heroin and Opiate-Overdose

Realization of the life-saving potential of "take-home naloxone" has been a personal journey, but it has also been a collective journey. It has been a story of individual exploration and growth, and also a story of changes at a societal level. "Take-home naloxone" has matured since its first conceptualization a quarter of a century ago. It required recognition of the enormous burden of deaths from drug overdose (particularly heroin and other opioids), and also realization of critical clusterings (such as post-release from prison). It also required realization that, since many overdose deaths are witnessed, we can potentially prevent many deaths by mobilizing drug users themselves, their families, and the wider caring community to act as intervention workforce to give life-saving interim emergency care. Summary of Scope: This article explores 5 areas (many illustrations UK-based where the author works): firstly, the need for strong science; secondly, our improved understanding of opioid overdose and deaths; thirdly, the search for greater impact from our policies and interventions; fourthly, developing better forms of naloxone; and fifthly, examining the challenges still to be addressed.. "Take-home naloxone" is an exemplar of harm reduction with potential global impact - drug policy and practice for the public good. However, "having the potential" is not good enough - there needs to be actual implementation. This will be easier once the component parts of "take-home naloxone" are improved (better naloxone products, better training aids, revised legislation, and explicit funding support). Many improvements are already possible, but we hesitate about implementation. It is our responsibility to drive progress faster. With "take-home naloxone," we can be proud of what we have achieved, but we must also be humble about how much more we still need to do.

Topics: Analgesics, Opioid; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The US overdose crisis is driven by fentanyl, heroin, and prescription opioids. One evidence-based policy response has been to broaden naloxone distribution, but how much naloxone a community would need to reduce the incidence of fatal overdose is unclear. We aimed to estimate state-level US naloxone need in 2017 across three main naloxone access points (community-based programmes, provider prescription, and pharmacy-initiated distribution) and by dominant opioid epidemic type (fentanyl, heroin, and prescription opioid).. In this modelling study, we developed, parameterised, and applied a mechanistic model of risk of opioid overdose and used it to estimate the expected reduction in opioid overdose mortality after deployment of a given number of two-dose naloxone kits. We performed a literature review and used a modified-Delphi panel to inform parameter definitions. We refined an established model of the population at risk of overdose by incorporating changes in the toxicity of the illicit drug supply and in the naloxone access point, then calibrated the model to 2017 using data obtained from proprietary data sources, state health departments, and national surveys for 12 US states that were representative of each epidemic type. We used counterfactual modelling to project the effect of increased naloxone distribution on the estimated number of opioid overdose deaths averted with naloxone and the number of naloxone kits needed to be available for at least 80% of witnessed opioid overdoses, by US state and access point.. Need for naloxone differed by epidemic type, with fentanyl epidemics having the consistently highest probability of naloxone use during witnessed overdose events (range 58-76% across the three modelled states in this category) and prescription opioid-dominated epidemics having the lowest (range 0-20%). Overall, in 2017, community-based and pharmacy-initiated naloxone access points had higher probability of naloxone use in witnessed overdose and higher numbers of deaths averted per 100 000 people in state-specific results with these two access points than with provider-prescribed access only. To achieve a target of naloxone use in 80% of witnessed overdoses, need varied from no additional kits (estimated as sufficient) to 1270 kits needed per 100 000 population across the 12 modelled states annually. In 2017, only Arizona had sufficient kits to meet this target.. Opioid epidemic type and how naloxone is accessed have large effects on the number of naloxone kits that need to be distributed, the probability of naloxone use, and the number of deaths due to overdose averted. The extent of naloxone distribution, especially through community-based programmes and pharmacy-initiated access points, warrants substantial expansion in nearly every US state.. National Institute of Health, National Institute on Drug Abuse.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid Epidemic; Prescriptions; United States

Food and Drug Administration (FDA) risk evaluation and mitigation strategies (REMs) encourage emergency responders, paramedics, law enforcement agents, and even laypeople to be trained in the administration of naloxone with the intent of rescuing individuals from a known or suspected opioid overdose.. Although naloxone is generally safe and effective at reversing respiratory depression caused by a conventional opioid such as morphine or heroin by competing with the opioid and displacing it from the μ-opioid receptor, questions increasingly are arising as to whether naloxone can adequately reverse opioid overdoses that may involve the potent opioids fentanyl and its analogues (F/FAs). In other words, as more and more opioid overdoses involve F/FAs, can naloxone keep up?. As a competitive antagonist at μ-opioid receptors, naloxone is often a life-saving agent in cases of overdose caused by conventional opioids, but it may not be versatile or powerful enough to combat the rising tide of overdoses due to fentanyl and its illicit analogues, or in cases of overdose involving combinations of opioids and non-opioids.

Topics: Diaphragm; Dose-Response Relationship, Drug; Fentanyl; Heroin; Humans; Laryngismus; Muscle Rigidity; Naloxone; Narcotic Antagonists; Opiate Overdose; Receptors, Opioid, mu; Thoracic Wall

The heroin epidemic has existed for decades, but a sharp rise in opioid overdose deaths (OODs) jolted the nation in the mid-twenty-teens and continues as a major health crisis to this day. Although the new wave of OODs was initially approached as a rural problem impacting a White/Caucasian demographic, surveillance records suggest severe impacts on African Americans and urban-dwelling individuals, which have been largely underreported. The focus of this report is on specific trends in OOD rates in Black and White residents in states with a significant Black urban population and declared as hotspots for OOD: (Maryland (MD), Illinois (IL), Michigan (MI), and Pennsylvania (PA)), and Washington District of Columbia (DC). We compare OODs by type of opioid, across ethnicities, across city/rural demographics, and to homicide rates using 2013-2020 data acquired from official Chief Medical Examiners' or Departments of Health (DOH) reports. With 2013 or 2014 as baseline, the OOD rate in major cities (Baltimore, Chicago, Detroit, Philadelphia) were elevated two-fold over all other regions of their respective state. In DC, Wards 7 and 8 OODs were consistently greater than other jurisdictions, until 2020 when the rate of change of OODs increased for the entire city. Ethnicity-wise, Black OOD rates exceeded White rates by four- to six-fold, with fentanyl and heroin having a disproportionate impact on Black opioid deaths. This disparity was aggravated by its intersection with the COVID-19 pandemic in 2020. African Americans and America's urban dwellers are vulnerable populations in need of social and political resources to address the ongoing opioid epidemic in under-resourced communities.

Topics: Adolescent; Analgesics, Opioid; Black or African American; COVID-19; Health Status Disparities; Healthcare Disparities; Heroin; Humans; Opiate Overdose; Opioid Epidemic; Pandemics; Philadelphia; Social Determinants of Health; United States; Urban Population; White

Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions.. Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data.. United States.. A total of 711 447 drug overdose deaths.. We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing).. Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties.. In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.

Topics: Analgesics, Opioid; Bayes Theorem; Drug Overdose; Heroin; Humans; Opiate Overdose; Prescriptions; United States

The opioid overdose death toll in the United States is an ongoing public health crisis. We characterized the magnitude and duration of respiratory depression, the leading cause of death in opioid overdose cases, induced by heroin or fentanyl and the development of tolerance in male and female rats. We used whole-body plethysmography to first establish dose-response curves by recording breathing for 60 minutes post-intravenous opioid injection. We then tested the development of respiratory tolerance to acute heroin or fentanyl over several weeks and to chronic fentanyl with acute fentanyl or heroin challenge. Heroin and fentanyl each provoked dose-dependent respiratory depression. Heroin caused prolonged (45-60 minute) respiratory depression in female and male rats, characterized by decreased frequency, tidal volume, and minute ventilation and increased inspiratory time and apneic pause. Fentanyl produced similar changes with a shorter duration (10-15 minutes). High-dose heroin or fentanyl produced robust respiratory depression that was slightly more severe in females and, when given intermittently (acute doses 2 to 3 weeks apart), did not lead to tolerance. In contrast, chronic fentanyl delivered with an osmotic minipump resulted in tolerance to acute fentanyl and heroin, characterized by a shorter duration of respiratory depression. This effect persisted during withdrawal in males only. Our model and experimental design will allow for investigation of the neurobiology of opioid-induced respiratory depression and for testing potential therapeutics to reverse respiratory depression or stimulate breathing. SIGNIFICANCE STATEMENT: Fentanyl was more potent and had shorter duration in producing respiratory depression than heroin in both sexes, whereas female rats were more sensitive than males to heroin-induced respiratory depression. Tolerance/cross-tolerance develops in chronic fentanyl administration but is minimized with long interadministration intervals.

Topics: Analgesics, Opioid; Animals; Female; Fentanyl; Heroin; Male; Opiate Overdose; Plethysmography; Rats; Respiratory Insufficiency; Sex Characteristics

There are growing concerns about illicitly manufactured fentanyl (IMF) contamination of methamphetamine. This study aims to characterize the lay views and experiences with IMF-contaminated methamphetamine (IMF/meth) and identify participants with unknown IMF exposures through urine toxicology analysis.. Between December-2019 and November-2021, structured interviews were conducted with 91 individuals who reported past 30-day use of methamphetamine and resided in Dayton, Ohio, USA. Lab-based urine toxicology analyses were conducted to identify fentanyl/analogs, methamphetamine, and other drugs. Bivariate analyses were conducted to identify characteristics associated with attitudes and experiences with IMF/meth, and unknown IMF exposures.. The majority (95.6%) of the study participants were non-Hispanic white, and 52.7% were female. Past 30-day use of methamphetamine was reported on a mean of 18.7 (SD 9.1) days, and 62.6% also reported past 30-day use of heroin/IMF. Most (76.9%) had a history of an unintentional drug-related overdose, but 38.5% rated their current risk for an opioid overdose as none. Besides fentanyl (71.9%), toxicology analysis identified nine fentanyl analogs/metabolites (e.g., 42.7% acetyl fentanyl, 19.0% fluorofentanyl, 5.6% carfentanil), and 12.4% tested positive for Xylazine. The majority (71.4%) believed that IMF/meth was common, and 59.3% reported prior exposures to IMF/meth. 11.2% tested positive for IMF but reported no past 30-day heroin/IMF use (unknown exposure to IMF). Views that IMF/meth was common showed association with homelessness (p = 0.04), prior overdose (p = 0.028), and greater perceived risk of opioid overdose (p = 0.019). Self-reported exposure to IMF/meth was associated with homelessness (p = 0.007) and obtaining take-home naloxone (p = 0.025). Individuals with unknown IMF exposure (test positive for IMF, no reported past 30-day heroin/IMF use) were older (49.9 vs. 41.1 years, p < 0.01), and reported more frequent past 30-day use of methamphetamine (24.4 vs. 18.0 days, p < 0.05). They indicated lower perceived risk of opioid overdose (0.1 vs. 1.9, scale from 0 = "none" to 4 = "high," p < 0.001).. This study suggests a need for targeted interventions for people who use methamphetamine and expansion of drug checking and other harm reduction services.

Topics: Analgesics, Opioid; Drug Overdose; Female; Fentanyl; Heroin; Humans; Male; Methamphetamine; Opiate Overdose; Self Report

Our objective was to explore evolving trends in US drug overdose mortality, overall and by age, sex, race, urbanization, and geography from 1999-2020.. This is a descriptive epidemiologic study. We used the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research and Multiple Cause of Death files from the National Center for Health Statistics. We used crude and age-adjusted cause of death and mortality rate ratios as measures of effects and 95% confidence limits to test for significance.. From 1999-2020, drug overdoses caused 1,013,852 deaths and 4.3-fold increase in mortality rate ratios. Subgroup findings were sex (4.5 men, 4.0 women), race (4.6 White, 3.9 Black or African American, 4.0 Asian or Pacific Islanders, 5.1 Native Americans or Alaskan Natives), age (highest 5.6 in 25-34 years, lowest 1.1 in 75-84, and 0.77 in 85+), geography (highest 6.0 in Midwest, lowest 2.6 in West), and urbanization (highest 6.2 in non-metro, lowest 3.7 in metro).. Drug overdoses in the United States from 1999-2020 increased 4.3-fold, with the highest increase in White and Native American or Alaskan Native populations, and Midwest and non-metro areas. The data create preventive and therapeutic challenges, including restrictions on pharmaceutical industries and enhanced efforts by health care providers in safer prescribing. Addiction care should be integrated into all clinical practices, regardless of specialty, and into undergraduate, graduate, and continuing medical education. Targeted interventions are needed to adequately assess patients and provide care. Analytic studies designed a priori are necessary to test hypotheses formulated from these data.

Topics: Adult; American Indian or Alaska Native; Analgesics, Opioid; Asian American Native Hawaiian and Pacific Islander; Black or African American; Female; Heroin; Humans; Male; Opiate Overdose; United States

Tracking specific drugs contributing to drug overdose deaths is limited when relying on death certificate (DC) data alone. This study aimed to determine whether integrating DC data with medical examiner/coroner reports, including postmortem toxicology and death investigation findings, would enhance identification of (1) heroin and pharmaceutical morphine involvement in overdose deaths and (2) fentanyl source (illicitly manufactured versus pharmaceutical).. Retrospective analysis of heroin, pharmaceutical morphine, illicitly manufactured fentanyl (IMF) and pharmaceutical fentanyl involvement in fatal overdoses. DC and toxicology data were compared with enhanced definitions integrating overdose scene, witness and toxicology evidence.. United States: 38 states and the District of Columbia, participating in Centers for Disease Control and Prevention (CDC)-funded opioid overdose death surveillance.. Opioid overdose decedents from funded jurisdictions; deaths during 1 January 2018-31 December 2019.. Using medical examiner/coroner report data, deaths with 6-acetylmorphine and/or morphine detected by postmortem toxicology were defined as confirmed, probable or suspected heroin deaths, or probable pharmaceutical morphine deaths. Fentanyl was defined as probable or suspected IMF or probable pharmaceutical fentanyl.. The enhanced definition defined 18 393 deaths as confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths. Among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF and 1.0% as probable pharmaceutical fentanyl. Fentanyl source could not be determined for 9.7% of deaths.. Integrating drug overdose scene, witness and toxicology findings can improve identification of specific drugs contributing to overdose deaths and enhance overdose intervention targeting.

Topics: Analgesics, Opioid; District of Columbia; Drug Overdose; Fentanyl; Heroin; Humans; Illicit Drugs; Morphine; Opiate Overdose; Retrospective Studies; United States

Illicit opioid use and heroin treatment admissions among individuals age 50+ have increased. Little research has, however, examined correlates of illicit opioid overdose deaths in this age group before or during the COVID-19 pandemic or the healthcare services used in these cases.. The sample included illicit opioid (heroin, fentanyl, or other synthetic, nonpharmaceutical opioids) poisoning cases age 50+ (. The 6-year average overdose death rate from illicit opioids among those age 50+ was 2.9%, increasing from 1.4% in 2015 to 4.0% in 2019 and 3.6% in 2020. Logistic regression results showed that exposure year was not a significant factor in the odds of overdose death; however, odds were significantly higher among cases that were not managed at any healthcare facility (HCF) (adjusted odds ratio [AOR] = 4.60, 95% confidence interval [CI] = 3.19-6.63) and lower among those who received naloxone therapy (AOR = 0.64, 95% CI = 0.45-0.92). The odds of death were also higher among cases involving exposure at own or another's home and co-use of prescription opioids, alcohol, and other illicit drugs.. Although the NPDS did not show increases in illicit opioid overdose death rates among cases age 50+ in 2020 compared to 2019, overdose deaths were greater among cases that were not managed at HCF and did not receive naloxone therapy. Many appear to have died before they received any intervention to prevent death. Improved access to healthcare services and social support and access to naloxone therapy for older adults with opioid use problems are needed.

Topics: Aged; Analgesics, Opioid; COVID-19; Drug Overdose; Fentanyl; Heroin; Humans; Middle Aged; Opiate Overdose; Pandemics; Poisons

To describe the association between population size, population growth and opioid overdose deaths-overall and by type of opioid-in US commuting zones (CZs) in three periods between 2005 and 2017.. 741 CZs covering the entirety of the US CZs are aggregations of counties based on commuting patterns that reflect local economies.. We used mortality data at the county level from 2005 to 2017 from the National Center for Health Statistics.. Opioid overdose deaths were defined using underlying and contributory causes of death codes from the International Classification of Diseases, 10th revision (ICD-10). We used the underlying cause of death to identify all drug poisoning deaths. Contributory cause of death was used to classify opioid overdose deaths according to the three major types of opioid, that is, prescription opioids, heroin and synthetic opioids other than methadone.. Opioid overdose deaths were disproportionally higher in largely populated CZs. A CZ with 1.0% larger population had 1.10%, 1.10%, and 1.16% higher opioid death count in 2005-2009, 2010-2014, and 2015-2017, respectively. This pattern was largely driven by a high number of deaths involving heroin and synthetic opioids, particularly in 2015-2017. Population growth over time was associated with lower age-adjusted opioid overdose mortality rate: a 1.0% increase in population over time was associated with 1.4% (95% CI: -2.8% to 0.1%), 4.5% (95% CI: -5.8% to -3.2%), and 1.2% (95% CI: -4.2% to 1.8%) lower opioid overdose mortality in 2005-2009, 2010-2014, and 2015-2017, respectively. The association between positive population growth and lower opioid mortality rates was stronger in larger CZs.. Opioid overdose mortality in the USA was disproportionately higher in mid-sized and large CZs, particularly those affected by declines in population over time, regardless of the region where they are located.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Heroin; Humans; Opiate Overdose; United States

Since 2017, an increasing number of opioid overdoses in Oslo, Norway, has been categorized as involving unspecified opioids, as noted in the patient records by the doctor treating the patient. In this study we compare the characteristics of overdoses involving unspecified opioids, long-acting opioids, and heroin. Data on patients presenting with opioid overdose was retrospectively collected from 1 October 2013 to 31 December 2019 at the Oslo Accident and Emergency Outpatient Clinic.. Among 2381 included cases, 459 (19.3%) involved unspecified opioids, 134 (5.6%) long-acting opioids, and 1788 (75.1%) heroin. Overdoses involving unspecified opioids needed longer observation, median 5 h 29 min vs. 4 h 54 min (long-acting opioids) and 4 h 49 min (heroin) (p < 0.001), and had a lower Glasgow coma scale score, median 10 vs. 13 in both the other groups (p < 0.001). Naloxone was given in 23.3% of cases involving unspecified opioids, vs. 12.7% involving long-acting opioids and 30.2% involving heroin (p < 0.001). A larger proportion of patients were transferred to hospital care when unspecified or long-acting opioids were involved compared to heroin, 16.3% and 18.7% respectively vs. 10.1% (p < 0.001). Our results indicate that the category "unspecified opioids" encompasses a substantial proportion of opioids acting longer than heroin.

Topics: Analgesics, Opioid; Drug Overdose; Heroin; Humans; Opiate Overdose; Retrospective Studies

Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality.. We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted.. Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone.. Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Analgesics, Opioid; Coroners and Medical Examiners; Drug Overdose; Heroin; Humans; Methadone; Opiate Overdose

Novel opioids in the illicit drug supply, such as the "nitazene" group of synthetic opioids, present an ongoing public health problem due to high potency and respiratory depressant effects. We describe three patients in whom. This is a case series of patients with acute opioid overdose enrolled in an ongoing multicenter prospective cohort study. Data collected included reported substance use, clinical course, naloxone dose and response, outcome, and analytes detected in biological samples.. Between October 6, 2020 and October 31, 2021, 1006 patients were screened and 412 met inclusion criteria. Of these, three patients (age 33-55) tested positive for. These cases represent a local outbreak of a novel "nitazene" opioid. Public health toxicosurveillance should incorporate routine testing of this emerging class of synthetic compounds in the illicit drug supply.

Topics: Adult; Alprazolam; Analgesics, Opioid; Benzimidazoles; Cocaine; Codeine; Drug Overdose; Fentanyl; Heroin; Humans; Illicit Drugs; Levamisole; Middle Aged; Naloxone; Narcotic Antagonists; Opiate Overdose; Phenacetin; Prospective Studies; Tramadol

Opioid overdose is a leading public health problem in the United States; however, national data on overdose deaths are delayed by several months or more.. To build and validate a statistical model for estimating national opioid overdose deaths in near real time.. In this cross-sectional study, signals from 5 overdose-related, proxy data sources encompassing health, law enforcement, and online data from 2014 to 2019 in the US were combined using a LASSO (least absolute shrinkage and selection operator) regression model, and weekly predictions of opioid overdose deaths were made for 2018 and 2019 to validate model performance. Results were also compared with those from a baseline SARIMA (seasonal autoregressive integrated moving average) model, one of the most used approaches to forecasting injury mortality.. Time series data from 2014 to 2019 on emergency department visits for opioid overdose from the National Syndromic Surveillance Program, data on the volume of heroin and synthetic opioids circulating in illicit markets via the National Forensic Laboratory Information System, data on the search volume for heroin and synthetic opioids on Google, and data on post volume on heroin and synthetic opioids on Twitter and Reddit were used to train and validate prediction models of opioid overdose deaths.. Model-based predictions of weekly opioid overdose deaths in the United States were made for 2018 and 2019 and compared with actual observed opioid overdose deaths from the National Vital Statistics System.. Statistical models using the 5 real-time proxy data sources estimated the national opioid overdose death rate for 2018 and 2019 with an error of 1.01% and -1.05%, respectively. When considering the accuracy of weekly predictions, the machine learning-based approach possessed a mean error in its weekly estimates (root mean squared error) of 60.3 overdose deaths for 2018 (compared with 310.2 overdose deaths for the SARIMA model) and 67.2 overdose deaths for 2019 (compared with 83.3 overdose deaths for the SARIMA model).. Results of this serial cross-sectional study suggest that proxy administrative data sources can be used to estimate national opioid overdose mortality trends to provide a more timely understanding of this public health problem.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Heroin; Humans; Information Storage and Retrieval; Opiate Overdose; United States

During the last decade, opioid prescription policies in Norway have been liberalised and pharmaceutical opioid (PO) dispensing has increased. Against this backdrop, we examined the trends in and the correlates of accidental overdose deaths attributable to PO in the period 2010-2018 in comparison with traditional heroin overdose deaths.. Accidental overdose deaths attributable to PO or heroin were identified through the Norwegian Cause of Death Registry (n = 1267) and cross-linked with population and patient registries. Overdose death correlates were examined using multivariable logistic regression.. The trend in accidental overdose deaths attributable to PO increased significantly from 2010 to 2018. Females, people aged 50 years or older, disability pension recipients and/or those with the highest net wealth had a greater risk of a PO vs. heroin overdose death, while those dying in public spaces, living in urban areas, having recent specialized drug treatment encounters, and/or criminal charge(s) had a lower risk. Among those with primary health care encounters, those with back problems and accidents and injuries had a greater risk of a PO vs. heroin overdose death, while those with a substance use disorder had a lower risk.. The increase in accidental overdose deaths attributable to PO coincides with the period of opioid prescription policy liberalization and an increase in PO consumption in Norway. The PO and heroin overdose deaths differed in terms of the associated sociodemographic characteristics, primary and secondary health care encounters, diagnoses, and criminal charges, indicating a need for additional interventions aimed at preventing PO overdose deaths specifically.

Topics: Analgesics, Opioid; Drug Overdose; Female; Heroin; Humans; Opiate Overdose; Pharmaceutical Preparations; Policy; Prescriptions; Substance-Related Disorders

To differentiate the severity of acute opioid toxicity and describe both the clinical and physiological features associated with heroin overdose in a cohort of witnessed overdose cases.. Witnessed heroin overdose cases over a 12-month period (30 June 2018 - 30 June 2019) at the Medically Supervised Injecting Room (MSIR) in Melbourne, Australia were examined. The severity of acute opioid toxicity was classified according to the level of clinical intervention required to manage the overdose cases where an escalating level of care was provided. Heroin overdose cases were classified into one of three graded severity categories and a fourth complicated heroin overdose category.. A total of 1218 heroin overdose cases were identified from 60,693 supervised injecting visits over the study period. On the spectrum of toxicity, 78% (. We demonstrated that heroin overdose is a dynamic illness and cases differ in the severity of acute opioid toxicity. The risk of airway occlusion including positional asphyxia was an early and consistent feature across all levels of toxicity, while exaggerated respiratory depression together with exaggerated depression of consciousness was increasingly observed with greater levels of toxicity. We also demonstrated the importance of early intervention in overdose cases, where in a large cohort of heroin overdose cases there were no fatal outcomes, a very low hospitalisation rate and most cases were able to be managed to clinical resolution on-site.

Topics: Analgesics, Opioid; Australia; Cohort Studies; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Narcotics; Needle-Exchange Programs; Opiate Overdose; Retrospective Studies

Heroin overdose is a leading cause of mortality among drug users. This paper aims to identify individual and contextual factors associated with lethal and non-lethal heroin-related overdoses on the basis of case reports and semi-structured proxy interviews. Typical patterns within these cases are determined by means of cluster analysis.. Within the CaRe (Case Reports of heroin-related overdoses) study, case reports (100 proxy reports of overdose events from 36 different facilities) were gathered and evaluated as part of a nationwide survey of experts conducted in Germany in 2019. Following initial descriptive analyses a two-step cluster analysis with the four binary variables of gender, age, time and place was conducted to identify patterns within the reported cases.. The case reports grouped into five clusters: 1) Younger male drug users, found in a public space during the daytime; 2) Female drug users; 3) Older male drug users, found in a public space during the daytime; 4) Drug users found at home at night; 5) Drug users found outside at night. Overdoses by female drug users and those which occurred at home and/or at night were significantly more likely to have a fatal outcome.. Future prevention and intervention measures should aim to consider the context, i.e. typical constellations of risk, and attempt to inhibit this through appropriate counter measures.

Topics: Drug Overdose; Drug Users; Female; Heroin; Heroin Dependence; Humans; Male; Opiate Overdose

Topics: Heroin; Humans; Morphine Derivatives; Opiate Overdose; Substance Abuse Detection; Vitreous Body

As opioid overdoses and deaths increase globally, little is known about these dimensions in Sub-Saharan Africa. In this paper, we explore factors associated with opioid overdose experiences among a sample of women who use opioids in Dar es Salaam, Tanzania.. We conducted a cross-sectional survey with 200 women who use opioids in Dar es Salaam, Tanzania, recruited via respondent-driven sampling. We fitted unadjusted and adjusted log-binomial regression models with robust standard errors to examine associations between participant characteristics and reporting ever had an opioid overdose in terms of prevalence ratios.. Thirty-four percent (n = 68) of participants reported having ever had an opioid overdose. In the final adjusted model, having ever attempted to stop using heroin (adj. PR = 1.46, 95% CI: 1.01-2.12), sleeping outside in the past 6 months (adj. PR = 1.93, 95% CI: 1.29-2.91), injecting drugs (adj. PR = 1.78, 95% CI: 1.19-2.66), alcohol use (adj. PR = 1.56, 95% CI: 1.09-2.23), and having moderately severe to severe depression (adj. PR = 3.10, 95% CI: 1.07-8.97) were all found to be significantly associated with having ever had an opioid overdose.. We demonstrate factors associated with opioid overdose among women who use drugs in Tanzania that may not be addressed with injection-focused harm reduction efforts. Our findings suggest the need for overdose surveillance efforts and further work to characterize overdose risks in this context in order to design relevant, targeted interventions to prevent opioid overdose in sub-Saharan Africa.

Topics: Adult; Alcohol Drinking; Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Heroin; Humans; Male; Opiate Overdose; Prevalence; Tanzania

The opioid crisis is a major public health emergency. Current data likely underestimate the full impact on mortality due to limitations in reporting and toxicology screening. We explored the relationship between opioid overdose and firearm-associated emergency department visits (ODED & FAED, respectively).. For the years 2010 to 2017, we analyzed county-level ODED and FAED visits in Kentucky using Office of Health Policy and US Census Bureau data. Firearm death certificate data were analyzed along with high-dose prescriptions from the Kentucky All Schedule Prescription Electronic Reporting records. Socioeconomic variables analyzed included health insurance coverage, race, median household earnings, unemployment rate, and high-school graduation rate.. ODED and FAED visits were correlated (Rho = 0.29, P< 0.01) and both increased over the study period, remarkably so after 2013 (P < 0.001). FAED visits were higher in rural compared to metro counties (P < 0.001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (Std. B = 0.24, P= 0.001), high-dose prescriptions (0.21, P = 0.008), rural status (0.19, P = 0.012), percentage white race (-0.28, P = 0.012), and percentage high school graduates (-0.68, P < 0.001). Unemployment and earnings were bivariate correlates with FAED visits (Rho = 0.42, P < 0.001 and -0.32, P < 0.001, respectively) but were not significant in the multivariable model.. In addition to recognized nonfatal consequences of the opioid crisis, firearm violence appears to be a corollary impact, particularly in rural counties. Firearm injury prevention efforts should consider the contribution of opioid use and abuse.

Topics: Analgesics, Opioid; Drug Prescriptions; Emergency Service, Hospital; Heroin; Humans; Kentucky; Opiate Overdose; Opioid Epidemic; Rural Population; Socioeconomic Factors; Violence; Wounds, Gunshot

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and under-studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

Topics: Administration, Intravenous; Analgesics, Opioid; Canada; Harm Reduction; Heroin; Humans; Hydromorphone; Opiate Overdose; Opiate Substitution Treatment; Opioid-Related Disorders

Opioid overdose is preventable and reversible. To target overdose prevention training and naloxone distribution, it is important to understand characteristics of those people who use drugs most likely to witness an overdose. In this paper we report the proportion and characteristics of women who use heroin that have witnessed an opioid overdose in Dar es Salaam, Tanzania.. We conducted a cross-sectional survey with 200 women who use heroin. We fitted unadjusted and adjusted logistic regression models with witnessing an opioid overdose as the dependent variable and sociodemographic and drug use-related variables as independent variables.. The majority of participants (85%) reported having ever witnessed an opioid overdose. Age (adjusted Odds Ratio [aOR] = 1.09; 95% CI: 1.02-1.12), having ever attempted to stop heroin use (aOR = 11.27; 95% CI: 2.25-56.46), history of arrest (aOR = 3.75; 95% CI: 1.32-10.63), and spending time daily in places where people use drugs (aOR = 3.72; 95% CI: 1.43-9.64) were found to be independently associated with ever witnessing an overdose.. Findings suggest the need for expanded access to naloxone to lay people and community and peer-based overdose prevention training in Tanzania, including the distribution of naloxone in settings with high drug use.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Female; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Tanzania

A large percentage of opioid overdose fatalities involve fentanyl or one of its legal or illegal analogs (F/FAs). Is there something about the pharmacology of these drugs that make them unusually dangerous in an overdose?. Some of the reasons for the dangers of overdose of F/FAs is their high potency and low cost (that leads to wide distribution). But it is rarely asked if the basic pharmacology of F/FAs differ in some fundamental way from conventional opioids such as morphine and heroin. In addition to centrally mediated respiratory depression via opioid receptors, F/FAs cause rigidity in the key respiratory muscles of the chest, upper airway and diaphragm ("wooden chest syndrome," WCS) by a non-opioid mechanism.. WCS is an atypical pharmacology of F/FAs. Because of its rapid onset and non-opioid mechanism, WCS makes F/FA overdose particularly dangerous.

Topics: Diaphragm; Fentanyl; Heroin; Humans; Laryngismus; Muscle Rigidity; Opiate Overdose; Syndrome; Thoracic Wall

Medically treated opioid overdoses identify a population at high risk of subsequent mortality and need for treatment. This study reports on medically treated opioid overdose trends in a state with rapid fentanyl spread.. We conducted stratified trend analysis of medically treated overdose due to heroin, synthetic opioids, methadone, or other natural opioids among New Jersey Medicaid beneficiaries aged 12-64 years (2014-2019); evaluated associations with demographics and co-occurring conditions; and examined trends in fentanyl penetration in suspected heroin seizures from New Jersey State Police data.. Overdose risk more than tripled from 2014 to 2019, from 120.5 to 426.8 per 100,000 person-years, respectively. Increases primarily involved heroin and synthetic opioids and were associated with co-occurring alcohol and other non-opioid drug disorders, major depressive disorder, and hepatitis C. Concurrent changes in the drug exposure environment (2015-2019) included an increase in fentanyl penetration (proportion of suspected heroin seizures that included fentanyls) from 2% to 80%, and a decrease in the proportion of Medicaid beneficiaries who received opioid analgesic prescriptions from 23% to 13%.. Results document a rapid increase in overdose risk among individuals with opioid use disorder in an environment in which fentanyl is highly prevalent, and highlight the need for intensified services and engagement of non-treatment seekers, and integrated models to address multiple co-occurring conditions and risk factors.

Topics: Adolescent; Adult; Analgesics, Opioid; Child; Comorbidity; Depressive Disorder, Major; Drug Overdose; Fentanyl; Heroin; Humans; Medicaid; Middle Aged; New Jersey; Opiate Overdose; United States; Young Adult

To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected.. Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex.. Victoria, Australia.. The population of Victoria aged 12+ years.. Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation.. There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone.. In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.

Topics: Abuse-Deterrent Formulations; Adolescent; Adult; Aged; Analgesics, Opioid; Child; Emergency Medical Services; Female; Heroin; Humans; Interrupted Time Series Analysis; Male; Middle Aged; Morbidity; Opiate Overdose; Oxycodone; Prescription Drug Misuse; Victoria; Young Adult

Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA.. To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose.. Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses.. Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose.. Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults.. There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]).. Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Heroin; Humans; Opiate Overdose; Patient Protection and Affordable Care Act; United States; Young Adult

The US has seen a rapid increase in synthetic opioid-related overdose deaths. We investigate Ohio, a state with one of the highest overdose death rates in 2017 and substantial numbers of deaths related to fentanyl, carfentanil, and other fentanyl analogs, to provide detailed evidence about the relationship between changes in the illicit drug market and overdose deaths.. We investigate the illicit drug market using Ohio's Bureau of Criminal Investigation's (BCI) crime lab data from 2009 to 2018 that shows the content of drugs seized by law enforcement. We use Poisson regression analysis to estimate the relationship between monthly crime lab data and monthly unintentional drug overdose death data at the county level.. During this time period there has been a rapid change in the composition of drugs analyzed by the BCI labs, with a rapid fall in heroin observations, simultaneous rise in synthetic opioids, and an increase in the number of different fentanyl analogs. We find that the increased presence of fentanyl, carfentanil, and other fentanyl analogs have a strong correlation with an increase in overdose deaths. The types of opioids most associated with deaths varies by the population size of the county.. Crime lab data has the potential to be used as an early warning system to alert persons who inject drugs, harm reduction services, first responders, and law enforcement about changes in the illicit opioid risk environment.

Topics: Analgesics, Opioid; Crime; Drug Overdose; Female; Fentanyl; Forensic Medicine; Heroin; Humans; Illicit Drugs; Law Enforcement; Male; Ohio; Opiate Overdose

New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis.. Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data.. Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs.. A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Topics: Adolescent; Adult; Analgesics, Opioid; Female; Fentanyl; Harm Reduction; Heroin; Humans; Male; Needle-Exchange Programs; New Hampshire; Opiate Overdose; Rural Population; Self Report; Surveys and Questionnaires; Young Adult

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Topics: Analgesics, Opioid; Canada; Health Services Accessibility; Heroin; Humans; Hydromorphone; Opiate Overdose

With the emergence of illicit fentanyl, fentanyl-involved overdose rates increased from 2013 to 2017 in the United States (US). We describe US trends in opioid-related overdose mortality rates by race, age, urbanicity, and opioid type before and after the emergence of fentanyl.. Using the Centers for Disease Control and Prevention's WONDER database, we estimated crude and age-standardized opioid-related overdose mortality rates at the intersections of race (non-Hispanic [NH] Black and white), age (<55 and ≥55 years), sex (male and female) and urbanicity (urban and rural residence) from 2005 to 2017. We compare relative changes in mortality from 2013 to 17, and describe changes in the contributions of fentanyl, heroin, and other opioids to opioid-related overdose mortality.. From 2013 to 2017, the overall opioid overdose mortality rate was consistently higher in NH white Americans, however, the rate increase was greater among NH Black (174 %) compared to NH white (85 %) Americans. The steepest increases occurred in the overdose rates between 2013 and 2017 among younger (aged <55 years) urban NH Black Americans (178 % increase). Among older (≥55 years) adults, only urban NH Black Americans had an increase in overdose-related mortality rate (87 % increase). Urban NH Black Americans also experienced the greatest increase in the percent of fentanyl-involved deaths (65 % in younger, 61 % in older).. In the era of increased availability of illicitly manufactured fentanyl (2013-2017), there has been a disproportionate increase in opioid-related overdose deaths among urban NH Black Americans. Interventions for urban NH Black Americans are urgently needed to halt the increase in overdose deaths.

Topics: Adult; Aged; Analgesics, Opioid; Centers for Disease Control and Prevention, U.S.; Databases, Factual; Epidemics; Female; Fentanyl; Heroin; Humans; Male; Middle Aged; Opiate Overdose; Time Factors; United States; Young Adult