Prescription Drug Overdose Research Articles

Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report.

Introduction: Prescription drug overdoses are the leading cause of accidental death in the United States. Alternatives to opioids for the treatment of pain are necessary to address this issue. Cannabis can be an effective treatment for pain, greatly reduces the chance of dependence, and eliminates the risk of fatal overdose compared to opioid-based medications. Medical cannabis patients report that cannabis is just as effective, if not more, than opioid-based medications for pain.Materials and Methods: The current study examined the use of cannabis as a substitute for opioid-based pain medication by collecting survey data from 2897 medical cannabis patients.Discussion: Thirty-four percent of the sample reported using opioid-based pain medication in the past 6 months. Respondents overwhelmingly reported that cannabis provided relief on par with their other medications, but without the unwanted side effects. Ninety-seven percent of the sample “strongly agreed/agreed” that they are able to decrease the amount of opiates they consume when they also use cannabis, and 81% “strongly agreed/agreed” that taking cannabis by itself was more effective at treating their condition than taking cannabis with opioids. Results were similar for those using cannabis with nonopioid-based pain medications.Conclusion: Future research should track clinical outcomes where cannabis is offered as a viable substitute for pain treatment and examine the outcomes of using cannabis as a medication assisted treatment for opioid dependence.

Opioid Safety: We Are Not There Yet

Opioids are highly effective in acute pain control; however, their use for the treatment of chronic non-cancer pain is controversial. Chronic opioid use is associated with several side effects that include and are not limited to tolerance, dependence, and hyperalgesia. Opioid prescription drug overdose is at a national epidemic status in the USA. It is estimated that a prescription drug overdose death occurs every 19 min. Several national and state interventions have been implemented to address the staggering statistics of increased deaths due to opioid overdose. The recently released Center of Disease Control (CDC) practice guidelines are designed to improve physician patient communication and avoid opioid prescription drug overdose. In this chapter, we will review some of the recent guidelines for opioid prescribing and the current efforts in place to address this epidemic.

The impact of a closed formulary on prescribing patterns in the treatment of injured workers

Prescription drug spending accounts for nearly twenty percent of workers’ compensation (WC) health care costs, and prescription drug overdose is a leading cause of death in the United States. To guide physicians to prescribe safer, less addictive, and more cost-effective drugs, Texas WC implemented one of the first formularies tailored specifically for the treatment of work-related injuries by establishing a list of non-preferred drugs that require preauthorization before they can be prescribed. I draw on Texas WC administrative data on medical and pharmacy bills to examine the impact of the formulary on health care bills paid for through WC several months after a worker’s initial injury. I find that the closed formulary results in workers being half as likely to use non-preferred drugs and reduces average spending on non-preferred drugs by half several months after claims begin. I find no evidence that spending on preferred drugs or spending on non-pharmacy medical care increase to compensate for the decreased spending on non-preferred drugs. The lack of a shift towards preferred drugs suggests that doctors were not choosing non-preferred drugs over preferred drugs prior to the formulary. Instead, non-preferred drugs were one of multiple approaches doctors used in treating work-related injuries.

Conduites suicidaires et corticothérapie : à propos d’un cas

BackgroundIn 2010, over 220 000 people attempted suicide in France, in other words up to one suicide attempt every 85s. Numerous risk factors are involved, including iatrogenic factors. Data from previous retrospective studies indicate, on average, 5.7 % of people treated with corticosteroids develop severe steroid-induced psychiatric disorders. Steroid-induced suicidal behavior is not explicitly specified in these studies, except for one recent descriptive study. Its prevalence remains unclear and is probably underestimated. Case reportWe report the case of a 50-year-old woman treated by intravenous methylprednisolone for a relapsing-remitting multiple sclerosis relapse. Two weeks following a five-day intravenous treatment, she attempted suicide by prescription drug overdose at home. In the two months leading up to this event, she described symptoms of major depressive disorder which were left untreated. In retrospect, high doses of corticosteroids seem to have played a significant role in the occurrence of transient acute suicidal behavior. The patient improved significantly under antidepressant treatment and was discharged after three weeks of hospitalization. DiscussionThis clinical case points out that corticosteroids are likely to precipitate suicidal behavior in a patient with a premorbid undiagnosed depressive disorder. Early detection of psychiatric disorders before starting corticotherapy seems to be essential. However, management strategies are not explicit enough in the literature to be recommended. Treatment discontinuation should not be done systematically, but tapering should be considered in combination with an antidepressant drug. A recent longitudinal study by Fardet et al. on oral corticotherapy suggests a positive correlation between steroids treatment and suicidal behavior. These results may support our clinical observation. In addition, the neurobiologic correlates may give credit to the underlying pathophysiology proposed as a potential explanation to the patient's sudden suicidal behavior after corticotherapy. Physicians and patients must be aware of possible risks of increased suicidality when undergoing corticosteroid treatment in order to prevent fatal outcomes for the patient.

The Pharmacist as Gatekeeper of Prescription Drug Abuse: Return to "Community Scientists"

The non-medical use or abuse of prescription drugs, including benzodiazepines, is a growing health problem in Japan. An association between prescription drug overdose and suicide risk has also been reported. The Japanese Ministry of Health, Labour and Welfare has expected pharmacists to act as "gatekeepers", facilitating early identification of individuals at high risk of prescription drug abuse including overdose, supplying medication counseling to patients, and helping to introduce these patients to appropriate medical care. Prescription drugs such as benzodiazepines are widely used in psychiatry. However, these drugs are prescribed not only by psychiatrists but also by other healthcare professionals including primary care physicians. Moreover, in recent years, the dispensing of prescriptions has moved rapidly from inside to outside hospitals, with prescription drugs being dispensed mainly at community pharmacies. Although all healthcare professionals including hospital pharmacists can play a role in preventing prescription drug abuse, the role of the community pharmacist is vital in addressing this problem. Formerly, community pharmacists were recognized as "community scientists", low-threshold accessible healthcare advisors. Now, community pharmacists should return to the role of community scientists to prevent prescription drug abuse. This article begins by reviewing the current situation of prescription drug abuse and dependence in Japan. The role of pharmacists as gatekeepers in preventing prescription drug abuse is then examined. Finally, this article discusses the effect of intervention in the form of gatekeeper training for community pharmacists.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature

Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature.

Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.

Pharmacist guide to medication-assisted treatment of substance abuse

C has categorized the current opioid prescription drug overdose problem in the United States as an “epidemic.” The most recent available statistics from CDC show a threefold increase in the total number of overdose deaths from prescription opioid pain relievers. These deaths claimed more than 16,000 lives in 2013. The most recent statistics from 2013 also show that an estimated 1.8 million American have an opioid use disorder related to prescription pain relievers.

National Rx Drug Abuse Summit: Pharmacists’ role, responsibility

In the United States, 52 million people older than 12 years have taken a prescription drug nonmedically in their lifetime. Prescription drug overdoses cause more deaths annually than car accidents do. Overdoses are responsible for more than a million emergency department visits every year. CDC has officially declared prescription drug abuse in the United States an epidemic.

Emergency department utilization and subsequent prescription drug overdose death

PurposePrescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. MethodsUsing data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. ResultsThe study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. ConclusionsFrequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality.

Mandatory use of prescription drug monitoring programs.

Mandatory use of prescription drug monitoring programs.

Treatment agreements, informed consent, and the role of state medical boards in opioid prescribing.

The statistics regarding prescription drug overdose in the United States are shocking and clear. One hundred people die from prescription drug overdoses every day in the United States, with three out of four of these drug overdoses caused by prescription painkillers. Prescription drug deaths are, however, just the tip of the iceberg. For every death from prescription pain killers, 10 people are admitted to treatment for drug abuse, 32 emergency department visits take place, and 130 people abuse these drugs or are dependent upon them [1]. Notably, while 70% of people who abuse prescription pain medication report that they obtained the drugs from friends or relatives [2], long-term abusers of opioid pain relievers are most likely to acquire their drugs through a prescription from a physician [3]. In addition to the chronic pain and the prescription drug abuse epidemics that are well documented in the United States, another third interrelated epidemic is now requiring attention as well. Widespread opioid pain reliever abuse has been associated with a dramatic rise in heroin use in the United States. In March 2014, US Attorney General Eric Holder noted this connection while raising concern about the “urgent public health crisis”—a 45% increase in US heroin overdose deaths from 2006 to 2010 [4]. The Food and Drug Administration (FDA) recently has taken actions that both acknowledge these trends and raise new concerns. In October 2013, the agency recommended that many prescription opioids be reclassified as Schedule II drugs [5]. Later that month, the FDA approved for use a powerful new, pure hydrocodone painkiller, Zohydro ER, leading to an outcry from at least 28 state attorneys general and medical experts concerned about the medication's potential for diversion and abuse [6]. As a response to this epidemic of prescription opioid deaths …

630: Prescription drug use and abuse in pregnancy: common and under recognized

Prescription drug abuse in women has increased dramatically with four times as many women dying from prescription drug overdose than cocaine and heroin combined. We sought to characterize the scope of controlled substance use and abuse in a cohort of pregnant women.

Knowing Opioid Medication Formulations and Eliminating Confusion

Timothy Nguyen, PharmD, BCPS Opioid medications are also known as narcotics and are often used for pain management. They workbybinding toopioid receptors and are highly addictive,whichmayproduce feelings of euphoria, warmth, and relaxation. Common side effects associated with opioids involve the central nervous system including sedation, respiratory depression, and mental confusion; the gastrointestinal system including nausea, vomiting, and constipation; and other side effects related to physical dependence and tolerance. Prolonged exposure to opioids will lead to opioid abuse and withdrawal symptoms upon discontinuation. According to the Centers for Disease Control and Prevention, 3 of 4 prescription drug overdoses are caused by inappropriate opioid use. Drug overdoses also contribute to high mortality rates. The current death rates associated with opioid overdose have more than tripled compared with the data in 1990.Opioidmisuse is widespread and represents serious problems for health care practitioners. There are multiple means to abuse opioids, and they may include overingesting pills or capsules, chewing or crushing the tablets into powder for snorting, dissolving content for injection, and altering the integrity of the pill or its purpose for illicit use. Several commercial opioid medications are formulated in “abuse-deterrent” dosage forms to prevent misusage. The Table lists some of these newer

Hydrocodone Combination Products Move to Schedule II

The Drug Enforcement Administration has made it harder to prescribe hydrocodone combination products. The move was expected, as the agency proposed in February to move hydrocodone combinations from schedule III to schedule II in response to requests from both the Department of Health & Human Services and the Food and Drug Administration. The DEA published the final rule on the rescheduling in the Federal Register on Aug. 22. Manufacturers, distributors, and prescribers will have to comply by Oct. 13. One caveat: Prescriptions that were issued before Oct. 6 and authorized for refilling may be dispensed in accordance with current schedule III guidelines, provided dispensing occurs before April 8, 2015. Some physician groups have opposed the move, saying that it will lead to more administrative burdens, do nothing to curb abuse and diversion, and potentially decrease access to medications. The agency said it is time to rein in opioid prescribing and that rescheduling will help accomplish that goal. “Almost 7 million Americans abuse controlled-substance prescription medications, including opioid painkillers, resulting in more deaths from prescription drug overdoses than auto accidents,” DEA administrator Michele Leonhart said in a statement. “Today's action recognizes that these products are some of the most addictive and potentially dangerous prescription medications available.” Hydrocodone combination products were placed on schedule III by Congress in 1970 when it created the Controlled Substances Act, in part because it was believed that adding acetaminophen or other non-narcotics might lessen the abuse potential. Hydrocodone itself was placed on schedule II. Now, “the scientific, medical, and epidemiological data are robust and support rescheduling [of hydrocodone combination products] into schedule II,” according to the final rule. The products are widely diverted and abused at rates similar to that of oxycodone products, which are schedule II, according to the DEA, which added that abuse is associated with severe psychological or physical dependence. The hydrocodone combinations also are associated with large numbers of deaths, said the agency. More than 16,000 deaths in 2010 were due to abuse of opioids, including hydrocodone combinations, according to the DEA. In comments to the proposed rule in April, the American Medical Association (AMA), along with a group of organiza­tions and companies in the long-term care (LTC) field, asked the agency to delay the final rule until an exception was made for nursing homes and other LTC facilities. The AMA's House of Delegates also had voted in 2013 to oppose rescheduling. The American College of Emergency Physicians also urged against rescheduling, telling the DEA that it would not likely solve the abuse and diversion problems, but would lead to a greater administrative hassle for physicians. The DEA said it received 573 comments after it proposed rescheduling, with 52% in favor, 41% opposed, and 7% taking no position. Most of the commenters opposed to rescheduling were pharmacists, pharmacy students, and patients. Those opposed were concerned about how it would affect prescribing practices and patient access to medicine, and how it might impact LTC facilities. Commenters also said that it would not prevent abuse or diversion. The DEA said that although moving to schedule II does, for instance, prohibit refills, it would not necessarily block physicians from writing prescriptions for supplies of longer than 30 days, or from writing multiple prescriptions at once. State laws might have limits, however, and those will take precedence over the DEA rule. The DEA rescheduling follows an FDA advisory committee recommendation in January 2013 to do so, and the FDA's backing of the proposal in October 2013. HHS followed with its own recommendation to the DEA.

Clinical behavior of Japanese community pharmacists for preventing prescription drug overdose.

Prescription drug abuse, including benzodiazepines, is a growing health problem in Japan. This study examined the community pharmacist's clinical behavior regarding patients who overdose on prescribed drugs, and explored the possibility of overdose prevention by community pharmacists. We surveyed all registered community pharmacies with dispensing functions (n = 1867) in the Saitama Pharmaceutical Association. An anonymous self-administered questionnaire was mailed to each pharmacy. Respondents were asked about clinical behavior such as medication counseling and referral to the prescriber if prescription drug overdose was identified. Among respondents, 26% of community pharmacists reported clinical experience of working with patients who overdosed on prescribed drugs in the previous year. Half of respondents evaluated their practice such as medication counseling and referral to the prescriber as 'good'. On multivariate analysis, a 'poor' self-evaluation of referral to the prescriber was significantly associated with the following perceptions: 'insufficient confidence in communication with prescribers' (odds ratio [OR], 2.7; 95% confidence interval [95%CI]: 1.4-5.3), and 'to avoid trouble with prescribers' (OR, 1.7; 95%CI: 1.0-2.7). Japanese community pharmacists could prevent prescription drug abuse in their practice, but the pharmacists who have insufficient confidence in communication with prescribers and who are afraid of trouble with a prescriber, reported poor self-evaluation for referral to the prescribers. All prescribers should understand the importance of referral by community pharmacists, to assist community pharmacists in playing a critical role in prevention of prescription drug abuse.

P-48 * THE JAPANESE COMMUNITY PHARMACIST AS A "GATEKEEPER" FOR PREVENTING PRESCRIPTION DRUG OVERDOSE

Introduction. Prescription drug abuse, including benzodiazepines, is a growing health problem in Japan. The Japanese government has expected community pharmacists to act as gatekeepers for prescription drug abusers. This study aimed to examine the pharmaceutical practices adopted by community pharmacists to prevent prescription drug abuse. Method. We surveyed all registered community pharmacies with dispensing functions (n = 1867) in the Saitama Pharmaceutical Association. An anonymous self-administered questionnaire was mailed to each pharmacy. Respondents were asked about pharmaceutical practices such as referral to the prescriber if prescription drug overdose is expected. Result. Questionnaires were completed by 1416 pharmacists (response rate of 76%). Among respondents, 26% of community pharmacists reported clinical experience of working with patients who overdosed on prescribed drugs in the previous year. On multivariable analysis, a poor self-evaluation of referral to the prescriber was significantly associated with the following perceptions by pharmacists: “Insufficient confidence in communication with prescribers” (OR = 2.7, 95% CI = 1.4–5.3), and “To avoid trouble with prescribers” (OR = 1.7, 95% CI = 1.0-2.7). Conclusion. All prescribers should understand the importance of referrals by community pharmacists, in order to assist the community pharmacists to play the critical role of gatekeeper for preventing prescription drug overdose.

Evolution and convergence of state laws governing controlled substance prescription monitoring programs, 1998-2011.

We sought to collect and characterize all laws governing the operation of prescription monitoring programs (PMPs), state-level databases that collect patient-specific prescription information, which have been suggested as a tool for reducing prescription drug overdose fatalities. We utilized a structured legal research protocol to systematically identify, review, and code all PMP statutes and regulations effective from 1998 through 2011. These laws were then abstracted along eleven domains, including reporting provisions, data sharing, and data access. PMP characteristics vary greatly among states and across time. We observed an increase in the types and frequency of data required to be reported, the types of individuals permitted to access PMP data, and the percentage of PMPs authorized to proactively identify outlier prescribers and patients. As of 2011, 10 states required PMPs to report suspicious activity to law enforcement, while only 3 required reporting to the patient's physician. None required linkage to drug treatment or required all prescribers to review PMP data before prescribing. Few explicitly address data retention. State PMP laws are heterogeneous and evolving. Future studies of PMP effectiveness should take these variations into account.

Prescription drug monitoring and drug overdose mortality.

BackgroundAbuse of prescription drugs, particularly opioid analgesics, has become a major source of injury mortality and morbidity in the United States. To prevent the diversion and misuse of controlled substances, many states have implemented prescription drug monitoring programs (PDMPs). This study assessed the impact of state PDMPs on drug overdose mortality.MethodsWe analyzed demographic and drug overdose mortality data for state-quarters with and without PDMPs in 50 states and the District of Columbia during 1999–2008, and estimated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) of drug overdose mortality associated with the implementation of state PDMPs through multivariable negative bionomial regression modeling.ResultsDuring the study period, annual national death rates from drug overdose increased by 96%, from 5.7 deaths per 100,000 population in 1999 to 11.2 in 2008. The impact of PDMPs on drug overdose mortality varied greatly across states, ranging from a 35% decrease in Michigan (aRR = 0.65; 95% CI = 0.54–0.77) to a more than 3-fold increase in Nevada (aRR = 3.37; 95% CI = 2.48–4.59). Overall, implementation of PDMPs was associated with an 11% increase in drug overdose mortality (aRR = 1.11; 95% CI = 1.02–1.21).ConclusionsImplementation of PDMPs did not reduce drug overdose mortality in most states through 2008. Program enhancement that facilitates the access and use of prescription drug monitoring data systems by healthcare practitioners is needed.Electronic supplementary materialThe online version of this article (doi:10.1186/2197-1714-1-9) contains supplementary material, which is available to authorized users.

On the Use of Glasgow Coma Scale as a Predictor of ICU Admission in Deliberate Drug Poisoning

Dear Editor, In this issue, we read with interest the article by Maignan and colleagues 1 regarding predictive factors for ICU admission in poisoned patients. Deliberate drug poisoning (DDP) is indeed a significant public health threat, particularly considering the current prescription drug overdose epidemic in the United States 2. To their credit, the authors acknowledge the limitations of their data set with regard to ‘toxicological anamnesis’ as well as the issue of generalizability to other regions that do not routinely practice direct ICU admission and bypass the ED. However, we feel some aspects of the methodology deserve some comments with regard to the interpretation of their final model, particularly on the use of Glasgow Coma Scale (GCS) as a predictor and ICU admission as the end-point in the study. The major limitation to the study is the use of ICU admission as the main outcome, rather than objective adverse end-points such as shock or cardiac arrest. The likely reason for this was the retrospective nature of the study, which likely precluded the ability to definitively capture adverse events such as shock or arrhythmias. Unfortunately, in doing so, the authors' model derived predictors of ICU admission, which are hospital dependent and practitioner dependent, may be significantly impacted by hospital census and do not necessarily signify that an adverse event has occurred. For example, patients in their study who were admitted to the ICU actually had similar median vital signs when comparing ED arrival and ICU arrival. Thus, the model essentially furthers a practice based on fear of certain toxic exposures, such as ‘cardiac drugs’, without using objective criteria (e.g. electrocardiographic factors) 3 to guide practice. In addition, the authors retrospectively applied the GCS to their patients and tested this as a predictor of ICU admission, which remained significant in the final model. This approach presents a variety of significant problems. Firstly, GCS is very difficult to calculate retrospectively and is often not charted even when calculated. The authors state that they did not adjust the model for missing values, which is a limitation to their statistical approach to logistic regression. In addition, GCS score for any individual patient changes dynamically across the time from ingestion; so given a population of patients with varying times to presentation, this appears to be quite a moving target. Most importantly, we are concerned that use of the GCS to guide triage in poisoning would lead to gross over-admission of patients to the ICU, particularly considering simple ethanol-intoxicated patients who present with coma (i.e. GCS < 8) but clearly do not require the precious resources afforded by the ICU. In summary, we applaud the authors' efforts to derive a risk stratification scheme for DDP triage, but would strongly caution against the use of their derived tool for individual patient triage, nor would we recommend the use of GCS to guide admission to the ICU. We look forward to future prospective work from the authors to improve upon their preliminary work.