Suspected Drug Overdose Research Articles

Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022

Layperson-administered naloxone (LAN) is a powerful but incompletely characterized intervention to prevent opioid-related overdose mortality. LAN trends are relevant to policy and strategic planning in naloxone distribution initiatives. To assess the 2-year LAN trend for persons in the United States receiving naloxone during emergency medical services (EMS) activations. This retrospective cross-sectional study was conducted in the United States from June 2020 to June 2022 among 65 621 195 EMS activations from 911 responses, EMS standbys, or when EMS crews functioned in an ambulance intercept role or during mutual aid to another ambulance response. Activations within health care settings and interfacility or medical transports were excluded. Data are from the National Emergency Medical Services Information System (NEMSIS), the national EMS patient care record database. From June 2020 to June 2022, NEMSIS included more than 96 million EMS activations from nearly 14 000 agencies across 54 states and territories. EMS clinician-reported LAN. The primary outcome was the trend of receiving LAN, measured by EMS clinician documentation. From June 2020 to June 2022, EMS reported 744 078 patients receiving naloxone, with 24 990 (3.4%) involving LAN. Patients were predominantly male (17 331 [69.4%]) and had a median (IQR) age of 42 (31-56) years, with the majority treated in urban homes or residences (21 692 [86.8%] urban; 13 223 [52.9%] in-home or residence). Of the total naloxone recipients, 243 985 patients (32.8%) had suspected drug overdose documentation as either the primary or secondary impression. Overall, the percentage change in naloxone administration rates decreased 6.1% over the study period (from 1140.1 [95% CI, 1135.1-1145.1] per 100 000 EMS activations to 1070.1 [95% CI, 1064.9-1075.3] per 100 000 EMS activations), while the percentage change of persons receiving LAN increased 43.5% (from 30.0 [95% CI, 29.2-30.8] per 100 000 EMS activations to 43.1 [95% CI, 42.0-44.1] per 100 000 EMS activations). In this cross-sectional study, the LAN rate increased from June 2020 to June 2022 as reported in the national EMS database. These findings help inform policies and practices aimed at mitigating the devastating impacts of the opioid epidemic and saving lives. Novel public health strategies are needed to measure the effects of this intervention nationally, evaluate approaches to expand naloxone distribution, and address naloxone usage barriers.

Step-By-Step Procedure to Identify Previously Unknown Compounds by LC-QTOF-MS Exemplified by an Intoxication With the Methaqualone Analog SL-164.

In September 2019, a 22-year-old man with a history of drug abuse presented to the hospital with altered mental status. Due to a suspected drug overdose, a blood sample taken on admission and a urine sample collected 30 h thereafter were submitted to our laboratory to test for illegal drugs, pharmaceutical substances, and designer drugs. During the routine toxicological analysis of the serum sample, morphine and phenobarbital were identified by liquid chromatography-quadrupole-time-of-flight mass spectrometry (LC-QTOF-MS). Additionally, two compounds showing identical accurate masses and isotope ratios as the designer benzodiazepine diclazepam and the benzodiazepine lormetazepam were found. However, retention times differed significantly from the expected values, and the acquired MS/MS spectra did not match the library entries of the two compounds, indicating the presence of two previously unknown substances. After further investigation, SL-164 (5-chloro-3-(4-chloro-2-methylphenyl)-2-methyl-4(3H)-quinazolinone), a methaqualone analog, which has recently emerged on the research chemical market, and its hydroxy metabolite were tentatively identified by accurate mass, isotope matching, and plausible fragmentation. However, for unequivocal confirmation and quantification, a reference standard is required. As no reference material was available by the end of 2019, SL-164 was obtained from an online shop, and its identity and purity (97.8%) were confirmed by nuclear magnetic resonance spectroscopy. The subsequent quantitative analysis revealed a concentration of 390 ng/mL SL-164 in serum. In the urine sample, the parent compound was not detected, but three suspected monohydroxylated metabolites were found. This example shows that LC-QTOF-MS is a powerful approach for the (tentative) identification of unknown compounds in biological matrices.

Trends in Suspected Opioid Drug Overdose Events in Emergency Medical Service Encounters in South Carolina, 2019-2022.

The number of drug overdoses and drug-related deaths has increased across the United States in recent years. Reports of suspected opioid drug overdoses identified through emergency medical services (EMS) are valuable sources of information for shaping the public health response to drug overdoses. The objective of this study was to describe trends in the number of EMS-reported suspected opioid drug overdose events in South Carolina from 2019 through 2022. We included reports of suspected opioid drug overdoses if they met the definition of nonfatal opioid overdose syndrome in our analysis. We analyzed statewide data reported from EMS agencies to biospatial, Inc, from January 2019 through December 2022 to understand demographic trends for a statewide overdose and response program in South Carolina. In 2022, a total of 11 078 suspected opioid drug overdose events, or 216.4 per 100 000 South Carolina residents, were reported by EMS. During the 4-year study period, the number of EMS-reported suspected opioid drug overdoses increased by 82%, with African American people experiencing a 133% increase and White people experiencing a 68% increase. The number of opioid overdoses increased among all age groups during the study period. Approximately 84% of opioid overdoses were reported in urban counties, but rural counties had a higher number of opioid overdose reports per capita than urban counties. Monitoring trends in suspected opioid drug overdoses allows decision makers to adjust resources and programs for overdose response and is essential for local coordinated response. Continued monitoring of trends is needed for an equitable response to prevent opioid drug overdoses.

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020.

While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time. The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates. During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952). Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

Distribution of donepezil in postmortem casework

Donepezil is one of the primary treatments options for patients suffering from Alzheimer's Disease. In a review of more than 2200 postmortem donepezil positive blood specimens, 76% of concentrations were higher than the proposed therapeutic range. Means and medians were similar between central blood specimens and peripheral specimens, indicating minimal postmortem redistribution.Postmortem concentrations may not reflect those circulating antemortem. Mean and median postmortem blood concentrations were approximately 3-fold higher than those in antemortem blood specimens. Additionally, in cases where antemortem blood was available for testing, large increases in donepezil concentrations were reported between antemortem and postmortem specimens without documented administration by medical personnel. Elevated blood donepezil concentrations have been reported in multiple postmortem cases where cause of death was unrelated. The blood concentrations reported in cases where donepezil did not contribute to death overlapped with those in suspected drug overdose cases where other drugs may have been present. In 4 out of 5 suspected donepezil overdose cases, blood concentrations greater than 1000 ng/mL were reported, whereas less than 1% of all postmortem blood samples reviewed achieved these concentrations. Blood concentrations greater than 1000 ng/mL should be considered contributory when a drug overdose is suspected. Postmortem donepezil concentrations should be interpreted with caution in the context of a comprehensive case history.

Therapeutic Drug Monitoring of Carbamazepine: A 20-Year Observational Study.

Background: Carbamazepine (CBZ) is a first-generation anticonvulsant drug. Hence, in certain cases, therapeutic drug monitoring (TDM) supports pharmacotherapy. Methods: The presented research was based on a retrospective analysis including 710 ambulatory and hospitalized patients treated with CBZ between the years 1991 and 2011. The method used for the determination of the CBZ concentration was fluorescence polarization immunoassay (FPIA) performed using an Abbott GmbH TDx automatic analyzer, with the therapeutic range for carbamazepine being 4–12 µg/mL. Results: The therapeutic range was observed more often in patients between 3 and 17 years of age compared with the population ≥18 years of age (73.5% vs. 68.8%). The therapeutic level was exceeded less frequently in the population between 3 and 17 years of age despite them being given a significantly higher dose per kilogram of body weight than in the population ≥18 years of age (13.64 mg/kg vs. 10.43 mg/kg, p < 0.0001). Patients ≥18 years of age were statistically significantly more likely to be in the group with a suspected drug overdose (73.9% vs. 26.1%), and suicide attempts only occurred in elderly patients (100.0% vs. 0.0%, p = 0.003). Conclusion: The results of the TDM of CBZ showed that only 71% of all samples were at the therapeutic level. To ensure the maximum efficacy and safety of the therapy, it is necessary to monitor the concentration of CBZ regardless of sex and age.

Improvements in Toxicology Testing to Identify Fentanyl Analogs and Other Novel Synthetic Opioids in Fatal Drug Overdoses, Connecticut, January 2016–June 2019

Drug overdose deaths in Connecticut increasingly involve a growing number of fentanyl analogs and other novel nonfentanyl synthetic opioids (ie, novel synthetics). Current postmortem toxicology testing methods often lack the sophistication needed to detect these compounds. We examined how improved toxicology testing of fatal drug overdoses can determine the prevalence and rapidly evolving trends of novel synthetics. From 2016 to June 2019, the Connecticut Office of the Chief Medical Examiner increased its scope of toxicology testing of suspected drug overdose deaths in Connecticut from basic to enhanced toxicology testing to detect novel synthetics. The toxicology laboratory also expanded its testing panels during this time. We analyzed toxicology results to identify and quantify the involvement of novel synthetics over time. From 2016 to June 2019, 3204 drug overdose deaths received enhanced toxicology testing; novel synthetics were detected in 174 (5.4%) instances. Ten different novel synthetics were detected with 205 total occurrences. Of 174 overdose deaths with a novel synthetic detected, most had 1 (n = 146, 83.9%) or 2 (n = 26, 14.9%) novel synthetics detected, with a maximum of 4 novel synthetics detected. Para-fluorobutyrylfentanyl/FIBF, furanylfentanyl, and U-47700 were most identified overall, but specific novel synthetics came in and out of prominence during the study period, and the variety of novel synthetics detected changed from year to year. Enhanced toxicology testing for drug overdose deaths is effective in detecting novel synthetics that are not identified through basic toxicology testing. Identifying emerging novel synthetics allows for a timely and focused response to potential drug outbreaks and illustrates the changing drug market.

A latent class analysis of drug and substance use patterns among patients treated in emergency departments for suspected drug overdose

IntroductionPolysubstance use and misuse can increase risks for nonfatal and fatal drug overdose. To categorize drugs used in combination in nonfatal overdoses, we analyzed data from emergency department (ED) overdose-related visits in 18 states funded by CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program. MethodsFrom 2017 to 2018, 120,706 ED visits included at least one hospital discharge code indicating acute drug poisoning for opioids, stimulants, hallucinogens, cannabis, anti-depressants, sedatives, alcohol, benzodiazepines, or other psychotropic drugs. Latent class analyses were conducted to determine the groupings of drug combinations in overdose visits. ResultsLatent class analyses indicated a model of 5 classes – mostly heroin overdose (42.5% of visits); mostly non-heroin opioid overdose/use (27.3%); opioid, polysubstance (11.0%); female, younger (<25 years), other non-opioid drugs (10.5%); female, older (>55 years), benzodiazepine (8.0%). Findings indicated that heroin continues to be a large burden to EDs, yet EDs are also seeing overdose survivors with polydrug toxicity. ConclusionsMedication-assisted treatment could be initiated in the emergency department following overdose for patients with opioid use disorder, and post-overdose protocols, such as naloxone provision and linkage to treatment and harm reduction services, have the potential to prevent future overdose for those at risk.

Long-term trends in the epidemiology of out-of-hospital cardiac arrest precipitated by suspected drug overdose

BackgroundLittle is known about the long-term trends in the incidence and outcomes of drug overdose out-of-hospital cardiac arrests (OHCA). MethodBetween 2000 and 2017, we retrospectively reviewed drug overdose OHCAs from the Victorian Ambulance Cardiac Arrest Registry. Incidence was assessed using linear regression, and the baseline characteristics and survival outcomes were assessed using nonparametric test for trend. Arrest factors associated with survival to hospital discharge were assessed using logistic regression. The 12-month functional recovery and health related quality of life for survivors was summarised using descriptive statistics. ResultsThe incidence of emergency medical services (EMS)-attended and EMS-treated cases was 5.8 and 2.0 per 100,000 person-years, respectively, with no significant changes in trend over time. Return of spontaneous circulation increased from 23% to 34% (p for trend = 0.001), event survival increased from 23% to 30% (p for trend = 0.007), and survival to hospital discharge increased from 4% to 13% (p for trend = 0.03). Age, arrest witnessed by bystander or EMS, initial shockable rhythm or pulseless electrical activity, intubation, epinephrine and sodium bicarbonate administration were independently associated with survival. The adjusted-temporal trend for survival was not significant (per year increase; OR 1.02, 95% CI: 0.98, 1.07; p = 0.244). Of the 12-month survivors, 50% of the responders reported good functional recovery, and few reported severe problems with mobility, self-care, daily activity, pain, and anxiety/depression. ConclusionAlthough the incidence of drug overdose OHCA remained unchanged between 2000 and 2017, the rates of survival have significantly improved.

Syndrome definitions for drug overdose: How far down the rabbit hole do we go?

ObjectiveTo discuss the process for developing and revising suspected drug overdose queries in syndromic surveillance (SyS) systems.IntroductionState and local jurisdictions have been exploring the use of SyS data to monitor suspected drug overdose outbreaks in their communities. With the increasing awareness and use of SyS systems, staff from the Centers for Disease Control and Prevention (CDC) worked to develop several queries that jurisdictions could use to better capture suspected drug overdose visits. In 2017, CDC released their first two queries on heroin overdose and opioid overdose, followed in 2018 by stimulant and all drug overdose queries. Over time, and with the assistance from the SyS community and the CDC-funded Enhanced State Opioid Overdose Surveillance (ESOOS) state health departments, CDC has revised the queries to address suggestions from jurisdictions. However, it’s not clear how often and in what way the syndrome definitions are updated over time. This is particularly true as new drugs emerge and the names of those drugs are integrated into syndrome definitions (e.g., recent “Spice” and “K2” synthetic cannabinoid outbreaks).DescriptionThis roundtable will provide a forum for national, state, and local users of SyS and drug overdose syndrome queries to discuss the process of query development, with an eye towards determining when a definition is “good enough.” CDC staff will facilitate the discussion and present the current portfolio of drug-related overdose queries. Participants will be encouraged to provide feedback on the queries, share what has been/has not been working in their jurisdiction with regard to syndrome query development, and discuss the process for revising queries as the epidemic evolves. The focus of this roundtable will be on suspected drug overdose query development and revision with emergency department SyS data.How the Moderator Intends to Engage the Audience in Discussions on the TopicWith most jurisdictions grappling with the impact of the opioid epidemic, this roundtable is well suited for widespread audience participation. Though some jurisdictions have been using SyS to monitor suspected drug overdose outbreaks for some time, others are not using SyS in this way. Thus, opportunities for sharing of work, experiences, barriers, and facilitators will be useful for all SyS users

Maternal Overdose That Results in Respiratory Arrest During Pregnancy

Acute respiratory failure in pregnancy is a rare but life-threatening event that requires specialized management between the obstetric and critical care teams. There are very few case reports regarding the treatment of the mother and the fetus in the case of respiratory failure during pregnancy. We report a case of a 30-year-old woman who was at 31 weeks, 5 days gestation and was found unresponsive at home with a suspected drug overdose. On admission, the patient was unresponsive after intubation that was difficult because of facial and upper airway edema. Fetal heart tones were assessed and found to be in the 130s, with no fetal movement detected. The patient was diagnosed with acute respiratory failure, hypoxic ischemic encephalopathy, hypertension, gestational diabetes, asthma, and pneumonia; in addition, urine toxicity screening was positive for opiates. Initial treatment included therapeutic hypothermia, mechanical ventilation, electroencephalogram (EEG) monitoring, electronic fetal monitoring, bedside ultrasound with biophysical profile, sedation, magnesium for preeclampsia prophylaxis, an antihistamine for significant facial edema, steroids for fetal lung maturity, and an insulin drip to manage diabetes. A repeat cesarean was performed on Day 2 of hospital admission due to worsening neurological status. The neonate was born with Apgar scores of 3 at 1 min and 4 at 5 min and transferred to NICU. On Day 6 of admission, an EEG concluded a diagnosis of postanoxic myoclonus that was consistent with diffuse cerebral dysfunction and injury. Findings and the prognosis were discussed with the family, and the decision to withdraw support was made. The woman was a registered organ donor, and donation after cardiac death occurred on Day 6 of hospital admission. The newborn was discharged to home on Day 49 of life; there was continued concern for possible hypoxic-ischemic sequelae, although EEG, end-organ function lab values, and evolving examination were reassuring. Coordination of care with a multidisciplinary team is necessary to provide the best and most appropriate care to a very complex obstetric patient. In the absence of published evidence-based practice guidelines, in regard to treatment options, case reports and clinical judgment need to be used in the decision-making process.

Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine

Drug overdose deaths continue to increase, despite the leveling off of prescription opioid use and policy changes limiting opioid prescribing. Illicit fentanyl is the leading cause of drug overdose death, and it is important to characterize the emerging combination of other illicit drugs with fentanyl, which increases the risk of overdose. To determine whether rates of the combination of nonprescribed fentanyl with cocaine or methamphetamine have changed in urine drug test (UDT) results through time. This cross-sectional study of UDT results from January 1, 2013, through September 30, 2018, included patient specimens submitted for UDTs by health care professionals as part of routine care. Patients were selected from health care practices across the United States, including substance use disorder treatment centers, pain management practices, primary care practices, behavioral health practices, obstetrics and gynecology practices, and multispecialty groups. The UDT analysis used liquid chromatography-tandem mass spectrometry to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl. Specimens from individuals reported to have been prescribed fentanyl were excluded. A convenience sample approach was used to randomly select 1 million unique patient UDT specimens from Millennium Health's UDT database for further analysis. Each specimen had associated cocaine, methamphetamine, and fentanyl UDT results. Medically necessary UDT to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl, ordered by a health care professional as part of routine patient care. Rates of nonprescribed fentanyl positivity among cocaine- or methamphetamine-positive UDT results, quantified through time. In a sampling of 1 million unique patients' UDT specimens analyzed for cocaine and fentanyl (median [interquartile range] age, 44 [19-69] years; 55.0% women), positivity rates for nonprescribed fentanyl among the cocaine-positive results increased significantly, from 0.9% (n = 84) (95% CI, 0.7%-1.1%) in 2013 to 17.6% (n = 427) (95% CI, 16.1%-19.1%) in 2018, a 1850% increase (τ = 0.78; z = 9.45; P < .001). In the same sampling of 1 million specimens, positivity rates for nonprescribed fentanyl among the methamphetamine-positive results also increased significantly, from 0.9% (n = 29) (95% CI, 0.6%-1.2%) in 2013 to 7.9% (n = 344) (95% CI, 7.1%-8.7%) in 2018, a 798% increase (τ = 0.72; z = 8.75; P < .001). An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.

A case of cocaine trafficking via body packer as reported by chemical examinerlaboratory, Punjab, India

Drug trafficking is a global illicit trade. The international drug trade uses various methods to smuggle narcotics. These methods include hiding the narcotics in vehicles or carried items, attaching them to one's body or use of the body as a container. A viscera case was received by Chemical Examiner Laboratory (CEL) in July, 2015 with history of suspected drug overdose along with two capsules (one intact and one ruptured). This was a case of body packer which was clarified from the copy of postmortem report (PMR) sent by autopsy surgeon along with various exhibits. We are writing this case because this is the only reported body packer syndrome in which viscera was analyzed by CEL.

Enhanced surveillance to monitor response to a provincial overdose emergency, Canada

ObjectiveTo describe the use of multiple data sources to monitor overdoses in near real-time in order to evaluate response to the provincial overdose emergencyIntroductionOn April 14, 2016, British Columbia (BC)’s Provincial Health Officer declared a public health emergency due to a significant increase in drug-related overdoses and deaths in the Province. Despite the declaration, 161 suspected drug overdose deaths were reported across the Province in December 2016, a 137% increase over the number of deaths occurring in the same month of 2015 [1]. In response to the surge overdoses, Vancouver Coastal Health Authority (VCH), one of 5 health regions within BC, rapidly implemented a number of novel harm reduction initiatives. Overdose Prevention Sites (OPS) were opened on December 8, 2016. At these sites, people using illicit drugs are supervised by peers who can provide rapid intervention if an overdose occurs. The Mobile Medical Unit (MMU), a temporary state-of-art medical facility, was deployed on December 13, 2016 to reduce the congestion for the BC Ambulance Service (BCAS) and a major urban emergency department (ED) [2]. Following deployment of the MMU, services were transitioned to a permanent program at the Downtown Eastside Connections Clinic (DTES Connections) in the spring of 2017. DTES Connections was created to provide rapid access to addiction treatment [3]. In order to keep pace with the rapidly increasing number of novel harm reduction initiatives, enhanced surveillance programs were implemented at VCH to monitor and evaluate these innovative harm reduction activities, including development of new surveillance programs for the MMU, OPS and DTES Connections, along with existing routine surveillance system from EDs and a Supervised Injection Site (Insite).MethodsSince 2011, after a spike of heroin-related deaths was reported in the Vancouver region, VCH started weekly monitoring of overdoses at nine EDs and Insite. Daily data extracts from EDs are automatically transferred to a secure driver by secure file transfer protocols. Groups of ICD 9/10 codes and keywords were refined to identify overdoses from EDs. A formal epidemiological evaluation was conducted to measure the algorithm’s accuracy in 2013. A live connection with Insite database was set up in 2011. Overdose events at Insite are clinically determined by clinical staff. Substance injected, characteristics of overdose event and emergency interventions are entered in the database.With the implementation of MMU, OPS and DTES Connections, a series of protocols were developed to monitor visitors' information and overdose events from each site. Demographic information, visit information, clinical presentations and substance used are collected from MMU and DTES Connections. A subset of data fields, including client handle, visit information, substance involved, overdose occurrence, naloxone intervention and ED transfer, are collected from OPS to minimize impact on peers and community partners who run the sites.ResultsBetween November 2016 and January 2017, a sharp increase in overdoses was identified from EDs and Insite. Opioids, especially fentanyl and analogs, most likely contributed to the sudden increase. Weeks with government income assistance payment showed an even greater increase in overdoses.Since December 2016, six OPS opened in Vancouver. Four of them are still operating and one received federal approval to become a supervised consumption site. By September 2017, there were 184,760 visits to the OPS. 1,017 overdoses were reversed.A total of 2,798 patients visited the MMU during the whole operation period. 589 (21%) presented from treatment of overdose. The highest number of overdose visits occurred on December 21, 2016 after that month’s income assistance payment. Since then, the number of visits fluctuated with most visits driven by non-overdose related reasons. 89% of overdose visits arrived by BCAS and 79% of overdoses needed emergent and urgent care.108 patients were transferred to DTES Connections by BCAS for treatment of overdoses by September 2017. All patients presented with opioid addiction issues.As of the end of September 2017, no deaths were reported from OPS, MMU and DTES Connections since operations.ConclusionsAs VCH continues responding to the drug overdose emergency in face of increasing drug overdoses, enhanced surveillance data have been widely used by the VCH Emergency Overdose Response Committee for decision making on harm reduction activities, such as expanding operation hours at OPS and Insite on income assistance payment days; examining the impact on EDs of opening the MMU; encouraging users to avoid using alone; opening new supervised injection service and women’s only OPS; and referring ED patients with non-fatal overdose to rapid access opioid agonist treatment and outreach follow-up.

P105: BC’s public health emergency and naloxone administration by the BC Ambulance Service

Introduction: In 2015, there were 476 apparent illicit drug overdose deaths, prompting BC’s Provincial Health Officer to declare a public health emergency on 14 Apr 2016. Paramedics of BC’s Ambulance Service (BCAS) are on the front lines in this crisis. Here we examine recent trends in the number of suspected overdose events attended by the BCAS and the use of naloxone, an opioid antagonist, by BCAS paramedics. Methods: The BC Centre for Disease Control receives a weekly data feed from BC Emergency Health Services that includes all records from the BCAS Patient Care Record where: naloxone was administered by paramedics; the primary impression code indicates poisoning or overdose; or, the originating call is associated with ingestion poisoning (‘card 23’). Here, we report a descriptive analysis of these data for suspected drug overdose events during the period January 1, 2010 to September 30, 2016. Results: Between January 2010 and September 2016 BCAS paramedics attended 164,227 suspected overdose events; 12% of these events (n=16,944) included naloxone administration by BCAS paramedics. Paralleling the rise in illicit drug overdose deaths in BC, naloxone administration by paramedics has been increasing rapidly, doubling from approximately 180/month in 2014, to 370/month in 2016. When naloxone was administered by paramedics, 90% of these patients were transported, whereas 77% were transported when naloxone was not administered. Administrations occurred most frequently on Friday and Saturday evenings. Almost half (46%) of all naloxone administrations by paramedics were recorded as being in a home or residence; 18% were recorded as occurring on a street or highway. The proportion of naloxone administrations among males has increased yearly. In 2010, 58% of naloxone administrations were in males compared to 69% in 2016. Conclusion: The number of overdose deaths in BC has risen drastically in recent years and the proportion of ambulance calls requiring administration of naloxone by BCAS has climbed correspondingly. The vast majority of overdose cases-especially those requiring naloxone-are transported to the emergency department. With the overdose crisis showing little sign of abating, the administration of naloxone by BC paramedics will continue to be a critical element of the provincial response.

Characteristics and trends of emergency patients with drug overdose in Osaka.

Drug overdose is an important issue in emergency medicine. However, studies covering overdose patients transported by ambulance have not been sufficiently carried out. We attempted to clarify problems of suspected drug overdose patients transported by ambulance. This is a prospective population-based cohort study. Data were collected by emergency medical service crews in Osaka City, Japan, between January 1998 and December 2010. Drug overdose cases increased annually from 1,136 in 1998 to 1,822 in 2010 (P < 0.0001 for trend). In these cases, the dominant age range was between 16 and 40 years and the age distribution did not change over time. The age of non-overdose cases increased (P < 0.0001 for trend), with patients aged ≥66 years becoming most common in recent years, reflecting the aging of society. Males comprised most non-overdose patients, but the percentage of females increased annually (P < 0.0001 in trend). Females comprised approximately 70% in overdose cases annually throughout the study period. The duration from the emergency call to the arrival at the hospital for overdose patients has increased markedly in recent years. It also takes more time to obtain acceptance from hospitals to care for patients of suspected overdose. The characteristics of drug overdose patients are clearly different from those of non-overdose patients. Recent trends of drug overdose patients indicate the accelerated burden on emergency medical services system.

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

IntroductionWe sought to compare characteristics of emergency medical services-treated out-of-hospital cardiac arrests resulting from suspected drug overdose with non-overdose cases and test the relationship between suspected overdose and survival to hospital discharge. MethodsData from emergency medical services-treated, non-traumatic out-of-hospital cardiac arrests from 2006 to 2008 and late 2009 to 2011 were obtained from four EMS agencies in the Pittsburgh, Pennsylvania metropolitan area. Case definition for suspected drug overdose was naloxone administration, indication on the patient care report and/or indication by a review of hospital records. Resuscitation parameters included chest compression fraction, rate, and depth and the administration of resuscitation drugs. Demographic and outcome variables compared by suspected overdose status included age, sex, and survival to hospital discharge. ResultsFrom 2342 treated out-of-hospital cardiac arrests, 180 were suspected overdose cases (7.7%) and were compared to 2162 non-overdose cases. Suspected overdose cases were significantly younger (45 vs. 65, p<0.001), less likely to be witnessed by a bystander (29% vs. 41%, p<0.005), and had a higher rate of survival to hospital discharge (19% vs. 12%, p=0.014) than non-overdoses. Suspected overdose cases had a higher overall chest compression fraction (0.69 vs. 0.67, p=0.018) and higher probability of adrenaline, sodium bicarbonate, and atropine administration (p<0.001). Suspected overdose status was predictive of survival to hospital discharge when controlling for other variables (p<0.001). ConclusionPatients with suspected overdose-related out-of-hospital cardiac arrest were younger, received different resuscitative care, and survived more often than non-overdose cases.

Incidence of Adverse Cardiovascular Events in Adults Following Drug Overdose

Drug overdose is a leading cause of cardiac arrest and is currently the second leading cause of overall injury-related fatality in the United States. Despite these statistics, the incidence of adverse cardiovascular events (ACVEs) in emergency department (ED) patients following acute drug overdose is unknown. With this study, we address the 2010 American Heart Association Emergency Cardiovascular Care update calling for research to characterize the incidence of in-hospital ACVE following drug overdose. This was a prospective cohort study at two tertiary care hospitals over 12 months. Consecutive adult ED patients with acute drug overdose were prospectively followed to hospital discharge. The main outcome was occurrence of in-hospital ACVE, defined as the occurrence of one or more of the following: myocardial injury, shock, ventricular dysrhythmia, and cardiac arrest. There were 459 ED patients with suspected drug overdose, of whom 274 acute drug overdose qualified and were included for analysis (mean [± SE] age=40.3 [± 1.0] years; 63% male). Hospital course was complicated by ACVE in 16 patients (some had more than one): 12 myocardial injury, three shock, two dysrhythmia, and three cardiac arrest. The incidence of ACVE was 5.8% overall (95% confidence interval [CI]=3.6% to 9.3%) and 10.7% (95% CI=6.6% to 16.9%) among inpatient admissions, with all-cause mortality at 0.7% (95% CI=0.2% to 2.6%). Based on this study of adult patients with acute drug overdose, ACVE may occur in up to 9.3% overall and up to 16.9% of hospital admissions. Implications for the evaluation and triage of ED patients with acute drug overdose require further study with regard to optimizing interventions to prevent adverse events.

Urine Drug Testing in the Treatment of Chronic Noncancer Pain in a Kentucky Private Neuroscience Practice: The Potential Effect of Medicare Benefit Changes in Kentucky

Background: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. Study Design: A retrospective review of urine drug testing services. Objective: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. Methods: An audit of services provided during 2007 was conducted using computer software. Outcome Measures: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. Results: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/ or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. Limitations: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. Conclusion: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician’s toolbox, the physician’s ability to accurately diagnose and treat these patients could be impaired. Key words: Chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose

Objectives: This study aimed to evaluate the usefulness of a comprehensive drug screening method as a first line diagnostic tool on clinical decision making in patients attending an emergency department...