Trends in reported GHB-related presentations to Sydney emergency departments between 2012 and 2021.

OBJECTIVES: In overdose, gamma-hydroxybutyrate (GHB) and its precursors can cause decreased levels of consciousness, coma and death. Here, we aim to describe reported exposure to GHB at four EDs in Sydney, New South Wales (NSW), Australia. METHODS: We searched the ED databases of four Sydney metropolitan hospitals for presentations relating to GHB exposure between 2012 and 2021. We calculated annual number of presentations stratified by hospital, age, sex, mode of arrival and triage category. RESULTS: A total of 3510 GHB-related presentations to ED were recorded across the four hospitals. Data for all hospitals were only available from 2015 onwards and between 2015 and 2021; there was a 114% increase in annual presentations (from 228 to 487). Males represented 68.7% of all presentations and the median age was 31 years (range 16-74 years). There was an increase in the proportion of female presentations between 2012 and 2021 (from 27.9% to 37.9%) along with the severity of presentation over the same period, with the proportion of presentations with a triage category 1 increasing from 19.7% to 34.5%. CONCLUSIONS: Increases in recorded absolute number and severity of GHB-related presentations to Sydney EDs are a major public health concern. There may also be shifts in the demographics of those with GHB-related presentations. Renewed efforts are required to understand the drivers of these increases to optimally target harm reduction approaches.

Impact of overdose on health plan disenrollment among patients prescribed long-term opioids: Retrospective cohort study.

CONTEXT: Health plan disenrollment may disrupt chronic or preventive care for patients prescribed long-term opioid therapy (LTOT). PURPOSE: To assess whether overdose events in patients prescribed LTOT are associated with subsequent health plan disenrollment. DESIGN: Retrospective cohort study. SETTING AND DATASET: Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages and geographical regions across the United States. PATIENTS: Adults prescribed stable opioid therapy (≥10 morphine milligram equivalents/day) for a 6-month baseline period prior to an index opioid prescription from January 1, 2018 to December 31, 2018. MAIN MEASURES: Health plan disenrollment during follow-up. RESULTS: The cohort comprised 404,151 patients who were followed up after 800,250 baseline periods of stable opioid dosing. During a mean follow-up of 9.1 months, unadjusted disenrollment rates among primary commercial beneficiaries and Medicare Advantage enrollees were 37.2 and 13.9 per 100 person-years, respectively. Incident overdoses were associated with subsequent health plan disenrollment with a statistically significantly stronger association among primary commercial insurance beneficiaries [adjusted incidence rate ratio (aIRR) 1.48 (95% CI: 1.33-1.64)] as compared to Medicare Advantage enrollees [aIRR 1.15 (95% CI: 1.07-1.23)]. CONCLUSIONS: Among patients prescribed long-term opioids, overdose events were strongly associated with subsequent health plan disenrollment, especially among primary commercial insurance beneficiaries. These findings raise concerns about the social consequences of overdose, including potential health insurance loss, which may limit patient access to care at a time of heightened vulnerability.

Electrocardiographic Effects of Bupropion Toxicity Suggesting Dysfunction of the Gap Junction or Connexin 43.

This is a case of a 20-year-old pregnant female presenting EKG abnormalities associated with an overdose of bupropion. These ECG abnormalities are prolongation of the QRS, prolongation of the corrected QT interval (QTc), right axis deviation, and a terminal R wave. The propagation of electricity through the myocardium is dependent on many factors. It is dependent on the flow of sodium from the extracellular to intracellular space, flow of potassium from intracellular to extracellular space, and ultimately the propagation of the signal at the gap junction by Connexin 43 (Cx-43). We postulate that the ECG abnormalities in this case are secondary to bupropion's effect on the potassium rectifier channels (Kir) and or Cx-43 at the gap junction.

Fentanyl and its derivatives: Pain-killers or man-killers?

Fentanyl is a synthetic µ-opioid receptor agonist approved to treat severe to moderate pain with faster onset of action and about 100 times more potent than morphine. Over last two decades, abuse of fentanyl and its derivatives has an increased trend, globally. Currently, the United States (US) faces the most serious situation related to fentanyl overdose, commonly referred to as the opioid epidemic. Nowadays, fentanyl is considered as the number one cause of death for adults aged 18-45 in the US. Synthesis and derivatization of fentanyl is inexpensive to manufacture and easily achievable. Indeed, more than 1400 fentanyl derivatives have been described in the scientific literature and patents. In addition, accessibility and efficacy of fentanyl and its derivatives can play a potential role in misuse of these compounds as a chemical weapon. In this review, the properties, general pharmacology, and overdose death cases associated with fentanyl and selected derivatives are presented. Moreover, current opioid epidemic in the US, Moscow theatre hostage crisis, and potential misuse of fentanyl and its derivatives as a chemical weapon are disclosed.

Occupational patterns of opioid-related harms comparing a cohort of formerly injured workers to the general population in Ontario, Canada.

OBJECTIVES: The role of work-related injuries as a risk factor for opioid-related harms has been hypothesized, but little data exist to support this relationship. The objective was to compare the incidence of opioid-related harms among a cohort of formerly injured workers to the general population in Ontario, Canada. METHODS: Workers' compensation claimants (1983-2019) were linked to emergency department (ED) and hospitalization records (2006-2020). Incident rates of opioid-related poisonings and mental and behavioural disorders were estimated among 1.7 million workers and in the general population. Standardized incidence ratios (SIRs) and 95% confidence intervals (CI) were calculated, adjusting for age, sex, year, and region. RESULTS: Compared to the general population, opioid-related poisonings among this group of formerly injured workers were elevated in both ED (SIR = 2.41, 95% CI = 2.37-2.45) and hospitalization records (SIR = 1.54, 95% CI = 1.50-1.59). Opioid-related mental and behavioural disorders were also elevated compared to the general population (ED visits: SIR = 1.86, 95% CI = 1.83-1.89; hospitalizations: SIR = 1.42, 95% CI = 1.38-1.47). Most occupations and industries had higher risks of harm compared to the general population, particularly construction, materials handling, processing (mineral, metal, chemical), and machining and related occupations. Teaching occupations displayed decreased risks of harm. CONCLUSION: Findings support the hypothesis that work-related injuries have a role as a preventable risk factor for opioid-related harms. Strategies aimed at primary prevention of occupational injuries and secondary prevention of work disability and long-term opioid use are warranted.

RéSUMé: OBJECTIFS: Le rôle des accidents du travail en tant que facteur de risque pour les méfaits liés aux opioïdes a été supposé, mais il existe peu de données pour étayer cette relation. L'objectif était de comparer l'incidence des méfaits liés aux opioïdes dans une cohorte de travailleurs anciennement blessés à la population générale de l'Ontario, au Canada. MéTHODES: Les dossiers de demandes d'indemnisation des travailleurs (1983‒2019) ont été reliés aux dossiers des services d'urgence et d'hospitalisation (2006‒2020). Les taux d'incidence des empoisonnements liés aux opioïdes et des troubles mentaux et comportementaux ont été estimés parmi 1,7 million de travailleurs et dans la population générale. Les ratios d'incidence standardisés (RIS) et les intervalles de confiance (IC) à 95 % ont été calculés en tenant compte de l'âge, du sexe, de l'année et de la région. RéSULTATS: Comparativement à la population générale, les empoisonnements liés aux opioïdes chez ce groupe de travailleurs anciennement blessés étaient élevés dans les dossiers des services d'urgence (RIS = 2,41, IC à 95 % = 2,37-2,45) et d'hospitalisation (RIS = 1,54, IC à 95 % = 1,50-1,59). Les troubles mentaux et comportementaux liés aux opioïdes étaient également élevés par rapport à la population générale (visites aux urgences RIS = 1,86, IC à 95 % = 1,83-1,89; hospitalisations RIS = 1,42, IC à 95 % = 1,38-1,47). La plupart des professions et des secteurs d'activité présentaient des risques de méfaits plus élevés par rapport à la population générale, en particulier la construction, la manutention, le traitement (minéral, métallique, chimique) et l'usinage des matières premières et activités connexes. Les professions de l'enseignement présentaient des risques de méfaits moindres. CONCLUSION: Les résultats confirment l'hypothèse selon laquelle les accidents du travail constituent un facteur de risque évitable pour les méfaits liés aux opioïdes. Des stratégies visant la prévention primaire des accidents du travail et la prévention secondaire de l'incapacité de travail et de la consommation d'opioïdes à long terme sont justifiées.

Evaluation of in-house drug evidence testing by King County Medical Examiner's Office in "real-time" fatal overdose surveillance.

With the escalating overdose epidemic, many surveillance efforts have appeared. In 2018, King County Medical Examiner's Office (KCMEO) initiated a fatal overdose surveillance project aimed at expediting death certification and disseminating timely information. In this project, KCMEO investigators collected items of evidence of drug use from overdose death scenes, which were tested by five in-house methods, four using handheld devices: TruNarc Raman spectrometer, with and without the manufacture's H-Kit, Rigaku ResQ Raman spectrometer, and MX908 mass spectrometer. The fifth in-house method used fentanyl-specific urine test strips. Results from in-house testing were compared with results from Washington State Patrol (WSP) Materials Analysis Laboratory. From 2019 to 2022, there were 4244 evidence items of drugs and paraphernalia collected from 1777 deaths scenes. A total of 7526 in-house tests were performed on collected specimens, and 2153 tests were performed by the WSP laboratory using standard analytical methods. The WSP results served as reference standards to calculate performance metrics of the in-house methods. Sensitivities, specificities, and predictive values ranged from good to poor depending on the method, drug, and evidence type. Certain drugs were often associated with specific evidence types. Acetaminophen was frequently found in combination with fentanyl. Fentanyl test strips gave good scores for detecting fentanyl; otherwise, in-house methods using handheld devices had poor performance scores with novel drugs and drugs diluted in mixtures. The results showed that in-house testing of drug evidence has value for medical examiner overdose surveillance, but it is resource intensive, and success depends on collaboration with forensic laboratories.

Trends in non-fatal and fatal opioid overdoses during the first two years of the coronavirus disease-2019 pandemic.

PURPOSE: This study assessed opioid-involved overdose rates by age, sex, and race-ethnicity across strict pandemic mitigation phases and how this varied across data systems. METHODS: We examined opioid-involved overdoses using medical examiner and hospital data for Cook County, Illinois between 2016-2021. Multivariable segmented regression was used to assess weekly overdose rates across subgroups of age, sex and race/ethnicity and strict pandemic mitigation phases. RESULTS: The overall rate of weekly opioid-involved overdoses increased when assessing the medical examiner (ß = 0.01; 95% CI = 0.01,0.02; P ≤ .001) and emergency department visits data sources (ß = 0.15; 95% CI = 0.09,0.20; P ≤ .001) but not for the hospital admissions data source. We found differences in overdose rates across subgroups and phases of pandemic mandates. Fatal overdoses increased during lockdown-1 while admissions and emergency department (ED) visits for opioid-involved overdoses generally decreased across all phases of pandemic mitigation mandates except for the period following lockdown-1. Across pandemic mitigation phases, Hispanics and individuals under 25 years did not demonstrate any change in admissions and ED visits for overdoses. CONCLUSIONS: We underscore the importance of utilizing multiple sources of surveillance to better characterize opioid-involved overdoses and for public health planning.

Accidental substance-related acute toxicity deaths among youth in Canada: a descriptive analysis of a national chart review study of coroner and medical examiner data. / Décès accidentels attribuables à une intoxication aiguë due à une substance chez les jeunes au Canada : analyse descriptive d'une étude nationale portant sur l'examen des dossiers des données de coroners et de médecins légistes.

INTRODUCTION: Substance-related acute toxicity deaths (ATDs) are a public health crisis in Canada. Youth are often at higher risk for substance use due to social, environmental and structural factors. The objectives of this study were to understand the characteristics of youth (aged 12-24 years) dying of accidental acute toxicity in Canada and examine the substances contributing to and circumstances surrounding youth ATDs. METHODS: Data from a national chart review study of coroner and medical examiner data on ATDs that occurred in Canada between 2016 and 2017 were used to conduct descriptive analyses with proportions, mortality rates and proportionate mortality rates. Where possible, youth in the chart review study were compared with youth in the general population and youth who died of all causes, using census data. RESULTS: Of the 732 youth who died of accidental acute toxicity in 2016-2017, most (94%) were aged 18 to 24 years. Youth aged 20 to 24 who were unemployed, unhoused or living in collective housing were overrepresented among accidental ATDs. Many of the youth aged 12 to 24 who died of accidental acute toxicity had a documented history of substance use. Fentanyl, cocaine and methamphetamine were the most common substances contributing to death, and 38% of the deaths were witnessed or potentially witnessed. CONCLUSION: The findings of this study point to the need for early prevention and harm reduction strategies and programs that address mental health, exposure to trauma, unemployment and housing instability to reduce the harms of substance use on Canadian youth.

Accidental substance-related acute toxicity deaths in older adults in 2016 and 2017: a national chart review study. / Décès accidentels liés à une intoxication aiguë due à une substance chez les aînés en 2016 et en 2017 : une étude nationale d'examen des dossiers.

INTRODUCTION: Limited research exists on substance-related acute toxicity deaths (ATDs) in older adults (≥60 years) in Canada. This study aims to examine and describe the sociodemographic characteristics, health histories and circumstances of death for accidental ATDs among older adults. METHODS: Following a retrospective descriptive analysis of all coroner and medical examiner files on accidental substance-related ATDs in older adults in Canada from 2016 to 2017, proportions and mortality rates for coroner and medical examiner data were compared with general population data on older adults from the 2016 Census. Chisquare tests were conducted for categorical variables where possible. RESULTS: From 2016 to 2017, there were 705 documented accidental ATDs in older adults. Multiple substances contributed to 61% of these deaths. Fentanyl, cocaine and ethanol (alcohol) were the most common substances contributing to death. Heart disease (33%), chronic pain (27%) and depression (26%) were commonly documented. Approximately 84% of older adults had contact with health care services in the year preceding their death. Only 14% were confirmed as having their deaths witnessed. CONCLUSIONS: Findings provide insight into the demographic, contextual and medical history factors that may influence substance-related ATDs in older adults and suggest key areas for prevention.

Disaggregating Asian-American Mortality in Drug-Related Overdoses and Behavioral Disorders: A Cross-Sectional Study.

Asian Americans have been historically underrepresented in the national drug overdose discourse due to their lower substance use and overdose rates compared to other racial/ethnic groups. However, aggregated analyses fail to capture the vast diversity among Asian-American subgroups, obscuring critical disparities. We conducted a cross-sectional study between 2018 and 2021 examining Asian-American individuals within the CDC WONDER database with drug overdoses as the underlying cause of death (n = 3195; ICD-10 codes X40-X44, X60-X64, X85, and Y10-Y14) or psychoactive substance-related mental and behavioral disorders as one of multiple causes of death (n = 15,513; ICD-10 codes F10-F19). Proportional mortality ratios were calculated, comparing disaggregated Asian-American subgroups to the reference group (Asian Americans as a single aggregate group). Z-tests identified significant differences between subgroups. Compared to the reference group (0.99%), drug overdose deaths were less prevalent among Japanese (0.46%; p < 0.001), Chinese (0.47%; p < 0.001), and Filipino (0.82%; p < 0.001) subgroups, contrasting with a higher prevalence among Asian Indian (1.20%; p < 0.001), Vietnamese (1.35%; p < 0.001), Korean (1.36%; p < 0.001), and other Asian (1.79%; p < 0.001) subgroups. Similarly, compared to the reference group (4.80%), deaths from mental and behavioral disorders were less prevalent among Chinese (3.18%; p < 0.001), Filipino (4.52%; p < 0.001), and Asian Indian (4.56%; p < 0.001) subgroups, while more prevalent among Korean (5.60%; p < 0.001), Vietnamese (5.64%; p < 0.001), Japanese (5.81%; p < 0.001), and other Asian (6.14%; p < 0.001) subgroups. Disaggregated data also revealed substantial geographical variations in these deaths obscured by aggregated analyses. Our findings revealed pronounced intra-racial disparities, underscoring the importance of data disaggregation to inform targeted clinical and public health interventions.

Older adult drug overdose: an application of latent class analysis to identify prevention opportunities.

BACKGROUND: Older adult overdose death rates have increased significantly in recent years. However, research for prevention of drug overdose death specific to older adults is limited. Our objective is to identify profiles based on missed intervention points (touchpoints) to inform prevention of future older adult unintentional overdose deaths. METHODS: We used latent class analysis methods to identify profiles of decedents aged 55 + years in the Illinois Statewide Unintentional Drug Overdose Reporting System. This system collects data on 92.6% of all unintentional overdose deaths in Illinois and includes data from death certificates, coroner/medical examiner, toxicology, and autopsy reports. Data include decedent demographics, circumstances leading up to and surrounding the fatal overdose and details regarding the overdose. Variables in the latent class analysis model included sex, race, alcohol test result, social isolation, recent emergency department (ED) visit, chronic pain, and pain treatment. RESULTS: We identified three distinct decent profiles. Class 1 (13% of decedents) included female decedents who were in pain treatment, had physical health problems, and had greater likelihood of a recent ED visit before their death. Class 2 (35% of decedents) decedents were most likely to be socially connected (live with others, employed, had social or family relationships) but less likely to have recent healthcare visits. Class 3 (52% of decedents) decedents had higher social isolation (lived alone, unemployed, unpartnered), were mostly male, had fewer known physical health conditions, and more alcohol positivity at time of death. White decedents are clustered in class 1 while Black decedents are predominant in classes 2 and 3. CONCLUSIONS: These profiles link to potential touchpoint opportunities for substance use disorder screening harm reduction and treatment. Class 1 members were most likely to be reachable in healthcare settings. However, most decedents were members of Classes 2 and 3 with less engagement in the healthcare system, suggesting a need for screening and intervention in different contexts. For Class 2, intervention touchpoints might include education and screening in work or social settings such as senior centers given the higher degree of social connectivity. For Class 3, the most isolated group, touchpoints may occur in the context of harm reduction outreach and social service delivery.

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

OBJECTIVE: 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. MATERIALS AND METHODS: 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. RESULTS: 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). PRACTICE IMPLICATIONS: 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.

Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report.

BACKGROUND: Despite the efficacy and safety of DIGIFab, it is relatively expensive and has limited availability. In addition, alternative interventions, such as therapeutic plasma exchange, may need to be considered in massive digoxin overdoses. Although few case reports describe its efficacy. CASE PRESENTATION: We report a case of a 17-year-old white male patient brought by family members to our emergency department in Riyadh, Saudi Arabia. After intentionally ingesting 48 mg of digoxin tablets to commit suicide, the patient's initial digoxin serum level was 8.04 ng/mL. The patient was resuscitated in the emergency department. After admission to the intensive care unit, the patient underwent therapeutic plasma exchange, because of insufficient DIGIFab doses. Afterward, the serum digoxin levels drastically decreased, and his symptoms reverted. The patient was successfully managed and discharged 7 days after admission. CONCLUSION: Despite insufficient evidence and a limited number of case reports describing the use of extracorporeal treatment in digoxin overdose, we noted the significant impact of therapeutic plasma exchange on our patient. However, therapeutic plasma exchange's use in routine treatment requires stronger evidence to confirm its benefits.

Drug Deactivation Pouches for Primary Prevention of Opioid Overdose: Perceptions and Attitudes of Community Members.

IMPORTANCE: A substantial number of opioid analgesics dispensed into communities will go unused and be susceptible to diversion for misuse. Convenient, efficient, and environmentally safe mechanisms for disposal are needed to prevent the diversion of unused opioid analgesics. OBJECTIVE: This initiative piloted the feasibility of distributing drug deactivation pouches in a community setting and examined community members' acceptance, intention to use drug deactivation pouches, and their current disposal practices of unused opioid analgesics. Although many studies have examined the benefits of deactivation pouches in preventing drug overdose, few have explored community members' perspectives, the feasibility, and the acceptability of these pouches in disposing of unused medications. METHODS: In the fall of 2017, we piloted the distribution of drug deactivation pouches to assess the overall interest in the pouches at a 3-day community event and continued the second wave of this pilot in the community from the summer of 2018 to the spring of 2019.Our main outcomes and measures included the acceptance of the drug deactivation pouches and the intention to use the pouches. "Acceptance" was defined as study participants physically taking the kit and "Intention" was how participants intended to use the pouch. RESULTS: A total of 170 community members were approached at a community event about the drug deactivation pouches and 116 accepted at least 1 pouch (68.2% acceptance rate). In the second wave, 124 community members were approached by Community Health Workers; 100% accepted the pouch. Overall, the acceptance rate was 81.6%. People mentioned significant interest in using the pouches. Furthermore, surveys that assessed community members' intention to use the deactivation pouches showed that 48% intended to use the pouch. CONCLUSIONS AND RELEVANCE: The distribution of drug deactivation pouches is feasible in a community setting and although community members expressed interest in using drug deactivation pouches to dispose of unused opioid analgesics and other drugs, the majority still disposed of their unused medications through other avenues. This, underscore the need to raise community members' awareness about the importance, benefits, and viability of these pouches as a tool for the primary prevention of opioid overdose because of their ease of use, safety, environmental considerations, and cost-effectiveness.

Abnormal blood concentration changes in a 71-year-old female who survived a 10,000mg overdose of clozapine: a case report.

BACKGROUND: Clozapine is a highly effective second-generation antipsychotic with few extrapyramidal reactions, making it a preferred choice among clinicians. However, instances of acute clozapine poisoning resulting from suicide attempts and misuse have been reported. Through our review of existing literature, we identified that we believe to be the highest recorded overdose of clozapine in elderly patients, resulting in a nonfatal outcome. CASE PRESENTATION: The case report involves a 71-year-old female with a history of depression who ingested a dose of 10,000 mg of clozapine. Approximately 6 h after the overdose, the clozapine level was 5,200 µg/L, significantly surpassing the recommended therapeutic concentration range of 350-600 µg/L. After gastric lavage and hemoperfusion, the blood level dropped to 1847.11 µg/L. Notably, during therapeutic drugs monitoring (TDM), we found a perplexing spike in the patient's blood level to 5554.15 µg/L after the second hemoperfusion. CONCLUSION: In this case we mainly focused on the abnormal fluctuations in the concentration of clozapine. We conducted a comprehensive analysis of potential factors contributing to this abnormal phenomenon in terms of the patient's age, clinical symptoms, various laboratory test indexes, and the pharmacokinetics of clozapine. Our findings underscore the importance of timely TDM and the precision of results in managing elderly patients experiencing high-dose clozapine poisoning.

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships.

PURPOSE: To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States. METHODS: We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317). RESULTS: We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state). CONCLUSIONS: This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

Income inequality and deaths of despair risk in Canada, identifying possible mechanisms.

BACKGROUND: Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services). METHODS: We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion, and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death. RESULTS: Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HRadj. = 1.28; 95 CI = 1.05, 1.55), suicide (HRadj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HRadj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HRadj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes. CONCLUSION: Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada.

"I go out of my way to give them an extra smile now:" A study of pharmacists who participated in Respond to Prevent, a community pharmacy intervention to accelerate provision of harm reduction materials.

BACKGROUND: Community pharmacies are well-positioned to improve the health of people with opioid use disorder and who use drugs by providing naloxone and other essential public health supplies. Respond to Prevent (R2P) is a clinical trial which sought to accelerate provision of harm reduction materials through a multicomponent intervention that included in-store materials, online training, and academic detailing. OBJECTIVES: The objective of this study was to explore pharmacists' attitudes, knowledge, and experiences in providing naloxone, dispensing buprenorphine, and selling nonprescription syringes following participation in the R2P program. METHODS: Two online asynchronous focus groups were conducted with community-based chain pharmacists across Massachusetts, New Hampshire, Oregon, and Washington who had participated in the R2P program. Participants accessed an online repository of group interview items and responded to questions over a short period. Each pharmacist participated anonymously for approximately 30 min over 2 ½ days. Pharmacists answered questions on experiences with pharmacy-based harm reduction care and R2P intervention implementation barriers and facilitators. Qualitative data analysis was conducted by a multidisciplinary team using an immersion-crystallization approach. RESULTS: A total of 32 pharmacists participated in the two focus groups. Most participants were female (n = 18, 56%), non-Hispanic (n = 29, 91%), and white (n = 17, 53%). Four major themes were identified related to (1) addressing bias and stigma toward people with opioid use disorder and who use drugs, (2) familiarity and comfort with naloxone provision, (3) perspective and practice shifts in nonprescription syringe sales, (4) structural challenges to harm reduction care in the pharmacy. CONCLUSIONS: Community pharmacists across the four states identified attitudes, knowledge, and experiences that create barriers to providing care to people with opioid use disorder and who use drugs. R2P approaches and tools were effective at reducing stigma and changing attitudes but were less effective at addressing structural challenges from the pharmacists' perspective.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey.

Background: Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified. Methods: This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA). Results: Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic. Conclusion: Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.