PubMed Update September 2012

Another busy month in overdose-related research (11 papers), including several toxicology and epidemiology papers, some of which represent novel analytic approaches that serve to advance the field.

1. Oxycodone overdose causes naloxone responsive coma and QT prolongation.

Berling I, Whyte IM, Isbister GK.

QJM. 2012 Sep 28. [Epub ahead of print]

PMID: 23023890 [PubMed - as supplied by publisher]

Comment: High-dose opioids can cause QT prolongation, a hypothetical bugaboo for methadone maintenance. What is QT prolongation? It is a warning sign that somebody might be at risk for a potentially fatal heart rhythm. More detail, you ask? Well, the EKG is a record of electrical activity in the heart – see below. Some medications make the time from Q to T longer. If it gets long enough (usually requiring very high doses of opioids in combination with either other medications or a genetic tendency to have a long QT) it can result in a dangerous heart rhythm. 

2. Factors associated with mortality among heroin users after seeking treatment with methadone: A population-based cohort study in Taiwan.

Huang CL, Chung-Wei L.

J Subst Abuse Treat. 2012 Sep 25. pii: S0740-5472(12)00138-9. doi: 10.1016/j.jsat.2012.08.003. [Epub ahead of print] 

Comment: Methadone is protective from death, but there still is quite a bit of mortality, including overdose.

3. Delayed posthypoxic leukoencephalopathy: Case reports.

Okuda S, Ueno M, Hayakawa M, Araki M, Kanda F, Takano S.

Rinsho Shinkeigaku. 2012;52(9):672-6. 

Comment: Two case reports of a debilitating white matter brain disease from benzodiazepine overdose.

4. The relationship between alcohol use and injecting drug use: Impacts on health, crime and wellbeing.

Dietze P, Jenkinson R, Aitken C, Stoové M, Jolley D, Hickman M, Kerr T.

Drug Alcohol Depend. 2012 Sep 15. pii: S0376-8716(12)00330-4. doi: 10.1016/j.drugalcdep.2012.08.013. [Epub ahead of print]

Comment: Drug injectors who drink heavily have more violent crime and poorer life satisfaction. Somewhat surprisingly, other health outcomes (like heroin overdose) did not survive controlling for potential confounders.

India Takes Up Overdose Prevention

by Nandini Pillai

Manipur, in Northeast India, has long battled an injection driven HIV epidemic, but took early steps to address it.  The state was among the first places in the country to adopt harm reduction measures, first "bleach and teach” programs before needle and syringe programs (NSPs) were considered acceptable, and then NSPs starting in 1994.  Manipuris were among the first to accept OST and run community based OST programs (1999-2002 and then again in 2006 continuing today).  Manipur was the first state in India to develop an HIV policy based in harm reduction principles in 1996, a policy that was later used as the basis of the national AIDS policy.  

Despite this forward thinking, naloxone isn’t currently available in state funded drop-in centers (DICs).  It is available for purchase in pharmacies in the cities, but it is often inaccessible because pharmacists know that people only buy naloxone in emergency situations and inflate the prices, sometimes to as much as 3000 rupees (about USD 50). In a place where harm reduction has been embraced for decades, it is sad to see that overdose prevention hasn’t been more of a priority.  

The good news is overdose awareness and advocacy for naloxone availability is on the agenda.  NGOs operating under Project ORCHID, the Bill & Melinda Gates funded HIV prevention program in Manipur and Nagaland, have stocked naloxone in DICs and trained staff to promote overdose awareness since 2009.  The Northeast India Knowledge Network Project has documented this program in a new publication, In Time: Drug overdose management in Manipur and Nagaland.    

The success of this program, as well as advocacy efforts from user groups and other service providers have helped to highlight overdose awareness at state and national levels.  The two main hospitals in Imphal now stock naloxone in their emergency departments, so patients' friends or relatives no longer have to negotiate with pharmacists outside the hospital.  Recently, the National AIDS Control Program included overdose management in their plans, meaning that even state funded DICs will stock naloxone.  Once integrated into government funded DICs, overdose will also be tracked as part of the central information management system which I hope will help us better understand overdose trends, and respond to them more effectively.

For more information about HIV prevention programs in Northeast India, please visit the Northeast India Knowledge Network webpage.

Nandini Pillai is a Project Officer with the Australian International Health Institute in New Delhi, India.

Policy: Overdose Legislation

The Network for Public Health Law has developed an excellent summary of naloxone access and Good Samaritan legislation in the United States. The authors have generated a helpful table to explain the confusing range of protections offered by the distinct language in each law