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 OverdoseWith 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 receivingnaloxone?

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.

7) Development and applications of the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdoseand suicide.

Oliva EM, Bowe T, Tavakoli S, Martins S, Lewis ET, Paik M, Wiechers I, Henderson P, Harvey M, Avoundjian T, Medhanie A, Trafton JA.

Psychol Serv. 2017 Feb;14(1):34-49. doi: 10.1037/ser0000099.

Comments: Can’t access the full article, but abstract describes a compelling effort to use EMRs in the VA system to identify patients for overdose prevention.

8) Commentary: Hypnotic Medications and Suicide: Risk, Mechanisms, Mitigation, and the FDA.

Ruan X, Luo JJ, Kaye AD.

Front Psychiatry. 2017 Jan 13;7:210. doi: 10.3389/fpsyt.2016.00210. No abstract available.

Comments: Authors respond to associations between certain medications and suicide, noting that associations are not causation and suggesting that they are can lead to a “nocebo” effect, causing the symptoms among those who read the warnings.

9) Buprenorphine prescribing practice trends and attitudes among New York providers.

Kermack A, Flannery M, Tofighi B, McNeely J, Lee JD.

J Subst Abuse Treat. 2017 Mar;74:1-6. doi: 10.1016/j.jsat.2016.10.005.

Comments: Major barriers were prior authorization (oy, it’s way past time for prior auths to be eliminated for bup), and limited clinic space and support. Utilizing home inductions is a great way to deal with the second concern. A lack of psychiatric support is the third noted concern, although data support buprenorphine provision with or without counseling.

10) Effect of tamoxifen and brain penetrant PKC and JNK inhibitors on tolerance to opioid-induced respiratory depression in mice.

Withey SL, Hill R, Lyndon A, Dewey WL, Kelly E, Henderson G.

J Pharmacol Exp Ther. 2017 Jan 27. pii: jpet.116.238329. doi: 10.1124/jpet.116.238329. [Epub ahead of print]

Comments: Investigators concluded that protein kinase C mediates tolerance to the respiratory depressive effects of morphine, and PKC blockers (like tamoxifen) reverse that tolerance and could therefore increase the risk of opioid overdose.

11) Examining Fatal Opioid Overdoses in Marion County, Indiana.

Ray B, Quinet K, Dickinson T, Watson DP, Ballew A.

J Urban Health. 2017 Jan 26. doi: 10.1007/s11524-016-0113-2. [Epub ahead of print]

Comments: Reduced opioid prescribing appears to have reduced death from prescribed opioids but increased deaths from illicit opioids.

12) Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department, Massachusetts, 2013-2014.

Ellison J, Walley AY, Feldman JA, Bernstein E, Mitchell PM, Koppelman EA, Drainoni ML.

Public Health Rep. 2016 Sep;131(5):671-675. doi: 10.1177/0033354916661981.

Comments: Using ICD-9 codes in ED visits identified 4.6% of patients with opioid poisoning or abuse/dependency codes. An additional 14.7% were prescribed opioids in the ED.

13) A case of massive methadone overdose presented with refractory hypoglycemia.

Li AT, Chu FK.

Clin Toxicol (Phila). 2017 Mar;55(3):233. doi: 10.1080/15563650.2016.1277236. No abstract available.

Comments: Fascinating complication of methadone toxicity.

14) Social mixing and correlates of injection frequency among opioid use partnerships.

Rowe C, Santos GM, Raymond HF, Coffin PO.

Int J Drug Policy. 2017 Jan 20;41:80-88. doi: 10.1016/j.drugpo.2016.11.016. [Epub ahead of print]

Comments: Identifies network correlates of frequent injection and witnessing overdose.

15) Development of an Opioid-Related Overdose Risk Behavior Scale (ORBS).

Pouget ER, Bennett AS, Elliott L, Wolfson-Stofko B, Almeñana R, Britton PC, Rosenblum A.

Subst Abus. 2017 Jan 23:0. doi: 10.1080/08897077.2017.1282914. [Epub ahead of print]

Comments: An interesting scale for opioid overdose risk. Would be great to see a prospective validation.

16) Lack of overlap and large discrepancies in the characteristics of the deceased in two sources of drug death. A linkage study of the Cause of Death and the Police Registries in Norway 2007-2009.

Amundsen EJ.

Int J Drug Policy. 2017 Jan 19;41:74-79. doi: 10.1016/j.drugpo.2016.12.016. [Epub ahead of print]

Comments: Interesting, if not surprising, results. Police registries didn’t include older, female, prescription opioid-involved drug deaths.

17) The pharmacist’s role in overdose: Using mapping technologies to analyzenaloxone and pharmacy distribution.

Burrell A, Ethun L, Fawcett JA, Rickard-Aasen S, Williams K, Kearney SM, Pringle JL.

J Am Pharm Assoc (2003). 2017 Jan 18. pii: S1544-3191(16)30889-5. doi: 10.1016/j.japh.2016.11.006. [Epub ahead of print]

Comments: Can’t access the full paper. They mapped overdose deaths and pharmacies carrying naloxone in Allegheny County, PA, finding that areas with more overdose were more likely to have pharmacies with naloxone.

18) Pharmaceutical opioid use among oral and intravenous users in Australia: A qualitative comparative study.

Dertadian G, Iversen J, Dixon TC, Sotiropoulos K, Maher L.

Int J Drug Policy. 2017 Jan 17;41:51-58. doi: 10.1016/j.drugpo.2016.12.007. [Epub ahead of print]

Comments: Oral opioid users were more well-off and resourced than those who injected.

19) Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity.

Isbister GK, Heppell SP, Page CB, Ryan NM.

Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234.

Comments: Clonidine is a blood pressure medication often used to blunt the symptoms of opioid withdrawal during detoxification. Toxicity includes altered mental status and slow heart rate, which does not respond to naloxone.

20) High risk injecting behaviour among people who inject pharmaceutical opioids in Australia.

Iversen J, Dertadian G, Geddes L, Maher L.

Int J Drug Policy. 2017 Jan 16;42:1-6. doi: 10.1016/j.drugpo.2016.12.004. [Epub ahead of print]

Comments: Opioid injectors who had injected opioid analgesics in the past 6 months had elevated risk behaviors and overdose frequency. This may seem to be in contrast to a paper out of Vancouver last year, which showed that opioid analgesic-only injectors had a risk of overdose similar to those who consumed the drugs orally. However the Vancouver paper found those who injected heroin as well as opioid analgesics had just as much risk of overdose as those who injected heroin. I’m not entirely certain how to put these two stories together, but perhaps the answer is that any injection of drugs obtained on the street brings similar overdose risk.

21) Characterization and Management of Patients with Heroin versus Non-HeroinOpioid Overdoses: Experience at an Academic Medical Center.

Morizio KM, Baum RA, Dugan A, Marin JE, Bailey AM.

Pharmacotherapy. 2017 Jan 18. doi: 10.1002/phar.1902. [Epub ahead of print]

Comments: Looking at those admitted for an overdose is a quite narrow subset of events. In this study from Kentucky, this subset – those admitted for heroin overdose generally didn’t need naloxone once admitted – whereas others ended up on naloxone drips in the intensive care unit. 19% had a repeat admission and 7.6% had a repeat admission for an overdose on the same drug within the 5 year study period. I would have expected a higher rate of readmission.

22) Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.

Bounthavong M, Harvey MA, Wells DL, Popish SJ, Himstreet J, Oliva EM, Kay CL, Lau MK, Randeria-Noor PP, Phillips AG, Christopher ML.

J Am Pharm Assoc (2003). 2017 Jan 11. pii: S1544-3191(16)30886-X. doi: 10.1016/j.japh.2016.11.003. [Epub ahead of print]

Comments: Academic detailing is a neat development in medical education. The basic idea is to use similar tactics as the pharmaceutical industry does to promote evidence-based and public health-oriented education for physicians, nurse practitioners, physician assistants, and pharmacists. This paper demonstrated a benefit in terms of naloxone prescribing among VA providers.

23) Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically.

Macmadu A, Carroll JJ, Hadland SE, Green TC, Marshall BD.

Addict Behav. 2017 May;68:35-38. doi: 10.1016/j.addbeh.2017.01.014.

Comments: I struggle to find the silver lining of fentanyl-containing street opioids.

24) Blockade of Serotonin 5-HT2A Receptors Suppresses Behavioral Sensitization andNaloxone-Precipitated Withdrawal Symptoms in Morphine-Treated Mice.

Pang G, Wu X, Tao X, Mao R, Liu X, Zhang YM, Li G, Stackman RW Jr, Dong L, Zhang G.

Front Pharmacol. 2016 Dec 26;7:514. doi: 10.3389/fphar.2016.00514.

Comments: If I follow the abstract, blocking serotonin 2a receptors suppressed withdrawal symptoms when naloxone is administered to morphine-dependent mice. Interesting new direction.

25) State legal innovations to encourage naloxone dispensing.

Davis C, Carr D.

J Am Pharm Assoc (2003). 2017 Jan 7. pii: S1544-3191(16)30890-1. doi: 10.1016/j.japh.2016.11.007. [Epub ahead of print]

Comments: As of August 2016, 44 states allow third-party administration of naloxone, 42 states allow a standing order or similar mechanism to enhance distribution, and 5 states allow pharmacists to furnish naloxone without a prescription. Although providing naloxone is no more prone to liability than any other medication, 36 states provide additional civil liability protection for those providing naloxone, 32 provide additional criminal liability protections, and 31 explicitly state that providing naloxone cannot be ground for professional disciplinary action.

26) Is Kratom the New ‘Legal High’ on the Block?: The Case of an Emerging Opioid Receptor Agonist with Substance Abuse Potential.

Chang-Chien GC, Odonkor CA, Amorapanth P.

Pain Physician. 2017 Jan-Feb;20(1):E195-E198.

Comments: Kratom is a largely unregulated opioid receptor agonist that comes in the form of dietary supplements.

27) A review: Fentanyl and non-pharmaceutical fentanyls.

Suzuki J, El-Haddad S.

Drug Alcohol Depend. 2017 Feb 1;171:107-116. doi: 10.1016/j.drugalcdep.2016.11.033. Review.

Comments: Again, I struggle to see the silver lining.

28) The implementation of a naloxone rescue program in university students.

Panther SG, Bray BS, White JR.

J Am Pharm Assoc (2003). 2017 Jan 4. pii: S1544-3191(16)30885-8. doi: 10.1016/j.japh.2016.11.002. [Epub ahead of print]

Comments: Education strategies for overdose prevention among students.

29) Opioid overdose prevention and naloxone rescue kits: what we know and what we don’t know.

Kerensky T, Walley AY.

Addict Sci Clin Pract. 2017 Jan 7;12(1):4. doi: 10.1186/s13722-016-0068-3. Review.

Comments: A review of naloxone programming.

30) Trajectories of heroin use: 10-11-year findings from the Australian Treatment Outcome Study.

Teesson M, Marel C, Darke S, Ross J, Slade T, Burns L, Lynskey M, Memedovic S, White J, Mills KL.

Addiction. 2017 Jan 6. doi: 10.1111/add.13747. [Epub ahead of print]

Comments: About a fifth continue to use at high levels, about a fifth stopped using early on and remained abstinent. This study continues to provide incredibly useful information.

31) Naloxone administration for suspected opioid overdose: An expanded scope of practice by a basic life support collegiate-based emergency medical services agency.

Jeffery RM, Dickinson L, Ng ND, DeGeorge LM, Nable JV.

J Am Coll Health. 2017 Jan 6:1-5. doi: 10.1080/07448481.2016.1277730. [Epub ahead of print]

Comments: Title says it all.

32) QuickStats: Rates of Drug Overdose Deaths Involving Heroin,* by Selected Age Groups – United States, 2006-2015.

MMWR Morb Mortal Wkly Rep. 2017 Jan 6;65(52):1497. doi: 10.15585/mmwr.mm6552a12.

Comments: The increase, really starting in 2011, is across age groups, most pronounced in those 25-54 years of age.

33) Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-2015.

Rudd RA, Seth P, David F, Scholl L.

MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-1452. doi: 10.15585/mmwr.mm655051e1.

Comments: The rising fentanyl deaths are a tragedy. The rising heroin deaths may be somewhat expected as access to prescribed opioids declined. The lack of a decline – and actual increase – in other opioid analgesics is surprising.

34) Lack of respiratory depression in paracetamol-codeine combination overdoses.

Heppell SP, Isbister GK.

Br J Clin Pharmacol. 2016 Dec 30. doi: 10.1111/bcp.13224. [Epub ahead of print]

Comments: Interesting paper. The role of codeine formulations in opioid overdose death is still a bit murky. They can clearly contribute in a polydrug death, but can they result in death on their own, absent acetaminophen toxicity?

35) Experiences of peer-trainers in a take-home naloxone program: Results from a qualitative study.

Marshall C, Perreault M, Archambault L, Milton D.

Int J Drug Policy. 2016 Dec 24;41:19-28. doi: 10.1016/j.drugpo.2016.11.015. [Epub ahead of print]

Comments: This is the second qualitative paper finding empowerment through naloxone programs.

36) Opioid Overdose Prevention Training with Naloxone, an Adjunct to Basic Life Support Training for First Year Medical Students.

Berland N, Fox A, Tofighi B, Hanley K.

Subst Abus. 2016 Dec 27:0. doi: 10.1080/08897077.2016.1275925. [Epub ahead of print]

Comments: Training early med students in overdose prevention and naloxone is a great idea. Although there wasn’t a significant change in attitude toward drug users, I don’t understand how they used the scale. The text reads that it was scored from 1 (disagree) to 6 (agree), but the questions switch back and forth with regard to what is a favorable response. If the total score if higher with more favorable attitudes toward drug users (unsure if that’s the case), the participants already had a fairly favorable attitude.

37) Do More Robust Prescription Drug Monitoring Programs Reduce Prescription Opioid Overdose?

Pardo B.

Addiction. 2016 Dec 23. doi: 10.1111/add.13741. [Epub ahead of print]

Comments: The paper concludes that states with PDMPs and medical marijuana dispensaries have fewer prescription opioid overdoses. It’s a complex, ecologic analysis. Unfortunately these ecologic analyses have proven very problematic lately, and this one, as an example, doesn’t account for law enforcement against grossly overprescribing providers.

38) Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2010-2014.

Warner M, Trinidad JP, Bastian BA, Minino AM, Hedegaard H.

Natl Vital Stat Rep. 2016 Dec;65(10):1-15.

Comments: Useful analysis of drugs mentioned in medical examiner reports of drug-related deaths. Top drugs were opioids (heroin, oxycodone, methadone, morphine, hydrocodone, fentanyl), benzodiazepines (alprazolam, diazepam), and stimulants (cocaine, methamphetamine). Almost half (48%) had more than one drug listed.

39) The Rising Price of Naloxone – Risks to Efforts to Stem Overdose Deaths.

Gupta R, Shah ND, Ross JS.

N Engl J Med. 2016 Dec 8;375(23):2213-2215. No abstract available.

Comments: While it’s nice to think that this is unique to naloxone, the truth – that pricing in the entire pharmaceutical market is out of control – is far more disturbing.

40) Intravenous use of intranasal naloxone: A case of overdose reversal.

Das S, Shah N, Ghadiali M.

Subst Abus. 2016 Dec 7:1-4. doi: 10.1080/08897077.2016.1267686. [Epub ahead of print]

Comments: This involved the old jerry-rigged naloxone that is losing favor due to difficulties with use when an easier to use nasal spray is now available.

41) The Prevalence of Paraphernalia Found at the Scene of Drug-Related Deaths.

Lozano JG, Healy NL, Kimberley Molina D.

J Forensic Sci. 2016 Dec 6. doi: 10.1111/1556-4029.13329. [Epub ahead of print]

Comments: I find this paper fascinating, yet tautological. By reading the narrative on drug-related deaths, authors found presence of paraphernalia to be associated with the death being drug-related. However, the presence of that paraphernalia is part of why the medical examiner determined the death to be drug-related. I’m not sure what else we’ve learned.

42) The Portapotty Experiment: Neoliberal approaches to the intertwined epidemics of opioid-related overdose and HIV/HCV, and why we need cultural anthropologists in the South Bronx.

Wolfson-Stofko B, Curtis R, Fuentes F, Manchess E, Del Rio-Cumba A, Bennett AS.

Dialect Anthropol. 2016 Dec;40(4):395-410.

Comments: Interesting story about efforts to create safer spaces for injecting.

43) Small state takes big steps in opioid-overdose reversal.

Traynor K.

Am J Health Syst Pharm. 2016 Jun 1;73(11):734-8. doi: 10.2146/news160033. No abstract available.

Comments: A story about Vermont’s efforts with naloxone.

44) HIV and drugs: a common, common-sense agenda for 2016.

Buse K, Albers E, Phurailatpam S.

Lancet Glob Health. 2016 May;4(5):e292-3. doi: 10.1016/S2214-109X(16)00043-7. No abstract available.

Comments: A call for humane action.

45) Altered Mental Status in a 14-Year-Old Girl.

Guimera AL, Kulkarni D.

Pediatr Rev. 2016 Apr;37(4):175-6. doi: 10.1542/pir.2015-0164. No abstract available.

Comments: Can’t access.

46) Linkage to Primary Care for Persons First Receiving Injectable Naltrexone During Inpatient Opioid Detoxification.

Stein MD, Risi MM, Bailey GL, Anderson BJ.

J Subst Abuse Treat. 2016 May;64:44-6. doi: 10.1016/j.jsat.2016.01.007.

Comments: 55% followed up for a second injection, 32% got a third injection. This type of dropoff from injectable naltrexone therapy is not uncommon.

47) The liability risks of naloxone access expansion should be the least of our worries.

Humphreys K.

Am J Drug Alcohol Abuse. 2016 Mar;42(2):115-6. doi: 10.3109/00952990.2015.1137299. No abstract available.

Comments: We’ve contorted ourselves in odd ways to protect providers and users from a hypothetical liability that may never come to pass.

48) From risk reduction to implementation: Addressing the opioid epidemic and continued challenges to our field.

Binswanger IA, Gordon AJ.

Subst Abus. 2016;37(1):1-3. doi: 10.1080/08897077.2015.1134152. No abstract available.

Comments: A commentary on a series of articles in the journal addressing naloxone, overdose, and opioid prescribing.

49) Who gets antidotes? choosing the chosen few.

Buckley NA, Dawson AH, Juurlink DN, Isbister GK.

Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Review.

Comments: How to provide an antidote to a suspected poisoning is an art form. For example, if a patient suffering from opioid overdose is stable and closely monitored, the main indication for naloxone administration would be worsening oxygenation (i.e. reversing the opioid and causing withdrawal may not be necessary). This is good practice, but unfortunately adds to the confusion and challenges in surveillance efforts.

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.

Emergency department

4) Emergency Department-based Opioid Harm Reduction: Moving Physicians From Willing to Doing.

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

Acad Emerg Med. 2016 Apr;23(4):455-65. doi: 10.1111/acem.12910.

Comment: There needs to be some high-level leadership in emergency medicine before we see real movement from emergency docs.

5) Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment.

Drainoni ML, Koppelman EA, Feldman JA, Walley AY, Mitchell PM, Ellison J, Bernstein E.

BMC Res Notes. 2016 Oct 18;9(1):465.

Comment: Uptake of naloxone provision from emergency departments has been surprisingly challenging.

6) Factors Associated With Participation in an Emergency Department-Based Take-Home Naloxone Program for At-Risk Opioid Users.

Kestler A, Buxton J, Meckling G, Giesler A, Lee M, Fuller K, Quian H, Marks D, Scheuermeyer F.

Ann Emerg Med. 2016 Oct 10. pii: S0196-0644(16)30407-3. doi: 10.1016/j.annemergmed.2016.07.027. [Epub ahead of print]

Comment: If you offer it from emergency departments, you’ll get reasonable uptake. Interesting in the context of our other ED naloxone papers from this month.

Corrections

7)  Randomized controlled pilot trial of naloxone-on-release to prevent post-prison opioid overdose deaths.

Parmar MK, Strang J, Choo L, Meade AM, Bird SM.

Addiction. 2016 Oct 24. doi: 10.1111/add.13668. [Epub ahead of print]

Comment: Interesting piece on the N-ALIVE trial, which was possibly our last real hope for a definitive randomized controlled trial of naloxone provision. Unfortunately it didn’t work out, but there is still room for some innovative trial designs to try to get close to such definitive data.

8) Stakeholder perceptions and operational barriers in the training and distribution of take-home naloxone within prisons in England.

Sondhi A, Ryan G, Day E.

Harm Reduct J. 2016 Feb 3;13:5. doi: 10.1186/s12954-016-0094-1.

Comment: Interesting elements of the challenges of providing naloxone in prisons, including identifying eligible inmates, inmate and staff perceptions, and logistical barriers.

Substance use treatment

9) Opioid overdose and naloxone education in a substance use disorder treatment program.

Lott DC, Rhodes J.

Am J Addict. 2016 Apr;25(3):221-6. doi: 10.1111/ajad.12364.

Comment: If you don’t give them naloxone, they don’t go get it themselves. This is like a flu vaccination. People don’t go out of their way for preventive interventions.

Distribution program

10) Process evaluation of the Prevent Overdose in Toronto (POINT) program.

Leece P, Gassanov M, Hopkins S, Marshall C, Millson P, Shahin R.

Can J Public Health. 2016 Oct 20;107(3):e224-e230. doi: 10.17269/cjph.107.5480.

Comment: As above.

Law enforcement / emergency medical service response

11) Police Officers Can Safely and Effectively Administer Intranasal Naloxone.

Fisher R, O’Donnell D, Ray B, Rusyniak D.

Prehosp Emerg Care. 2016 Nov-Dec;20(6):675-680.

Comment: A relief that few patients become combative in this situation.

12) Law Enforcement Attitudes towards Naloxone Following Opioid OverdoseTraining.

Purviance D, Ray B, Tracy A, Southard E.

Subst Abus. 2016 Aug 11:0. [Epub ahead of print]

Comment: Changes in the role of police for people who use drugs is a meaningful element of this process.

13) Implementation of online opioid overdose prevention, recognition and response trainings for professional first responders: Year 1 survey results.

Simmons J, Rajan S, Goldsamt L, Elliott L.

Drug Alcohol Depend. 2016 Oct 11;169:1-4. doi: 10.1016/j.drugalcdep.2016.10.003. [Epub ahead of print]

Comment: Evaluation of online naloxone training, with some innovative elements.

These two papers address early release by emergency medical personnel after naloxone administration.

14) Do heroin overdose patients require observation after receiving naloxone?

Willman MW, Liss DB, Schwarz ES, Mullins ME.

Clin Toxicol (Phila). 2016 Nov 16:1-7. [Epub ahead of print]

Comment: The short answer is “no”. Nice summary.

15) Is a Prehospital Treat and Release Protocol for Opioid Overdose Safe?

Kolinsky D, Keim SM, Cohn BG, Schwarz ES, Yealy DM.

J Emerg Med. 2016 Oct 18. pii: S0736-4679(16)30777-6. doi: 10.1016/j.jemermed.2016.09.015. [Epub ahead of print]

Comment: Probably per this paper. Yes per the parallel one that came out this month.

Miscellaneous

16) Can Naloxone Be Used to Treat Synthetic Cannabinoid Overdose?

Jones JD, Nolan ML, Daver R, Comer SD, Paone D.

Biol Psychiatry. 2016 Aug 18. pii: S0006-3223(16)32710-X. doi: 10.1016/j.biopsych.2016.08.013. [Epub ahead of print] No abstract available.

Comment: Interesting that naloxone seemed to help in these cases, in the absence of presence of opioids. There is an interaction between the opioid and cannabinoid receptor systems (which was actually an element of my undergraduate work with cannabinoids and pain – a theory suggested by the late J Michael Walker from Brown University).

Prescription opioids and chronic pain

17) Prescription drug abuse – A timely update.

Monheit B, Pietrzak D, Hocking S.

Aust Fam Physician. 2016 Dec;45(12):862-866.

Comment: Prescription opioids in Australia. And buprenorphine is really safe.

18) Opioid Misuse/Abuse and Quality Persistent Pain Management in Older Adults.

Chang YP, Compton P.

J Gerontol Nurs. 2016 Dec 1;42(12):21-30. doi: 10.3928/00989134-20161110-06.

Comment: Hopefully the new efforts at opioid prescribing will help. I remain concerned that, without substantial investments in funding other pain management strategies, feelings of patient abandonment will worsen.

19) Challenges to Treatment of Chronic Pain and Addiction During the “Opioid Crisis”.

Krashin D, Murinova N, Sullivan M.

Curr Pain Headache Rep. 2016 Dec;20(12):65. Review.

Comment: Per title.

20) Turning the Tide or Riptide? the Changing Opioid Epidemic.

Kertesz SG.

Subst Abus. 2016 Nov 18:0. [Epub ahead of print]

Comment: A pointed analysis of issues with the continued focus on opioid prescribing, when reforms have been followed by explosions in the use and consequences of street opioids.

21) Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain.

Wilder CM, Miller SC, Tiffany E, Winhusen T, Winstanley EL, Stein MD.

J Addict Dis. 2016;35(1):42-51. doi: 10.1080/10550887.2016.1107264.

Comment: Everybody underestimates their overdose risk. The next question is what does this mean (e.g. does this apply to most medical disorders?) and what do we do with the information?

22) Opioid Overdose: Risk Assessment and Mitigation in Outpatient Treatment.

Lin LA, Hosanagar A, Park TW, Bohnert AS.

J Addict Med. 2016 Nov/Dec;10(6):382-386.

Comment: Can’t access this case report of a patient with comorbid chronic pain and substance use disorder who had a heroin overdose.

23) Declines in Opioid Prescribing After a Private Insurer Policy Change – Massachusetts, 2011-2015.

García MC, Dodek AB, Kowalski T, Fallon J, Lee SH, Iademarco MF, Auerbach J, Bohm MK.

MMWR Morb Mortal Wkly Rep. 2016 Oct 21;65(41):1125-1131. doi: 10.15585/mmwr.mm6541a1.

Comment: Opioid stewardship interventions reduced opioid prescribing in Massachusetts. No surprise there. But no analysis of what happened to patients who were no longer prescribed opioids. We’re in the midst of a crisis and really need to go further than just looking at opioid prescribing.

24) 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: It takes a lot of work to manage patients well; many providers do not have the resources to pull this off.

25) Efficacy and safety of two methadone titration methods for the treatment of cancer-related pain: The EQUIMETH2 trial (methadone for cancer-related pain).

Poulain P, Berleur MP, Lefki S, Lefebvre D, Chvetzoff G, Serra E, Tremellat F, Derniaux A, Filbet M; EQUIMETH2 Study Group..

J Pain Symptom Manage. 2016 Sep 29. pii: S0885-3924(16)30312-8. doi: 10.1016/j.jpainsymman.2016.05.022. [Epub ahead of print]

Comment: Use of methadone as second-line pain control in cancer patients.

26) Factors associated with opioid overdose: a 10-year retrospective study of patients in a large integrated health care system.

Boscarino JA, Kirchner HL, Pitcavage JM, Nadipelli VR, Ronquest NA, Fitzpatrick MH, Han JJ.

Subst Abuse Rehabil. 2016 Sep 16;7:131-141.

Comment: Nice, large study, no surprising results.

27) Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM.

Health Aff (Millwood). 2016 Oct 1;35(10):1876-1883.

Comment: Wow this is complicated. And I’m unsure that amalgamated national data can appropriately reflect the reasons for such complicated results. The real impact in terms of overdose mortality, if there is one, is from prescribed opioids. It seems a stretch to say these data show a reduction in overall opioid overdose mortality.

Toxicology reports:

28) Risk Factors for Mortality and Endotracheal Intubation after MethadoneIntoxication.

Hassanian-Moghaddam H, Soltaninejad K, Shadnia S, Kabir A, Movahedi M, Mirafzal A.

Basic Clin Pharmacol Toxicol. 2016 Mar;118(3):231-7. doi: 10.1111/bcpt.12476.

Comment: Interesting that age seemed to predict the worst outcomes in methadone overdose. Again makes me wonder about what makes older opioid users seem more likely to die of overdose while younger users overdose more frequently.

27) Non-cardiogenic pulmonary edema, rhabdomyolysis and myocardial injury following heroin inhalation: a case report.

Bazoukis G, Spiliopoulou A, Mourouzis K, Grigoropoulou P, Yalouris A.

Hippokratia. 2016 Jan-Mar;20(1):84-87.

Comment: Title says it all.

28) An Unusual Case of Alternating Ventricular Morphology on the 12-Lead Electrocardiogram.

Sammon M, Dawood A, Beaudoin S, Harrigan RA.

J Emerg Med. 2016 Oct 7. pii: S0736-4679(16)30686-2. doi: 10.1016/j.jemermed.2016.08.027. [Epub ahead of print]

Comment: An overdose reversal case that led to the diagnosis of a variant of Wolff-Parkinson White, which is a cardiac disorder that can be life threatening.

29) Clinical effects of unintentional pediatric buprenorphine exposures: experience at a single tertiary care center.

Toce MS, Burns MM, O’Donnell KA.

Clin Toxicol (Phila). 2016 Oct 19:1-6. [Epub ahead of print]

Comment: Effects are similar to other opioids for infants/toddlers, and duration of observation required is dependent upon dose.

Substance use disorder treatment

30) Striatal H3K27 Acetylation Linked to Glutamatergic Gene Dysregulation in Human Heroin Abusers Holds Promise as Therapeutic Target.

Egervari G, Landry J, Callens J, Fullard JF, Roussos P, Keller E, Hurd YL.

Biol Psychiatry. 2016 Sep 28. pii: S0006-3223(16)32833-5. doi: 10.1016/j.biopsych.2016.09.015. [Epub ahead of print]

Comment: Interesting exploration of novel interventions for opioid use disorder.

31)  Fifty Years in the Development of a Glutaminergic-Dopaminergic Optimization Complex (KB220) to Balance Brain Reward Circuitry in Reward Deficiency Syndrome: A Pictorial.

Blum K, Febo M, Badgaiyan RD.

Austin Addict Sci. 2016;1(2). pii: 1006.

Comment: More on novel pharmacotherapies for opioid use disorder.

32) Treatment utilization among persons with opioid use disorder in the United States.

Wu LT, Zhu H, Swartz MS.

Drug Alcohol Depend. 2016 Oct 19;169:117-127. doi: 10.1016/j.drugalcdep.2016.10.015. [Epub ahead of print]

Comment: Yup, the United States has issues with providing appropriate treatments for opioid use disorder. These issues are multi-faceted, ranging from the unbelievable stigma faced by a person who even admits to any drug use in a medical setting, to the finance issues in a fragmented, barely hung together healthcare system slated to be further trampled in the next couple of years.

Epidemilogy / qualitative results

33) Assessing gender disparities in excess mortality of heroin or cocaine users compared to the general population.

Brugal MT, Molist G, Sarasa-Renedo A, de la Fuente L, Espelt A, Mesías B, Puerta C, Guitart AM, Barrio G; Spanish Working Group for the Study of Mortality amongDrug Users..

Int J Drug Policy. 2016 Nov 11;38:36-42. doi: 10.1016/j.drugpo.2016.10.009. [Epub ahead of print]

Comment: Gender comparison in overdose.

34) [Harm reduction interventions in drug users: current situation and recommendations].

Bosque-Prous M, Brugal MT.

Gac Sanit. 2016 Nov;30 Suppl 1:99-105. doi: 10.1016/j.gaceta.2016.04.020. Spanish.

Comment: Review of harm reduction strategies from Spain.

35) 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 Nov 1;168:140-146. doi: 10.1016/j.drugalcdep.2016.08.638.

Comment: Psychological distress is a major and fascinating domain in substance use disorders.

36) Drug use in business bathrooms: An exploratory study of manager encounters in New York City.

Wolfson-Stofko B, Bennett AS, Elliott L, Curtis R.

Int J Drug Policy. 2016 Oct 18;39:69-77. doi: 10.1016/j.drugpo.2016.08.014. [Epub ahead of print]

Comment: Interesting argument for supervised injection facilities.

36) County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs, United States.

Van Handel MM, Rose CE, Hallisey EJ, Kolling JL, Zibbell JE, Lewis B, Bohm MK, Jones CM, Flanagan BE, Siddiqi AE, Iqbal K, Dent AL, Mermin JH, McCray E, Ward JW, Brooks JT.

J Acquir Immune Defic Syndr. 2016 Nov 1;73(3):323-331.

Comment: Great paper. Innovative approach and analysis. Kudos.

37) Performance measures of diagnostic codes for detecting opioid overdose in the emergency department.

Rowe C, Vittinghoff E, Santos GM, Behar E, Turner C, Coffin P.

Acad Emerg Med. 2016 Oct 20. doi: 10.1111/acem.13121. [Epub ahead of print]

Comment: ICD coding for opioid poisoning in a safety net hospital detected only a quarter of opioid overdose cases, suggesting that surveillance of this issue based on billing codes in emergency departments may vastly underestimate the number of cases. It is also possible that there is huge variation in how cases are coded. Unfortunately, this is another strike against using “big data” in substance use research. The reasons for poor coding are many, including stigma.

38) Risk of fentanyl overdose among clients of the Sydney Medically Supervised Injecting Centre.

Latimer J, Ling S, Flaherty I, Jauncey M, Salmon AM.

Int J Drug Policy. 2016 Oct 14;37:111-114. doi: 10.1016/j.drugpo.2016.08.004. [Epub ahead of print]

Comment: Nice work by this team! Fentanyl injection had twice the risk of overdose of heroin injection and eight times the risk of injection other prescribed opioids. Although this is observational, it’s the first data we have to start to paint the picture.

39) Communicating risk in the context of methadone formulation changes: A qualitative study of overdose warning posters in Vancouver, Canada.

Markwick N, McNeil R, Anderson S, Small W, Kerr T.

Int J Drug Policy. 2016 Jan;27:178-81. doi: 10.1016/j.drugpo.2015.10.013. No abstract available.

Comment: Warnings should emphasize the specific risks for harm, not the potency.

40) Emergence of methadone as a street drug in St. Petersburg, Russia.

Heimer R, Lyubimova A, Barbour R, Levina OS.

Int J Drug Policy. 2016 Jan;27:97-104. doi: 10.1016/j.drugpo.2015.10.001.

Comment: Methadone use has increased from 4% in 2010 to 53% in 2012/13, and its use is associated with fewer HIV risk behaviors than heroin use.

41) Do drug seizures predict drug-related emergency department presentations or arrests for drug use and possession?

Wan WY, Weatherburn D, Wardlaw G, Sarafidis V, Sara G.

Int J Drug Policy. 2016 Jan;27:74-81. doi: 10.1016/j.drugpo.2015.09.012.

Comment: Not really, in Australia at least.

Reviews

42) 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 Oct 26. doi: 10.1038/pr.2016.193. [Epub ahead of print] Review.

Comment: So interesting to merge these three areas in thinking about public health interventions.

43) In Response to: “The Evolution of Recommended Naloxone Dosing for OpioidOverdose by Medical Specialty”.

Lombardi J, Villeneuve E, Gosselin S.

J Med Toxicol. 2016 Oct 24. [Epub ahead of print] No abstract available.

In Reply: “The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty”.

Connors NJ, Nelson LS.

J Med Toxicol. 2016 Oct 24. [Epub ahead of print] No abstract available.

Comment: Can’t access these letters

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.

6) Buprenorphine/Naloxone Versus Methadone for the Treatment of Opioid Dependence: A Review of Comparative Clinical Effectiveness, Cost-Effectiveness and Guidelines [Internet].

Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Sep 02.

Comment: Buprenorphine is safe, effective, and cost-effective compared to methadone.

7) Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain.

Dunn KE, Barrett FS, Fingerhood M, Bigelow GE.

Pain Med. 2016 Sep 20. pii: pnw228. [Epub ahead of print]

Comment: Not enough of these type of studies – addressing opioid overdose experience and knowledge among patients on opioids for chronic pain. 19% had a lifetime history of opioid overdose – similar to the study #2 above, although that study found that number to double when patients were asked about “bad reactions” that were characterized by not breathing or not being able to be woken up without help after using opioids.

8) Co-prescribing naloxone does not increase liability risk.

Davis CS, Burris S, Beletsky L, Binswanger I.

Subst Abus. 2016 Sep 20:0. [Epub ahead of print]

Comment: There is no particular liability in prescribing naloxone.

9) Trends in the Distribution of Opioids in Puerto Rico, 1999-2013.

El Burai Félix S, Mack KA, Jones CM.

P R Health Sci J. 2016 Sep;35(3):165-9.

Comment: Interesting that overdose deaths aren’t increasing as Rx opioid distribution is increasing. Hmm.

10) Standing Against Addiction.

Berlin J.

Tex Med. 2016 Sep 1;112(9):49-54.

Comment: Standing orders for naloxone in Texas.

11) Methadone conversion in infants and children: Retrospective cohort study of 199 pediatric inpatients.

Fife A, Postier A, Flood A, Friedrichsdorf SJ.

J Opioid Manag. 2016 May-Jun;12(2):123-30. doi: 10.5055/jom.2016.0324.

Comment: When we convert people from one opioid to another we use conversion ratios. When converting to methadone, kids were very under-dosed.

12) Location of fatal prescription opioid-related deaths in 12 states, 2008-2010: Implications for prevention programs.

Easterling KW, Mack KA, Jones CM.

J Safety Res. 2016 Sep;58:105-9. doi: 10.1016/j.jsr.2016.07.004. Epub 2016 Aug 7.

Comment: Most overdose deaths occur at home, more so for prescription opioid deaths.

13) Evaluating the impact of a national naloxone programme on ambulance attendance at overdose incidents: a controlled time series analysis.

McAuley A, Bouttell J, Barnsdale L, Mackay D, Lewsey J, Hunter C, Robinson M.

Addiction. 2016 Sep 10. doi: 10.1111/add.13602. [Epub ahead of print]

Comment: Naloxone distribution was not associated with a reduction in ambulances attending opioid overdoses. There could be other explanations for this, but the authors believe it suggests that people call for emergency medical assistance just as often when naloxone is available as when it is not.

14) Take-home naloxone treatment for opioid emergencies: a comparison of routes of administration and associated delivery systems.

Elzey MJ, Fudin J, Edwards ES.

Expert Opin Drug Deliv. 2016 Sep 16:1-14. [Epub ahead of print]

Comment: Hmm … an unambiguous endorsement – that nothing but the auto-injector should be used – coming from the makers of the auto-injector.

15) Analysis of Novel Synthetic Opioids U-47700, U-50488 and Furanyl Fentanyl by LC-MS/MS in Postmortem Casework.

Mohr AL, Friscia M, Papsun D, Kacinko SL, Buzby D, Logan BK.

J Anal Toxicol. 2016 Sep 1. [Epub ahead of print]

Comment: Synthetic opioids. Harrumph.

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).

5) Application of human factors engineering (HFE) to the design of a naloxone auto-injector for the treatment of opioid emergencies.

Raffa RB, Taylor R Jr, Pergolizzi JV Jr, Nalamachu S, Edwards ES, Edwards ET.

Drug Deliv Transl Res. 2016 Aug 25. [Epub ahead of print]

Comments: This is a paper about the naloxone auto-injector.

6) The paradox of decreasing nonmedical opioid analgesic use and increasing abuse or dependence – An assessment of demographic and substance use trends, United States, 2003-2014.

Jones CM.

Addict Behav. 2016 Aug 17. pii: S0306-4603(16)30306-9. doi: 10.1016/j.addbeh.2016.08.027. [Epub ahead of print]

Comments: We are not nearly out of the woods yet.

7) Increases in Fentanyl-Related Overdose Deaths – Florida and Ohio, 2013-2015.

Peterson AB, Gladden RM, Delcher C, Spies E, Garcia-Williams A, Wang Y, Halpin J, Zibbell J, McCarty CL, DeFiore-Hyrmer J, DiOrio M, Goldberger BA.

MMWR Morb Mortal Wkly Rep. 2016 Aug 26;65(33):844-9. doi: 10.15585/mmwr.mm6533a3.

Comments: Ugh.

8) Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved OverdoseDeaths – 27 States, 2013-2014.

Gladden RM, Martinez P, Seth P.

MMWR Morb Mortal Wkly Rep. 2016 Aug 26;65(33):837-43. doi: 10.15585/mmwr.mm6533a2.

Comments: Ugh.

9) OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain. Trial protocol.

Lin CW, McLachlan AJ, Latimer J, Day RO, Billot L, Koes BW, Maher CG.

BMJ Open. 2016 Aug 24;6(8):e011278. doi: 10.1136/bmjopen-2016-011278.

Comments: Interesting study protocol. Worthwhile effort.

10) A case of U-47700 overdose with laboratory confirmation and metabolite identification.

Jones MJ, Hernandez BS, Janis GC, Stellpflug SJ.

Clin Toxicol (Phila). 2016 Aug 23:1-5. [Epub ahead of print]

Comments: U-47700 can be detected in serum and the demethylated metabolites in urine.

11) Talking about screening, brief intervention, and referral to treatment for adolescents: An upstream intervention to address the heroin and prescription opioid epidemic.

Harris BR.

Prev Med. 2016 Aug 18. pii: S0091-7435(16)30227-4. doi: 10.1016/j.ypmed.2016.08.022. [Epub ahead of print]

Comments: SBIRT for adolescents. I’m mixed on this as SBIRT hasn’t fared so well in recent studies.

12) Development of a Proto-Typology of Opiate Overdose Onset.

Neale J, Bradford J, Strang J.

Addiction. 2016 Aug 20. doi: 10.1111/add.13589. [Epub ahead of print]

Comments: Totally fascinating and much needed work to elucidate different typologies of overdose.

13) Non-accidental non-fatal poisonings attended by emergency ambulance crews: an observational study of data sources and epidemiology.

John A, Okolie C, Porter A, Moore C, Thomas G, Whitfield R, Oretti R, Snooks H.

BMJ Open. 2016 Aug 18;6(8):e011049. doi: 10.1136/bmjopen-2016-011049.

Comments: Review of ambulance calls for poisoning in Wales.

14) Opioid Overdose: Risk Assessment and Mitigation in Outpatient Treatment.

Lin LA, Hosanagar A, Park TW, Bohnert AS.

J Addict Med. 2016 Aug 11. [Epub ahead of print]

Comments: A discussion of a case. Can’t access.

15) NIDA Clinical Trials Network CTN-0051, Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT): Study design and rationale.

Lee JD, Nunes EV, Mpa PN, Bailey GL, Brigham GS, Cohen AJ, Fishman M, Ling W, Lindblad R, Shmueli-Blumberg D, Stablein D, May J, Salazar D, Liu D, Rotrosen J.

Contemp Clin Trials. 2016 Aug 10. pii: S1551-7144(16)30202-6. doi: 10.1016/j.cct.2016.08.004. [Epub ahead of print]

Comments: Title says it all.

16) Commentary on Darke & Duflou (2016): Heroin-related deaths-identifying a window for intervention.

Tas B, McDonald R.

Addiction. 2016 Sep;111(9):1614-5. doi: 10.1111/add.13467. No abstract available.

Comments: Really interesting commentary addressing multiple possible implications of the cited article, which was discussed in a prior PubMed Update.

17) Addiction classics: Heroin overdose.

Darke S.

Addiction. 2016 Aug 10. doi: 10.1111/add.13516. [Epub ahead of print] Review.

Comments: Thanks to the author for reminding us where the current thinking about overdose emerged – since the 1970s there have been investigators proposing the tenets that currently serve as the foundation for our understanding of the field.

18) The Opioid Crisis and the Physician’s Role in Contributing to its Resolution: Step One–Prevention of Overdoses.

Wolfe S, Bouffard DL, Modesto-LoweE V.

Conn Med. 2016 Jun-Jul;80(6):325-34. Review.

Comments: Can’t access the paper, but appears to review for primary care providers the role of overdose prevention education and naloxone.

19) Recognition and response to opioid overdose deaths-New Mexico, 2012.

Levy B, Spelke B, Paulozzi LJ, Bell JM, Nolte KB, Lathrop S, Sugerman DE, Landen M.

Drug Alcohol Depend. 2016 Aug 3. pii: S0376-8716(16)30208-3. doi: 10.1016/j.drugalcdep.2016.07.011. [Epub ahead of print]

Comments: Interesting comparison of heroin to other opioid (OPR) deaths. OPR deaths were more likely to have multiple co-morbidities and prescribed polypharmacy. OPR detahs were just as likely to be witnessed (71.8% for OPR vs 74.5% for heroin), although more likely to be described as “abnormal drowsiness” and “snoring” for OPR than heroin. EMS was just as likely to be called to the scene and naloxone was half as likely to be given by paramedics for OPR vs heroin deaths. Drug paraphernalia or signs of injection were less likely in OPR deaths.

20) An autopsy case of acetyl fentanyl intoxication caused by insufflation of ‘designer drugs’.

Takase I, Koizumi T, Fujimoto I, Yanai A, Fujimiya T.

Leg Med (Tokyo). 2016 Jul;21:38-44. doi: 10.1016/j.legalmed.2016.05.006. Epub 2016 May 18.

Comments: Snored for 12 hours before being attended to.

1) Factors associated with knowledge of a Good Samaritan Law among young adults who use prescription opioids non-medically.

Evans TI, Hadland SE, Clark MA, Green TC, Marshall BD.

Harm Reduct J. 2016 Jul 26;13(1):24. doi: 10.1186/s12954-016-0113-2.

Comments: Less than half knew about it.

2) Reasons for Benzodiazepine Use Among Persons Seeking Opioid Detoxification.

Stein MD, Kanabar M, Anderson BJ, Lembke A, Bailey GL.

J Subst Abuse Treat. 2016 Sep;68:57-61. doi: 10.1016/j.jsat.2016.06.008. Epub 2016 Jun 16.

Comments: Important work, as there’s an effort to also reduce benzodiazepine prescribing among people who are on opioids. Understanding the drivers of BDZ use should be helpful in structuring interventions. Anxiety and managing opioid withdrawal were two main reasons.

3) Trends in Methadone Distribution for Pain Treatment, Methadone Diversion, and Overdose Deaths – United States, 2002-2014.

Jones CM, Baldwin GT, Manocchio T, White JO, Mack KA.

MMWR Morb Mortal Wkly Rep. 2016 Jul 8;65(26):667-71. doi: 10.15585/mmwr.mm6526a2.

Comments: Interesting analysis of methadone prescribing, overdose, and diversion. It seems that efforts to reduce methadone, beginning in 2006, corresponded with reduced diversion and overdose; unfortunate that opioid overdose death overall continued to escalate.

4) Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine.

Makarenko I, Mazhnaya A, Polonsky M, Marcus R, Bojko MJ, Filippovych S, Springer S, Dvoriak S, Altice FL.

Drug Alcohol Depend. 2016 Aug 1;165:213-20. doi: 10.1016/j.drugalcdep.2016.06.011. Epub 2016 Jun 17.

Comments: Barriers to enrolling in agonist treatment in Ukraine.

5) The next three letters were responding to an earlier paper from several months ago regarding intranasal naloxone:

While we dither, people continue to die from overdose: Comments on ‘Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?’

Coffin P, Rich J, Dailey M, Stancliff S, Beletsky L.

Addiction. 2016 Jul 14. doi: 10.1111/add.13412. [Epub ahead of print] No abstract available.

Comments on Strang et al. (2016): ‘Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?’

Doe-Simkins M, Banta-Green C, Davis CS, Green TC, Walley AY.

Addiction. 2016 Jul 14. doi: 10.1111/add.13399. [Epub ahead of print] No abstract available.

Letters to Addiction from Coffin et al. and Doe-Simpkins et al. re: ‘For Debate’ on clinical use of improvised nasal naloxone sprays: authors’ response.

Strang J, Mcdonald R.

Addiction. 2016 Jul 13. doi: 10.1111/add.13468. [Epub ahead of print] No abstract available.

6) Opioid agonist treatment for pharmaceutical opioid dependent people.

Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N.

Cochrane Database Syst Rev. 2016 May 9;(5):CD011117. doi: 10.1002/14651858.CD011117.pub2. Review.

Comment: Low to moderate evidence to support this intervention, but it appears more effective than other options.

7) [Death from fentanyl: Causative and preventive approaches in Bavaria].

Erbas B, Arnold M.

MMW Fortschr Med. 2016 Feb 18;158(3):54-6. doi: 10.1007/s15006-016-7821-0. Review. German. No abstract available.

Comments: Can’t access.

8) Australia reschedules naloxone for opioid overdose.

Lenton SR, Dietze PM, Jauncey M.

Med J Aust. 2016 Mar 7;204(4):146-7. No abstract available.

Comments: In Australia this means it is now available for over-the-counter purchase!

9) Take-home naloxone programs and calls to emergency services.

Kirwan A, Curtis M, van Beek IA, Cantwell K, Dietze PM.

Med J Aust. 2016 Mar 7;204(4):143. No abstract available.

Comments: Can’t access.

10) Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013.

Jones CM, Lurie PG, Compton WM.

Am J Public Health. 2016 Apr;106(4):689-90. doi: 10.2105/AJPH.2016.303062. Epub 2016 Feb 18.

Comments: 1170% increase in naloxone dispensed from US retail pharmacies from 2013-2015. Not sure the actual numbers because I can’t access the article.

11) Recurring Epidemics of Pharmaceutical Drug Abuse in America: Time for an All-Drug Strategy.

Herzberg D, Guarino H, Mateu-Gelabert P, Bennett AS.

Am J Public Health. 2016 Mar;106(3):408-10. doi: 10.2105/AJPH.2015.302982. Epub 2016 Jan 21.

Comments: Fascinating take. And timely, as we’ve already started seeing some – albeit still spotty – policy movements away from the calls for humane treatment in the current opioid epidemic in the U.S.

1) Community pharmacist knowledge, attitudes and confidence regarding naloxone for overdosereversal.

Nielsen S, Menon N, Larney S, Farrell M, Degenhardt L.

Addiction. 2016 Jul 1. doi: 10.1111/add.13517. [Epub ahead of print]

Comment: Most pharmacists in Australia would provide naloxone, but a minority feel comfortable selecting patients and educating about naloxone use and overdose.

2) Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.

Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, Vittinghoff E.

Ann Intern Med. 2016 Jun 28. doi: 10.7326/M15-2771. [Epub ahead of print]

Comment: Naloxone can be successfully prescribed to primary care patients on longterm opioids for chronic pain, and receipt of naloxone is associated with a remarkable reduction in opioid-related emergency department visits.

3) Opioid Use Disorders.

Sharma B, Bruner A, Barnett G, Fishman M.

Child Adolesc Psychiatr Clin N Am. 2016 Jul;25(3):473-87. doi: 10.1016/j.chc.2016.03.002. Epub 2016 Apr 9. Review.

Comment: Review of opioid use disorder and treatments.

4) Predictors of seeking emergency medical help during overdose events in a provincial naloxone distribution programme: a retrospective analysis.

Ambrose G, Amlani A, Buxton JA.

BMJ Open. 2016 Jun 21;6(6):e011224. doi: 10.1136/bmjopen-2016-011224.

Comment: Respondents administering naloxone to overdoses on the street were more likely to call for medical assistance than those doing so in a private residence. This makes a lot of sense. Imaging if giving a breathing treatment for asthma in a home versus on the street – the latter setting is more likely to result in seeking assistance.

5) A qualitative study of reasons for seeking and ceasing opioid substitution treatment in prisons in New South Wales, Australia.

Larney S, Zador D, Sindicich N, Dolan K.

Drug Alcohol Rev. 2016 Jun 21. doi: 10.1111/dar.12442. [Epub ahead of print]

Comment: Fascinating paper on why many people want to stop opioid treatment while in correctional settings.

6) Weighing the Risks and Benefits of Chronic Opioid Therapy.

Lembke A, Humphreys K, Newmark J.

Am Fam Physician. 2016 Jun 15;93(12):982-90.

Comment: Interesting article on opioid therapy, noting that the presence of a use disorder does not necessarily obviate the value of opioids.

7) Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain.

Ray WA, Chung CP, Murray KT, Hall K, Stein CM.

JAMA. 2016 Jun 14;315(22):2415-23. doi: 10.1001/jama.2016.7789.

Comment: I haven’t reviewed how they did the propensity matching, but if these findings hold, they raise some real concerns for this medical intervention.

8) The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty.

Connors NJ, Nelson LS.

J Med Toxicol. 2016 Jun 7. [Epub ahead of print]

Comment: Interesting that the dose for reversing an overdose in medical specialty literature is an order of magnitude different – from 0.05mg to 0.4mg IV – and we have yet another order of magnitude higher variation for lay reversal products.

9) Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members.

Wagner KD, Bovet LJ, Haynes B, Joshua A, Davidson PJ.

Drug Alcohol Depend. 2016 Aug 1;165:22-8. doi: 10.1016/j.drugalcdep.2016.05.008. Epub 2016 May 18.

Comment: This is the most detailed study looking at law enforcement naloxone to-date; nice job.

10) Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists.

Lim JK, Bratberg JP, Davis CS, Green TC, Walley AY.

J Addict Med. 2016 Jun 3. [Epub ahead of print]

Comment: Nice review of lay naloxone.

1) Methadone-Related Overdose Deaths in a Liberal Opioid Maintenance Treatment Programme.

Tjagvad C, Skurtveit S, Linnet K, Andersen LV, Christoffersen DJ, Clausen T.

Eur Addict Res. 2016 Jun 1;22(5):249-258. [Epub ahead of print]

Comments: Patients on very high doses of methadone or also using benzodiazepines were at higher risk of death.

2) Heroin use.

Salani DA, Zdanowicz M, Joseph L.

J Psychosoc Nurs Ment Health Serv. 2016 Jun 1;54(6):30-7. doi: 10.3928/02793695-20160518-05.

Comments: Epidemiologic review.

3) Academic physicians’ and medical students’ perceived barriers toward bystander administered naloxone as an overdose prevention strategy.

Gatewood AK, Van Wert MJ, Andrada AP, Surkan PJ.

Addict Behav. 2016 May 17;61:40-46. doi: 10.1016/j.addbeh.2016.05.013. [Epub ahead of print]

Comments: Qualitative interviews with medical providers.

4) Patient Characteristics and Outcomes in Unintentional, Non-fatal Prescription Opioid Overdoses: A Systematic Review.

Elzey MJ, Barden SM, Edwards ES.

Pain Physician. 2016 May;19(4):215-28.

Comments: Non-fatal events are far more common, not well-predicted by risk factors, and in need of additional research.

5) Incorporation of poison center services in a state-wide overdose education andnaloxone distribution program.

Doyon S, Benton C, Anderson BA, Baier M, Haas E, Hadley L, Maehr J, Rebbert-Franklin K, Olsen Y, Welsh C.

Am J Addict. 2016 Jun;25(4):301-6. doi: 10.1111/ajad.12384. Epub 2016 May 24.

Comments: Interesting case series of naloxone reversals reported to poison control. They report a 75.6% “response rate” although some of the remainder was “unknown” and was there were only 2 deaths among 78 cases, suggesting a rate closer to 97.5%. Response rate to heroin was higher than for prescription opioids. Of the 43 suspected heroin events, 31 went to the ED, 25 were discharged, and 5 required ICU care. Of 31 suspected prescription opioid 20 went to the ED, 9 were discharged, and 6 required ICU care. This is consistent with the more complicated nature of prescription opioid overdose.

6) Police Officers Can Safely and Effectively Administer Intranasal Naloxone.

Fisher R, O’Donnell D, Ray B, Rusyniak D.

Prehosp Emerg Care. 2016 May 24:1-6. [Epub ahead of print]

Comments: About a 65% response rate among 117 administrations and 1 combative individual.

7) Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions.

Sharma A, O’Grady KE, Kelly SM, Gryczynski J, Mitchell SG, Schwartz RP.

Subst Abuse Rehabil. 2016 Apr 27;7:27-40. doi: 10.2147/SAR.S81602. eCollection 2016. Review.

Comments: Overdose morality is through the roof when people leave correctional settings. Starting medications in-house is critical.

8) Confronting the HIV, Tuberculosis, Addiction, and Incarceration Syndemic in Southeast Asia: Lessons Learned from Malaysia.

Culbert GJ, Pillai V, Bick J, Al-Darraji HA, Wickersham JA, Wegman MP, Bazazi AR, Ferro E, Copenhaver M, Kamarulzaman A, Altice FL.

J Neuroimmune Pharmacol. 2016 May 24. [Epub ahead of print] Review.

Comments: Managing syndemics in Malaysia.

9) Qualitative assessment of take-home naloxone program participant and law enforcement interactions in British Columbia.

Deonarine A, Amlani A, Ambrose G, Buxton JA.

Harm Reduct J. 2016 May 21;13(1):17. doi: 10.1186/s12954-016-0106-1.

Comments: Interesting qualitative study of drug users and police regarding naloxone.

10) [Overdose of heroin and influencing factors in intravenous drug users in parts of Yunnan].

Zhou Y, Luo W, Cao XB, Zhang B, Wu ZY.

Zhonghua Liu Xing Bing Xue Za Zhi. 2016 May 10;37(5):648-52. doi: 10.3760/cma.j.issn.0254-6450.2016.05.012. Chinese.

Comments: 42% had ever overdosed and 16% had done so in the past year, a relatively low rate.

11) Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review.

Bauer LK, Brody JK, León C, Baggett TP.

J Health Care Poor Underserved. 2016;27(2):846-59. doi: 10.1353/hpu.2016.0075.

Comments: Of 219 homeless individuals who died of overdose in Boston, 81% of deaths involved opioids, 85% of decedents had substance use disorders, 61% had psychiatric illness, 45% had chronic pain, and 32% had all three of those issues. This is really complex clinical care.

12) The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings.

Chandler RK, Finger MS, Farabee D, Schwartz RP, Condon T, Dunlap LJ, Zarkin GA, McCollister K, McDonald RD, Laska E, Bennett D, Kelly SM, Hillhouse M, Mitchell SG, O’Grady KE, Lee JD.

Contemp Clin Trials. 2016 May;48:166-72. doi: 10.1016/j.cct.2016.05.003. Epub 2016 May 11.

Comments: Extended-release naltrexone studies.

13) Identifying mortality risks in patients with opioid use disorder using brief screening assessment: Secondary mental health clinical records analysis.

Bogdanowicz KM, Stewart R, Chang CK, Downs J, Khondoker M, Shetty H, Strang J, Hayes RD.

Drug Alcohol Depend. 2016 Jul 1;164:82-8. doi: 10.1016/j.drugalcdep.2016.04.036. Epub 2016 May 6.

Comments: Overdose death was associated with unsafe injecting and clinically-appraised suicidality.

14) Extended-release naltrexone opioid treatment at jail re-entry (XOR).

McDonald RD, Tofighi B, Laska E, Goldfeld K, Bonilla W, Flannery M, Santana-Correa N, Johnson CW, Leibowitz N, Rotrosen J, Gourevitch MN, Lee JD.

Contemp Clin Trials. 2016 May 10. pii: S1551-7144(16)30059-3. doi: 10.1016/j.cct.2016.05.002. [Epub ahead of print]

Comments: Description of a planned study.

15) Opioid Overdose Prevention Through Pharmacy-based Naloxone Prescription Program: Innovations in Healthcare Delivery.

Bachyrycz A, Shrestha S, Bleske BE, Tinker D, Bakhireva LN.

Subst Abus. 2016 May 10:0. [Epub ahead of print]

Comments: First paper I’ve seen on the uptake of naloxone from pharmacies. Promising data!

16) Opioid agonist treatment for pharmaceutical opioid dependent people.

Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N.

Cochrane Database Syst Rev. 2016 May 9;5:CD011117. doi: 10.1002/14651858.CD011117.pub2. Review.

Comments: Agonist treatment works, maintenance is best.

17) Naloxone access increases, as does price.

Thompson CA.

Am J Health Syst Pharm. 2015 Sep 1;72(17):1426-7. doi: 10.2146/news150056. No abstract available.

Comments: Nothing new here. Unfortunately, for the most effective approach – giving the medication away at low-threshold programs – the cost needs to be in the low single digits.

18) Opioid Use Trajectories, Injection Drug Use, and Hepatitis C Virus Risk Among Young Adult Immigrants from the Former Soviet Union Living in New York City.

Guarino H, Marsch LA, Deren S, Straussner SL, Teper A.

J Addict Dis. 2015;34(2-3):162-77. doi: 10.1080/10550887.2015.1059711.

Comments: Many participants got syringes only from a pharmacy to avoid being “outed” as a drug injector and did not receive any information about overdose – or other safety messaging – from that source.

19) Opioid abuse in the United States and Department of Health and Human Services actions to address opioid-drug-related overdoses and deaths.

U S Department Of Health And Human Services.

J Pain Palliat Care Pharmacother. 2015 Jun;29(2):133-9. doi: 10.3109/15360288.2015.1037530.

Comments: Yup.

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.

4) Design of a randomized controlled trial of extended-release naltrexone versus daily buprenorphine-naloxone for opioid dependence in Norway (NTX-SBX).

Kunøe N, Opheim A, Solli KK, Gaulen Z, Sharma-Haase K, Latif ZE, Tanum L.

BMC Pharmacol Toxicol. 2016 Apr 28;17(1):18. doi: 10.1186/s40360-016-0061-1.

Comment: Methods paper for above planned study.

5) Removal of methadone by extended dialysis using a high cut-off dialyzer: implications for the treatment of overdose and for pain management in patients undergoing light chain removal.

Arelin V, Schmidt JJ, Kayser N, Kühn-Velten WN, Suhling H, Eden G, Kielstein JT.

Clin Nephrol. 2016 Apr 27. [Epub ahead of print]

Comment: Doesn’t really remove methadone, so not useful in an overdose but also not problematic for patients on methadone undergoing light-chain removal.

6) Utilizing a train-the-trainer model for multi-site naloxone distribution programs.

Madah-Amiri D, Clausen T, Lobmaier P.

Drug Alcohol Depend. 2016 Apr 14. pii: S0376-8716(16)30034-5. doi: 10.1016/j.drugalcdep.2016.04.007. [Epub ahead of print]

Comment: Title is self-explanatory.

7) Opioid-related Policies in New England Emergency Departments.

Weiner SG, Raja AS, Bittner JC, Curtis KM, Weimersheimer P, Hasegawa K, Espinola JA, Camargo CA Jr.

Acad Emerg Med. 2016 Apr 21. doi: 10.1111/acem.12992. [Epub ahead of print]

Comment: Intriguing look at ED policies in New England. 18% had an opioid screening tool, 78% used the PDMP, 41% alerted the primary doctor when prescribing opioids, 70% gave substance use treatment referrals, and 12% offered take-home naloxone.

8) Opioid Overdose Prevention in a Residential Care Setting: Naloxone Education and Distribution.

Pade P, Fehling P, Collins S, Martin L.

Subst Abus. 2016 Apr 19:0. [Epub ahead of print]

Comment: Naloxone in a residential treatment program. Hopefully the first bit of data with much more to come.

9) 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 19:0. [Epub ahead of print]

Comment: New Mexico study of 164 chronic pain patients on opioids who were provided naloxone. There were no overdoses.

10) Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status.

Friedman MS, Manini AF.

J Med Toxicol. 2016 Apr 15. [Epub ahead of print]

Comment: Fascinating abstract – I don’t have full access. They set up “naloxone criteria” of (1) respiratory rate <12, miotic pupils, or drug paraphernalia, and (2) altered mental status by AVPU or GCS and then looked to see if those criteria predicted a beneficial effect of naloxone. They did – with an OR of 7 and 83% sensitivity. Miotic pupils were the best predictor of a response to naloxone. Authors also found that naloxone was underutilized – in only 44.2% of cases where it may have been beneficial. This is a fascinating area, as we don’t yet understand the reasons why naloxone is or is not administered in emergency services.

11) The toxicology of heroin-related death: estimating survival times.

Darke S, Duflou J.

Addiction. 2016 Apr 15. doi: 10.1111/add.13429. [Epub ahead of print]

Comment: 6-MAM, the best way to confirm heroin as a cause of overdose death, is only present if the death occurs in under 30 minutes. In this study, 6-MAM was present in 43% of heroin overdose cases, suggesting that most people took longer to expire.

12) Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition.

Lewis DA, Park JN, Vail L, Sine M, Welsh C, Sherman SG.

Am J Public Health. 2016 Apr 14:e1-e4. [Epub ahead of print]

Comment: Distribution program increased self-efficacy.

13) Findings and lessons learnt from implementing Australia’s first health service based take-home naloxone program.

Chronister KJ, Lintzeris N, Jackson A, Ivan M, Dietze P, Lenton S, Kearley J, van Beek I.

Drug Alcohol Rev. 2016 Apr 13. doi: 10.1111/dar.12400. [Epub ahead of print]

Comment: First data on an Australian naloxone program. 83 people given naloxone. Among the 42% completing follow-up, 30 overdoses were successfully reversed and participants still felt informed and able to use naloxone.

14) OVERDOSED ON OPIOIDS: A deadly opioid epidemic sweeping the country has lawmakers working hard to find solutions.

Hoback J.

State Legis. 2016 Apr;42(4):9-13. No abstract available.

Comment: On a quick glance, seems a bit inflammatory.

15) Safety concerns with long-term opioid use.

Harned M, Sloan P.

Expert Opin Drug Saf. 2016 Apr 26:1-8. [Epub ahead of print]

Comment: Prospective trials are needed to evaluate longterm opioid therapy for chronic pain.

16) Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders.

Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RA Jr, Wilson D, McDonald R, Rotrosen J, Gourevitch MN, Gordon M, Fishman M, Chen DT, Bonnie RJ, Cornish JW, Murphy SM, O’Brien CP.

N Engl J Med. 2016 Mar 31;374(13):1232-42. doi: 10.1056/NEJMoa1505409.

Comment: Pretty good data on extended-release naltrexone and low overdose risk. Unfortunately, overdose wasn’t specifically asked about, but instead was treated as any other adverse events in a clinical trial and had to be reported by the participants.

17) Overdose Deaths in West Virginia.

Yablonsky TA, Thompson GL.

W V Med J. 2016 Mar-Apr;112(2):16-7. No abstract available.

Comment: Can’t access, but there are a lot.

18) [Accidental ingestion of methadone by children and suggestions for better prevention].

Hein H, Püschel K, Schaper A, Iwersen-Bergmann S.

Arch Kriminol. 2016 Jan-Feb;237(1-2):38-46. German.

Comment: Lockboxes.

19) FASTER RESPONSE. Hospitals backing increased use of opioid antidote.

Asplund J.

Hosp Health Netw. 2016 Jan;90(1):20, 22, 2.

Comment: This is apparently about police and naloxone.

20) Increases in Drug and Opioid Overdose Deaths–United States, 2000-2014.

Rudd RA, Aleshire N, Zibbell JE, Gladden RM.

MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82. doi: 10.15585/mmwr.mm6450a3.

Comment: Really well done. Discusses opioids in a sophisticated and honest manner. Impressive work from the CDC.

21) Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study.

Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF.

Ann Intern Med. 2016 Jan 5;164(1):1-9. doi: 10.7326/M15-0038. Epub 2015 Dec 29.

Comment: Patients who have an overdose usually continue to receive opioids. If opioids stop, they have a lower risk of recurrent overdose.

22) Prescription opioid related deaths in New York City: a 2 year retrospective analysis prior to the introduction of the New York State I-STOP law.

Sgarlato A, deRoux SJ.

Forensic Sci Med Pathol. 2015 Sep;11(3):388-94. doi: 10.1007/s12024-015-9699-z. Epub 2015 Aug 2.

Comment: 36.7% of decedents had a valid opioid prescription; benzos were involved in 68.4% of cases with alprazolam the most common (35.1%).

23) Patterns and correlates of alcohol use amongst heroin users: 11-year follow-up of the Australian Treatment Outcome Study cohort.

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

Addict Behav. 2015 Nov;50:78-83. doi: 10.1016/j.addbeh.2015.06.030. Epub 2015 Jun 14.

Comment: Heavy drinking was associated with overdose (OR 1.6).

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.

6) Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care.

Levine M, Sanko S, Eckstein M.

Prehosp Emerg Care. 2016 Mar 28:1-4. [Epub ahead of print]

Comments: Studies of pre-hospital naloxone without transport to the hospital have uniformly shown extremely low rates of re-overdose or death in the ensuing 24 hours. This study examined 205 people over a much longer period and identified 3 deaths in the subsequent month. Again, this supports the relative safety of naloxone management and yet emphasizes the high risk of mortality in this population.

7) Opioid overdose and naloxone education in a substance use disorder treatment program.

Lott DC, Rhodes J.

Am J Addict. 2016 Apr;25(3):221-6. doi: 10.1111/ajad.12364. Epub 2016 Mar 22.

Comments: Education is excellent, but providing the medication on-site is critical.

8) Effective Use of Naloxone by Law Enforcement in Response to Multiple Opioid Overdoses.

Kitch BB, Portela RC.

Prehosp Emerg Care. 2016 Mar-Apr;20(2):226-9. doi: 10.3109/10903127.2015.1076097.

Comments: Police administering naloxone in the setting of fentanyl overdoses.

9) Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?

Burns G, DeRienz RT, Baker DD, Casavant M, Spiller HA.

Clin Toxicol (Phila). 2016 Mar 21:1-4. [Epub ahead of print]

Comments: Fascinating article! Many of us have wondered why fentanyl is such an extreme problem when used illicitly. This paper describes the phenomenon of chest wall rigidity with rapid IV administration of fentanyl, a possible explanation for the high risk of death in the setting of increased illicit fentanyl availability.

10) A Longitudinal Study of Multiple Drug Use and Overdose Among Young People Who Inject Drugs.

Riley ED, Evans JL, Hahn JA, Briceno A, Davidson PJ, Lum PJ, Page K.

Am J Public Health. 2016 May;106(5):915-7. doi: 10.2105/AJPH.2016.303084. Epub 2016 Mar 17.

Comments: Increased use is associated with increased overdose. This has been a persistent finding, potentially in conflict with the findings that periods of abstinence are associated with overdose. That is to say, even though low tolerance is a risk for overdose, it seems that more regular rather than more sporadic use increases overdose risk. Prevention messaging on this topic remains challenging.

11) Reducing the Risks of Relief – The CDC Opioid-Prescribing Guideline.

Frieden TR, Houry D.

N Engl J Med. 2016 Mar 15. [Epub ahead of print]

Comments: An editorial on the new CDC guidelines described below.

12) CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016.

Dowell D, Haegerich TM, Chou R.

JAMA. 2016 Mar 15. doi: 10.1001/jama.2016.1464. [Epub ahead of print]

Comments: New guidelines for opioid prescribing that emphasize reliance upon other therapies first and limited doses of opioids. They do recommend use of opioid agonist treatments for patients with co-morbid chronic pain and opioid use disorder, such as buprenorphine which can be prescribed by general practitioners in the U.S., and co-prescription of naloxone to patients on higher doses (>50 morphine equivalent milligrams) or other risk factors.

13) Engagement in a National Naloxone Programme among people who inject drugs.

McAuley A, Munro A, Bird SM, Hutchinson SJ, Goldberg DJ, Taylor A.

Drug Alcohol Depend. 2016 May 1;162:236-40. doi: 10.1016/j.drugalcdep.2016.02.031. Epub 2016 Mar 3.

Comments: Increased utilization but reduced likelihood of participants actually carrying naloxone on their person.

14) Improving Outcomes of Opioid Overdose: Preparing Nursing Students to Intervene.

Dion KA.

J Addict Nurs. 2016 Jan-Mar;27(1):7-11. doi: 10.1097/JAN.0000000000000106.

Comments: Training nursing students in opioid overdose management.

15) What is known about community pharmacy supply of naloxone? A scoping review.

Nielsen S, Van Hout MC.

Int J Drug Policy. 2016 Feb 15. pii: S0955-3959(16)30014-7. doi: 10.1016/j.drugpo.2016.02.006. [Epub ahead of print]

Comments: There’s some information out there but much more needed.

The next series of articles are all related to the lead author’s thesis that nasal naloxone is problematic; the final 5 being responses to the lead author’s recent article inAddiction critiquing nasal naloxone. Dr Strang has been a longtime advocate of naloxone, but not nasally administered. It’s important to note, as can be seen in the disclosures of his papers, that he/his employer hold a patent for buccal naloxone (#17 & 18). I’ll withhold any further comments.

16) Naloxone without the needle – systematic review of candidate routes for non-injectable naloxone for opioid overdose reversal.

Strang J, McDonald R, Alqurshi A, Royall P, Taylor D, Forbes B.

Drug Alcohol Depend. 2016 Mar 9. pii: S0376-8716(16)00141-1. doi: 10.1016/j.drugalcdep.2016.02.042. [Epub ahead of print] Review.

17) Amorphous Formulation and in Vitro Performance Testing of Instantly Disintegrating Buccal Tablets for the Emergency Delivery of Naloxone.

Alqurshi A, Kumar Z, McDonald R, Strang J, Buanz A, Ahmed S, Allen E, Cameron P, Rickard JA, Sandhu V, Holt C, Stansfield R, Taylor D, Forbes B, Royall PG.

Mol Pharm. 2016 Mar 28. [Epub ahead of print]

18) New approved nasal naloxone welcome, but unlicensed improvised naloxone spray kits remain a concern: proper scientific study must accompany innovation.

Strang J, Mcdonald R.

Addiction. 2016 Apr;111(4):590-2. doi: 10.1111/add.13319. No abstract available.

19) Ensure global access to naloxone for opioid overdose management.

Balster RL, Walsh SL.

Addiction. 2016 Apr;111(4):589-90. doi: 10.1111/add.13274. No abstract available.

20) Ethical issues and stakeholders matter.

Dale O.

Addiction. 2016 Apr;111(4):587-9. doi: 10.1111/add.13267. No abstract available.

21) Radical red tape reduction by government supported nasal naloxone: the Norwegian pilot project is innovative, safe and an important contribution to further development and dissemination of take-home naloxone.

Lobmaier PP, Clausen T.

Addiction. 2016 Apr;111(4):586-7. doi: 10.1111/add.13261. No abstract available.

22) Intranasal naloxone soon to become part of evolving clinical practice around opioid overdose prevention.

Dietze P, Cantwell K.

Addiction. 2016 Apr;111(4):584-6. doi: 10.1111/add.13260. No abstract available.

23) Tangled-up and blue: releasing the regulatory chokehold on take-home naloxone.

Winstanley EL.

Addiction. 2016 Apr;111(4):583-4. doi: 10.1111/add.13255. No abstract available.

1) As opioid overdose deaths reach record highs, call for systematic changes grows louder.

ED Manag. 2016 Feb;28(2):13-9.

Comments: Review of the new CDC opioid prescribing guidelines.

2) Australia reschedules naloxone for opioid overdose.

Lenton SR, Dietze PM, Jauncey M.

Med J Aust. 2016 Mar 7;204(4):146-7. No abstract available.

Comments: Naloxone can now be over the counter in Australia, but there’s some work to be done in product design.

3) Science Over Stigma: Saving Lives-Implementation of Naloxone Use in the School Setting.

King R.

NASN Sch Nurse. 2016 Mar;31(2):96-101. doi: 10.1177/1942602X16628890.

Comments: Naloxone for school nurses in Delaware.

4) Electrocardiogram Abnormality Associated with Methadone Overdose.

Agahi M, Shakoori V, Marashi SM.

Sultan Qaboos Univ Med J. 2016 Feb;16(1):e113-4. doi: 10.18295/squmj.2016.16.01.022. Epub 2016 Feb 2. No abstract available.

Comments: Long QT interval is a side effect of high methadone doses.

5) Demographics and post-mortem toxicology findings in deaths among people arrested multiple times for use of illicit drugs and/or impaired driving.

Ahlner J, Holmgren A, Jones AW.

Forensic Sci Int. 2016 Feb 3;265:138-143. doi: 10.1016/j.forsciint.2016.01.036. [Epub ahead of print]

Comments: Yet another population that may benefit from overdose prevention programming – persons arrested for impaired driving.

6) Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013.

Jones CM, Lurie PG, Compton WM.

Am J Public Health. 2016 Apr;106(4):689-90. doi: 10.2105/AJPH.2016.303062. Epub 2016 Feb 18.

Comments: Some increase in sales; much of this increase may be accounted for by a selected number of programs. These data were also presented at the FDA meeting on naloxone in July 2015.

7) Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction.

Butler MM, Ancona RM, Beauchamp GA, Yamin CK, Winstanley EL, Hart KW, Ruffner AH, Ryan SW, Ryan RJ, Lindsell CJ, Lyons MS.

Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01567-X. doi: 10.1016/j.annemergmed.2015.11.033. [Epub ahead of print]

Comments: 59% of opioid dependent participants were initially exposed via a medical prescription to them and 29% of those prescriptions came from emergency departments.

8) “There’s nothing here”: Deindustrialization as risk environment for overdose.

McLean K.

Int J Drug Policy. 2016 Mar;29:19-26. doi: 10.1016/j.drugpo.2016.01.009. Epub 2016 Jan 18.

Comments: This is fascinating. Poverty and social isolation.

9) Changes in the medical management of patients on opioid analgesics following a diagnosis of substance abuse.

Paulozzi LJ, Zhou C, Jones CM, Xu L, Florence CS.

Pharmacoepidemiol Drug Saf. 2016 Feb 10. doi: 10.1002/pds.3980. [Epub ahead of print]

Comments: Studying opioid prescribing is really complicated, because it involves making sense of – and trying to quantify – very complex and confusing medical decisions. This is an interesting analysis attempting to determine how much documentation of concerning opioid use behaviors results in changes in opioid prescribing.

10) Assessment of provider attitudes toward #naloxone on Twitter.

Haug NA, Bielenberg J, Linder SH, Lembke A.

Subst Abus. 2016 Jan-Mar;37(1):35-41. doi: 10.1080/08897077.2015.1129390.

Comments: Naloxone-trained individuals on Twitter “had the highest optimism and the lowest amount of burnout and stigma.”