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Objective To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.Design Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.Setting 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006.Participants OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. Intervention OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.Main outcome measures Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.Results Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100 000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100 000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.Conclusions Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.

This review provides a national summary of what is currently known about the Canadian opioid crisis with respect to opioid-related deaths and harms and potential risk factors as of December 2017. We reviewed all public-facing opioid-related surveillance or epidemiological reports published by provincial and territorial ministries of health and chief coroners' or medical examiners' offices. In addition, we reviewed publications from federal partners and reports and articles published prior to December 2017. We synthesized the evidence by comparing provincial and territorial opioid-related mortality and morbidity rates with the national rates to look for regional trends. The opioid crisis has affected every region of the country, although some jurisdictions have been impacted more than others. As of 2016, apparent opioid-related deaths and hospitalization rates were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. Current evidence suggests regional age and sex differences with respect to health outcomes, especially when synthetic opioids are involved. However, differences between data collection methods and reporting requirements may impact the interpretation and comparability of reported data. This report identifies gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis. The Public Health Agency of Canada will continue to work closely with the provinces, territories and national partners to further refine and standardize national data collection, conduct special studies and expand information-sharing to improve the evidence needed to inform public health action and prevent opioid-related deaths and harms.

Drug overdose deaths in the United States are a substantial public health issue. The number of annual reported drug overdose deaths increased roughly 3-fold, from 23 500 in 2002 to 70 200 in 2017. Of even greater concern, during this same period, the number of opioid-related overdose deaths increased 4-fold, from 11 900 in 2002 to 47 600 in 2017.From 2016 to 2017, rates of opioid-related overdose deaths rose from 42 400 to 47 600, an increase of 12%. Also during this period, death rates associated with cocaine and psychostimulants increased by 34.4% (from 3.2 to 4.3 per 100 000 population) and 33.3% (from 2.4 to 3.2 per 100 000 population), respectively, likely contributing to the rise in overall drug overdose deaths. On the other hand, the number of overdose deaths related to either prescription opioids (which include buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tramadol) or heroin did not increase.In this Executive Perspective, we review data on the opioid crisis and describe recent US and global trends in the role of toxic adulterants and other pharmacologically active components in illicitly manufactured street drugs. We also highlight the role of toxic adulterants in opioid-related overdose deaths, chronic illicit drug abuse, and other public health issues. Finally, based on the information provided, we propose that clinicians increase attention to the potential role of toxic adulterants when evaluating and treating patients involved in drug abuse, overdose death, and addiction and that future public and personal health responses to the opioid epidemic emphasize building awareness and knowledge about the presence and dangers of toxic adulterants. In this way, we can further highlight the need to aggressively decrease the supply of illicitly manufactured drugs.

Opioid-related mortality appears to be increasing in Canada. We examined the true extent of the problem and the impact of the introduction of long-acting oxycodone. We examined trends in the prescribing of opioid analgesics in the province of Ontario from 1991 to 2007. We reviewed all deaths related to opioid use between 1991 and 2004. We linked 3271 of these deaths to administrative data to examine the patients' use of health care services before death. Using time-series analysis, we determined whether the addition of long-acting oxycodone to the provincial drug formulary in January 2000 was associated with an increase in opioid-related mortality. From 1991 to 2007, annual prescriptions for opioids in creased from 458 to 591 per 1000 individuals. Opioid-related deaths doubled, from 13.7 per million in 1991 to 27.2 per million in 2004. Prescriptions of oxycodone increased by 850% between 1991 and 2007. The addition of long-acting oxycodone to the drug formulary was associated with a 5-fold increase in oxycodone-related mortality (p < 0.01) and a 41% increase in overall opioid-related mortality (p = 0.02). The manner of death was deemed unintentional by the coroner in 54.2% and undetermined in 21.9% of cases. Use of health care services in the month before death was common: for example, of the 3066 patients for whom data on physician visits were available, 66.4% had visited a physician in the month before death; of the 1095 patients for whom individual-level prescribing data were available, 56.1% had filled a prescription for an opioid in the month before death. Opioid-related deaths in Ontario have increased markedly since 1991. A significant portion of the increase was associated with the addition of long-acting oxycodone to the provincial drug formulary. Most of the deaths were deemed unintentional. The frequency of visits to a physician and prescriptions for opioids in the month before death suggests a missed opportunity for prevention.

BACKGROUND:Prescription drug monitoring programs (PDMPs) that collect and distribute information on dispensed controlled substances have been adopted by nearly all US states. We know little about program characteristics that modify PDMP impact on prescription opioid (PO) overdose deaths. METHODS:We measured associations between adoption of any PDMP and changes in fatal PO overdoses in 2002–2016 across 3109 counties in 49 states and D.C. We then measured changes related to the adoption of “proactive PDMPs,” which report outlying prescribing/dispensing patterns and provide broader access to PDMP data by law enforcement. Comparisons were made within 3 time intervals that broadly represent the evolution of PDMPs (2002–2004, 2005–2009, and 2010–2016). We modeled overdoses using Bayesian space-time models. RESULTS:Adoption of electronic PDMP access was associated with 9% lower rates of fatal PO overdoses after three years (rate ratio [RR] = 0.91, 95% credible interval [CI]0.88–0.93) with well-supported effects for methadone (RR = 0.86,95% CI0.82–0.90) and other synthetic opioids (RR = 0.82, 95% CI0.77–0.86). Compared with states with no/weak PDMPs, proactive PDMPs were associated with fewer deaths attributed to natural/semi-synthetic opioids (2002–2004RR = 0.72 [0.66–0.78]; 2005–2009RR = 0.93 [0.90–0.97]; 2010–20160.89 [0.86–0.92]) and methadone (2002–2004RR = 0.77 [0.69–0.85]; 2010–2016RR = 0.90 [0.86–0.94]). Unintended effects were observed for synthetic opioids other than methadone (2005–2009RR = 1.29 [1.21–1.38]; 2010–2016RR = 1.22 [1.16–1.29]). CONCLUSIONS:State adoption of PDMPs was associated with fewer PO deaths overall while proactive PDMPs alone were associated with fewer deaths related to natural/semisynthetic opioids and methadone, the specific targets of these programs. See video abstract at, http://links.lww.com/EDE/B619.

Background: Prescription drug abuse is a major health concern nationwide, with West Virginia having one of the highest prescription drug death rates in the United States. Studies are lacking that compare living subjects with persons who died from drug overdose for evidence of doctor and pharmacy shopping for controlled substances. The study objectives were to compare deceased and living subjects in West Virginia for evidence of prior doctor and pharmacy shopping for controlled substances and to identify factors associated with drug-related death. Methods: A secondary data study was conducted using controlled substance, Schedule II—IV, prescription data from the West Virginia Controlled Substance Monitoring Program and drug-related death data compiled by the Forensic Drug Database between July 2005 and December 2007. A case-control design compared deceased subjects 18 years and older whose death was drug related with living subjects for prior doctor and pharmacy shopping. Logistic regression identified factors related to the odds of drug-related death. Results: A significantly greater proportion of deceased subjects were doctor shoppers (25.21% vs. 3.58%) and pharmacy shoppers (17.48% vs. 1.30%) than living subjects. Approximately 20.23% of doctor shoppers were also pharmacy shoppers, and 55.60% of pharmacy shoppers were doctor shoppers. Younger age, greater number of prescriptions dispensed, exposure to opioids and benzodiazepines, and doctor and pharmacy shopping were factors with greater odds of drug-related death. Conclusions: Doctor and pharmacy shopping involving controlled substances were identified, and shopping behavior was associated with drug-related death. Prescription monitoring programs may be useful in identifying potential shoppers at the point of care.

ABSTRACT BACKGROUND Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids. OBJECTIVE To identify characteristics related to unintentional prescription opioid overdose deaths in Utah. DESIGN Interviews were conducted (October 2008–October 2009) with a relative or friend most knowledgeable about the decedent’s life. SUBJECTS Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid. KEY RESULTS Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which “to get high”]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %). CONCLUSIONS The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.

Background Acute poisoning is a common chief complaint leading to emergency department visits and hospital admissions in developing countries such as Iran. Data describing the epidemiology of different poisonings, characteristics of the clinical presentations, and the predictors of outcome are lacking. Such data can help develop more efficient preventative and management strategies to decrease morbidity and mortality related to these poisonings. This manuscript describes the epidemiology of acute poisoning among patients admitted to the intensive care unit (ICU) in Birjand, Iran. Methods This retrospective, cross-sectional study was conducted to characterize acute poisonings managed in the ICU during a 7-year period from March 2010 to March 2017 in a single center in Birjand, Iran. Patient characteristics, suspected exposure, the route of exposure, and outcome data were collected from hospital medical records. Results During the study period, 267 (64% male and 36% female) patients met inclusion criteria. Pharmaceutical medication (36.6%), opioids (26.2%) followed by pesticides (13.9%) were the most common exposures 38.2% of these cases were identified as suicide attempts. There were different frequencies in terms of xenobiotic exposure in relation to gender ( p  = 0.04) and the survival ( p  = 0.001). There was a significant difference between various xenobiotics identified as the cause of poisoning (p = 0.001). Mortality rate in our study was 19.5%. The incidence of outcomes was significantly higher in patients poisoned with opioids, pesticides, benzodiazepines, and tricyclic antidepressants ( p  < 0.05). The median length of hospital stay was higher in pesticide-poisoned patients ( p  = 0.04). Conclusion Opioids and pesticides were the most common exposures. The mortality rate of the poisoned patients in the ICU was proportionately high. The mortality rate due to opioid poisoning is a major concern and the most significant cause death due to poisoning in the region. Further monitoring and characterization of acute poisoning in Birjand, Iran is needed. These data can help develop educational and preventative programs to reduce these exposures and improve management of exposures in the prehospital and hospital settings.

To describe recent trends in opioid prescribing and prescription opioid poisoning resulting in hospitalisation or death in Victoria, Australia. This is a population‐based ecological study of residents of Victoria, 2006 – 14. Australian Bureau of Statistics residential population data were combined with Pharmaceutical Benefits Scheme (PBS) opioid prescription data, Victorian Admitted Episodes Data (VAED) and cause of death data. Annual opioid dispensings increased by 78% in 2006 – 13, from 0.33 to 0.58 per population. Opioid use increased with age: in 2013, 14% of Victorian residents aged ≥65 years filled at least one oxycodone prescription. In 2006 – 14, prescription opioid related hospital admissions increased by 6.8% per year, from 107 to 187 /1,000,000 person‐years; 56% were due to intentional self‐poisoning. Annual deaths increased from 21 to 28 /1,000,000 persons, in 2007 – 11. Admissions and deaths peaked at 25–44 years. Although both opioid prescribing and poisoning have increased, there is discrepancy between the exposed group (dispensings increased with age) and those with adverse consequences (rates peaked at ages 25–44 years). A better understanding is needed of drivers of prescribing and adverse consequences. Together with monitoring of prescribing and poisoning, this will facilitate early detection and prevention of a public health problem.