Narcana vs Death

An amazing mural conceived of and painted by Erin Ruch and Mikey Reger, artists with Mission Minicomix, in Clarion Alley, the Mission District of San Francisco.

PubMed Update October 2013

A slight reprieve from the onslaught, only 6 articles this month – some of which are really interesting.

1) The Toxicology Investigators Consortium Case Registry-The 2012 Experience.

Wiegand T, Wax P, Smith E, Hart K, Brent J.

J Med Toxicol. 2013 Nov 1. [Epub ahead of print]

Comments: Fascinating TocIC Registry, including cases that were attended to by boarded medical toxicologists (so this would represent a tiny subset of the type of accidental drug overdoses we generally discuss on this site). I’m unable to access the full article.

2) Acute coronary syndrome after methadone overdose in an opiate-naive patient.

De Cuyper A, Lambert M, Hantson P.

Acta Clin Belg. 2013 May-Jun;68(3):250-1. No abstract available.

Comments: Unable to access and no abstract available.

3) Delayed post-hypoxic leukoencephalopathy: case report with a review of disease pathophysiology.

Meyer MA.

Neurol Int. 2013 Jul 22;5(3):e13. doi: 10.4081/ni.2013.e13.

Comments: There was a similar review we discussed in 2012. This is a devastating white matter neurologic disease that has been reported after severe opioid overdoses; tends to occur days to weeks after the event.

4) Revisiting the role of the urban environment in substance use: the case of analgesic overdose fatalities.

Cerdá M, Ransome Y, Keyes KM, Koenen KC, Tardiff K, Vlahov D, Galea S.

Am J Public Health. 2013 Dec;103(12):2252-60. doi: 10.2105/AJPH.2013.301347. Epub 2013 Oct 17.

Comments: Fascinating analysis of opioid analgesic overdose fatalities in New York City from 2000-2006, compared to heroin overdose deaths and non-overdose unintentional deaths. Opioid analgesic deaths basically fit in the middle in terms of neighborhood wealth and social structure, between heroin deaths (lower income, socially fragmented) and non-overdose deaths (higher income, less fragmented). This article is also the first academic publication I’ve seen that demonstrates the unique geographic nature of opioid analgesic overdose mortality in NYC – Staten Island is an epicenter, a location that was historically essentially exempt from heroin overdose death.

5) Opioid overdose mortality in kansas, 2001-2011: toxicologic evaluation of intent.

Okic M, Cnossen L, Crifasi JA, Long C, Mitchell EK.

J Anal Toxicol. 2013 Nov;37(9):629-35. doi: 10.1093/jat/bkt085.

Comments: Analysis of opioids in deaths in Kansas, including drug concentrations. The most notable finding is that there is a very wide range of concentrations in overdose deaths involving these agents, a result consistent with decades of toxicological literature suggesting that tolerance plays a big role on risk for overdose and subsequent death.

6) Training family members to manage heroin overdose and administer naloxone: randomized trial of effects on knowledge and attitudes.

Williams AV, Marsden J, Strang J.

Addiction. 2013 Sep 17. doi: 10.1111/add.12360. [Epub ahead of print]

Comments: Authors randomized family members to receive just information versus a 60-minute training. They found that family members who went through the training scored higher on the standardized knowledge and attitude scales authors had previously published. Of note, naloxone was administered in witnessed overdose events for 3 out of 92 who just received information and 5 out of 95 who received the 60-minute training. This raises the very different question of what is sufficient for non-medical personnel to safely and effectively administer naloxone in the community? Information alone may be the answer to that question. While in-depth trainings are fantastic when available and accessible, requiring such activities can easily become an unnecessary obstacle to dissemination of the intervention … perhaps similar to historic requirements for extensive counseling and consent processes prior to HIV testing.

PubMed Update September 2013

12 articles this month.

1) Effectiveness of Naltrexone in the Prevention of Delayed Respiratory Arrest in Opioid-Naive Methadone-Intoxicated Patients.

Aghabiklooei A, Hassanian-Moghaddam H, Zamani N, Shadnia S, Mashayekhian M, Rahimi M, Nasouhi S, Ghoochani A.

Biomed Res Int. 2013;2013:903172. Epub 2013 Sep 9.

Comments: Interesting use of the long-acting opioid antagonist naltrexone in this study from Iran. The likely downside of this approach of course is that, in those with opioid dependence (constituting the vast majority of overdose cases), it doesn’t allow for titration of antagonist effect to minimize withdrawal symptoms.

2) An investigation of the interactions between methadone and elvitegravir/cobicistat in subjects receiving chronic methadone maintenance.

Bruce RD, Winkle P, Custodio JM, Wei X, Rhee MS, Kearney BP, Ramanathan S, Friedland GH.

Antimicrob Agents Chemother.2013 Sep 30. [Epub ahead of print]

Comments: This is a promising finding for the new HIV regimen.

3) Interaction of Different Antidepressants with Acute and Chronic Methadone in Mice, and Possible Clinical Implications.

Schreiber S, Barak Y, Hostovsky A, Baratz-Goldstein R, Volis I, Rubovitch V, Pick CG.

J MolNeurosci.2013 Sep 22. [Epub ahead of print]

Comments: Really interesting study, since many opioid overdoses occur in the presence of anti-depressant medications. These results are too preliminary to draw strong conclusions, but it’s an important pursuit.

4) Law enforcement attitudes toward overdose prevention and response.

Green TC, Zaller N, Palacios WR, Bowman SE, Ray M, Heimer R, Case P.

Drug Alcohol Depend.2013 Sep 2.doi:pii: S0376-8716(13)00334-7. 10.1016/j.drugalcdep.2013.08.018. [Epub ahead of print]

Comments: Interesting qualitative analysis of police attitudes toward lay naloxone.

5) Days of heroin use predict poor self-reported health in hospitalized heroin users.

Meshesha LZ, Tsui JI, Liebschutz JM, Crooks D, Anderson BJ, Herman DS, Stein MD.

Addict Behav. 2013 Aug 14;38(12):2884-2887. doi:

Comments: More days of heroin use is associated with worse self-reported health and worse self-reported health is associated with non-fatal overdose events.

6) Assisted injection among people who inject drugs in Thailand.

Lee WK, Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, Kerr T.

Subst Abuse Treat Prev Policy. 2013 Sep 10;8(1):32. [Epub ahead of print]

Comments: This is a useful contribution to overdose literature. There has long been a concern that people who require assistance to inject (often women) would overdose more. This hasn’t held up in studies and this study corroborates that lack of association. It may be well worth exploring further, but thus far we don’t have any evidence that assistance with injecting increases overdose risk.

7) BET 3: Is nebulised naloxone effective in opioid overdose?

[No authors listed]

Emerg Med J. 2013 Oct;30(10):860. doi: 10.1136/emermed-2013-203100.3.

Comments: Yes, in breathing patients.

8) The lethal burden of drug overdose.

[No authors listed]

Lancet. 2013 Sep 7;382(9895):833. doi: 10.1016/S0140-6736(13)61844-9. No abstract available.

Comments: Brief commentary on opioid overdose mortality in UK and US. Notable that there is no mention of naloxone.

9) [Maintaining opioid abstinence long after inpatient treatment with opioid substitution in an addictology hospital unit].

Bouab O, Lahmek P, Meunier N, Aubin HJ, Michel L.

Rev Med Brux. 2013 May-Jun;34(3):132-40. French.

Comments: Basically inpatient withdrawal from agonist maintenance treatment.

10) The pharmacokinetic and pharmacodynamic interactions between buprenorphine/naloxone and elvitegravir/cobicistat in subjects receiving chronic buprenorphine/naloxone treatment.

Bruce RD, Winkle P, Custodio JM, Wei LX, Rhee MS, Kearney BP, Ramanathan S, Friedland GH.

J Acquir Immune DeficSyndr. 2013 Aug 1;63(4):480-4. doi: 10.1097/QAI.0b013e3182961d31.

Comments: The new combined HIV med (Stribild) modestly increases buprenorphine levels.

11) Problem based review: The patient taking methadone.

Arora A, Williams K.

Acute Med. 2013;12(1):51-4. Review.

Comments: Methadone maintenance review.

12) Low-frequency heroin injection among out-of-treatment, street-recruited injection drug users.

Harris JL, Lorvick J, Wenger L, Wilkins T, Iguchi MY, Bourgois P, Kral AH.

J Urban Health. 2013 Apr;90(2):299-306. doi: 10.1007/s11524-012-9720-8.

Comments: Another useful contribution – infrequent heroin injectors had a lower risk of non-fatal overdose. As with most overdose epidemiology, the relationship between use frequency and overdose risk is likely complex.

PubMed Update: Another Year in Overdose

Another year in overdose, September 2012-August 2013, generally in reverse chronological order, and following the same loosely-formed categories as last year. 

Once again, this is opioid focused and misses anything not listed in the PubMed database – which means it misses many interesting papers to which you are warmly welcomed to post links!

This year there were 99 papers, up from 81 in the preceding 12 months. 

PubMed Update August 2013

16 papers today – this is getting to be a big job. Naloxone, fentanyl, methadone, stars, pain, Central Asia, primary care, injection facilities, personal stories …

1) Notes from the field: acetyl fentanyl overdose fatalities - rhode island, march-may 2013.

Centers for Disease Control and Prevention (CDC).

MMWR Morb Mortal Wkly Rep. 2013 Aug 30;62(34):703-4.

Comment: The evidence of synthetic fentanyl was difficult to detect and concerning to many as heralding a possible repeat of the 2006/2007 fentanyl-tainted heroin overdose outbreak.

2) Methadone induced sensorineural hearing loss.

Saifan C, Glass D, Barakat I, El-Sayegh S.

Case Rep Med. 2013;2013:242730. doi: 10.1155/2013/242730. Epub 2013 Jul 29.

Comment: In this case the patient was restarted on methadone and the sensorineural hearing loss was permanent.

3) Opioids compared to placebo or other treatments for chronic low-back pain.

Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC.

Cochrane Database Syst Rev. 2013 Aug 27;8:CD004959. doi:

Comment: There are no quality data to support long-term management of non-cancer pain with opioids.

4) Cory monteith dies of a heroin overdose at age 31.

Willens JS.

Pain Manag Nurs. 2013 Sep;14(3):125. doi: 10.1016/j.pmn.2013.07.004. No abstract available.

Comment: The Glee star.

PubMed Update July 2013

8 papers this month. Police, pharmacology, prisons, methadone, money, and plants. Enjoy!

1) Police Officers' and Paramedics' Experiences with Overdose and Their Knowledge and Opinions of Washington State's Drug Overdose-Naloxone-Good Samaritan Law.

Banta-Green CJ, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC.

J Urban Health. 2013 Jul 31. [Epub ahead of print]

Comment: Expands on the limited data we have regarding police and paramedics knowledge and opinions regarding opioid overdose prevention initiatives.

2) [Heroin].

Demaret I, Lemaître A, Ansseau M.

Rev Med Liege. 2013 May-Jun;68(5-6):287-93. French.

Comment: Only saw the abstract, but appears to be a nice summary of heroin, particularly overdose risk factors.

3) Potential P-glycoprotein Pharmacokinetic Interaction of Telaprevir With Morphine or Methadone.

Fudin J, Fontenelle DV, Fudin HR, Carlyn C, Hinden DA, Ashley CC.

J Pain Palliat Care Pharmacother. 2013 Jul 24. [Epub ahead of print]

Comment: Some potential interactions of the HCV protease inhibitor with selected opioids. Hopefully we won’t be using telaprevir too much longer as more advanced, effective, and easily tolerated regimens are expected as early as the end of 2013.

4) Non-fatal overdose among adult prisoners with a history of injecting drug use in two Australian states.

Moore E, Winter R, Indig D, Greenberg D, Kinner SA.

Drug Alcohol Depend. 2013 Jul 15. doi:pii: S0376-8716(13)00220-2.

Comments: Survey of prisoners lifetime history of overdose.

5) Factors associated with high-frequency illicit methadone use among rural Appalachian drug users.

Hall MT, Leukefeld CG, Havens JR.

Am J Drug Alcohol Abuse. 2013 Jul;39(4):241-6. doi:

Comment: I can’t access this article, but have some concerns about the utility of the analysis of covariates presented in the abstract.

6) Methadone-Related Overdose Deaths in Rural Virginia: 1997 to 2003.

Wunsch MJ, Nuzzo PA, Behonick G, Massello W, Walsh SL.

J Addict Med. 2013 Jul 8. [Epub ahead of print]

Comments: Analysis of methadone-related deaths.

7) The Economic Burden of Opioid-Related Poisoning in the United States.

Inocencio TJ, Carroll NV, Read EJ, Holdford DA.

Pain Med. 2013 Jul 10. doi: 10.1111/pme.12183. [Epub ahead of print]

Comments: Intriguing analysis of costs of opioid overdose, focusing on the costs to the healthcare system.

8) A drug fatality involving Kratom.

Neerman MF, Frost RE, Deking J.

J Forensic Sci. 2013 Jan;58 Suppl 1:S278-9. doi: 10.1111/1556-4029.12009. Epub 2012 Oct 19.

Comments: Kratom is a plant that grows in North America (this case is from Texas) and many other parts of the world. Its use is prohibited in Thailand. It acts as a mu-opioid receptor agonist.