Overdose-related Deaths Research Articles

The Crushing Effects Of Opiate Abuse: Two Cases Illustrating The Morphologic Features Of Acute And Chronic Intravenous Administration Of Crushed Oral Opiates

Abstract Introduction/Objective Drug overdose related deaths in the US have shown a four-fold increase over the past two decades, increasing from 6.1 to 21.7 per 100,000, the increasing majority of which involve synthetic opioid use. With this continuing increase, it is important for pathologists to become aware of unusual gross and microscopic changes related to unconventional modes of drug abuse. A less recognized unconventional method for opiate abusers to ingest these substances exemplified by our two cases is by crushing oral tablets and inhaling or injecting the drug intravenously, subcutaneously or intramuscularly. Methods The two cases being presented show morphological features of acute and chronic opiate abuse by autopsy study. Case 1 was a 38-year old female, who underwent spinal fusion surgery 1 month prior, and was found unresponsive at home. Case 2 was a 37-year-old female with a history of Antiphospholipid Antibody Syndrome (APA) and upper limb DVTs who was found unresponsive one day after elective utero-vaginal prolapse surgery. Results At autopsy, Case 1 showed extensive embolization of polarizable foreign body material (possible “pill filler”) and fibrin in small and medium sized vessels without inflammatory reaction in the lungs bilaterally. The foreign material was also present in the small vessels of the heart associated with multifocal acute inflammation, hemorrhage, foreign body giant cell reaction and multiple myocardial infarcts (elevated troponin levels clinically). Blood and vitreous fluid were positive for oxycodone. At autopsy, Case 2 showed an extensive angiocentric miliary pattern of granulomatous reaction to polarizable foreign material, consistent with pill filler in the lungs bilaterally. This foreign material was also present within the lumens and walls of pulmonary vessels and in the skin of the legs. Chronic changes of hypertrophic cardiomyopathy, hepatic cirrhosis and congestive splenomegaly were evident. The blood oxycodone levels were ten times the normal limit. Conclusion These cases illustrate the importance of recognizing the clinical and morphological features of unorthodox acute and chronic opiate abuse. Lack of familiarity with their differing features can lead to a delay in diagnosis and institution of appropriate timely management and treatment.

Comparing mortality and healthcare utilization in the year following a paramedic-attended non-fatal overdose among people who were and were not transported to hospital: A prospective cohort study using linked administrative health data

BackgroundAs the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose. MethodsUsing a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event. ResultsIn this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days. ConclusionsTransport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20–59 and people without chronic conditions.

Careful Prescribing of Benzodiazepines during COVID-19 Pandemic: A Review

Benzodiazepines have been commonly prescribed for the treatment of anxiety and insomnia in the last few decades. There has been a rising concern regarding safety of benzodiazepines due to overdose related deaths, addictions, and cognitive side effects. COVID- 19 pandemic is expected to cause a mental health crisis. Several studies have shown an increase in anxiety and insomnia. This could mean that prescriptions of benzodiazepine could increase due to increase in anxiety and insomnia. We caution health care providers to use best practices and treat patients with psychotherapy as the first line of treatment and not pharmacotherapy. Prescription Drug Monitoring programs (PDMPs) were started due to this concern of overdose deaths, diversion related to opioids and benzodiazepines. PDMPs are mandatory in most states in the United States of America now.We recommend all health care providers to look at their benzodiazepine prescribing practice, monitor PDMP data and make policies to implement changes in order to avoid the next crisis of benzodiazepines after opioids.

Opioid Prescribing with Take-Home Naloxone: Rationale and Recommendations

Although take-home naloxone is available for prescribing, recommended for certain high-risk patients, and can prevent overdose-related deaths, access to naloxone remains a challenge. This review describes the high-risk population on opioids that benefit from naloxone co-prescription, guidelines, and the current trends in naloxone prescribing, and the barriers faced by all the stakeholders. Opioid-related overdoses and deaths still occur at critically high numbers. Short-acting opioid antagonists like naloxone can reverse the effect of an overdose in a few minutes. The US Food and Drug Administration (FDA) approved naloxone nasal spray, and auto-injectable kits are both effective and easy to administer. An increasing number of states in the USA mandate the co-prescription of naloxone for patients on chronic opioid therapy, irrespective of the presence of other underlying risk factors. The lack of provider education is one of the significant barriers for co-prescribing naloxone with opioids. Naloxone can be lifesaving in patients experiencing an opioid overdose. Providers are encouraged to co-prescribe take-home naloxone for high-risk patients on chronic opioid therapy. Understanding the barriers, creating awareness, and providing education can increase the prescription of take-home naloxone and help prevent opioid overdose-related deaths.

Modeling dynamics of fatal opioid overdose by state and across time.

Opioid overdose fatalities include deaths from natural opioids (morphine and codeine), semi-synthetic opioids (oxycodone, hydrocodone), synthetic opioids (prescription and illicit fentanyl, tramadol), methadone, and heroin. From 1999 to 2017, there were 702,568 drug overdose deaths in the U.S., with 399,230 attributed to opioids. This study aimed to assess the dynamics of opioid related fatalities throughout the U.S. from 2006-2016. This study is a secondary analysis of data obtained through the Kaiser Family Foundation's analysis of Centers for Disease Control and Prevention data, 1999-2016. The data obtained were from all 50 states and the District of Columbia. A total of 272,130 individuals were included in the analysis. This represents the number of opioid overdose deaths in the United States from 2006-2016. Descriptive analysis of overall rates was conducted and mapped for visualization. Novel predictive models of increase for each drug overdose category were developed and used to calculate rate changes. Finally, the elasticity of change in rate for each drug category was calculated annually for the past 11 years. The highest rate of opioid overdose-related death occurred in West Virginia (40.03 per 100,000). In our secondary analysis, we explored the change in the rate of opioid-related deaths from 2015 to 2016. The changing dynamics of fatal opioid overdose at the state level is critical to guiding policy makers in addressing this crisis. Rates of fatal opioid overdose vary across the states, but we identify some trends. Regional differences are identified in states with the highest overdose rates from all opioids combined.

San Bernardino County Youth Opioid Response: Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder.

Opioid use disorder (OUD) and related overdose deaths have become a crisis of epidemic proportions in the United States. In 2018, over 10 million people age 12 years or older misused opioids.Substance use is also correlated with increased physical and mental health disorders, and developmental challenges among youths. Medication-assisted treatment (MAT) has been reported to reduce mortality, opioid use, and human immunodeficiency virus and hepatitis C virus transmission while increasing treatment retention in adults. The San Bernardino County Youth Opioid Response (SBCYOR) program was formed to explore best practices for youths at risk of opioid use disorders and/or overdose. SBCYOR is a coalition of professionals in healthcare, behavioral health, public education, law enforcement, emergency medical services (EMS) agencies, and juvenile detention centers throughout San Bernardino County, California. SBCYOR focuses on high-risk and addicted individuals between the ages of 12 to 24 years in San Bernardino County’s correctional system. It utilizes a strategy of collaboration, prevention, risk mitigation, medication, psychological treatment, and community outreach. This study aimed to evaluate the implementation and progress of SBCYOR.

Brief Report: Rates of Fentanyl Use Among Psychiatric Emergency Room Patients.

Opioid overdose-related deaths increased from approximately 18 000 deaths in 2007 to 46 802 deaths in 2018. Fentanyl is primarily responsible for the increase in opioid overdose deaths from 2011 through 2017. The primary aim of this study is to determine the rates of fentanyl in the urine drug screens of all patients who presented to the psychiatric emergency room at VA Connecticut, over 7 months in 2018. Data were collected for all patient presentations between June 2018 and December 2018. There were 746 total patient presentations, with 497 being unique. Collected data included basic demographic information, psychiatric diagnosis, and urine drug screen for various illicit substances, including fentanyl. Over 15% of patients screened positive for fentanyl. Patients who tested positive for fentanyl were further classified based on positive urine drug screening results for other opioids, cocaine, or both. Twenty percent of patients who screened positive for fentanyl and cocaine tested negative for other opioids. This category suggests that some veterans might be consuming fentanyl with cocaine. Fentanyl was found at a high rate, even in the absence of other opioids, which suggests that some veterans might be consuming fentanyl with cocaine. Consequently, harm reduction strategies should be broadened to include all patients at risk of fentanyl overdose, including patients who use substances (eg, cocaine) that are potentially adulterated with fentanyl. This study is the first one of its kind that looked at rates of fentanyl use in all presentations to a psychiatric emergency room. While it is well-known that fentanyl is highly prevalent, these findings extend the current state of knowledge by replication in a psychiatric emergency population. (Am J Addict 2021;30:92-95).

Measuring the Effectiveness of Benzodiazepine Prescriptions Control in Community Setting Using Prescription Drug Monitoring Program (PDMP).

Benzodiazepines have been widely prescribed for several years for the treatment of anxiety, insomnia, and post-traumatic stress disorder (PTSD). Benzodiazepines were meant to be for short term use but in clinical settings long term use has been the "norm" for the treatment. Benzodiazepines are known for addiction potential and have been involved in accidental overdose deaths. According to the National Institute on Drug Abuse (NIDA), there has been a tenfold increase in the number of deaths due to overdose from 1999 to 2017. Benzodiazepines contributed to staggering high figures of 11,537 deaths in 2017 alone. Kentucky was ranked 4th in overdose related deaths in 2015 by CDC. Seeing this rise in overdose deaths, our community mental health clinics (CMHC) took the initiative to protect the community by removing benzodiazepines from the approved formulary in all adult outpatient community mental health clinics (total six clinics) in 2016. This project was initiated to protect the community from overdose deaths. In order to see the decrease in the benzodiazepine prescriptions, we did a quarterly Kentucky All Schedule Prescription Electronic Reporting (KASPER) prescriber's reports to see the trend. The goal of this project was to monitor the trend of benzodiazepine prescription control in CMHC. Our hypothesis was implementation of CMHC "No Benzodiazepine" policy would decrease in the number of prescriptions. To implement this change, we made a committee to educate staff including physicians, APRN's and therapists. Patients were also educated and informed regarding benzodiazepine free policy. Education materials were posted in the clinics and handed over to patients. Patients were offered individual and group therapy sessions to learn coping skills to cope with their anxiety. Patients had the option of inpatient detoxification, if clinically indicated. No new patients were started on benzodiazepines and patients who were already on benzodiazepines were slowly titrated off. Slow titration over the course of a few months was done as needed and tolerated. Quarterly, prescriber's prescription reports were generated with the help of KASPER (KASPER is PDMP in the state of Kentucky). After analyzing quarterly reports over the span of 2years, we concluded that there was a total of 89% decrease in benzodiazepine prescriptions. We are hoping to reach close to 100% in the next few years. We conduct a Mental Health Statistics Improvement Program (MHSIP) which is a general patient satisfaction survey done annually. We used this data to monitor the change with this new policy. Open patients report was run to monitor any change in case load before and after the implementation of the policy. After compilation of the KASPER/ PDMP data of all the prescribers- MD's and APRN's, we found an 89% decrease in the number of benzodiazepines prescriptions over the span of 2years. We did the open patients report and did not find any decrease in case load. In 2016, there were 10,359 open patients and in 2018 there were 12,266 open patients. We reviewed the MHSIP general patient satisfaction survey that is done annually, and we did not find any major difference in overall satisfaction as compared to previous years. These practice- based interventions implementing harm reduction strategies suggest that, although it was a difficult task, with strict adherence to no benzodiazepine policy, we were able to achieve a stark drop in the number of benzodiazepine prescriptions, in the span of 2years, and have been able to continue to maintain the low numbers of benzodiazepine prescriptions.

Who receives naloxone from emergency medical services? Characteristics of calls and recent trends

Background: With the rapid rise in opioid overdose-related deaths, state policy makers have expanded policies to increase the use of naloxone by emergency medical services (EMS). However, little is known about changes in EMS naloxone administration in the context of continued worsening of the opioid crisis and efforts to increase use of naloxone. This study examines trends in patient demographics and EMS response characteristics over time and by county urbanicity. Methods: We used data from the 2013–2016 National EMS Information System to examine trends in patient demographics and EMS response characteristics for 911-initiated incidents that resulted in EMS naloxone administration. We also assessed temporal, regional, and urban–rural variation in per capita rates of EMS naloxone administrations compared with per capita rates of opioid-related overdose deaths. Results: From 2013 to 2016, naloxone administrations increasingly involved young adults and occurred in public settings. Particularly in urban counties, there were modest but significant increases in the percentage of individuals who refused subsequent treatment, were treated and released, and received multiple administrations of naloxone before and after arrival of EMS personnel. Over the 4-year period, EMS naloxone administrations per capita increased at a faster rate than opioid-related overdose deaths across urban, suburban, and rural counties. Although national rates of naloxone administration were consistently higher in suburban counties, these trends varied across U.S. Census Regions, with the highest rates of suburban administration occurring in the South. Conclusions: Naloxone administration rates increased more quickly than opioid deaths across all levels of county urbanicity, but increases in the percentage of individuals requiring multiple doses and refusing subsequent care require further attention.

The antagonistic activity profile of naloxone in μ-opioid receptor agonist-induced psychological dependence

Naloxone is a μ-opioid receptor antagonist that has been used to prevent overdose-related respiratory depression and deaths by the illicit use of opioids. Naloxone can also deter the abuse potential of opioids, but little has been reported regarding its antagonistic activity profile against opioid-induced psychological dependence. This study aimed to confirm the antagonistic activity profile of naloxone against several μ-opioid receptor agonists and investigate whether naloxone could affect the psychological dependence induced by widely used μ-opioid receptor agonist, oxycodone. In the Guanosine-5’-o-(3-thio) triphosphate (GTPγS) binding assay, naloxone (30−30,000 nM) inhibited the GTPγS binding induced by oxycodone, hydrocodone, morphine, and fentanyl. It elicited parallel rightward shifts in the concentration-response curves, indicating that naloxone possessed a competitive antagonistic activity profile against these μ-opioid receptor agonists. In the conditioned place preference test, oxycodone (0.01−1 mg/kg, i.v.) produced dose-dependent increases in place preference. The increased place preference induced by oxycodone (1 mg/kg) was significantly attenuated by co-administration of naloxone at a dose of 0.5 mg/kg but not 0.01 mg/kg. Naloxone (0.5 mg/kg, i.v.) also blocked oxycodone (1 mg/kg)-induced dopamine release in nucleus accumbens; however, at a lower dose (0.01 mg/kg), it did not affect the intrinsic dopamine release by oxycodone. These results indicate that the psychological dependence of oxycodone could be antagonized by naloxone, depending on the dose. This characterization might lead to a better understanding of the competitive antagonistic activity profile of naloxone for μ-opioid receptor in the brain.

Shortening treatment with direct-acting antivirals in HCV-positive organ transplantation

For individuals with end-stage organ dysfunction, transplantation is a life-saving option. However, this option is not timely or viable for many individuals owing to organ shortages; in the USA, one in 20 patients on the transplant waitlist die each day. Many countries have seen an epidemic in opioid use, and consequently overdose-related deaths, which have tripled in the USA in the past 15 years, increasing the number of organs potentially available for transplantation.1 However, high prevalence of hepatitis C virus (HCV) infection in people who inject drugs, particularly in the USA,2,3 has led to reluctance surrounding HCV-positive organ transplantation.

COVID-19: Studying the Global Pandemic – Foreword

COVID-19: Studying the Global Pandemic – Foreword

The fentanyls: pharmacological and clinical aspects relevant to Australia.

North American and other jurisdictions have seen an alarming rise in the abuse of the fentanyls, with related overdose deaths. We sought to review this group of drugs to alert Australian psychiatrists and drug and alcohol clinicians to their clinical effects and potential harms. The extreme potency of the fentanyls underlie their lethality. Vigilance and investment from both policy makers and health care providers are required to mitigate harm from a possible future Australian fentanyl epidemic.

Patient and clinician incentives and barriers for opioid use for musculoskeletal disorders a qualitative study on opioid use in musculoskeletal setting

IntroductionStrategies for pain alleviation have relied heavily on opioids in the recent decades. One consequence is a crisis of opioid misuse, overdose, and overdose related death. This study sought patient and clinician incentives and barriers to the use of opioids in musculoskeletal illness. MethodsIn this qualitative study, twenty-eight patients and eight clinicians participated in a semi-structured interview seeking incentives and barriers for opioid use and prescription in musculoskeletal illness. Interviews were conducted by a trained qualitative interviewer. The interview data were transcribed and analyzed using a thematic analysis framework. ResultsPatient incentives for opioid use included doctor's orders, opioids being the only effective way to alleviate pain, alleviating symptoms of depression and anxiety, being able to keep a job, and lower cost of opioids relative to alternative treatment options. Patient barriers included associated risks (side effects, addiction) and wanting to control pain intensity. Clinician incentives for prescribing opioids included adequate pain alleviation, patient satisfaction, relatively inexpensive costs of opioids, convenience and doing what was taught by the clinician's superior. Lacking time and resources to adequately inform patients on appropriate opioid use and alternative treatments, likely results in more opioid prescribing than arguably necessary. Barriers for opioid prescribing included specific patient characteristics (psychiatric background, history of opioid misuse) and illness characteristics (nature of the injury, medical contra-indications). ConclusionPatients feel that opioids should be used with caution. Clinicians in this study reported a tendency to default to opioids out of habit and convenience. Both patients and clinicians were aware that opioids are often misused to treat emotional pain.

A Deep Artificial Neural Network-Based Model for Prediction of Underlying Cause of Death From Death Certificates: Algorithm Development and Validation.

BackgroundCoding of underlying causes of death from death certificates is a process that is nowadays undertaken mostly by humans with potential assistance from expert systems, such as the Iris software. It is, consequently, an expensive process that can, in addition, suffer from geospatial discrepancies, thus severely impairing the comparability of death statistics at the international level. The recent advances in artificial intelligence, specifically the rise of deep learning methods, has enabled computers to make efficient decisions on a number of complex problems that were typically considered out of reach without human assistance; they require a considerable amount of data to learn from, which is typically their main limiting factor. However, the CépiDc (Centre d’épidémiologie sur les causes médicales de Décès) stores an exhaustive database of death certificates at the French national scale, amounting to several millions of training examples available for the machine learning practitioner.ObjectiveThis article investigates the application of deep neural network methods to coding underlying causes of death.MethodsThe investigated dataset was based on data contained from every French death certificate from 2000 to 2015, containing information such as the subject’s age and gender, as well as the chain of events leading to his or her death, for a total of around 8 million observations. The task of automatically coding the subject’s underlying cause of death was then formulated as a predictive modelling problem. A deep neural network−based model was then designed and fit to the dataset. Its error rate was then assessed on an exterior test dataset and compared to the current state-of-the-art (ie, the Iris software). Statistical significance of the proposed approach’s superiority was assessed via bootstrap.ResultsThe proposed approach resulted in a test accuracy of 97.8% (95% CI 97.7-97.9), which constitutes a significant improvement over the current state-of-the-art and its accuracy of 74.5% (95% CI 74.0-75.0) assessed on the same test example. Such an improvement opens up a whole field of new applications, from nosologist-level batch-automated coding to international and temporal harmonization of cause of death statistics. A typical example of such an application is demonstrated by recoding French overdose-related deaths from 2000 to 2010.ConclusionsThis article shows that deep artificial neural networks are perfectly suited to the analysis of electronic health records and can learn a complex set of medical rules directly from voluminous datasets, without any explicit prior knowledge. Although not entirely free from mistakes, the derived algorithm constitutes a powerful decision-making tool that is able to handle structured medical data with an unprecedented performance. We strongly believe that the methods developed in this article are highly reusable in a variety of settings related to epidemiology, biostatistics, and the medical sciences in general.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series.

In 2017, there were ≈47,600 opioid overdose‐related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non‐infectious complications of injection drug use. Point‐of‐care ultrasound has become a widely available, non‐invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound‐based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3‐system point‐of‐care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

1D2 Free Naloxone Discharge Kits: An Innovative Approach to the Prevention of Opioid Related Overdose Deaths

According to the CDC, opioids killed more than 49,000 people across the U.S. in 2017 (that's 5 times more deaths than in 1999). Our country saw an increase of greater than 15% opioid related deaths from 2016 to 2017. Furthermore, opioid-related overdoses claimed the lives of 2,199 Illinoisans in 2017, nearly 2 times the number of homicides in Chicago, and over 2 times the number of car accidents. This is a public health crisis that crosses all racial, ethnic, and socioeconomic boundaries. Statistics have shown that for every 1 fatal overdose there are 30 non-fatal overdoses and that one is at greater risk of a fatal overdose immediately after a non-fatal overdose. Since 2010, Advocate has served more than 30,000 patients in need of opioid overdose and addiction treatment and that number is projected to increase by 15%. The Emergency Department at Advocate Christ Medical Center and Advocate Children's Hospital, Oak Lawn are taking a major step to help prevent deaths by opioid overdose by providing free naloxone discharge kits. Our program is in partnership with the Chicago Recovery Alliance (CRA) who is donating the naloxone discharge kits as well as providing educational materials on how to inject the reversal agent. Before receiving a kit, patients and family members will be educated via a short video that outlines preventing, identifying, and responding to an overdose; rescue breathing; and the importance of still calling emergency services. This program is not designed to serve as a substitute for rehabilitation for patients, but rather allow a person experiencing an opioid overdose to live another day and hopefully seek the help they need. The chances of an addict or first-time user proactively filling a prescription for naloxone, should another overdose even occur, are relatively small. Any registered ED patient may request the kit.

Fewer Opioid Deaths May Be Due to Suicide Than Previously Estimated

Back to table of contents Previous article Next article ProfessionalFull AccessFewer Opioid Deaths May Be Due to Suicide Than Previously EstimatedKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:28 Feb 2020https://doi.org/10.1176/appi.pn.2020.2a30AbstractWhile the overall number of opioid-related deaths has increased, the percentage due to suicide decreased between 2000 and 2017.iStock/DNY59Fewer opioid overdose deaths may be due to suicide than has been estimated, according to a study published in JAMA.Though some studies have suggested that up to a quarter of all opioid overdose deaths are intentional, Mark Olfson, M.D., M.P.H., the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law at Columbia University Vagelos College of Physicians and Surgeons, and colleagues determined that 4% of opioid-related deaths were due to suicide in 2017.The researchers evaluated death certificates from 2000 to 2017 obtained from the National Vital Statistics System to determine the proportion of deaths that were unintentional, due to suicide, or of undetermined intent.Between 2000 and 2017, opioid-related deaths per 100,000 increased from 2.20 to 13.21 for unintentional deaths and 0.27 to 0.58 for suicides, according to the study.“Viewing the threat posed by opioid abuse and suicide as distinct, though sometimes related, conditions could change how people with opioid use disorders and their families understand opioid addictions and how they seek treatment for them,” Olfson said by email. “It is important for patients and their family members to understand that there are effective medication treatments for opioid addiction and different medication and psychological treatments for depression. These are separate conditions, which though they can occur together, respond to different treatments.”"Addition and mental health should be viewed as interrelated, especially since studies show that patients whe receive all their psychiatric services under one roof do better," said Elie Aoun, M.D.The study shows that the opioid crisis is clearly getting worse, said John Renner, M.D., a member of APA’s Council on Addiction Psychiatry and professor of psychiatry at Boston University. But it is difficult to clearly determine whether an overdose was intentional or unintentional, as the quality of coroner data is often inconsistent, he said.The authors also pointed this out as one of the study’s potential limitations, adding, “With greater public appreciation of the opioid epidemic since 2010, certifiers may be more likely to consider opioid overdose deaths as unintentional.”But even if a smaller proportion of overdose-related deaths are intentional than previously estimated, Renner said, that should not impact treatment. “There’s a very high overlap between other psychiatric disorders and substance use,” he said. “I certainly think that, if you are working in an emergency room and treating people who just overdosed, you ought to be asking very carefully whether or not people are suicidal or if they are depressed.”The line between opioid addiction and suicide is fine, agreed Elie Aoun, M.D., an assistant professor of psychiatry at New York University and vice chair of APA’s Council on Addiction Psychiatry. “We know that opioid use affects mood and anxiety, and increases the feeling of hopelessness,” he said. “So even if the opioid is not taken with the intention of causing death, opioid use causes severe mood symptoms, and a lot of the patients that we treat say that they reach the level of hopelessness that they don’t care if they die as a result of their opioid use.“It could cause more harm if we’re sending the message that suicide and unintentional opioid overdoses are not related,” he continued. “As much as we would like to separate these things into distinct categories, they’re really intertwined, and one affects the other.”The study did not have external funding. ■“Trends in Intentional and Unintentional Opioid Overdose Deaths in the United States, 2000-2017” is posted here. ISSUES NewArchived

Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program

The US opioid crisis was deemed a public health emergency in 2017. More than 130 individuals in the US die daily as a result of unintentional opioid overdose deaths. To measure use of take-home naloxone for overdose reversals performed by study participants with opioid use disorder receiving treatment at an opioid treatment program. In a year-long cohort study, between April 4, 2016, and May 16, 2017, 395 study participants enrolled at the University of New Mexico Addiction and Substance Abuse Opioid Treatment Program, an outpatient clinic treating substance use disorders. Inclusion criteria included all patients enrolled at University of New Mexico Addiction and Substance Abuse Opioid Treatment Program during the study enrollment period; positive history of opioid use disorder treated with methadone, buprenorphine, or naltrexone; and age 18 years or older. Exclusion criteria included allergy to naloxone and age younger than 18 years. The study closed 1 year after enrollment, on May 17, 2018. Data analysis was performed from May 2018 to July 2019. Two doses of take-home naloxone combined with opioid overdose education were provided to study participants. The primary outcome was to measure the association of take-home naloxone with overdose reversals performed by patients with opioid use disorder enrolled in an opioid treatment program. We enrolled 395 study participants (270 female [68.4%]; mean [SD] age, 35.4 [12.6] years; 260 [65.8%] with Hispanic white race/ethnicity) in the 1-year prospective trial. Sixty-eight female participants (25.2% of all female participants) were pregnant at the time of enrollment. Seventy-three of the 395 study participants (18.0%) performed 114 overdose reversals in the community. All community reversals were heroin related. Most study participants (86.8%) stated that the person on whom they performed an overdose reversal was a friend, relative, acquaintance, or significant other. In the year before enrollment, only 18 study participants (4.5%) had been prescribed naloxone. Take-home naloxone as part of overdose education and naloxone distribution provided to patients in an opioid treatment program may be associated with a strategic targeted harm reduction response for reversing opioid overdose-related deaths. Policy makers may consider regulations to mandate overdose education and naloxone distribution in opioid treatment programs.

Harm Reduction: A Concept Analysis

Background Over the last 25 years, harm reduction has shifted to focus on public health and addressing the opioid crisis. Nurses working in addictions treatment utilize the principles of harm reduction to improve the health of clients. Aims Concept clarity assists healthcare providers to understand the applications and attributes of a concept. Method A concept analysis of harm reduction using the Rodgers (1989) method of evolutionary analysis was undertaken. A comprehensive review of the literature was conducted using CINAHL Plus and Social Work Abstracts. Findings The key attributes of harm reduction include safety, supplies, education, partnerships, and policy. Applications of harm reduction include needle exchange programs, supervised consumption sites, medication-assisted treatment, and increased access to take-home naloxone kits. The main antecedent to harm reduction is the presence of harm. Consequences explored include safer injection practices, decreased transmission of blood-borne illnesses, improved client relationships, and decreased overdose-related deaths. Stigma, health promotion, and pragmatism are the related concepts discussed. A model case is provided. Conclusion The principles of harm reduction are becoming increasingly popular as an inclusive and evidence-based nursing approach to addictions treatment and management. As using substances continues to shift and increase, harm reduction strategies must remain malleable and available in both the community and hospital settings to address the issue and decrease the associated healthcare costs. Future implications for nursing practice and research are provided.