PubMed Update December 2016 / January 2017

49 in two months. Enjoy!

1) Multiple Fentanyl Overdoses - New Haven, Connecticut, June 23, 2016.

Tomassoni AJ, Hawk KF, Jubanyik K, Nogee DP, Durant T, Lynch KL, Patel R, Dinh D, Ulrich A, D'Onofrio G.

MMWR Morb Mortal Wkly Rep. 2017 Feb 3;66(4):107-111. doi: 10.15585/mm6604a4.

Comments: Nice description of an outbreak of and public health response to insufflated fentanyl causing severe overdose.

2) Patient Simulation for Assessment of Layperson Management of Opioid Overdose With Intranasal Naloxone in a Recently Released Prisoner Cohort.

Kobayashi L, Green TC, Bowman SE, Ray MC, McKenzie MS, Rich JD.

Simul Healthc. 2017 Feb;12(1):22-27. doi: 10.1097/SIH.0000000000000182.

Comments: Interesting and rigorous way to evaluate overdose knowledge after naloxone provision.

3) Pharmacokinetics of a new, nasal formulation of naloxone.

Tylleskar I, Skulberg AK, Nilsen T, Skarra S, Jansook P, Dale O.

Eur J Clin Pharmacol. 2017 Jan 31. doi: 10.1007/s00228-016-2191-1. [Epub ahead of print]

Comments: Data from another nasal naloxone in development.

4) In response to: Do heroin overdose patients require observation after receiving naloxone?

Eggleston W, Clemency BM.

Clin Toxicol (Phila). 2017 Jan 31:1-3. doi: 10.1080/15563650.2017.1284336. [Epub ahead of print] No abstract available.

Comments: Authors note that data on the safety of discharging patients after an hour of observation may not apply in the current era of synthetic opioids.

5) Pharmacists' role in opioid overdose: Kentucky pharmacists' willingness to participate in naloxone dispensing.

Freeman PR, Goodin A, Troske S, Strahl A, Fallin A, Green TC.

J Am Pharm Assoc (2003). 2017 Jan 28. pii: S1544-3191(16)31004-4. doi: 10.1016/j.japh.2016.12.064. [Epub ahead of print]

Comments: Mixed opinions.

6) 'Naloxone works': The politics of knowledge in 'evidence-based' drug policy.

Lancaster K, Treloar C, Ritter A.

Health (London). 2017 Jan 1:1363459316688520. doi: 10.1177/1363459316688520. [Epub ahead of print]

Comments: Interesting article on whose knowledge matters.

PubMed Update October/November 2016

43 papers this round, and there are some goodies in here for sure (don't miss #38!). Given the number and varied issues addressed, I divided them up into topic areas and, given the number on naloxone, I divided up the naloxone topic areas as well.

Naloxone interventions

Primary care

1) Co-prescription of naloxone as a Universal Precautions model for patients on chronic opioid therapy-Observational study.

Takeda MY, Katzman JG, Dole E, Bennett MH, Alchbli A, Duhigg D, Yonas H.

Subst Abus. 2016 Apr 19:1-6. [Epub ahead of print]

Comment: A pilot of naloxone co-prescribing.

2) Attitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain.

Mueller SR, Koester S, Glanz JM, Gardner EM, Binswanger IA.

J Gen Intern Med. 2016 Oct 31. [Epub ahead of print]

Comment: Shows that naloxone for patients prescribed opioids must be appropriately framed.

3) Acceptability of Naloxone Co-Prescription Among Primary Care Providers Treating Patients on Long-Term Opioid Therapy for Pain.

Behar E, Rowe C, Santos GM, Coffa D, Turner C, Santos NC, Coffin PO.

J Gen Intern Med. 2016 Nov 4. [Epub ahead of print]

Comment: When actually implemented, providers really like adding naloxone to opioid-related care. One of five papers out of the Naloxone for Opioid Safety Evaluation of a naloxone co-prescribing study in San Francisco.

PubMed Update September 2016

15 papers this month.

1) Drugs, Guns and Cars: How Far We Have Come to Improve Safety in the United States; Yet We Still Have Far to Go.

Dodington J, Violano P, Baum CR, Bechtel K.

Pediatr Res. 2016 Sep 27. doi: 10.1038/pr.2016.193. [Epub ahead of print] Review.

Comment: Review of safety efforts in public health.

2) Primary Care Patient Experience with Naloxone Prescription.

Behar E, Rowe C, Santos GM, Murphy S, Coffin PO.

Ann Fam Med. 2016 Sep;14(5):431-6. doi: 10.1370/afm.1972.

Comment: This is a partner paper to the study results reported a couple of months ago. Mixed methods interviews with 60 randomly selected patients on longterm opioid therapy for chronic pain who had been prescribed naloxone. The co-prescribing effort reached a population that was not really accessing naloxone through other community distribution sites in San Francisco. Some reported improved safety with opioids since receiving naloxone and none reported more high-risk use behaviors. About half of those who had overdosed denied “overdose” and described it as a bad reaction.

3) Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting.

Dunn KE, Barrett FS, Yepez-Laubach C, Meyer AC, Hruska BJ, Petrush K, Berman S, Sigmon SC, Fingerhood M, Bigelow GE.

J Subst Abuse Treat. 2016 Dec;71:1-7.

Comment: Can’t access the paper, but the abstract suggests higher rates of overdose among rural drug users versus urban, while there were fewer overdose risk behaviors among rural users (potentially raising concerns about our risk behaviors, which were retrospectively developed).

4) Longitudinal changes in psychological distress in a cohort of people who inject drugs in Melbourne, Australia.

Scott N, Carrotte ER, Higgs P, Cogger S, Stoové MA, Aitken CK, Dietze PM.

Drug Alcohol Depend. 2016 Sep 11;168:140-146. doi: 10.1016/j.drugalcdep.2016.08.638. [Epub ahead of print]

Comment: People who inject drugs have more psychological distress than the general population. Not surprised that intentional overdose (i.e. suicide attempt) is associated with psychological distress.

5) Notes from the Field: Furanyl-Fentanyl Overdose Events Caused by Smoking Contaminated Crack Cocaine - British Columbia, Canada, July 15-18, 2016.

Klar SA, Brodkin E, Gibson E, Padhi S, Predy C, Green C, Lee V.

MMWR Morb Mortal Wkly Rep. 2016 Sep 23;65(37):1015-1016. doi: 10.15585/mmwr.mm6537a6.

Comment: Fentanyl in crack. Ugh.

PubMed Update August 2016

A robust 20 papers this month. There are some excellent manuscripts this month, including several on fentanyl. I want to draw particular attention to a few papers that will be important reads for some of you: #1 addresses concurrent use of methamphetamine with heroin, #12 explores different “types” of opioid overdose, #17 reviews the foundational papers upon which much overdose research/knowledge today is based, and #19 compares deaths due to heroin to those due to prescription opioids.

1) Prevalence and Correlates of Heroin-Methamphetamine Co-Injection Among Persons Who Inject Drugs in San Diego, California, and Tijuana, Baja California, Mexico.

Meacham MC, Strathdee SA, Rangel G, Armenta RF, Gaines TL, Garfein RS.

J Stud Alcohol Drugs. 2016 Sep;77(5):774-81.

Comments: Really interesting results with regard to methamphetamine – co-use of methamphetamine increased overdose risk in San Diego but not Tijuana, suggesting that risk may have been behavioral rather than pharmacologic.

2) Combating Opioid Overdose With Public Access to Naloxone.

Mitchell KD, Higgins LJ.

J Addict Nurs. 2016 Jul-Sep;27(3):160-79. doi: 10.1097/JAN.0000000000000132.

Comments: Review of naloxone literature with an eye toward how it influences nursing.

3) Prescription opioids prior to injection drug use: Comparisons and public health implications.

Al-Tayyib AA, Koester S, Riggs P.

Addict Behav. 2016 Aug 19. pii: S0306-4603(16)30296-9. doi: 10.1016/j.addbeh.2016.08.016. [Epub ahead of print]

Comments: Those who initiated injection with prescription opioids were higher risk than those who started with heroin in the Denver Colorado’s NHBS cohort.

4) Awareness and Attitudes Toward Intranasal Naloxone Rescue for Opioid Overdose Prevention.

Kirane H, Ketteringham M, Bereket S, Dima R, Basta A, Mendoza S, Hansen H.

J Subst Abuse Treat. 2016 Oct;69:44-9. doi: 10.1016/j.jsat.2016.07.005. Epub 2016 Jul 18.

Comments: Investigators asked patients and providers how they thought things *would* change if they gave/received naloxone kits and found quite a few thought use would increase. In contrast, looking at what “did” happen suggests the opposite (see next month’s PubMed Update).

PubMed Update April 2016

23 for this month! Lots of interesting stuff, from large-scale epidemiology to randomized controlled trials.

1) Pharmacokinetic Properties and Human Use Characteristics of an FDA Approved IntranasalNaloxone Product for the Treatment of Opioid Overdose.

Krieter P, Chiang N, Gyaw S, Skolnick P, Crystal R, Keegan F, Aker J, Beck M, Harris J.

J Clin Pharmacol. 2016 May 5. doi: 10.1002/jcph.759. [Epub ahead of print]

Comment: Details on the pharmacokinetics and usability studies for the new nasal device.

2) The use of public health infrastructure probably the best strategy for national and large-scalenaloxone distribution programmes.

Madah-Amiri D, Clausen T.

Addiction. 2016 May 3. doi: 10.1111/add.13400. [Epub ahead of print] No abstract available.

Comment: Large-scale naloxone requires public health support.

3) The Opioid Epidemic in the United States.

Wilkerson RG, Kim HK, Windsor TA, Mareiniss DP.

Emerg Med Clin North Am. 2016 May;34(2):e1-e23. doi: 10.1016/j.emc.2015.11.002. Epub 2016 Feb 17. Review.

Comment: Focuses on risk factors for problematic opioid use and naloxone.

PubMed Update March 2016

23 this month.

1) Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria.

McDonald R, Strang J.

Addiction. 2016 Mar 30. doi: 10.1111/add.13326. [Epub ahead of print] Review.

Comments: Take-home naloxone meets all Bradford Hill criteria for causality in reducing opioid overdose mortality. Incidence of fatality among overdoses in the setting of take-home naloxone was 0.8%.

2) Managing Opioid Abuse in Older Adults: Clinical Considerations and Challenges.

Loreck D, Brandt NJ, DiPaula B.

J Gerontol Nurs. 2016 Apr 1;42(4):10-5. doi: 10.3928/00989134-20160314-04.

Comments: A review of the U.S. situation and treatments for opioid use disorder.

3) Years of potential life lost amongst heroin users in the Australian Treatment Outcome Study cohort, 2001-2015.

Darke S, Marel C, Mills KL, Ross J, Slade T, Tessson M.

Drug Alcohol Depend. 2016 May 1;162:206-10. doi: 10.1016/j.drugalcdep.2016.03.010. Epub 2016 Mar 18.

Comments: Heroin use is associated with 25-50 years of life lost. Over half of deaths and nearly two-thirds of years of life lost were due to opioid overdose.

4) Risk factors for unnatural death: Fatal accidental intoxication, undetermined intent and suicide: Register follow-up in a criminal justice population with substance use problems.

Olsson MO, Bradvik L, Öjehagen A, Hakansson A.

Drug Alcohol Depend. 2016 May 1;162:176-81. doi: 10.1016/j.drugalcdep.2016.03.009. Epub 2016 Mar 17.

Comments: Accidental overdose death and suicide are distinct entities, with distinct predictive variables. This is important.

5) An Initial evaluation of law enforcement overdose training in Rhode Island.

Saucier CD, Zaller N, Macmadu A, Green TC.

Drug Alcohol Depend. 2016 May 1;162:211-8. doi: 10.1016/j.drugalcdep.2016.03.011. Epub 2016 Mar 19.

Comments: Harm reduction programs training law enforcement, a critical step forward.

PubMed Update November 2015 - January 2016

We have 35 articles for your viewing this time, with apologies for the delay in getting this out. Thanks to Traci Green for offering to help out and for reviewing this post.

1) Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic.

Becker WC, Merlin JS, Manhapra A, Edens EL.

Addict Sci Clin Pract. 2016 Jan 28;11(1):3. doi: 10.1186/s13722-016-0050-0.

Comment: Fascinating article. Worth a read if you’re interested in management of pain and opioids.

2) Circumstances and contexts of heroin initiation following non-medical opioid analgesic use in New York City.

Harocopos A, Allen B, Paone D.

Int J Drug Policy. 2015 Dec 29. pii: S0955-3959(15)00374-6. doi: 10.1016/j.drugpo.2015.12.021. [Epub ahead of print]

Comment: Great to see some of the path from prescription opioids to heroin. Makes sense that first step is moving from a drug co-formulated with acetaminophen.

3) Emergency Department-Based Opioid Harm Reduction: moving physicians from willing to doing.

Samuels EA, Dwyer K, Mello MJ, Baird J, Kellogg A, Bernstein E.

Acad Emerg Med. 2016 Jan 27. doi: 10.1111/acem.12910. [Epub ahead of print]

Comment: To get EDs to enhance practices will require pressure from the top.

4) Internal Medicine Resident Knowledge, Attitudes and Barriers to Naloxone Prescription in Hospital and Clinic Settings.

Wilson JD, Spicyn N, Matson P, Alvanzo A, Feldman L.

Subst Abus. 2016 Jan 28:0. [Epub ahead of print]

Comment: Nice article from Baltimore finding that young physicians are ready and willing to prescribe naloxone, but aren’t routinely doing so yet.

PubMed Update March - May 2015

Three months. 46 papers. I’m already a month behind.

1) Development and implementation of intranasal naloxone opioid overdose response protocol at a homeless health clinic.

Dahlem CH, Horstman MJ, Williams BC.

J Am Assoc Nurse Pract. 2015 Mar 26. doi: 10.1002/2327-6924.12249. [Epub ahead of print]

Comments: Naloxone programs have been providing kits to settings where homeless people receive services for many years. This is a description of a program at a homeless health clinic.

2) Quantification of morphine, morphine 6-glucuronide, buprenorphine, and the enantiomers of methadone by enantioselective mass spectrometric chromatography in whole blood.

Christoffersen DJ, Brasch-Andersen C, Thomsen JL, Worm-Leonhard M, Damkier P, Brøsen K.

Forensic Sci Med Pathol. 2015 Jun;11(2):193-201. doi: 10.1007/s12024-015-9673-9. Epub 2015 Mar 24.

Comments: It’s been awhile since we had a forensics paper here. I think this is a novel method of identifying enantiomers.

3) A Comparison of Liver Disease Mortality With HIV and Overdose Mortality Among Georgia Prisoners and Releasees: A 2-Decade Cohort Study of Prisoners Incarcerated in 1991.

Spaulding AC, Sharma A, Messina LC, Zlotorzynska M, Miller L, Binswanger IA.

Am J Public Health. 2015 May;105(5):e51-7. doi: 10.2105/AJPH.2014.302546. Epub 2015 Mar 19.

Comments: Stunningly low rate of drug overdose mortality in this cohort of prisoners in Georgia. This is one of the first times I’ve seen a paper on opioid overdose find radically different results in a different setting. I can’t access for details.

4) A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice.

Mueller SR, Walley AY, Calcaterra SL, Glanz JM, Binswanger IA.

Subst Abus. 2015 Mar 16:1-14. [Epub ahead of print]

Comments: A review toward the end of using community distribution data to build clinical care naloxone prescription.

5) Long-term course of opioid addiction.

Hser YI, Evans E, Grella C, Ling W, Anglin D.

Harv Rev Psychiatry. 2015 Mar-Apr;23(2):76-89. doi: 10.1097/HRP.0000000000000052.

Comments: This is a systematic review of long-term studies of opioid users. Among many fascinating data reported, the length of time not using a drug of choice increases the likelihood of continuing to not use that drug. This seems obvious to many, but I don’t believe it’s been documented before. Good read for anyone looking to understand some of the longitudinal outcome data.

PubMed Update November 2014 - February 2015

Catching up on 51 papers in 4 months. Did you miss me?

1) New Drugs of Abuse.

Rech MA, Donahey E, Cappiello Dziedzic JM, Oh L, Greenhalgh E.

Pharmacotherapy. 2014 Dec 4. doi: 10.1002/phar.1522. [Epub ahead of print]

Comment: Review of management of drug toxicities among novel, synthetic compounds.

2) Police officer attitudes towards intranasal naloxone training.

Ray B, O'Donnell D, Kahre K.

Drug Alcohol Depend. 2015 Jan 1;146:107-10. doi: 10.1016/j.drugalcdep.2014.10.026. Epub 2014 Nov 8.

Comment: Police officers like being trained to carry naloxone.

3) Intranasal naloxone administration for treatment of opioid overdose.

Robinson A, Wermeling DP.

Am J Health Syst Pharm. 2014 Dec 15;71(24):2129-35. doi: 10.2146/ajhp130798.

Comment: Review of intranasal naloxone for overdose reversal.

4) Observed transition from opioid analgesic deaths toward heroin.

Dasgupta N, Creppage K, Austin A, Ringwalt C, Sanford C, Proescholdbell SK.

Drug Alcohol Depend. 2014 Dec 1;145:238-41. doi: 10.1016/j.drugalcdep.2014.10.005. Epub 2014 Oct 18.

Comment: Heroin overdoses are increasing.

5) Brief overdose education can significantly increase accurate recognition of opioid overdose amongheroin users.

Jones JD, Roux P, Stancliff S, Matthews W, Comer SD.

Int J Drug Policy. 2014 Jan;25(1):166-70. doi: 10.1016/j.drugpo.2013.05.006. Epub 2013 Jun 15.

Comment: Brief overdose training works for naloxone distribution. This is important because many places are requiring prolonged trainings that end up limiting access to those who are unable or unwilling to invest that degree of time.

6) Brief overdose education is sufficient for naloxone distribution to opioid users.

Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO.

Drug Alcohol Depend. 2015 Mar 1;148:209-12. doi: 10.1016/j.drugalcdep.2014.12.009. Epub 2014 Dec 19.

Comment: Again, brief overdose training works for naloxone distribution.

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 October/November 2012

My apologies for tardiness. I'll try to be on time next month. 13 papers described below.

1. Prevention of fatal opioid overdose.

Beletsky L, Rich JD, Walley AY.

JAMA. 2012 Nov 14;308(18):1863-4. doi: 10.1001/jama.2012.14205.

Comment: An excellent summary of key issues in overdose prevention and increasing naloxone availability for lay overdose reversal. Read it.

2. Management of opioid analgesic overdose.

Picetti E, Rossi I, Caspani ML.

N Engl J Med. 2012 Oct 4;367(14):1371-3

Comment: Multiple letters in response to the recent review article.

3. Randomized trial of long-acting sustained-release naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence.

Krupitsky E, Zvartau E, Blokhina E, Verbitskaya E, Wahlgren V, Tsoy-Podosenin M, Bushara N, Burakov A, Masalov D, Romanova T, Tyurina A, Palatkin V, Slavina T, Pecoraro A, Woody GE.

Arch Gen Psychiatry. 2012 Sep;69(9):973-81.

Comment: This was a randomized, placebo-controlled trial comparing naltrexone implant to oral naltrexone to nothing for preventing relapse to opioid dependence among detoxified patients in Russia. Participants were followed for six months and then followed up a year later to see if there was more death from overdose. The implant was more effective in retaining participants through the six months although by 3 months off therapy there was no difference between the groups. Authors only report “no evidence of increased risk of death due to overdose after  naltrexone treatment” and cite the initial paper showing injectable naltrexone as effective for opioid dependence in Russia (I’m unclear as to why this citation was present). I find this radically insufficient. Naltrexone has lab evidence (animal evidence shows that exposing opioid receptors to naltrexone makes them more sensitive to opioids than mere abstinence) and clinical evidence (high death rates after oral naltrexone treatment) suggesting that it increases risk of overdose and overdose death. The authors of this paper provide no details as to how they showed no evidence of increased overdose. How many people were they able to follow-up with at 18 months (their numbers were really small to begin with)? Did they inquire as to non-fatal overdose? How did they collect information about overdose death (coroners in Russia rarely identify overdose as a cause of death due to stigma and payment issues)? While extended-release naltrexone formulations *might* have less of an association with overdose, the concerns about oral naltrexone are well-established - how did the investigators get approval for oral naltrexone for opioid users from a U.S. government funded study? This is a vulnerable population for whom greater attention to toxicities should be demanded. A high level of attention to overdose outcomes might put to rest these concerns, but I have not seen that as of yet.

Department of Foreseeable Consequences: Tamper resistant OxyContin leads people to use more heroin

The New England Journal of Medicine today published a letter by Drs. Theodore Cicero, Matthew Ellis and Hilary Surratt that presents their research into how people who illegally use prescription opioids responded to the introduction of tamper-resistant OxyContin.  In a nutshell:

[T]he selection of OxyContin as a primary drug of abuse decreased from 35.6% of respondents before the release of the abuse-deterrent formulation to just 12.8% 21 months later (P<0.001). Simultaneously, selection of hydrocodone and other oxycodone agents increased slightly, whereas for other opioids, including high-potency fentanyl and hydromorphone, selection rose markedly, from 20.1% to 32.3% (P=0.005). Of all opioids used to “get high in the past 30 days at least once," OxyContin fell from 47.4% of respondents to 30.0% (P<0.001), whereas heroin use nearly doubled.

The idea with tamper-resistant formulation of OxyContin is that it's difficult crush pills for snorting or put them into solution for injecting (though users quickly found ways to do so by further processing the pills). What the authors have shown is that, at least in their small sample, this seems to have worked: significantly fewer people are using OxyContin to get high. What they haven't found is any reduction in overall opioid use.


And the kinds of opioid use people are turning to in lieu of OxyContin is what makes this a public health failure and an overdose concern: people appear to largely be turning to much more dangerous drugs. Heroin use, of course, carries risks associated with impurities in the cut, which in some cases may contribute to vein damage, infections, or a variety of toxic effects. The variable quality of street heroin, moreover, increases the likelihood that users' tolerance will fluctuate, thereby increasing overdose risk. Increased use of high potency opioids such as fentanyl is an obvious overdose risk, and indeed has been linked to spikes in overdose mortality in a number of locations. 

PubMed June 2012 Update

This chart was produced in 2007 to demonstrate the increase in overdose literature in the late 1990s and early 2000s - a trend that has continued. Twenty years ago there would have been 1 article for this post every 3-4 months, which may have been okay since you would have received it by actual post. 


Read on for a month of 8 papers laden with epidemiology...

1) HCV Infection Prevalence Lower Than Expected among 18-40-Year-Old Injection Drug Users in San Diego, CA.

Garfein RS, Rondinelli A,Barnes RF, Cuevas J, Metzner M, Velasquez M, Rodriguez D, Reilly M, Xing J,Teshale EH.

J Urban Health. 2012 Jul 6.[Epub ahead of print]

Comment: Focusing on the overdose component of the manuscript: Dr Garfein and colleagues found a relatively low rate of lifetime overdose in this cohort of 18-40 year olds of 28.1% (an analysis of these data with overdose as the outcome is clearly warranted). Most notably, they found an independent association of history of overdose with HCV infection. 

     This is consistent with other recent data suggesting an association between overdose and other drug-related risk behaviors such as syringe sharing. A poster this month at the International AIDS Conference shows that those who administer naloxone at their most recent witnessed overdose are less likely to share syringes than those who didn't administer naloxone. Moreover, the reductions in overdose we have seen in regions with well-funded naloxone distribution programs have been far more impressive than mathematical modeling would suggest. All together, these data force me to wonder if naloxone distribution has an effect well in excess of its ability to reverse an overdose.

2) Estimating the prevalence of illicit opioid use in New York City using multiple data sources.

McNeely J, Gourevitch MN, Paone D, Shah S, Wright S, Heller D.

BMC Public Health. 2012 Jun 18;12(1):443. [Epub ahead of print]

Comment: An excellent team of authors has attempted the perhaps impossible task of estimating the number of opioid users in New York City - a task that was hard enough with heroin alone. The results seem consistent enough to what would be predicted by large-scale epidemiologic studies to be of substantial use in future. I've asked for additional thoughts on this approach and will post comments when they come.

3) 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. 2012 Jun 12. [Epub ahead of print]

Comment: Among "low frequency" heroin users (who used 1-10 times in the past 30 days) 7.0% had overdosed in the past year. Among "high frequency" heroin users, 14.8% had overdosed in the past year. So infrequent heroin injectors overdose less in this sample. The low frequency injectors were marginally older, which may partially explain less overdose (that is, users who survive to older ages are less likely to overdose in a given year), yet I am still somewhat surprised by this result as I would presume low frequency injectors would have low or inconsistent opioid tolerance that might raise their risk of overdose. At this time, we clearly can't consider bouts of abstinence as a behavioral risk factor for overdose.

4) Vital signs: risk for overdose from methadone used for pain relief - United States, 1999-2010.

Centers for Disease Controland Prevention (CDC).

MMWR Morb Mortal Wkly Rep.2012 Jul 6;61:493-7.

Comment: Methadone has been the likely culprit for a large portion of prescription opioid deaths in the U.S. in the past 8-9 years. This likely occurred for a couple of reasons. First, extended release oxycodone was associated with a surge in opioid overdose deaths 10-12 years ago, so switching to methadone as the long-acting opioid seemed reasonable at the time. Unfortunately, dosing of methadone is complicated, with a non-linear dose-response curve that makes doses over 30mg dangerous for methadone-naive patients.