Additive Effects of Cointoxicants in Single-Opioid Induced Deaths

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.

Characterizing profiles of polysubstance use among high school students in Baltimore, Maryland: A latent class analysis

BACKGROUND

Adolescent drug use has long term health consequences, like substance use disorders and psychiatric illnesses. Proximal health risks, especially for overdose, are amplified when multiple substances are combined. Existing literature on polysubstance use among adolescents has largely focused on alcohol, tobacco, and marijuana, but has largely excluded other drugs like opioids. Understanding how adolescents combine illicit drugs is essential for intervening to prevent poor health outcomes.

METHODS

We aimed to explore patterns of lifetime polysubstance use among adolescents in Baltimore City. We used data on 9th-12th graders recruited to participate in the 2017 local Baltimore Youth Risk Behavior Survey who reported any lifetime drug use (n = 387; 60 % female, 77 % non-Hispanic Black). We then conducted a latent class analysis using 10 indicators of lifetime drug and alcohol use. After selecting the class model, we tested for associations between the class profiles and race, sex, school grade, and lifetime injection drug use.

RESULTS

We identified three profiles of lifetime polysubstance use in our sample: alcohol and marijuana (68.6 % of sample), polysubstance (22.0 %), and alcohol/pain medication/inhalant use (9.4 %). Members of the polysubstance use class were more likely to be male and to report injection drug use.

CONCLUSIONS

Understanding broader patterns of drug use beyond alcohol, tobacco and marijuana among adolescents is a crucial step towards preventing adverse drug and health-related outcomes later in life. More research is needed to characterize the full health impact of youth polysubstance use patterns and related risk behaviors like injection drug use.

Quantifying enhanced risk from alcohol and other factors in polysubstance-related deaths

BACKGROUND

To quantify how alcohol, polysubstance use and other factors influence opioid concentrations in drug-related deaths in West Virginia (WV), United States.

METHODS

Multiple linear regression models were employed to identify relationships among alcohol, other factors, and the concentrations of four commonly identified opioids (fentanyl, hydrocodone, oxycodone, methadone), accounting for demographic, toxicological and comorbid characteristics in WV drug-related deaths from 2005 to 2018.

RESULTS

Alcohol concentrations of 0.08% or above were associated with significant reductions in blood concentrations of fentanyl (27.5%), hydrocodone (30.5%) and methadone (32.4%). Significantly lower predicted concentrations of all opioids studied were associated with multiple opioid vs. single opioid presence, with predicted concentration reductions ranging from 13.7% for fentanyl to 65-66% for hydrocodone and oxycodone. Benzodiazepine presence was associated with small, non-statistically significant changes in opioid concentrations, while stimulant presence was associated with statistically significant reductions in hydrocodone and oxycodone concentrations.

CONCLUSIONS

Co-ingestion of alcohol, multiple opioids or stimulants were associated with significantly decreased predicted concentrations of commonly identified opioids in drug deaths. Further evidence is provided for enhanced risks from polysubstance use with opioids, which has important public health implications.

Alcohol or Benzodiazepine Co-involvement With Opioid Overdose Deaths in the United States, 1999-2017

IMPORTANCE

The use of benzodiazepines or alcohol together with opioids increases overdose risk, but characterization of co-involvement by predominant opioid subtype is incomplete to date. Understanding the use of respiratory depressants in opioid overdose deaths (OODs) is important for prevention efforts and policy making.

OBJECTIVE

To assess the prevalence and number of alcohol- or benzodiazepine-involved OODs by opioid subtypes in the United States from 1999 to 2017.

DESIGN AND SETTING

This repeated cross-sectional analysis used data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database of all opioid-involved poisoning deaths from January 1, 1999, to December 31, 2017, for the United States. State-level binge drinking prevalence rates for 2015 to 2017 were obtained from the Behavior Risk Factor Surveillance System of the Centers for Disease Control and Prevention, and benzodiazepine prescribing rates for 2012 (most recent available data) were obtained from IMS Health, a commercial database. Data were analyzed from July 10, 2018, to May 16, 2019.

MAIN OUTCOMES AND MEASURES

Prevalence of alcohol or benzodiazepine co-involvement for all OODs and by opioid subtype, nationally and by state.

RESULTS

From 1999 to 2017, 399 230 poisoning deaths involved opioids, of which 263 601 (66.0%) were male, and 204 560 (51.2%) were aged 35 to 54 years. Alcohol co-involvement for all opioid overdose deaths increased nonlinearly from 12.4% in 1999 to 14.7% in 2017. By opioid subtype, deaths involving heroin and synthetic opioids (eg, fentanyl; excluding methadone) had the highest alcohol co-involvement at 15.5% and 14.9%, respectively, in 2017. Benzodiazepine co-involvement in all OODs increased nonlinearly from 8.7% in 1999 to 21.0% in 2017. Benzodiazepines were present in 33.1% of prescription OODs and 17.1% of synthetic OODs in 2017. State-level rates of binge drinking were significantly correlated with alcohol co-involvement in all OODs (r = 0.34; P = .02). State benzodiazepine prescribing rates were significantly correlated with benzodiazepine co-involvement in all OODs (r = 0.57; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that alcohol and benzodiazepine co-involvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. These results may inform state policy initiatives in harm reduction and overdose prevention efforts.

Polysubstance use in rural West Virginia: Associations between latent classes of drug use, overdose, and take-home naloxone

BACKGROUND

Rural communities in the United States have been disproportionately affected by the opioid crisis. Little research has explored the relationship between polysubstance use and overdose experiences among people who inject drugs (PWID) in rural communities. We sought to identify classes of polysubstance drug use among rural PWID and evaluate the associations between polysubstance drug use classes, recent overdose experiences, and receipt of take-home naloxone (THN).

METHODS

We surveyed 420 PWID (June-July 2018) who had injected drugs in the previous 6 months in Cabell County, West Virginia. Participants were recruited from the local syringe services program and through street-based recruitment. We conducted a latent class analysis using 9 measures of injection and non-injection drug use and tested for associations with having experienced an overdose in the past 6 months and having received THN in the past 6 months.

RESULTS

We identified four substance use classes in our sample: polydrug/polyroute use (35.0% of the sample), polyroute stimulant/injection opioid use (33.3%), polyroute stimulant use (20.3%), and injection opioid use (11.3%). Overall, 42.6% of the sample had experienced an overdose in the past 6 months. The classes differed in terms of overdose (χ=91.53, p<0.001), with the polydrug/polyroute use class having the highest probability of overdose and the polyroute stimulants class having the lowest. Only 46.5% of participants had received THN, and probabilities differed between classes (χ=21.93, p<0.001). The polyroute stimulants/injection opioid use and polydrug/polyroute use classes had the highest levels of THN receipt while the polyroute stimulants use class had the least.

CONCLUSION

Among rural PWID in West Virginia, polysubstance use was prevalent and associated with overdose and THN acquisition. These analyses demonstrate the importance of scaling up naloxone distribution in rural settings. Overdose prevention initiatives are reaching persons at high risk of overdose, but expansion of services is needed.

Prescribed Dose of Opioids and Overdose: A Systematic Review and Meta-Analysis of Unintentional Prescription Opioid Overdose

BACKGROUND

The rate of an unintentional drug overdose involving prescription opioids continues to rise. An understanding of the threshold dose and dose(s) associated with unintentional prescription opioid overdose will help to mitigate this epidemic.

OBJECTIVE

The objective of this systematic review is to systematically synthesise and meta-analyse studies on doses of prescription opioids and ascertain the doses of opioids that are associated with increased risk of severe opioid poisoning or mortality.

DATA SOURCES

A search of PubMed, EMBASE, CINAHL and Web of Science from inception to 16 January 2017 was conducted using search strategies and the MeSH (Medical Subject Headings) terms for studies of adult patients using prescription opioids who experienced an accidental overdose.

STUDY SELECTION

Of the 1332 studies identified, 117 were selected for full article review. Ten met the inclusion criteria for qualitative analysis, but only seven studies were meta-analysed. The included studies were in English, and participants met predetermined International Classification of Diseases (ICD) codes. Studies were excluded if they included only paediatric participants or the participants met the ICD code for intentional self-harm.

DATA EXTRACTION AND SYNTHESIS

Two researchers elaborated and validated a data extraction form. Data were then independently extracted by both reviewers as per this form. We assessed study quality using the Newcastle-Ottawa Scale (NOS) for non-randomised studies in meta-analyses. We performed a meta-regression using a random-effect model and summarised the results using relative risk (RR) and 95% confidence intervals (CIs). The threshold dose for an unintentional overdose is 20 morphine milligram equivalents (MME)/day. There were higher risks with larger doses: (1) ≤ 20 versus ≥ 21 MME/day: RR 2.81, 95% CI 1.09-7.22, p < 0.001; (2) ≤ 50 versus > 50 MME/day: RR 3.87, 95% CI 2.36-6.33, p < 0.001; (3) ≤ 100 versus > 100 MME/day: RR 4.28, 95% CI 2.61-7.1, p < 0.001; and (4) ≤ 50 versus > 50-100 MME/day: RR 3.09, 95% CI 1.84-5.18, p < 0.001). Heterogeneity was explained by the type of overdose event, inpatient or outpatient status, and length of observation. Type of pain (cancer or non-cancer pain) had no impact on heterogeneity.

LIMITATIONS

The definition of exposure in studies included in the meta-analysis was heterogeneous. Some studies defined exposure as the filling of a prescription while others defined exposure as the prescription of an opioid to the patient, and all studies assumed that patients took the prescribed opioid. Medications that may contribute to overdose, such as benzodiazepines and other drugs, were not considered.

CONCLUSIONS

A significantly increased risk of inadvertent prescription opioid overdose was found with 20-50 MME/day, with fatality more likely with opioid doses above 50 MME/day, although extensive heterogeneity was found with the dose comparisons. Clinicians should inform patients of this risk and monitor them closely.

PROTOCOL REGISTRATION

This protocol was registered with PROSPERO 2017: CRD42017058426.

Opioid Toxicity

In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.