Methadone and buprenorphine-related deaths among people prescribed and not prescribed Opioid Agonist Therapy during the COVID-19 pandemic in England.

BACKGROUND: The coronavirus pandemic resulted in many changes which had the potential to impact mortality related to opioid agonist therapy (OAT; methadone, buprenorphine), including changes in the prescribing and dispensing of OAT and patterns of drug availability and use. We aimed to assess the impact of the first lockdown (initiated March 23rd 2020) on methadone- and buprenorphine-related deaths in England in people both prescribed and not prescribed OAT using data from the National Programme on Substance Abuse Deaths. METHODS: This was a retrospective post-mortem toxicology study of OAT-related deaths which occurred in the 3-month period March 23rd to June 22nd in the years 2016-2020. Provisional data regarding numbers accessing treatment for opioid use disorder was provided by the National Drug Treatment Monitoring System. RESULTS: We found a 64% increase in methadone-related deaths in March to June 2020 compared to March to June 2019 (2019 n = 96; 2020 projected n = 157). There were increases in the mortality rate of both in-treatment decedents (22% increase; 2019 n = 45; an exponential smoothing model of the 2016-19 trend [α=0.5] predicted 44 deaths in 2020, 55 were reported) and decedents not prescribed methadone (74% increase; 2019 n = 46; 2016-19 trend predicted 43 deaths in 2020, 80 were reported). There was no increase in buprenorphine-related deaths (2019 n = 9/529; 2020 n = 11/566). There were no changes in the numbers of deaths where other opioids or multiple substances were detected, or in methadone levels detected. Numbers of people accessing treatment for opioid use disorder in 2020 did not decrease relative to previous years (p >0.05). CONCLUSIONS: Methadone-related deaths in non-prescribed individuals, but not prescribed individuals, increased considerably above the annual trend forecast for 2020 during the first COVID-19 lockdown in England. Further studies are thus needed to understand this difference.

Waveform morphology and amplitude variability in facial-nerve electroneurography.

This study assesses the effect of using bipolar recording electrodes in the nasolabial crease versus using monopolar recording electrodes in the crease and on the nasal alae. Seven normal patients had three trials of facial-nerve electroneurography on three separate test days. Peak-to-peak amplitudes of combined motor action potentials were measured; amplitude variability was not affected by the measurement site. A biphasic waveform shape was most consistently obtained by using the nasal alae as the recording point rather than the nasolabial crease. We hypothesize that alar electrodes primarily detect combined motor action potential activity from relatively synchronous, fast-conducting facial-nerve fibers, while the combined motor action potential detected by electrodes in the nasolabial crease reflect a relatively complex summation of both fast and slow fibers.

A model of waveform reliability in facial nerve electroneurography.

This study identifies four factors that should be considered when evaluating the reliability of new testing methods in facial nerve electroneurography (ENOG): (1) waveform peak-to-peak amplitude; (2) response variability; (3) statistical significance of day-to-day test/retest differences; and (4) waveform morphology. These factors were applied to data gathered on seven normal subjects who had three trials of facial-nerve ENOG on three separate test days in order to determine an optimal recording electrode montage. Both bipolar and monopolar recording-electrode montages were used on the nasal alae and on the nasolabial crease. Resultant peak-to-peak amplitudes of combined motor action potentials were recorded and measured using a clinical evoked-potential instrument. A biphasic waveform shape with optimal peak-to-peak point rather than the nasolabial crease. The contribution to the assessment of response reliability of each of the four factors is discussed.

A study of suicide and attempted suicide by self-immolation in an Irish psychiatric population: an increasing problem.

In the Western World self-immolation is an uncommon but dramatic method of attempting suicide. In-patients who attempt suicide by fire-setting tend to be female with severe psychopathology. In a previous study from the South of Ireland, seven cases from a psychiatric and prison population were identified in a five year period from 1984 to 1989. This would represent an annual rate of 1.07 per cent of burns treated in the burns unit at Cork University Hospital. In this study 12 cases were identified for the years 1994 and 1995. This represents an increase of 3.5 per cent from 1.07 to 4.6 per cent of all burns treated at the same institution. Ten of these patients had a previous psychiatric history and eight of them were resident on a psychiatric ward when they committed the act. Seven of the patients were found to have a high degree of suicide intent of whom four died of their injuries, which gives a mortality rate for this group of 33 per cent. Effective prevention policies are necessary if this increasing problem is to be curtailed.

Deliberate self-poisoning, unemployment and public health.

The purpose of the present investigation was to explore further the known relationship between deliberate self-poisoning and social deprivation. Each individual who attended one of Cork city's three casualty departments following an act of deliberate self-poisoning in 1988 was examined. The place of residence (ward) of each city resident patient was established. The social status of the city's 34 wards was estimated using a number of indices obtained from the 1981 and 1986 census reports and social service records. A comparison was made between the 1988 self-poisoning rate for each ward and the rate found in a 1982 study of the city. Correlations between self-poisoning rate and seven social deprivation indices were found to be significant. Multiple regression, factor, and partial correlation analyses were carried out to examine more closely the interrelationships between the social deprivation indices. With respect to explaining the variation in the self-poisoning rate, unemployment alone performed almost as well as all of the indices together and as well as the factors derived using factor analysis. The correlation between unemployment and self-poisoning rate remained highly significant when the other related variables were controlled for. However, at fixed levels of unemployment, these variables were found to be independent of the self-poisoning rate. It is suggested that whereas clinical intervention may benefit the individual, deliberate self-poisoning as an issue requires a public health approach for its resolution.

Euthanasia and the terminally ill: can the civil killing of others be eroded?

The present paper assesses attitudes towards the ending of life among a sample of 100 terminally ill hospice patients. Such a sample best provides an insight into the demand for euthanasia in this most extreme of circumstances. Of the completed interviews (64), 43 patients were fully aware of the implications of their condition; 35 expressed a definite opinion regarding euthanasia, 22 of whom favored the individual's right to choose the timing of death. Only 6 of these 22 were fully competent at the time of the interview and were not suffering from any depressive disorder. The implications of these results point to the need to consider the prevalence of depression, anxiety, and related disorders among those who seek an end to life. A failure to do so is likely to affect legislation worldwide, and, in turn, civilization itself.

The cost of hospital care in the year before and after parasuicide.

This study, based in Ireland in the Limerick centre of the WHO/EURO Multicentre Study of Parasuicide, tests the hypothesis that the uptake of hospital services increases significantly following an act of parasuicide. To investigate this, the costs of hospital attendance in the year before and in the year after an act of parasuicide are measured and compared. The sample is comprised of the first 100 individuals who attended an acute general hospital following an act of parasuicide after July 1, 1995. Using a computerized patient record system, every hospital attendance is identified, for each individual, in the 12 months before and after the parasuicide act. This includes every visit to the Emergency Room as well as both general and psychiatric inpatient admissions and outpatient attendances. There was a 50% increase in the uptake of hospital services--32% of the sample attended hospital in the year before compared with 48% in the year after. The total yearly costs for the 100 patients almost doubled from IR 53,652 Pounds (Euro 68,138) to IR 104,454 Pounds (Euro 132,657). Generalizing to the 539 individuals who engaged in parasuicide in the Limerick catchment area, total costs increased from IR 289,184 Pounds (Euro 367,264) to IR 563,007 Pounds (Euro 715,019). This study is an initial step toward the more complex task of estimating to what extent the increased uptake of hospital services is due to the consequences of parasuicide and how much is due to other aspects of the patient's health.

Euthanasia and related practices worldwide.

The present paper examines the occurrence of matters relating to the ending of life, including active euthanasia, which is, technically speaking, illegal worldwide. Interest in this most controversial area is drawn from many varied sources, from legal and medical practitioners to religious and moral ethicists. In some countries, public interest has been mobilized into organizations that attempt to influence legislation relating to euthanasia. Despite the obvious international importance of euthanasia, very little is known about the extent of its practice, whether passive or active, voluntary or involuntary. This examination is based on questionnaires completed by 49 national representatives of the International Association for Suicide Prevention (IASP), dealing with legal and religious aspects of euthanasia and physician-assisted suicide, as well as suicide. A dichotomy between the law and medical practices relating to the end of life was uncovered by the results of the survey. In 12 of the 49 countries active euthanasia is said to occur while a general acceptance of passive euthanasia was reported to be widespread. Clearly, definition is crucial in making the distinction between active and passive euthanasia; otherwise, the entire concept may become distorted, and legal acceptance may become more widespread with the effect of broadening the category of individuals to whom euthanasia becomes an available option. The "slippery slope" argument is briefly considered.

Religious sanctions and rates of suicide worldwide.

In order to understand differences in suicide rates between the countries affiliated to the International Association for Suicide Prevention (IASP), the present paper investigates whether there is a relationship between the existence of religious sanctions and aggregate national suicide rates as reported to the World Health Organization. Through their participation in this study, 49 IASP national representatives reported on the existence of religious sanctions against suicide. It was discovered that countries with religious sanctions were less likely to return rates of suicide to the WHO. Comparative analysis revealed that the average reported rates for countries with sanctions are lower than those for countries without religious sanctions. The difference is particularly significant for females. Overall, then, at an aggregate level, it would appear that an inverse relationship does exist; however, while countries with religious sanctions against suicide return lower rates of suicide, as recorded by the WHO, recording and reporting procedures may be affected by the existence of sanctions, thus diminishing the reliability of reported rates. Furthermore, distinctions between rates among the different denominations seem to have been somewhat blurred, in particular between Catholics and Protestants, to the extent that in certain societies Catholics have a higher reported rate of suicide--despite the fact that, doctrinally, Catholicism is more severe in the condemnation of suicide than the majority of Protestant churches (with a few notable exceptions, such as the Orthodox Calvinists).

The relevance of diagnosis to the epidemiology and teaching of psychiatry.

The evidence presented suggests that while there are large differences in the diagnostic practices of psychiatrists trained in the United States and Great Britain and Ireland that in general psychiatrists trained in Britain and Ireland diagnose similarly. Some evidence is also presented suggesting that these trans-atlantic differences may be reduced, at least in the short time, by medical education.The overall similarities in diagnostic habits of psychiatrists working in Ireland and Great Britain as well as between Irish trained and British trained psychiatrists emphasize the importance of investigating further the differences in diagnostic statistics generated by mental hospitals in Ireland and England and Wales.

The service implications of regional differences in suicide rates in the Republic of Ireland.

This paper examines variations in suicide within the Republic of Ireland in order to determine if the services, as currently available, require redistribution. The rates of suicide and undetermined death in the four provinces, 26 counties and five cities of Ireland are examined for the years 1976 to 1994, with the age and gender distributions of local populations taken into consideration. Marked variations between areas are noted with a threefold difference between the counties with the highest and lowest rates. Counties tend to be similarly ranked for men and women but the male suicide rate, overall, was almost three times that for women. The male:female ratio was 2.3:1 for the first half of the study, but this increased to 3.4:1 for the second half; a reflection of increasing numbers of male suicides. Surprisingly, the male suicide rate in Dublin city has stayed steady at 12 per 100,000 over the entire study period, while the national male rate has more than doubled reaching approximately 18 per 100,000 in recent years. There is a need for improved services in rural Ireland. If the various available services are to help reduce the suicide rate, then a mechanism must be found to deliver these in areas of low population density where the need could well be greatest.

Variation in suicide rates between Health Board areas.

This paper examines variations in suicide in the eight Health Boards of the Republic of Ireland for the years 1976 to 1995. It is found that while all have experienced a rise in male suicide, it has been much less pronounced in the Eastern Health Board which is somewhat surprising when one considers Dublin's much-publicised problems with homelessness and hard drug misuse. Since the mid-eighties, female rates have been somewhat higher in the southern half of the country, comprising the Southern, Mid-Western and South-Eastern Health Boards. This variation may reflect a difficulty with contacting services for psychological distress in rural areas, either because of stigma or simple practical problems associated with transport. The development of appropriate services, especially in rural areas, should be at the top of the agenda of any Resource Officer to be appointed subsequent to the Final Report of the Task Force.

Suicide, road traffic and cancer deaths among the young in Ireland.

Every young suicide occurring in Ireland from 1976 to 1993 was reviewed and comparisons made with deaths from road traffic accidents and deaths from cancer. As well as this, suicide occurring in the under 25 age group in a series of a hundred consecutive suicides were examined to see what methods were used and what treatments received. Whereas cancer deaths and road traffic deaths are falling among the young, suicide among young Irish males continues to rise. Few appear to have elected for psychiatric treatment in the year before their death. The research implications of these findings are discussed.

Elderly suicides in Ireland.

A comparison is made between the male and female Irish suicide rates for the young (15-24 year-olds) and the old (over 65 years). The incidence of suicide among the elderly has traditionally been higher than among the young. While this continues to be the case for females the rates for young and old have recently converged. Within the over 65 year-old age group itself, a further comparison was made between the suicide rates of the 'young' old and 'old' old. In general, suicide is significantly more common in the 'young' old age group. The method of suicide employed by the elderly was then analysed. As expected hanging, drowning and poisoning were most common although the extent to which they were used differed for males and females. Twelve elderly suicides were examined as part of an on-going psychological autopsy study of Cork suicides. Information relating to their domestic, marital and psychological situation is discussed. Given these findings and those relating to method of suicide, the subject of suicide prevention in the elderly is discussed.

Improving procedures for recording suicide statistics.

OBJECTIVE: To explore the changing relationship between rates of suicide and undetermined death in Britain and Ireland. DESIGN: Longitudinal analysis of the official statistics relating to unnatural deaths in England and Wales and the Republic of Ireland between 1976 and 1992. MAIN OUTCOME MEASURES: Male and female rates of suicide and undetermined deaths for Ireland and England and Wales, age adjusted to the standard world population. Ratio of undetermined deaths to suicide. RESULTS: The official Irish male suicide rate is now much higher than that of England and Wales while the female rates are broadly similar. The rate of undetermined deaths has risen amongst English males and remained stable for females but has significantly fallen off among both Irish males and females. The proportion of deaths classified as 'undetermined' is now very much less in Ireland than in England and Wales. DISCUSSION: National plans for suicide prevention in either country cannot be properly audited unless improved procedures are put in place to increase the validity and reliability of the official suicide figures. Each country could beneficially learn from the other in this regard.

Suicide levels in Cork City 1987/1991.

This study investigates the level of suicide in Cork City during the 5-year period 1987/1991. Both male and female crude rates were higher than the corresponding national levels. The male/female ratio was 2.3:1, which is consistent with established findings. Vulnerability to suicide is most pronounced in 20-39 year old males and females in the 40-59 age category. There was some evidence of an increased risk of suicide among single elderly males; otherwise marital status was not a significant factor. A positive association was noted between unemployment and suicide rate for males. Drowning was used as the method of suicide by approximately half the male and female sub-groups; this was followed by hanging in the case of males and overdosing among females. However all suicide cases under 20 years of age used hanging.

Parasuicide and general practice: a pilot study.

General Practitioners from Cork City and its environs were sent a questionnaire regarding their experience of parasuicide in the previous twelve months. Replies were received from 133 of the 185 GPs. 189 individuals, accounting for 212 episodes of parasuicide, were seen by 78 doctors, indicating a lower level of repetition than that found in hospital-referred cases. Almost a third of doctors saw no cases, just over one fifth saw one episode and the same proportion dealt with two. A small number of general practitioners saw many cases. Regarding management, 128 (60%) were referred to Casualty, 31 of whom were also referred for psychiatric care. Thirty percent were referred directly for psychiatric care. While only fourteen were retained within general practice without referral, 40% of the GPs felt that, ideally, acts of parasuicide should be retained with more specialised advice being obtained. Furthermore, 88.1% believed that management of parasuicide should form part of an integral part of post-graduate or continued general practitioner medical training. Clearly, GPs are willing to play a more active role in the management of parasuicide.