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JAMA Network Open Aug 2023Synthetic opioids, such as the fentanyl analogue and nitazene drug class, are among the fastest growing types of opioids being detected in patients in the emergency...
IMPORTANCE
Synthetic opioids, such as the fentanyl analogue and nitazene drug class, are among the fastest growing types of opioids being detected in patients in the emergency department (ED) with illicit opioid overdose (OD). However, clinical outcomes from OD of novel potent opioids (NPOs), specifically nitazenes, are unknown aside from small case series.
OBJECTIVE
To determine naloxone administration and clinical sequelae of patients who were in the ED with NPO overdose compared with fentanyl OD.
DESIGN, SETTING, AND PARTICIPANTS
This is a cohort study subgroup analysis of adults admitted to the ED and tested positive for NPOs among in the ongoing nationwide ToxIC Fentalog cohort study from 2020 to 2022. Patients who were in the ED with a presumed acute opioid OD and residual blood samples were included, and those testing positive for NPOs were analyzed. Patients were included in this analysis if their confirmatory testing was positive for an NPO analyte, such as brorphine, isotonitazene, metonitazene, and/or N-piperidinyl etonitazene. A comparison group included patients that were positive for fentanyl and devoid of any other analytes on toxicologic analysis.
EXPOSURES
Patients were exposed to NPOs, including brorphine, isotonitazene, metonitazene and/or N-piperidinyl etonitazene.
MAIN OUTCOMES AND MEASURES
The primary outcome was the total number of naloxone doses and total cumulative naloxone dose administered as part of routine clinical care following the OD. Naloxone requirements and clinical sequelae of NPO-positive patients were compared with those testing positive for fentanyl only.
RESULTS
During the study period, 2298 patients were screened, of whom 717 met inclusion criteria, 537 had complete laboratory testing data, with 11 (2.0%) positive for only fentanyl and 9 (1.7%) positive for NPOs (brorphine, isotonitazene, metonitazene, or N-piperidinyl etonitazene). The age range of patients was aged 20 to 57 years (4 males [44.4%] and 5 females [55.6%]). The NPO group received a statistically significantly higher mean (SD) number of naloxone boluses in-hospital (1.33 [1.50]) compared with the fentanyl group (0.36 [0.92]) (P = .02), which corresponded to a moderately large effect size (Cohen d = 0.78). Metonitazene overdose was associated with cardiac arrest and more naloxone doses overall. Metonitazene cases had a mean (SD) number of 3.0 (0) naloxone doses, and 2 of 2 patients (100%) with metonitazene overdoses were administered cardiopulmonary resuscitation.
CONCLUSIONS AND RELEVANCE
In this cohort study of patients admitted to the ED with confirmed opioid overdose testing positive for NPOs, in-hospital naloxone dosing was high compared with patients who tested positive for fentanyl alone. Further study is warranted to confirm these preliminary associations.
Topics: Adult; Female; Male; Humans; Young Adult; Middle Aged; Analgesics, Opioid; Opiate Overdose; Cohort Studies; Drug Overdose; Fentanyl; Disease Progression; Emergency Service, Hospital
PubMed: 37642962
DOI: 10.1001/jamanetworkopen.2023.31264 -
Clinical Toxicology (Philadelphia, Pa.) Apr 2022Synthetic cannabinoids (SCs) are a structurally heterogenous synthetic class of drugs of abuse. The objective was to describe the incidence of acute respiratory failure... (Observational Study)
Observational Study
CONTEXT
Synthetic cannabinoids (SCs) are a structurally heterogenous synthetic class of drugs of abuse. The objective was to describe the incidence of acute respiratory failure in Emergency Department (ED) patients with confirmed SC exposure, and to investigate the association between SC overdose with respiratory failure compared to non-SC overdose.
METHODS
This was an observational cohort of ED patients ≥18 years with suspected cannabinoid overdose between 2015 and 2020 at two tertiary-care hospitals. Patient serum was analyzed liquid chromatography/quadrupole time-of-flight mass spectrometry using a library with >800 drugs including novel psychoactive substances. The primary outcome was acute respiratory failure.
DISCUSSION
Of 83 patients with suspected cannabinoid overdose, there were 29 confirmed SC overdoses: 5 F-MDMB-PICA ( = 18) and its metabolite 5OH-MDMB-PICA ( = 16), ADB-FUBINACA ( = 4), AB-CHIMINACA ( = 4), AB-FUBINACA ( = 1), AB-PINACA ( = 1), MDMB-4en-PINACA ( = 1), and 4 F-MDMB-BINACA ( = 1). Overall, incidence of acute respiratory failure was 31.3% (95%CI 21.6-42.4). Compared to non-SC overdose, confirmed SC overdose was significantly associated with respiratory failure (25.0% SC vs. 4.2% non-SC, = 0.05).
CONCLUSION
This study demonstrates that SCs are associated with respiratory failure. Since respiratory depression is a potentially lethal adverse effect of SC overdose, future research is warranted.
Topics: Cannabinoids; Drug Overdose; Humans; Mass Spectrometry; Respiratory Insufficiency
PubMed: 34499005
DOI: 10.1080/15563650.2021.1975734 -
Harm Reduction Journal Sep 2023Xylazine, an α2-adrenoceptor agonist sedative commonly used in veterinary medicine, is not approved for human use. Nevertheless, xylazine-involved overdose rates have... (Review)
Review
INTRODUCTION
Xylazine, an α2-adrenoceptor agonist sedative commonly used in veterinary medicine, is not approved for human use. Nevertheless, xylazine-involved overdose rates have surged in recent years, fueled by an increasingly toxic and synthetic illicit drug supply in North America.
METHODS
This narrative review assessed major epidemiological trends in xylazine-involved overdoses in North America, aiming to identify harm reduction priorities. A literature search was conducted using four bibliographic databases (PubMed, Scopus, Embase, and ScienceDirect) and three preprint servers (medRxiv, bioRxiv, and Europe PMC) on May 28, 2023, to capture articles related to combinations of keywords such as "xylazine", "opioid", and "harm reduction".
RESULTS
Xylazine emerged as an adulterant in Puerto Rico in 2001, likely diverted from veterinary supplies. By the mid-2010s, it began proliferating across unregulated US drug markets, often contemporaneously with illicitly manufactured fentanyl (IMF), displaying characteristics of a syndemic. Initially concentrated in Northeastern regions (e.g., Philadelphia, Connecticut, Maryland), xylazine-involved overdoses later extended to the Rust Belt, Southern, and Western regions of the USA in the late 2010s and early 2020s. During this time, xylazine-involved overdoses also surged in Canada, particularly in Western provinces (British Columbia and Alberta) and Ontario with established IMF-dominated unregulated drug markets.
DISCUSSION
Over the past two decades, xylazine-involved overdoses have been rapidly rising in North America and exhibit few signs of slowing down, representing a serious public health epidemic. Numerous factors may have contributed to this, including limited epidemiological surveillance and drug checking for xylazine and emerging novel adulterants; further, barriers to comprehensive, trauma-informed, non-stigmatizing treatment and social services have also exacerbated this issue. While several epidemiological and ethnographic studies have assessed these factors in the USA, limited evidence is available in Canada where xylazine emerged more recently. This underscores the need for additional research and harm reduction measures.
CONCLUSION
Harm reduction-informed public health guidelines and programs are urgently needed to promote a safer supply, strengthen the healthcare system capacity to prevent and respond to xylazine-involved overdoses, and address social and structural disparities in health outcomes.
Topics: Humans; Public Health; Xylazine; Harm Reduction; Drug Overdose; Alberta
PubMed: 37700329
DOI: 10.1186/s12954-023-00867-x -
The International Journal on Drug Policy Apr 2022The dominant focus of North America's current overdose crisis has been opioids, resulting in considerable research and harm reduction efforts to address opioid-related...
BACKGROUND
The dominant focus of North America's current overdose crisis has been opioids, resulting in considerable research and harm reduction efforts to address opioid-related overdose risks. Less attention has been paid to people who use stimulants (PWUS) despite recent increases in stimulant use and stimulant-involved overdoses (i.e., "overamping"). Stimulant users' definitions, risk factors and experiences of, and responses to, overamping are poorly understood, thereby putting PWUS at heightened risk of adverse health outcomes. This study explores how PWUS understand, experience, and respond to overamping.
METHODS
In-depth qualitative interviews were conducted with 61 PWUS in Vancouver, Canada's Downtown Eastside neighbourhood. Thematic analysis of interviews focused on contextualizing stimulant overdoses, including how PWUS understand, define, experience, and respond to overamping.
RESULTS
Participants associated overamping experiences with commonly identified signs and symptoms, such as rapid onset, elevated heart rate, incontinence, and audiovisua hallucinations, but also reported more serious indicators of overamping, such as unconsciousness, cardiac arrests and seizures. Our findings demonstrate that, among PWUS, there was no unified understanding of overamping such as with opioid overdose and individual experiences had substantial variation in severity and presentation. This impacted the ability to adequately respond to stimulant overdoses, which were primarily self-managed through methods including stabilizing breathing, polysubstance use, and cold showers.
CONCLUSION
Given the growing role of stimulants in North America's overdose crisis, there is an urgent need to improve the identification of stimulant overdoses in real world settings. Our findings identify a gap in current understandings of stimulant overdose, and demonstrate the need for public health and harm reduction interventions to better address overamp risk among PWUS, including harm reduction campaigns to disseminate information regarding identifying signs of, and proper responses to, overamping.
Topics: Analgesics, Opioid; Central Nervous System Stimulants; Drug Overdose; Harm Reduction; Humans; Opiate Overdose; Qualitative Research
PubMed: 35114520
DOI: 10.1016/j.drugpo.2022.103592 -
Substance Abuse 2022Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality....
Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. : We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. : Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. : OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.
Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York City; Opiate Overdose; Opioid-Related Disorders
PubMed: 34666633
DOI: 10.1080/08897077.2021.1986877 -
Harm Reduction Journal Sep 2022The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the... (Review)
Review
BACKGROUND
The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events.
METHODS
Data in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers' notes (n = 2192).
RESULTS
In 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person's breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases.
CONCLUSIONS
With appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.
Topics: COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York; Opiate Overdose; Pandemics; Police
PubMed: 36123614
DOI: 10.1186/s12954-022-00682-w -
Maternal and Child Health Journal Jul 2023Opioid overdose is a leading cause of maternal mortality, yet limited attention has been given to the consequences of opioid use disorder (OUD) in the year following... (Review)
Review
OBJECTIVE
Opioid overdose is a leading cause of maternal mortality, yet limited attention has been given to the consequences of opioid use disorder (OUD) in the year following delivery when most drug-related deaths occur. This article provides an overview of the literature on OUD and overdose in the first year postpartum and provides recommendations to advance maternal opioid research.
APPROACH
A rapid scoping review of peer-reviewed research (2010-2021) on OUD and overdose in the year following delivery was conducted in PubMed, PsycINFO, and Web of Science databases. This article discusses existing research, remaining knowledge gaps, and methodological considerations needed.
RESULTS
Seven studies were included. Medication for OUD (MOUD) was the only identified factor associated with a reduction in overdose rates. Key literature gaps include the role of mental health disorders and co-occurring substance use, as well as interpersonal, social, and environmental contexts that may contribute to postpartum opioid problems and overdose.
CONCLUSION
There remains a limited understanding of why women in the first year postpartum are particularly vulnerable to opioid overdose. Recommendations include: (1) identifying subgroups of women with OUD at highest risk for postpartum overdose, (2) assessing opioid use, overdose, and risks throughout the first year postpartum, (3) evaluating the effect of co-occurring physical and mental health conditions and substance use disorders, (4) investigating the social and contextual determinants of opioid use and overdose after delivery, (5) increasing MOUD retention and treatment engagement postpartum, and (6) utilizing rigorous and multidisciplinary research methods to understand and prevent postpartum overdose.
Topics: Humans; Female; Analgesics, Opioid; Opiate Overdose; Opioid-Related Disorders; Drug Overdose; Opiate Substitution Treatment; Postpartum Period
PubMed: 36840785
DOI: 10.1007/s10995-023-03614-7 -
Addiction (Abingdon, England) Feb 2022To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.
AIMS
To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.
DESIGN
A retrospective cohort study using data from the Health Facts Database.
SETTING
Over 600 United States healthcare facilities.
PARTICIPANTS
Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work.
MEASUREMENTS
The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).
FINDINGS
Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose [AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41).
CONCLUSIONS
Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.
Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Retrospective Studies; United States
PubMed: 34286895
DOI: 10.1111/add.15643 -
Annals of Medicine Dec 2022U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose... (Review)
Review
U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.
Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders; Pain; Risk Factors; Veterans
PubMed: 35792749
DOI: 10.1080/07853890.2022.2092896 -
The Journal of International Medical... Aug 2023To investigate the association between seasonality and intentional drug overdose (IDO), a commonly seen method of self-harm in daily emergency medicine practice.
OBJECTIVE
To investigate the association between seasonality and intentional drug overdose (IDO), a commonly seen method of self-harm in daily emergency medicine practice.
METHODS
Cases of IDO were retrospectively selected using the International Classification of Diseases (ICD)-10 coding system (codes T36-T50), in patients who attended the Emergency Department of MacKay Memorial Hospital between January 2018 and August 2019. Data regarding age, sex, arrival time, marital status, vital signs, comorbidities, psychiatric history, social conflicts, substance of overdose, and length of hospital stay by season, were analysed using Student's -test and χ-test.
RESULTS
Of all included cases ( = 196), IDO occurred most frequently in spring (32.1%), particularly in male patients (28/49 male cases). First-time IDO occurred most frequently in spring (51/133 first-time cases) and most spring cases were first-time IDO (51/63 spring cases). Repeat IDO occurred most frequently in autumn (20/63 repeat cases). Female conflict with father and/or boyfriend, and personality disorder in patients who overdosed, showed seasonality with a spring peak. Hospital admission rate was highest in winter (10/45 winter cases [22.2%]).
CONCLUSION
Episodes of IDO exhibited seasonality, with a spring peak, particularly for male patients, female patients in conflict with father and/or boyfriend, and those with personality disorder. Clinicians should pay close attention to the abovementioned patient groups.
Topics: Humans; Female; Male; Retrospective Studies; Drug Overdose; Emergency Service, Hospital; Friends; Hospitals
PubMed: 37632450
DOI: 10.1177/03000605231192779