A number of good papers this month! Most notable are the MMWR report and the intriguing Copenhagen data on opioid overdoses attended by emergency medical services.
Whelan PJ, Remski K.
J Neurosci Rural Pract. 2012 Jan;3(1):45-50.
Comment: Includes a brief review of the lower overdose risk with buprenorphine.
Delayed leukoencephalopathy after alprazolam and methadone overdose: A case report and review of the literature.
Carroll I, Heritier Barras AC, Dirren E, Burkhard PR, Horvath J.
Clin Neurol Neurosurg. 2012 Feb 16. [Epub ahead of print] No abstract available.
Comment: The precipitating event in this case is a hypoxic event in a patient with an enzyme deficiency, not a direct opioid or benzodiazepine toxicity.
Centers for Disease Control and Prevention (CDC).
MMWR Morb Mortal Wkly Rep. 2012 Feb 17;61:101-5.
Comment: Hooray! Read this for a review of U.S. nationwide naloxone program data.
Fernández P, Seoane S, Vázquez C, Tabernero MJ, Carro AM, Lorenzo RA.
J Appl Toxicol. 2012 Feb 15. doi: 10.1002/jat.2722. [Epub ahead of print]
Comment: An interesting method for identifying several drugs of abuse simoultaneously.
J Opioid Manag. 2011 Nov-Dec;7(6):443-9.
Comment: The importance of this article is not reflected in the title. This is a data linkage study in Australia looking at mortality rates among those receiving methadone (0.7%) versus naltrexone (2.6%) for opioid therapy. Again this raises the major concerns about opioid overdose after naltrexone therapy, concerns that were clearly inadequately addressed prior to FDA approval of naltrexone for opioid dependence.
Attitudes and knowledge about naloxone and overdose prevention among detained drug users in Ningbo, China.
Liu Y, Bartlett N, Li L, Lv X, Zhang Y, Zhou W.
Subst Abuse Treat Prev Policy. 2012 Feb 8;7(1):6. [Epub ahead of print]
Comment: Incarcerated drug users would like to have naloxone.
Comparative analysis of pathological and toxicological features of opiate overdose and non-overdose fatalities.
Soravisut N, Rattanasalee P, Junkuy A, Thampitak S, Sribanditmongkol P.
J Med Assoc Thai. 2011 Dec;94(12):1540-6.
Comment: There's an error in this title - it should be opiate versus non-opiate overdose deaths. Basic epidemiology.
Treatment of opioid overdose in a physician-based prehospital EMS: frequency and long-term prognosis.
Nielsen K, Nielsen SL, Siersma V, Rasmussen LS.
Resuscitation. 2011 Nov;82(11):1410-3. Epub 2011 Jun 15.
Comment: Very useful review of opioid overdoses attended by emergency medical services in Copenhagen. Of 3245 cases, 69% were released at the scene without transport to the hospital, 11% had cardiac arrest at the scene, 21% were admitted to the hospital, and 10% died. These data seem pretty consistent with my current understanding of EMS attended overdoses. Nonetheless, I find these data intensely interesting because, notwithstanding many theories, we still don't really know what happens to the overdoses that occur in the community.
Rudolph SS, Jehu G, Nielsen SL, Nielsen K, Siersma V, Rasmussen LS.
Resuscitation. 2011 Nov;82(11):1414-8. Epub 2011 Jul 2.
Comment: This is a sub-analysis of the prior study. They looked at the 69% of people that were released after naloxone was given and not transported to the hospital. They found that 3 of 2241 individuals died from a suspected "rebound overdose" after naloxone was given. Put in other words, 0.1% of overdose victims who were given naloxone at the scene and then released fell back into an opioid overdose and died. The authors looked pretty deeply into the circumstances post-release, so I think these data are reliable. While this figure is impressively low, it does reaffirm the need for bystanders to stay with overdose victims for several hours after reversing an overdose.
Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States.
Semaan S, Fleming P, Worrell C, Stolp H, Baack B, Miller M.
Drug Alcohol Depend. 2011 Nov 1;118(2-3):100-10. Epub 2011 Apr 23.
Comment: A review of data on supervised injection facilities, which have impressive data on reducing local overdose mortality in Vancouver.
Shaw KA, Babu KM, Hack JB.
J Emerg Med. 2011 Dec;41(6):635-9. Epub 2010 Dec 9.
Comment: An unusual toxicity to opioid overdose, but one that has been previously documented. Generally neurologic in origin and reversible with removal of the offending opioid agent.