Drug Abuse Deaths Research Articles

Characteristics of drug-related deaths where individuals are found submerged in a bath or hot tub in the United Kingdom, 1997-2023.

Recent media reports highlight that drug-related fatalities can occur while individuals are immersed in water in domestic settings. We aimed to determine the case characteristics, circumstances of death and type of implicated drugs among individuals dying due to unintentional drug-related causes found immersed in a bath or hot tub. Retrospective cohort study in the United Kingdom using coronial records from the National Programme on Substance Abuse Deaths, 1997-2023. Information was available on decedent socio-demographics, characteristics of death and drugs implicated in death. One hundred fifty-six decedents were found immersed in the bath and six in a hot tub, a mean of 6.4 deaths per year (SD 3.7; range 1-13). Overall decedents were predominantly male (n = 94, 58.0%), of White ethnicity (n = 98, 60.5%) with a mean age of 40 years (SD 13; range 19-74). Only 12 decedents had any physical contributory factor to death other than poisoning or drowning. The median number of drugs detected at post-mortem was 3 (interquartile range 2, 5) with multiple drug toxicity implicated in the majority of cases (n = 90, 55.6%). The most common implicated drugs were heroin (n = 53, 32.7%), alcohol (n = 46, 28.4%) and cocaine (n = 33, 20.4%). Over the last two decades in the United Kingdom there have been consistent numbers of unintentional drug-related deaths each year where individuals were found in a bath or hot tub. Polysubstance, opioid and alcohol use are overrepresented. Targeted advice to avoid bathing while intoxicated would appear to be an appropriate harm reduction message.

An evaluation of naloxone transit for opioid overdose using drones: A case study using real-world coroner data.

Opioids are now the most cited class in fatal overdoses. However, the antidote for opioid overdose-naloxone-is not always readily available. Our aim was to evaluate the feasibility of naloxone transit via drone to provide rapid access at the point of care. Real-world data pertaining to opioid overdoses, which occurred in the Teesside area of the UK 2015-2019, were extracted from the National Programme on Substance Abuse Deaths (NPSAD). The original locations of these opioid overdoses were used to compare the projected response times of ambulances with that of drones when considering the impacts of actual traffic and weather conditions, respectively; 58 cases were identified where a bystander-who could have called for and administered emergency naloxone-was likely present. In 78% of cases (n = 45/58) a class C1 commercial-off-the-shelf drone carrying naloxone could have reached the overdose location in 7min-the benchmark time for the arrival of emergency services for Category 1 calls in England. With the implementation of recent advances in drone engineering, such as increased speeds and temperature-controlled cargo cradles, it is estimated that 98% of overdoses could have been reached in this timeframe (n = 57/58). Ambulances were able to reach a significantly lower number of cases in 7min, even when considering best-case scenario traffic conditions (14%, n = 8/58, χ2 P < 0.001). This study provides proof-of-concept that, in the Teesside area of the UK, drones are more likely than ambulance to get naloxone to the site of an opioid overdose in 7min.

Trends in deaths following drug use in England before, during, and after the COVID-19 lockdowns.

This research aimed to describe how the characteristics of deaths following drug use changed during the COVID-19 pandemic in England, and how this can inform future strategy to support the health and social care of people who use drugs in future emergency scenarios. All deaths reported to the National Programme on Substance Abuse Deaths which occurred between January 2018 and December 2021 inclusive were extracted for analysis. Exponential smoothing models were constructed to determine any differences between forecasted vs. actual trends. Following the first lockdown period in England there were significant increases in the proportion of people who died at home beyond the 95% confidence bounds of the exponential smoothing model and concurrent decreases in the proportion of people who died in hospital. Whilst the overall proportion of deaths attributable to opioids did not significantly deviate from the forecasted trend, there were significant increases in methadone-related deaths and decreases in heroin/morphine-related death beyond the 95% confidence bounds. The proportion of deaths concluded as suicide increased, as did those implicating antidepressant use. There were no changes in the proportion of deaths following use of other drug classes, alcohol use in combination with psychoactive drugs, or on decedent demographics (gender, age, and drug user status). A small number of deaths due to drug use had COVID-19 infection itself listed as a cause of death (n = 23). For people who use drugs, the impact of the restrictions due to the COVID-19 pandemic was greater than that of infection from the virus itself. The health and social care strategy for these people needs to be pre-emptively adapted to mitigate against the specific risk factors for fatal drug overdose associated with future emergency scenarios.

Impact of COVID-19 on the lives of people with severe mental illness—front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers’ observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Opioid-related deaths during hospital admissions or shortly after discharge in the United Kingdom: A thematic framework analysis of coroner reports.

People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied. We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge. We identified 121 coroners' reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34-46); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression. Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care.

A case-control study of antipsychotic use and pneumonia-related mortality in the United Kingdom.

There is increasing evidence linking antipsychotic use with pneumonia, but limited evidence of an effect on pneumonia-related outcomes such as mortality. In this study, we aimed to examine the association of pneumonia-related death with specific antipsychotic exposure. Deaths analysed were those reported to a UK-based drug-related deaths database, the National Programme on Substance Abuse Deaths (NPSAD), between 1997 and September 2020. We conducted a case-control study with cases defined as pneumonia-related deaths and controls as cases with alternative causes of death. Cases were analysed by considering drugs detected at post-mortem (PM) and by drugs prescribed to the deceased at the time of their death with calculated odds ratios (ORs) adjusted to account for confounders. There were 2467 PM cases and 40,128 controls; 1818 prescribed cases and 28,018 controls. Second generation antipsychotics (SGAs) were robustly associated with an increased risk of pneumonia-related death compared with those not prescribed or taking antipsychotics (PM detection adjusted OR [AOR] 1·34 [95% CI 1·15-1·55]; prescribed AOR 1·28 [95% CI 1·11-1·49]). First generation antipsychotics had no clear association with death from pneumonia (PM detection AOR 1·06 [95% CI 0·77-1·47]; prescribed AOR 0·91 [95% CI 0·71-1·17]). Amongst SGAs, olanzapine was associated with an increased risk of death due to pneumonia (PM detection AOR 1·49 [95% CI 1·22-1·82]; prescribed AOR 1·44 [95% CI 1·18-1·76]) as was quetiapine (PM detection AOR 1·34 [95% CI 1·07-1·66]; prescribed AOR 1·28 [95% CI 1·01-1·64]). Olanzapine and quetiapine were found to increase the risk of pneumonia-related death in this NPSAD sample to a clinically important extent.

From Bumps to Binges: Overview of Deaths Associated with Cocaine in England, Wales and Northern Ireland (2000-2019).

The UK, as the "cocaine capital of Europe," currently accounts for ∼75% of all cocaine-related hospital admissions in Europe. This study aims to analyze the trends in cocaine-related deaths in England, Wales and Northern Ireland over 20 years (2000-2019). Cases reported to the National Programme on Substance Abuse Deaths (NPSAD) occurring between 2000 and 2019 where cocaine was detected at post-mortem (PM) were extracted for analysis. A total of 5,339 cases were retrieved, with an increase in the rate of reporting over time. Cocaine was deemed a cause of death and quantified in PM blood samples along with its major metabolite benzoylecgonine in 685 cases. Of these 685 cases, 25% (n = 170/685) occurred following acute use, 22% (n = 154/685) following chronic/binge use, 40% (n = 271/685) in combination with morphine, 4% (n = 29/685) in drug packer/swallower circumstances and 9% (n = 61/685) in a suicide context. Cardiac complications were evident in 22% of cases (n = 154/685). The average concentration of cocaine detected in cardiac cases (900 ng/mL) was considerably lower than that detected in cases where acute (19,100 ng/mL) or chronic/binge (6,200 ng/mL) dosing was evident. This is the first cocaine-related mortality study in these geographical areas. Deaths following cocaine use continue to rise despite its Class A drug listing in the UK. While underlying and external risk factors including polydrug use, cardiac complications and mental health can all contribute to the incidence of fatal drug toxicity following cocaine use, this study demonstrates that the risk of a cocaine overdose cannot be attributed to a specific blood concentration range.

Detection of novel benzodiazepines in post-mortem cases

The global prevalence of novel benzodiazepines (BZDs) has increased significantly in recent years with the predominant BZDs constantly changing to evade bans pertaining to specific chemical structures. As of 2020 the European Union Early Warning System (EWS) was monitoring 30 novel BZDs, 16 of which have been reported since 2016. Evidence of novel BZD-associated harms is growing and there is concern regarding their prevalence in drug-related deaths. We therefore analysed deaths in England, Wales, and Northern Ireland where novel BZDs, i.e., those that are not available on prescription via the National Health Service (NHS) in the United Kingdom, were detected at post-mortem in order to determine the circumstances surrounding novel BZD-associated fatalities. The National Programme on Substance Abuse Deaths (NPSAD) receives voluntary reports on drug-related deaths from coroners across England, Wales, and Northern Ireland that covers approximately 80% of all coronial jurisdictions. Deaths that occurred between 1999-2020 and were reported to NPSAD by the 1st of November 2021 where a novel BZD was detected at post-mortem were extracted for analysis. Qualifying cases contained toxicological evidence of novel BZDs and/or their metabolites in post-mortem tissue(s). Analysis and statistical tests were performed using the IBM® SPSS software (Version 26). 971 deaths were extracted from NPSAD where a novel BZD was detected at post-mortem, with the first post-mortem detection occurring in 1999 with flunitrazepam. A sharp increase in deaths has been reported since 2016 and a total of 16 different novel BZDs detected in submitted toxicology reports. Five of these novel BZDs were detected for the first time in 2019 and 2020 (flualprazolam, delorazepam, flubroalprazolam, cinolazepam, meclonazepam), but nevertheless represent 20% of total novel BZD detections ( n = 211/1,064 [note: in some cases multiple novel BZDs were detected]). The most commonly detected novel BZDs were alprazolam and phenazepam until 2018, after which etizolam, flubromazolam and flualprazolam detections prevail. The cause of death in 95% of cases ( n = 926/971) was due to drug toxicity in which novel BZDs were directly implicated in causing death in 34% ( n = 319/926). Polydrug use was evident in 99% of cases ( n = 964/971) and the majority involved the co-administration of at least one additional central nervous system (CNS) depressant (98%, n = 943/964), namely opioids (84%, n = 812/964). Most deaths were deemed to be accidental in nature (92%, n = 894/971), with small proportions due to suicide (4%, n = 42/971), natural causes (1%, n = 12/971), and those where intent could not be determined (2%, n = 23/971). Decedents were mainly male (83% of cases, n = 801/971), had a known history of illicit substance use (71%, n = 687/971) and lived in the most deprived areas of the country (deciles 1-3, 59% of cases; n = 541/971). The results of this study document a startling increase in novel BZD detections in post-mortem toxicology, with a shift in the predominant novel BZDs over time. As novel BZDs are sold on the Internet as ‘research chemicals’ or the illicit market at a low cost, there is greater access and less oversight which can lead to dosing errors and unintended adverse effects. The concomitant use with other CNS depressants furthers the likelihood of a fatal outcome through increased sedation and respiratory depression, as shown here with the majority of fatalities resulting from mixed drug toxicity. To our knowledge this is the largest dataset on novel BZD-related fatalities to date. Reporting of novel BZD deaths has increased considerably in England, Wales, and Northern Ireland with specific concerns relating to polydrug use. The wide availability of novel BZDs combined with the lack of complete understanding regarding their pharmacology is likely contributing to the exponential rise in novel BZD-associated fatalities.

China versus the world: Impact of international drug policy on postmortem stimulant detections in England, Wales and Northern Ireland

To highlight trends in postmortem detections of stimulants in England, Wales and Northern Ireland (2006–2020) and their correlation with UK, Chinese, and UN drug controls. Stimulant drugs increase central nervous system activity, and are used recreationally for their pleasurable and invigorating effects. The number of recreational stimulants available on the illicit drug market was considerably broadened in the mid-2000s by the introduction of novel stimulants within the wave of novel psychoactive substances (NPS), often purported to originate from China. The UK Government sought to reduce NPS use to curb their associated harms and mortality, and consequentially introduced a series of specific and generic controls within the 1971 Misuse of Drugs Act (MDA), followed by the 2016 Psychoactive Substances Act, which automatically bans all NPS not controlled under the MDA. Concurrently and since, the UN Commission on Narcotic Drugs (UNCND) and the Council of China have also banned various NPS: 7 stimulant NPS were added to the International Drug Control Conventions by UNCND, to which China is a signatory, between 2015 and 2021, with the Council of China banning a further 81 stimulant NPS within the same time frame. This study aims to evaluate how deaths following stimulant use in England, Wales and Northern Ireland have evolved over time, considering the introduction of UK, Chinese and UN prohibitive drug controls. The National Programme on Substance Abuse Deaths has collected data on deaths following psychoactive drug use from coroners across England, Wales and Northern Ireland since 1997. Basic decedent demographics are reported (e.g., age, gender) along with details pertaining to their death (e.g., cause of death, drugs detected at postmortem). Cases with stimulants detected at postmortem that occurred 2006–2020 were extracted on November 1st 2021 and analysed. The King's College London Biomedical and Health Sciences, Dentistry, Medicine and Natural and Mathematical Sciences Research Ethics Sub-Committee (BDM RESC) confirmed in November 2020 that NPSAD does not require BDM RESC review as all subjects are deceased. In 2006–2008 cocaine, amphetamine and MDMA comprised the majority (95%, n = 1651/1738) of postmortem stimulant detections. This fell to below 75% in 2010 ( n = 316/422) due to detections of stimulant NPS (25%, n = 106/422), before rising again to above 90% in 2016 ( n = 798/834). Cocaine detections are currently at an all-time high, having steadily increased from 233 detections in 2010 to 1094 in 2020 – an increase of 470%. Forty-five different stimulant NPS were detected in deaths reported to the NPSAD, and accounted for a total of 1242 detections. Where stimulant NPS were first controlled by UK drug legislation there is, in some instances, a clear effect in reducing detections (e.g., benzylpiperazine detections pre-UK control n = 54, post-UK control n = 11), but in others there was no clear effect (e.g., methylone detections pre-UK control n = 2, post-UK control n = 19). Similarly, when controlled in China, either through the Council of China or the UNCND, there were reductions in detections for some stimulant NPS (e.g., MDPHP detections pre-Chinese control n = 26, post-Chinese control n = 4), but not others (e.g., dibutylone detections pre-Chinese control n = 1, post-Chinese control n = 7). UK and Chinese prohibitive drug policies have had clear effects on overall stimulant NPS postmortem detection trends. The number of deaths following cocaine use has dramatically increased in recent years as the drug has become both cheaper and purer, further cementing the UK's reputation as the ‘cocaine capital of Europe’. Following their control stimulant NPS have fallen out of favour, with users turning or returning to use of classical stimulants, particularly cocaine. Urgent action is needed to address the ever-increasing mortality trend following cocaine use.

Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020).

Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death. This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations. Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed. From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L). Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

Fatalities associated with gabapentinoids in England (2004-2020).

The gabapentinoids were reclassified as Schedule II medications and Class C drugs in the UK in 2019 due to their potential misuse. In this study we examined deaths following gabapentinoid use in England reported to the National Programme on Substance Abuse Deaths.A total of 3051 deaths were reported (gabapentin: 913 cases; pregabalin: 2322 cases [both detected in 184 cases]). Prescribed and illicitly obtained gabapentinoids accounted for similar proportions of deaths (gabapentin illicit 38.0%, prescribed 37.1%; pregabalin illicit 41.0%, prescribed 34.6%). Opioids were co‐detected in most cases (92.0%), and co‐prescribed in a quarter (25.3%). Postmortem blood gabapentinoid concentrations were commonly (sub)therapeutic (65.0% of gabapentin cases; 50.8% of pregabalin cases). In only two cases was gabapentinoid toxicity alone attributed in causing death.Gabapentinoids alone rarely cause death. Clinically relevant doses can, however, prove fatal, possibly by reducing tolerance to opioids. Doctors and patients should be aware of this interaction.Gabapentinoid–opioid co‐prescribing needs urgent revision.

Substance Abuse during the Pandemic: Implications for Labor-Force Participation

The labor-force participation rates of prime-age U.S. workers dropped in March 2020-the start of the COVID-19 pandemic-and have still not fully recovered. At the same time, substance-abuse deaths were elevated during the pandemic relative to trend indicating an increase in the number of substance abusers, and abusers of opioids and crystal methamphetamine have lower labor-force participation rates than non-abusers.

Trends in Mortality From Novel Psychoactive Substances as "Legal Highs": Gender Differences in Manner of Death and Implications for Risk Differences for Women.

IntroductionThis study aimed to examine drug-related deaths in the UK in which novel psychoactive substances (NPS) are an implicated substance, and to focus on female deaths in comparison with male deaths. While male overdoses dominate epidemiological statistics, there is an increase in female drug-related deaths and a narrowing of the gap between gender mortality rates which is to date unexplained.MethodThis study analyzed data from the National Programme for Substance Abuse Deaths (NPSAD) database that records drug-related deaths in the UK from coronial records. A dataset was constructed using parameters to capture all drug-related cases during the period 2007–2017 when NPS were legal and highly available in the UK, in order to capture deaths recorded among both regular and occasional drug users, and to include all cases recorded during that period regardless of NPS status in order to make comparisons. The final dataset comprised 10,159 cases, with 456 NPS-related deaths. Data for NPS and non-NPS were compared, and comparisons were made between cohorts by gender. The dataset also includes coronial narrative notes which allowed a qualitative analysis of NPS female deaths to add contextual explanation.ResultsThe proportion of male NPS deaths is significantly higher than that for female NPS deaths but does not reflect the generalized difference between male and female drug-related mortality of this period studied. Demographic and outcome data by gender difference were significant for all drug-related deaths, but not for NPS-only deaths, indicating a greater homogeneity among NPS deaths by gender. Older women using NPS were more likely to have methadone or diazepam as another drug implicated and have established histories of drug misuse.ConclusionWhere NPS have been used, differences in drug death profiles are less likely to be accounted for by gender than other demographic or behavioral differences more typically found in opiate deaths. The social and health problems of older women may be key characteristics that differentiate female deaths from male deaths. These findings also support evidence of increasing uptake of NPS among older established drug users that adds further risk to polydrug use.

Highlighting the hidden dangers of a ‘weak’ opioid: Deaths following use of dihydrocodeine in England (2001–2020)

BackgroundDihydrocodeine (DHC) is considered a ‘weak’ opioid, but there is evidence of its increasing misuse in overdose deaths. This research aims to analyse trends in DHC-related deaths in England relevant to source and dose of DHC, and decedent demographics. MethodsCases from England reported to the National Programme on Substance Abuse Deaths (NPSAD) where DHC was identified at post-mortem and/or implicated in death between 2001 and 2020 were extracted for analysis. Results2071 DHC-related deaths were identified. The greatest number of deaths involved illicitly obtained DHC and a significant increase in these deaths was recorded over time (r = 0.5, p = 0.03). However, there was a concurrent decline in the implication rate of DHC in causing death (r = −0.6, p < 0.01). Fatalities were primarily due to accidental overdose (64.8%) and misuse was highly prevalent in combination with additional central nervous system depressants (95.3%), namely illicit heroin/morphine and diazepam. In contrast, when DHC was obtained over-the-counter (OTC) suicide mortality accounted for almost half of the deaths (42.5%). Differences in polysubstance use were also identified, with less heroin/morphine and benzodiazepine co-detection, but increased OTC codeine co-detection. ConclusionsDHC misuse in England is increasing. The pharmacological consideration of DHC as a ‘weak’ opioid may be misinterpreted by users, leading to accidental overdosing. There is an urgent need to understand increasing polypharmacy in overdose deaths. Additionally, suicides involving DHC is a potential cause for concern and a review of OTC opioid-paracetamol preparations is necessary to determine whether the benefits of these medications continue to outweigh the risks of intentional overdose.

In Vitro and In Vivo Analysis of Fentanyl and Fentalog Metabolites using Hyphenated Chromatographic Techniques: A Review.

Fentanyl and fentanyl analogues (also called fentalogs) are used as medical prescriptions to treat pain for a long time. Apart from their pharmaceutical applications, they are misused immensely, causing the opioid crisis. Fentanyl and its analogues are produced in clandestine laboratories and sold over dark Web markets to different parts of the world, leading to a rise in the death rate due to drug overdose. This is because the users are unaware of the lethal effects of the newer forms of fentalogs. Unlike other drugs, these fentalogs cannot be detected easily, as very little data are available, and this is one of the major reasons for the risk of life-threatening poisoning or deaths. Hence, rigorous studies of these drugs and their possible metabolites are required. It is also necessary to develop techniques for the detection of minute traces of metabolites in biological fluids. This Review provides an overview of the application of hyphenated chromatographic techniques used to analyze multiple novel fentalogs, using in vivo and in vitro methods. The article focuses on the metabolites formed in phase I and phase II processes in biological specimens obtained in recent cases of drug abuse and overdose deaths that could be useful for the detection and differentiation of multiple fentalogs.

Contraception Choice and Compliance Among Mothers with Opioid Addiction: Identifying Barriers to Care

West Virginia leads the nation in substance abuse deaths per capita. This epidemic has given rise to a novel population of high risk, obstetrics patients with opiate abuse. Appropriate education, counseling, and implementation of contraception is of extreme importance among this population due to risks of unintended pregnancy. This study was a retrospective chart review to determine compliance and uptake of contraceptive methods by patients in a maternal buprenorphine maintenance program prior to and following implementation of standardized contraception education and Medicaid coverage of immediate postpartum long acting reversible contraceptives (LARC). Rates of planned contraception and rates of actual method initiation were compared between two groups representing two distinct time periods before and after intervention. Rates of high efficacy contraception options, especially LARC options, were noted to statistically significantly increase following dedicated education and Medicaid coverage. Patients receiving no contraception at all significantly decreased following these interventions. Patients desiring surgical sterilization continued to encounter barriers to care as the rate of actual sterilization to desired sterilization was still very low.

Evaluation of Methadone Consumption Rate Based on Post-mortem Toxicology Examinations in Cases of Drug-related Deaths in Iran: 2015-2017

Background: Given the increasing prevalence of methadone overdose and the growing number of deaths in Iran, the present study was conducted to determine the mortality rate of methadone detected in the cadavers brought to the Forensic Medicine Organization between 2015 and 2017. Methods: This cross-sectional study was performed on 7,486 cases of substance abuse deaths registered in the Forensic Medicine Organization during 2015-2017. In order to investigate the drug abuse, samples collected from the cadavers were initially examined for their drug contents, such as methadone, by standard screening methods and then confirmed by Thin Layer Chromatography (TLC). Using two checklists, the information collected about each cadaver consisted of the identity, autopsy and laboratory data. After data collection, they were entered into the Stata software version 14 MP. Results: The cadavers’ mean age was 36.6±12.6 years. Over the 3-year duration of the study, the standardized mortality rate increased from 35 to 39 cases per million per year. Of these cases, 6066 were randomly assigned to toxicology, 50.1% had used methadone one month before their death. Approximately 75% of the methadone abusers had taken another drug simultaneously, mostly morphine or methamphetamine. Conclusion: Considering the relatively high prevalence of methadone detected post-mortem, monitoring for methadone entry into public market and identifying the death-related factors in the drug abusers are considered as significant measures to improve upon the current alarming situation in the Iranian society.

Deaths from novel psychoactive substances in England, Wales and Northern Ireland: Evaluating the impact of the UK psychoactive substances act 2016.

Background:‘Legal highs’ began appearing in the UK in the mid-2000s. Whilst many of these substances were controlled under the 1971 Misuse of Drugs Act, novel compounds and new variants of controlled compounds were continuously being introduced to the recreational drug market. The Psychoactive Substances Act (PSA) was therefore implemented in 2016 as a blanket ban on all novel psychoactive substances (NPS).Aim:To evaluate the impact of the PSA on deaths following NPS use in England, Wales and Northern Ireland.Methods:Cases reported to the National Programme on Substance Abuse Deaths where death had occurred 3 years pre- or post-implementation of the PSA were extracted. Cases with NPS detected at post-mortem were analysed and compared against cases non-NPS cases.Results:293 deaths with NPS detected were identified; 91 occurring before the PSA and 202 afterwards, indicating an 222.0% post-PSA increase. Contrastingly, non-NPS drug-related death case reporting increased by only 8.0%. Synthetic cannabinoid, anxiolytic/sedative and stimulant NPS were detected in the largest proportions of deaths pre-PSA; post-PSA stimulant NPS detections reduced whilst synthetic cannabinoid and anxiolytic/sedative detections increased.Post-PSA, average decedent age increased significantly (mean age pre-PSA 34.4 ± 10.8 vs post-PSA 38.3 ± 9.4), and they were significantly more likely to have been living in deprived areas (pre-PSA 50.0% vs post-PSA 65.9%).Conclusions:Reporting of deaths following NPS use has risen despite introduction of the PSA. Whilst deaths amongst younger individuals and those living in more affluent areas has reduced, additional approaches to prohibition are needed to curb their persistence in deprived demographics.

Recreational ketamine-related deaths notified to the National Programme on Substance Abuse Deaths, England, 1997-2019.

Background:Ketamine is a phencyclidine derivative with dissociative anaesthetic properties. Increasing numbers of individuals in England take ketamine recreationally. Information on deaths arising from such use in England is presented.Methods:Cases were extracted on 31 January 2020 from the National Programme on Substance Abuse Deaths database, based on text searches of the cause of death, coroner’s verdict and positive toxicology results for the terms ‘ketamine’ or ‘norketamine’.Findings:During 1997–2005, there were <5 deaths p.a. in which ketamine was implicated. Numbers increased until 2009 (21), plateauing until 2016; thereafter, deaths have risen to about 30 p.a. Decedents’ characteristics (N = 283): male 84.1%, mean age 31.2 (SD 10.0) years, employed 56.5%, drug use history 79.6% and living with others 60.3%. Ketamine was detected with other substances in most cases. Main (74.6%) underlying cause of death was accidental poisoning. Ketamine may have impaired judgement in other cases.Conclusions:Although controlled, recreational ketamine use and related fatalities continue to increase. Consumers need to be more aware of the potentially fatal risks they face.

Antihistamine-related deaths in England: Are the high safety profiles of antihistamines leading to their unsafe use?

Antihistamines are routinely taken to control allergic reactions or sedation to induce sleep. There are, however, growing concerns regarding sedating antihistamine misuse. This research aims to evaluate deaths related to antihistamines in England occurring during 2000-2019. Cases reported to the National Programme on Substance Abuse Deaths from England occurring in 2000-2019 with antihistamine detections at postmortem were extracted for analysis. In total, 1666 antihistamine postmortem detections were identified from 1537 cases. Sedating antihistamines available for purchase under pharmacist supervision but without need for a prescription (pharmacy-only medications) were present in a significant majority of cases (85.2%, P< .01). Despite an increasing trend for antihistamine-related deaths over time, the proportion of deaths where an antihistamine was implicated declined over the same period. Specific concerns with regards to the misuse of these pharmacy-only sedating antihistamines are raised with regards to the significant proportion of cases that were concluded as suicide (20.9%, P< .01), and the high prevalence of their use in combination with other central nervous system depressants (94.8% of cases). This is the first report in over 40 years regarding antihistamine-related mortality from England. The rising trend in sedating antihistamine-related deaths may be contributed to by their increasing availability and the perceived negligible dangers associated with antihistamines, both from the general public and learned professionals. Awareness of the dangerous sedative properties that some antihistamines possess is, however, heightened in individuals deliberately seeking these effects. Urgent review of sedating antihistamines currently assigned under the pharmacy-only classification is needed to achieve antihistamine harm reduction.