Methadone-related deaths in Montpellier and Region, from 2000 to 2010

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

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.

[Improve the benefit/risk balance of methadone by respecting its pharmacological specificities]

Recent data on methadone from 2008 to 2017 by the French addictovigilance network warms on the increase of methadone use, its diversion, its increase of overdose risk factors (opioids associated, occasional use) and deaths. Whereas methadone is an essential drug for opioid addiction, its use remains complex because of its pharmacology leading to increase the awareness of health professionals.

Fatal Poisonings Associated with New Psychoactive Substances

This chapter describes how new psychoactive substances (NPS) have been involved in fatal intoxications from 2010 and onwards. It summarizes the circumstances, antemortem symptoms, and adverse effects that have led to death after ingestion of one or more NPS and tabulates concentrations, and postmortem findings from these intoxications.Consumption of NPS exerts health problems and unknown risks for the users. Data on toxicity of many NPS are scarce or nonexistent and long-term toxicity and risks are still largely unknown. In addition, purity and composition of products containing NPS are often inconsistent or not known, which places users at high risk as evidenced by hospital emergency admissions and deaths.The most serious threat to drug users are the synthetic opioids that with strong central nervous depressant effects have caused numerous accidental deaths spread over the entire globe. The synthetic cannabinoids seem to be the most unpredictable with no clear toxidrome and unknown or poorly understood mechanisms of toxicity, but with adverse effects pointing toward the cardiovascular system. The toxidromes commonly encountered after ingestion of cathinones and phenethylamines are of sympathomimetic and hallucinogenic character, which includes risk of developing a serotonin syndrome, excited delirium, and life-threatening cardiovascular effects. In comparison to their conventional "parent" drug, i.e., heroin, cannabis, and amphetamine, most NPS appear to exhibit more severe adverse effects. The deaths attributed to NPS have dramatically increased in the last years. In our opinion, this is because of the shift from synthetic cannabinoids and cathinones to the even more toxic and dangerously potent fentanyl analogues.

Novel associations between FAAH genetic variants and postoperative central opioid-related adverse effects

Opioid effects are potentiated by cannabinoid agonists including anandamide, an endocannabinoid. Inter-individual variability in responses to opioids is a major clinical problem. Multiple deaths and anoxic brain injuries occur every year because of opioid-induced respiratory depression (RD) in surgical patients and drug abusers of opioids and cannabinoids. This study aimed to determine specific associations between genetic variants of fatty acid amide hydrolase (FAAH) and postoperative central opioid adverse effects in children undergoing tonsillectomy. This is a prospective genotype-blinded observational study in which 259 healthy children between 6 and 15 years of age who received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine were enrolled. Associations between frequent polymorphisms of FAAH and central postoperative opioid adverse effects including, RD, postoperative nausea and vomiting (PONV) and prolonged stay in Post Anesthesia Recovery Room (postoperative anesthesia care unit, PACU) due to RD and PONV were analyzed. Five specific FAAH single nucleotide polymorphisms (SNPs) had significant associations with more than twofold increased risk for refractory PONV (adjusted P<0.0018), and nominal associations (P<0.05) with RD and prolonged PACU stay in white children undergoing tonsillectomy. The FAAH SNP, rs324420, is a missense mutation with altered FAAH function and it is linked with other FAAH SNPs associated with PONV and RD in our cohort; association between PONV and rs324420 was confirmed in our extended cohort with additional 66 white children. Specific FAAH polymorphisms are associated with refractory PONV, opioid-related RD, and prolonged PACU stay due to opioid adverse effects in white children undergoing tonsillectomy.