Quantity fluctuations of illicitly used opioids and overdose risk

Rowe, Christopher; Wheeler, Eliza; Vittinghoff, Eric; Santos, Glenn-Milo; Behar, Emily; Coffin, Phillip O.

doi:10.1016/j.drugpo.2018.05.004

Cited by 7 publications

(2 citation statements)

References 31 publications

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“…These unintentional variations might result, in a worst‐case scenario, in an injection which can lead to fatal consequences, primarily if tolerance to opioids has changed or heroin is consumed in combination with other drugs [43]. In this context, a recent study shows that high inter‐administration variability in the quantity of opioid used is associated with a higher risk of overdose, probably coupled with a reduction in tolerance [44]. These unintentional alterations in the prepared heroin can be a relevant contributory element in polydrug overdoses, as they can involve users more prone to taking higher risks [45].…”

Section: Discussionmentioning

confidence: 99%

Does the preparation for intravenous administration affect the composition of heroin injections? A controlled laboratory study

et al. 2021

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Aims To study whether the preparation procedure, and its acidic and heating conditions, used by heroin users to prepare heroin for intravenous administration affects the final composition of the fluid to be injected. Methods Samples from different seizures of illegal heroin provided by the Norwegian police were prepared by adding water and ascorbic acid before heating under controlled conditions in the laboratory. Further, three seizures were prepared with different amounts of ascorbic or citric acid relative to their diacetylmorphine content. Pure diacetylmorphine base or salt was also submitted to the procedure applying two different heating intensities. The seizures and the final product after preparation were analysed for diacetylmorphine, 6‐acetylmorphine and morphine using liquid chromatography with tandem mass spectrometry (LC‐MS‐MS). Results After preparation, a decrease of 19.8% (25th and 75th percentiles = −29.2 and −15.3) in the initial diacetylmorphine content was observed. Both the 6‐acetylmorphine and morphine content increased but, due to their low content in the initial product, diacetylmorphine still represented 83.9% (25th and 75th percentiles = 77.3 and 88.0) of the sum of these three opioids in the final solution. The loss of water during preparation caused an increase in the concentration of diacetylmorphine, 6‐acetylmorphine and morphine, depending on the heating intensity applied. The content of these opioids was affected by the quantity and type of acid added in relation to the heroin purity and the level of diacetylmorphine dissolved being proportional to the amount of ascorbic acid, but not citric acid, in the sample with high heroin purity. Conclusions Preparation of heroin for intravenous injection appears to change the amount or concentration of diacetylmorphine and its active metabolites, 6‐acetylmorphine and morphine in the final product, depending on heroin purity, amount and type of acid used or heating conditions. These circumstances can contribute to unintentional variations in the potency of the final injected solution, and therefore affect the outcome after injection.

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Section: Discussionmentioning

confidence: 99%

Does the preparation for intravenous administration affect the composition of heroin injections? A controlled laboratory study

et al. 2021

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“…9 As the opioid epidemic continues, the United States needs aggressive public health research to understand characteristics of drug overdose death trends and the impact of tools such as PDMPs. 1,10 The aims of this study were to (i) examine individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in KASPER with individuals who had no recorded prescriptions. Specifically, we studied toxicology reports and KASPER data to estimate hypothetical impact of prescription data in preventing the deaths of hundreds.…”

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confidence: 99%

Prescription History Before Opioid Overdose Death: PDMP Data and Responsible Prescribing

Shreffler

Shaw

Berrones

et al. 2020

Journal of Public Health Management and Practice

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Introduction:As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions. Methods: This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ 2 analyses for categorical variable comparisons and a separate univariate analysis for age. Results: Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD).Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects. Conclusions: Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

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