietary interactions that can be administered at fixed doses with no or minimal monitoring. The recently approved oral direct thrombin inhibitor dabigatran, along with the emerging oral anti-factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have been developed to address many of the shortcomings of warfarin therapy. As warfarin is associated with extensive food and drug interactions, there is also a need to consider such interactions with the new oral anticoagulants. While to date few drug and dietary interactions have been reported with the new oral anticoagulants, it is still early in their development and clinical use cycle. Pharmacokinetic and pharmacodynamic profiles will have to be closely accounted for when determining the likelihood of a potential drug interaction prior to therapy initiation. As the list of drugs and supplements that interact with warfarin is continuously expanding, and the knowledge on drug interactions with the novel oral anticoagulants is still in its infancy, clinicians need to be vigilant when initiating any of these agents or when any changes in the patient's medication profile occur and perform a close screening for potential drug and dietary interactions. The objective of this paper is to give an update on drug and dietary interactions with warfarin and the novel oral anticoagulants, dabigatran, rivaroxaban, apixaban, and edoxaban.

A continuing black hole? The FDA boxed warning: an appeal to improve its clinical utility

The boxed warning is increasingly utilized by the Food and Drug Administration (FDA) as a clinical warning to prescribers of dangerous adverse drug reactions. As these warnings have expanded, we feel the utility and application of boxed warnings are becoming more nebulous. The use of drugs following issuance of a boxed warning has been variable. Droperidol sales decreased 10-fold in the year following the warning, yet there has been essentially no change in the methadone usage over a similar time period after its boxed warning. Including more information, such as estimation of incidence for the adverse drug reaction, would be more clinically useful to the prescriber. Reasonable standards using supplemental databases outside of the FDA (such as national poison center data) could be helpful in developing an integrated and balanced approach to boxed warnings.

Trends in the prescription of opioids for adolescents with non-cancer pain

OBJECTIVES

Opioids are among the most commonly abused drugs among adolescents, and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations.

METHODS

We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions and types of medications given, as well as clinical and demographic features of adolescents receiving opioids.

RESULTS

In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short-acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition.

DISCUSSION

Prescription of opioids among adolescents with NCP is common, and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.

Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base

This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence.

PERSPECTIVE

Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.

Prescription Drug Abuse & Diversion: Role of the Pain Clinic

The goal of this research is to better understand the role that South Florida pain management clinics may be playing in the abuse and diversion of prescription drugs. This study explores 1) the characteristics and practices of pain clinics that may be facilitating the drug-seeking endeavors of prescription drug abusers and 2) the drug-seeking behaviors of prescription drug abusers who use pain clinics as a primary source for drugs. Thirty in-depth interviews were conducted with prescription drug abusers in South Florida. Interviews were transcribed verbatim and codes were generated based on thematic analyses of the data. Using grounded theory strategies, the analysis revealed six main themes: "pill mills", on-site pharmacies, liberal prescribing habits, "sponsoring" drug diversion, pain doctor/pharmacy shopping, and faking symptoms/documentation. These findings should provide insights for law enforcement, regulatory agencies, and industry as they attempt to develop appropriate policy initiatives and recommendations for best practices.

Development of a coroner-based surveillance system for drug-related deaths in Los Angeles county

Existing data sources do not provide comprehensive and timely information to adequately monitor drug-related mortality in Los Angeles County. To fill this gap, a surveillance system using coroner data was developed to examine patterns in drug-related deaths. The coroner provided data on all injury deaths in Los Angeles County. A list of keywords that indicate a death was caused by drug use was developed. The cause of death variables in the coroner data were searched for mentions of one of the keywords; if a keyword was detected, that death was classified as drug related. The effectiveness of the keyword list in classifying drug-related deaths was evaluated by matching records in the coroner death data to records in the state death files. Then, the drug-related deaths identified using the keywords were compared to drug-related deaths in the state mortality files identified using International Classification of Death codes. Toxicological test results were used to categorize drug-related deaths based on the type and legality of the drug(s) ingested. Mortality rates were calculated for each category of drug and legal status and for different demographic groups. Compared to the gold standard state mortality files, the coroner data had a sensitivity of 95.6% for identifying drug-related deaths. Over three quarters of all drug-related deaths tested positive for opiates and/or stimulants. Males, Whites, and 35-54-year-olds each accounted for more than half of all drug-related deaths. The surveillance of drug-related deaths using coroner data has several advantages: data are available in a timely fashion, the data include information about the specific substances each victim ingested, and the data can be broken down to compare mortality among specific subpopulations.

Current and Emerging Detoxification Therapies for Critical Care

Toxicity resulting from prescription drugs such as tricyclic antidepressants and cardioactive steroids, as well as drugs of abuse and exposure to environmental chemicals, represents a major need for detoxification treatments. Particles and colloids, antibody fragments (Fab), and indirect treatment methods such as macroemulsions, are currently being developed or employed as detoxification therapies. Colloids, particles, and protein fragments typically mitigate toxicity by binding to the toxin and reducing its concentration in vital organs. Indirect methods such as macroemulsions and sodium bicarbonate act directly on the affected organs, rather than the toxin. In this review, key design parameters (i.e. binding affinity, biocompatibility, pharmacokinetics) are discussed for each type of detoxification treatment. In addition, some of the latest research in each area is reviewed.

Opioid prescriptions for chronic pain and overdose: a cohort study

BACKGROUND

Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.

OBJECTIVE

To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.

DESIGN

Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.

SETTING

HMO.

PATIENTS

9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.

MEASUREMENTS

Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.

RESULTS

51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.

LIMITATIONS

Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.

CONCLUSION

Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.

PRIMARY FUNDING SOURCE

National Institute of Drug Abuse.

Opioid prescriptions for chronic pain and overdose: a cohort study

BACKGROUND

Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.

OBJECTIVE

To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.

DESIGN

Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.

SETTING

HMO.

PATIENTS

9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.

MEASUREMENTS

Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.

RESULTS

51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.

LIMITATIONS

Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.

CONCLUSION

Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.

PRIMARY FUNDING SOURCE

National Institute of Drug Abuse.

Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality

BACKGROUND

Historical studies of news media have suggested an association between reporting and increased drug abuse. Period effects for substance use have been documented for different classes of legal and illicit substances, with the suspicion that media publicity may have played major roles in their emergence. Previous analyses have drawn primarily from qualitative evidence; the temporal relationship between media reporting volume and adverse health consequences has not been quantified nationally. We set out to explore whether we could find a quantitative relationship between media reports about prescription opioid abuse and overdose mortality associated with these drugs. We assessed whether increases in news media reports occurred before or after increases in overdose deaths.

METHODOLOGY/PRINCIPAL FINDINGS

Our ecological study compared a monthly time series of unintentional poisoning deaths involving short-acting prescription opioid substances, from 1999 to 2005 using multiple cause-of-death data published by the National Center for Health Statistics, to monthly counts of English-language news articles mentioning generic and branded names of prescription opioids obtained from Google News Archives from 1999 to 2005. We estimated the association between media volume and mortality rates by time-lagged regression analyses. There were 24,272 articles and 30,916 deaths involving prescription opioids during the seven-year study period. Nationally, the number of articles mentioning prescription opioids increased dramatically starting in early 2001, following prominent coverage about the nonmedical use of OxyContin. We found a significant association between news reports and deaths, with media reporting preceding fatal opioid poisonings by two to six months and explaining 88% (p<0.0001, df 78) of the variation in mortality.

CONCLUSIONS/SIGNIFICANCE

While availability, structural, and individual predispositions are key factors influencing substance use, news reporting may enhance the popularity of psychoactive substances. Albeit ecological in nature, our finding suggests the need for further evaluation of the influence of news media on health. Reporting on prescription opioids conforms to historical patterns of news reporting on other psychoactive substances.

Kava and St. John's Wort: current evidence for use in mood and anxiety disorders

BACKGROUND

Mood and anxiety disorders pose significant health burdens on the community. Kava and St. John's wort (SJW) are the most commonly used herbal medicines in the treatment of anxiety and depressive disorders, respectively.

OBJECTIVES

The objective of this study was to conduct a comprehensive review of kava and SJW, to review any evidence of efficacy, mode of action, pharmacokinetics, safety and use in major depressive disorder, bipolar disorder, seasonal affective disorder (SAD), generalized anxiety disorder, social phobia (SP), panic disorder (PD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

METHODS

A systematic review was conducted using the electronic databases MEDLINE, CINAHL, and The Cochrane Library during late 2008. The search criteria involved mood and anxiety disorder search terms in combination with kava, Piper methysticum, kavalactones, St. John's wort, Hypericum perforatum, hypericin, and hyperforin. Additional search criteria for safety, pharmacodynamics, and pharmacokinetics were employed. A subsequent forward search was conducted of the papers using Web of Science cited reference search.

RESULTS

Current evidence supports the use of SJW in treating mild-moderate depression, and for kava in treatment of generalized anxiety. In respect to the other disorders, only weak preliminary evidence exists for use of SJW in SAD. Currently there is no published human trial on use of kava in affective disorders, or in OCD, PTSD, PD, or SP. These disorders constitute potential applications that warrant exploration.

CONCLUSIONS

Current evidence for herbal medicines in the treatment of depression and anxiety only supports the use of Hypericum perforatum for depression, and Piper methysticum for generalized anxiety.

Opioid microinjection into raphe magnus modulates cardiorespiratory function in mice and rats

The raphe magnus (RM) participates in opioid analgesia and contains pain-modulatory neurons with respiration-related discharge. Here, we asked whether RM contributes to respiratory depression, the most prevalent lethal effect of opioids. To investigate whether opioidergic transmission in RM produces respiratory depression, we microinjected a mu-opioid receptor agonist, DAMGO, or morphine into the RM of awake rodents. In mice, opioid microinjection produced sustained decreases in respiratory rate (170 to 120 breaths/min), as well as heart rate (520 to 400 beats/min). Respiratory sinus arrhythmia, indicative of enhanced parasympathetic activity, was prevalent in mice receiving DAMGO microinjection. We performed similar experiments in rats but observed no changes in breathing rate or heart rate. Both rats and mice experienced significantly more episodes of bradypnea, indicative of impaired respiratory drive, after opioid microinjection. During spontaneous arousals, rats showed less tachycardia after opioid microinjection than before microinjection, suggestive of an attenuated sympathetic tone. Thus, activation of opioidergic signaling within RM produces effects beyond analgesia, including the unwanted destabilization of cardiorespiratory function. These adverse effects on homeostasis consequent to opioid microinjection imply a role for RM in regulating the balance of sympathetic and parasympathetic tone.