Pharmacobezoar Associated Prolonged Clinical Course in a Patient with Immediate Release Quetiapine Overdose.

INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.

Diphenhydramine Intoxication With Blood Extended Half-Life and a False Positive Result for Tricyclic Antidepressants.

Diphenhydramine is a first-generation antihistamine medication. Acute intoxication with diphenhydramine can be severe and potentially fatal. The current case is of a 13-year-old girl who presented with central nervous system depression after voluntary intake of unknown drugs. Serum concentration analysis showed diphenhydramine intoxication, blood half-life extension, and a false positive result for tricyclic antidepressants (TCAs) in urine examination. To our knowledge, this is the first reported case of confirmed diphenhydramine overdose with a false positive result for TCAs and measurement of the serum level in a child. Considering the similarities between the clinical symptoms of diphenhydramine and TCA intoxication, this case illustrates that all physicians should consider the possibility of cross-reactivity during the diagnosis of patients with unknown acute drug intoxication who test positive for TCAs.

Understanding Clinician Knowledge, Attitudes, and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction.

BACKGROUND: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies. METHODS: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups. RESULTS: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently). CONCLUSIONS: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.

Tricyclic Antidepressant and Antipsychotic Toxicity: Clomipramine and Ziprasidone Overdose.

This case report details an intentional overdose attempt utilizing tricyclic antidepressants (TCAs) and atypical antipsychotics with significant neurologic, pulmonary, and cardiac toxicity. In conjunction with the local poison control center, progression of the clinical toxidrome was anticipated, aggressively managed, and successfully treated. This case highlights the dangers of significant TCA toxicity, peak onset of toxicity within six hours, and the amplification of clinical toxidromes with co-ingestions.

Maternal mental health as a major contributor to maternal mortality.

Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum.

Drug Overdose Death Following Substance Use Disorder Treatment Termination in New York City: A Retrospective Longitudinal Cohort Study.

Drug overdose death rates are the highest recorded in New York City (NYC). Substance use disorder (SUD) treatment termination can confer increased risk of drug overdose death. Our objective was to determine the probability of, and factors associated with, drug overdose death following SUD treatment termination. Using a retrospective longitudinal cohort design, we identified those who had NYC-based SUD treatment terminated (01/2016-06/2019) using Chief Medical Examiner and SUD treatment data. Using survival analyses, we examined drug overdose deaths ≤ 14 and ≤ 90 days following SUD treatment termination, respectively. Of 51,171 patients with SUD treatment termination, 140 and 342 had a drug overdose death < 14 and ≤ 90 days, respectively. The crude drug overdose death rate was 26.7 per 1000 person-years at-risk in the ≤ 90-day period and was 71.6 per 1000 person-years at-risk in the ≤ 14-day period. In adjusted Cox proportional hazard model examining death ≤ 14 days, those unemployed (compared to employed) and those terminated from residential treatment (compared to medically supervised withdrawal, opioid treatment programs, and outpatient treatment) were more likely to have had a drug overdose death (all p-values < 0.01). In adjusted Cox proportional hazard model examining death ≤ 90 days, non-Hispanic White people (compared to non-Hispanic Black people), those not stably housed (compared to stably housed), those unemployed and those terminated from residential treatment were more likely to have had a drug overdose death (all p-values < 0.01). Strategies to improve retention including the reassessment of program treatment termination criteria along with strategies to promote ongoing OUD treatment, engagement in harm reduction, and distribution of naloxone are needed.

Methadone treatment utilization and overdose trends among Medicaid beneficiaries in New Jersey before and during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic disrupted the traditional mode of methadone maintenance treatment (MMT) delivery through the imposition of lockdowns and social distancing measures. In response, policy makers granted flexibilities to providers delivering MMT to change their practices to maintain patient participation while accommodating the measures imposed to prevent the spread of COVID-19. This study examines the utilization of MMT and overdoses of patients receiving MMT during the COVID-19 pandemic in one mid-Atlantic state. MATERIALS AND METHODS: We analyzed Medicaid claims data for 2018-2020, calculating weekly trends for starts, discontinuations, and medically-treated overdoses for beneficiaries receiving MMT who had been continuously enrolled in Medicaid for the previous 12 months, to account for changes in the composition of the Medicaid population following the COVID-19 public health emergency (PHE). We completed data analyses from January to June 2022. RESULTS: We observed countervailing trends in new starts, which experienced an immediate, non-significant dip of -22.47 per 100,000 Medicaid beneficiaries (95%CI, -50.99 to 6.04) at the outset of the pandemic followed by an increasing upward trend of 1.41 per 100,000 beneficiaries per week (95%CI, 0.37 to 2.46), and in discontinuations, which also experienced an immediate dip of -3.23 per 1000 MMT enrollees (95%CI, -4.49 to -1.97) followed by an increasing upward trend of 0.14 per 1000 MMT enrollees per week (95%CI, 0.09 to 0.19). The net result of these shifts was a stable, slowly increasing rate of MMT treatment of 0.02 % per week before and after the PHE. We also found no statistically significant association of the PHE with medically-treated overdoses among beneficiaries enrolled in MMT (trend change = 0.02 overdoses per 10,000 MMT enrollees, 95%CI, -0.05 to 0.09). CONCLUSIONS: New Jersey achieved overall stability in MMT treatment prevalence following the pandemic's onset, while some changes in treatment dynamics took place. This outcome may reflect that the extensive flexibilities granted to providers of MMT by the state and federal government successfully maintained access to MMT for Medicaid beneficiaries through the pandemic without increasing risk of medically-treated overdose. These findings should inform policy makers developing the post-COVID-19 legal and regulatory landscape.

Assessment of high-dose acetylcysteine in acute high-risk paracetamol (acetaminophen) ingestion.

BACKGROUND: Prompt acetylcysteine treatment with standard doses (300 mg/kg over 21 h in divided doses) is almost universally effective in preventing hepatotoxicity after paracetamol (acetaminophen) overdose. However, hepatotoxicity is reported despite early treatment when paracetamol concentrations exceed 300 mg/L (1,985 µmol/L) at 4 h. Prior studies evaluating high-dose acetylcysteine to treat high-risk ingestions have shown mixed results. We compared outcomes in patients with high-risk ingestions receiving standard or high-dose acetylcysteine. METHODS: Records from a single poison center were reviewed from 1 January 2017 to 31 December 2022. We included cases of acute paracetamol ingestion treated with intravenous acetylcysteine with an initial paracetamol concentration above the "300 mg/L" (1,985 µmol/L) line on the Rumack-Matthew nomogram. We compared standard and high-dose acetylcysteine groups by odds ratios and multivariable logistic regression. We defined hepatotoxicity as aminotransferase activity >1,000 U/L. RESULTS: We included 190 cases. Fifty-six percent received standard-dose acetylcysteine while 44% received high-dose acetylcysteine. Treatment within 8 h yielded no difference in hepatotoxicity between groups (odds ratio 1.67, 95% CI 0.067-42.3). Among patients treated after 8 h, hepatoxicity was more common in the high-dose group (odds ratio 3.39, 95% CI 1.25-9.2) though odds of liver failure were similar (odds ratio 2.78, 95% CI 0.89-8.69). Eighty-eight percent of patients with hepatotoxicity had elevated aminotransferase activity at presentation. No patient died or received a liver transplant. DISCUSSION: Rates of hepatotoxicity were low in patients treated within 8 h regardless of acetylcysteine dose. Unexpectedly, high-dose acetylcysteine treatment was associated with an increased odds of hepatoxicity in those treated after 8 h, but most had abnormal aminotransferase activities at presentation and there was no difference in rates of liver failure. Limitations include the use of retrospective, voluntarily reported poison center data. CONCLUSIONS: Prompt treatment with acetylcysteine, regardless of dose, prevented hepatotoxicity in high-risk paracetamol ingestion.

Three consecutive cases of acute liver failure in young women due to acetaminophen overdose: insights into Japanese social issues and transplantation landscape.

Acetaminophen (APAP) is an over-the-counter (OTC) drug known worldwide for its safety and efficacy. However, in Japan, OTC drug overdose has become a prominent social problem in recent years due to stricter regulations for other drugs, especially among young people, and APAP is an increasing cause of acute liver injury due to overdose. This report describes three consecutive cases of acute liver failure in young women (22, 22 and 19 years old) due to APAP overdose in December 2023. Despite severe liver injury, indicated by high ALT levels and coagulopathy, these cases recovered without requiring liver transplantation. This report discusses three cases of acute liver failure in young Japanese women following APAP overdose, reflecting a national increase in such cases due to increased misuse of OTC drugs and societal factors. Key findings include the need for early treatment with N-acetylcysteine (NAC) and the importance of mental health assessment in the management of overdose patients. The cases underscore the need for prompt team-based care to prevent serious outcomes and highlight the complexity of liver transplantation decisions in Japan, highlighting the need for comprehensive strategies to address the escalating problem of APAP overdose.

Using RE-AIM Framework to Evaluate Recovery Opioid Overdose Team Plus: A Peer-Led Post-overdose Quick Response Team.

Peer recovery coaches utilize their lived experiences to support overdose survivors, a role gaining prominence across communities. A convergent mixed methods design, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, was used to evaluate the Recovery Opioid Overdose Team Plus (ROOT +), through an iterative evaluation using web-based surveys and qualitative interviews. Reach: Over 27 months, ROOT + responded to 83% of suspected overdose referrals (n = 607) and engaged with 41% of survivors (n = 217) and 7% of survivors' family/friends (n = 38). Effectiveness: Among those initially engaged with ROOT +, 36% of survivors remained engaged, entered treatment, or were in recovery at 90 days post-overdose (n = 77). Adoption: First responders completed 77% of ROOT + referrals (n = 468). Implementation: Barriers included lack of awareness of ROOT + , working phones, and access to treatment from community partner interviews (n = 15). Maintenance: Adaptations to ROOT + were made to facilitate implementation. Peer-led teams are promising models to engage with overdose survivors.

Electrocardiogram Abnormality in Poisoned Patients with Tricyclic Antidepressant.

Background: A wide variety of electrocardiogram (ECG) changes can manifest with antidepressant drugs, occurring at both therapeutic doses and toxic levels. Notably, ECG abnormalities like wide QRS and QT prolongation may be observed in poisoned patients with tricyclic antidepressants (TCAs), indicating severe conditions that necessitate the implementation of cardiac monitoring systems. This study aimed to investigate ECG Abnormality in poisoned patients with tricyclic antidepressants. Methods: This retrospective patient record study was conducted at Razi Hospital in Ahvaz, Iran, from 2006 to 2009. Patient information was extracted from hospital medical records after the established protocol. The chi-square test was employed for initial analysis; subsequently, logistic regression was applied to identify risk factors associated with abnormal ECG findings. We analyzed the data using SPSS (Version 19; IBM) statistical software. P < 0.05 was defined as statistically significant. Results: Among the 210 poisoned patients, comprising 88 men (41.9%) and 122 women (58.1%), the majority fell within the age range of 15 to 25 years. In our study, the most commonly ingested drugs by poisoned patients were amitriptyline in 134 patients (63.8%) and nortriptyline in 42 patients (20%). A significant portion of 137 patients (65.2%) exhibited poisoning symptoms within ˂ 6 hours, while 73 patients (34.8%) showed symptoms between 6 and 24 hours. Our findings indicated that the initial symptoms in poisoned patients included a decreased level of consciousness in 168 patients (80%), nausea and vomiting in 20 patients (9.5%), and various other symptoms. Notably, our results revealed ECG changes in 70 patients, with 32 patients (15.2%) showing a QRS widening (> 0.1sec), 5 patients (2.4%) displaying a tall R wave in aVR, 5 patients (2.4%) exhibiting right axis deviation, and other observed changes. Conclusion: QRS widening in poisoned patients with tricyclic antidepressants is more frequently observed in symptomatic patients, highlighting the importance of ECG screening in these patients.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Loperamide positive deaths in Sweden 2012-2022 and Finland 2017-2022: Fatal loperamide intoxication exclusively for Sweden.

Loperamide, a potent µ-opioid receptor agonist used as an antidiarrheal drug, exhibits increased bioavailability at supratherapeutic doses, causing potential central nervous system effects. Its misuse for opioid withdrawal relief and euphoria can lead to dangerously elevated blood levels, causing severe cardiac dysrhythmias and death. This study aimed to compare loperamide positive autopsy cases in Sweden and Finland after the introduction of postmortem toxicological analysis of loperamide, focusing on loperamide's role in fatalities and identifying common characteristics among those affected. All cases with detected loperamide in femoral blood at forensic autopsies in Sweden (2012-2022) and Finland (2017-2022) were included. In Sweden, loperamide was detected in 126 individuals, and in Finland, in 111 individuals. The incidence of individuals positive for loperamide in postmortem femoral blood increased steadily over the study duration in both Sweden and Finland. Loperamide related fatalities were observed exclusively in Sweden (n=80), predominantly involving younger males with histories of substance abuse, typically classified as accidental deaths. The group of loperamide nonrelated deaths in Sweden mirrored the entirety of cases in Finland. The concentration of loperamide in postmortem femoral blood was significantly higher in cases where loperamide was considered the cause of death (median 0.140 µg/g) compared to cases where loperamide contributed (median 0.080 µg/g), as well as in deaths unrelated to loperamide in both countries (Sweden: median 0.029 µg/g; Finland: median 0.010 µg/ml). The high limit of quantification for loperamide in Sweden may underestimate therapeutic users in epidemiological assessments. This study underscores the absence of loperamide misuse in Finland and indicates a rising trend of loperamide abuse in Sweden.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

BACKGROUND AND AIMS: Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. DESIGN: Two-arm, randomized trial. SETTING: Two EDs in Rhode Island, USA. PARTICIPANTS: ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White. INTERVENTION AND COMPARATOR: Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). MEASUREMENTS: We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. FINDINGS: Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). CONCLUSIONS: In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

Risk factors for persistent fatal opioid-involved overdose clusters in Massachusetts 2011-2021: a spatial statistical analysis with socio-economic, accessibility, and prescription factors.

BACKGROUND: Fatal opioid-involved overdose rates increased precipitously from 5.0 per 100,000 population to 33.5 in Massachusetts between 1999 and 2022. METHODS: We used spatial rate smoothing techniques to identify persistent opioid overdose-involved fatality clusters at the ZIP Code Tabulation Area (ZCTA) level. Rate smoothing techniques were employed to identify locations of high fatal opioid overdose rates where population counts were low. In Massachusetts, this included areas with both sparse data and low population density. We used Local Indicators of Spatial Association (LISA) cluster analyses with the raw incidence rates, and the Empirical Bayes smoothed rates to identify clusters from 2011 to 2021. We also estimated Empirical Bayes LISA cluster estimates to identify clusters during the same period. We constructed measures of the socio-built environment and potentially inappropriate prescribing using principal components analysis. The resulting measures were used as covariates in Conditional Autoregressive Bayesian models that acknowledge spatial autocorrelation to predict both, if a ZCTA was part of an opioid-involved cluster for fatal overdose rates, as well as the number of times that it was part of a cluster of high incidence rates. RESULTS: LISA clusters for smoothed data were able to identify whether a ZCTA was part of a opioid involved fatality incidence cluster earlier in the study period, when compared to LISA clusters based on raw rates. PCA helped in identifying unique socio-environmental factors, such as minoritized populations and poverty, potentially inappropriate prescribing, access to amenities, and rurality by combining socioeconomic, built environment and prescription variables that were highly correlated with each other. In all models except for those that used raw rates to estimate whether a ZCTA was part of a high fatality cluster, opioid overdose fatality clusters in Massachusetts had high percentages of Black and Hispanic residents, and households experiencing poverty. The models that were fitted on Empirical Bayes LISA identified this phenomenon earlier in the study period than the raw rate LISA. However, all the models identified minoritized populations and poverty as significant factors in predicting the persistence of a ZCTA being part of a high opioid overdose cluster during this time period. CONCLUSION: Conducting spatially robust analyses may help inform policies to identify community-level risks for opioid-involved overdose deaths sooner than depending on raw incidence rates alone. The results can help inform policy makers and planners about locations of persistent risk.

Prospective multicenter study of the epidemiological features of emergency patients with overdose of over-the-counter drugs in Japan.

Aim: To investigate the epidemiological characteristics of patients presenting to the emergency department with an overdose of over-the-counter (OTC) drugs. Methods: A questionnaire survey was conducted to examine the sociodemographic characteristics of patients with OTC drugs overdoses visiting emergency departments at eight sites across the country. The patients were divided into "habitual" and "nonhabitual" groups according to their history of OTC drugs overdose. Student's t-test or Welch's t-test was performed for numerical variables, and Pearson's χ 2 test was performed for dichotomous and nominal variables between the two groups. Results: Of the 124 patients included in this study, 79% were women. The habitual (26.6%) and the nonhabitual (73.4%) groups showed no differences in sex, occupation, cohabitants, history of mental illness, or history of alcohol consumption or smoking; however, those in the habitual group were significantly younger. The proportion of OTC drugs obtained from physical stores was higher in the habitual group, whereas the nonhabitual group used more household medicines. Suicide and self-harm were more common reasons for overdose in the nonhabitual group. Antipyretic analgesics were significantly more common in the nonhabitual group, whereas antitussive expectorants and antihistamines were significantly more common in the habitual group. Conclusion: This is the first multicenter study to determine the status of OTC drugs overdose patients treated at emergency departments of medical facilities in Japan. To prevent new overdoses of OTC drugs, continued detailed epidemiologic studies of patient backgrounds and drug acquisition routes, and investigation of the components of OTC drugs that cause dependency are necessary.

Impact of a new state law and electronic health record prompt on naloxone prescribing in an academic medical center.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: To evaluate the impact of a best-practice advisory (BPA) and South Carolina legislation on naloxone prescribing patterns. The primary objective was to assess the change in naloxone prescription rates following BPA implementation. The secondary objective was to analyze the performance of the BPA. METHODS: Naloxone prescriptions generated before (July 28, 2020, through July 27, 2021) and after (July 28, 2021, through July 28, 2022) BPA implementation were analyzed via retrospective chart review. Lists of patients at risk for opioid overdose and patients for whom the BPA fired were generated for March 2022. The BPA's effectiveness was evaluated based on the proportion of at-risk patients missed by the alert, the frequency with which the BPA resulted in a naloxone prescription, and the reasons for not prescribing naloxone when the BPA fired. RESULTS: Following BPA implementation, there was a significant increase in the average monthly naloxone prescribing rate from 66.1 to 625.5 prescriptions per month. Overall, 2,086 patients were considered at risk for opioid overdose and 1,101 had a BPA alert during March 2022, with 32.7% of BPA alerts resulting in naloxone prescribing. The most common reasons selected for not prescribing naloxone were "patient refusal" and "criteria not met." Only 354 patients (17.1%) at risk for opioid overdose also had a BPA alert. CONCLUSION: State legislation and implementation of the BPA significantly increased naloxone prescribing rates. However, a significant proportion of patients identified as being at risk did not have a BPA alert and most BPA alerts did not result in naloxone prescribing, suggesting a need for improvement of the BPA.

Associations Between Drug Overdose Mortality and Recovery Ecosystems in the United States: A County-Level Analysis Using a Novel Index.

BACKGROUND: Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI). METHODS: The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores. RESULTS: Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate. CONCLUSIONS: REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.

Need for strategic communications and stakeholder engagement to advance acceptability of an overdose preventing vaccine targeting fentanyl.

BACKGROUND: Fentanyl is a synthetic opioid, exposure to which has led to hundreds of thousands of overdose deaths. Novel vaccines are being developed that might protect against fentanyl overdose. Proactive attention to strategic communications and stakeholder engagement may smooth uptake of a novel vaccine given known challenges around vaccine hesitancy and concern for stigma related to substance use. METHODS: Qualitative interviews (N = 74) with a purposive sample of adolescents/young adults with opioid use disorder (OUD), family members of persons with OUD, experts in substance use treatment and harm reduction, and community members were conducted and thematically analyzed to discern attitudes toward a fentanyl vaccine, and directions for communications and engagement. RESULTS: Major themes reflected personal concerns for biomedical risk and system-level concerns for alignment and integration of an overdose preventing vaccine with prevailing beliefs about addiction and associated frameworks and philosophies for treatment and response. CONCLUSION: Acceptability and implementation of a novel fentanyl vaccine targeting overdose will need precision communications that address biomedical, moral/spiritual, and structural perspectives about the nature of addiction. Education about the purpose and limits of a fentanyl vaccine, partnerships with diverse stakeholders from throughout the opioid response ecosystem and interweaving of a vaccine strategy into comprehensive prevention and treatment are recommended.