Demographics & Post-Mortem Toxicology Findings in Deaths among People Arrested Multiple Times for Use of Illicit Drugs and/or Impaired Driving

BACKGROUND:

Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem.

METHODS:

This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma.

RESULTS:

Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids.

CONCLUSIONS:

This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes

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By:  Ahlner J1, Holmgren A2, Jones AW3.

• 1Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden.
• 2Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden.
• 3Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden. Electronic address: wayne.jones@liu.se. 
• Forensic Sci Int. 2016 Feb 3;265:138-143. doi: 10.1016/j.forsciint.2016.01.036.

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Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use

Highlights

• The Consolidated Framework for Implementation Research structured a qualitative analysis of features of extended-release naltrexone that inhibited use for the treatment of alcohol and opioid use disorders.
• The processes of ordering, storing, and using and the cost of extended-release naltrexone were characteristics of the intervention that reduced use.
• Features of the outer setting (environment) that inhibited use included requirements for patients with opioid use disorders to be opioid free for 7 to 10 days and health plan formulary, benefit management, and reimbursement policies.
• Program cultures, resistance to change, and weak linkages with primary care for ongoing injections also affected routine use of the medication.

The Medication Research Partnership (a national health plan and nine addiction treatment centers contracted with the health plan) sought to facilitate the adoption of pharmacotherapy for alcohol and opioid use disorders. Qualitative analysis of interviews with treatment center change leaders, individuals working for the manufacturer and its technical assistance contractor, and health plan managers extracted details on the processes used to order, store, bill for, and administer extended-release naltrexone. Qualitative themes were categorized using domains from the Consolidated Framework for Implementation Research (intervention characteristics, outer setting, inner setting, and provider characteristics).

Characteristics of XR-NTX that inhibited use included the complexity of ordering and using the medication; cost was also a barrier. Outer setting barriers reflected patient needs and external health plan policies on formulary coverage, benefit management, and reimbursement. Program structures, the lack of physician linkages, a culture resistant to the use of medication, and unease with change were inner setting elements that limited use of XR-NTX. Patient stereotypes and a lack of knowledge about XR-NTX affected practitioner willingness to treat patients and prescribe XR-NTX. The Consolidated Framework for Implementation Research provided a useful lens to understand and interpret the processes affecting access to XR-NTX.

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By:   Kelly Alanis-Hirsch, P.hD.,  Raina Croff, Ph.D., James H. Ford II, Ph.D., Kim Johnson, Ph.D., Mady Chalk, Ph.D., Laura Schmidt, Ph.D., Dennis McCarty, Ph.D.

Affiliations

OHSU-PSU School of Public Health, Oregon Health & Science University

Correspondence

Corresponding author at: OHSU-PSU School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. Tel.: +503 494 1177.

mccartyd@ohsu.edu

DOI: http://dx.doi.org/10.1016/j.jsat.2015.10.003

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Reach for Me: Fighting to End the American Drug Overdose Epidemic

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Handout for California Pharmacists for Take-Home Naloxone

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Inside the "Naloxone Kit"

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Talking About Naloxone in a Substance Abuse Treatment Setting

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Talking About Naloxone in a Primary Care or Pain Management Setting

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Toxicological Findings in a Fatal Multidrug Intoxication Involving Mephedrone

The distribution of mephedrone in the body fluids and tissues of a subject found dead after the concomitant intake of cocaine and mephedrone is reported. 

Mephedrone (4-methylmethcathinone) is a designer drug of the phenethylamine family that is able to cause central nervous system stimulation, psychoactivity and hallucinations and that is becoming popular among youth as a recreational drug. Mephedrone has been available in Europe since 2007, and it is sold through the internet and by local shops as bath salt or plant food. 

In the case reported here, a 25-year-old man was found dead in the apartment of a friend after a night spent in several local clubs. A fragment of a blue diamond-shaped pill was found in the pocket of the trousers worn by the decedent. 

During the autopsy, no evidence of natural disease or trauma was found to account for this death. Blood, urine and gastric content samples were collected and submitted for toxicological analysis. Moreover, bile, brain, lung and hair samples were collected as additional matrices. The content of the pill was submitted to a general screening analysis in order to determine its composition. 

Mephedrone was detected in the blood, urine, gastric contents and in the additional matrices using an expressly validated GC/MS method. The blood and urine concentrations were 1.33mg/L and 144mg/L, respectively. 

Contextually, cocaine and cocaethylene were found in the blood and urine specimens. The distribution of mephedrone in the body organs was evaluated by analyzing the brain, bile and lung specimens. Hair analysis revealed a past exposure to mephedrone, ketamine, MDMA and cocaine. Sildenafil was identified as the main component of the blue, diamond-shaped pill. 

The quantitative determination of mephedrone in several body fluids and tissues provides significant knowledge about the distribution of this new drug of abuse in the human body after massive ingestion.

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By:  Gerace E1, Petrarulo M2, Bison F3, Salomone A4, Vincenti M5.

• 1Centro Regionale Antidoping "A. Bertinaria" - Laboratorio Regionale di Tossicologia, Regione Gonzole 10/1, Orbassano, Turin 10043, Italy. Electronic address: enrico.gerace@antidoping.piemonte.it.
• 2A.O. Ordine Mauriziano, Largo F. Turati 62, Torino 10128, Italy.
• 3Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale, Università degli Studi di Torino, corso G. Galilei 22, Turin 10126, Italy.
• 4Centro Regionale Antidoping "A. Bertinaria" - Laboratorio Regionale di Tossicologia, Regione Gonzole 10/1, Orbassano, Turin 10043, Italy.
• 5Centro Regionale Antidoping "A. Bertinaria" - Laboratorio Regionale di Tossicologia, Regione Gonzole 10/1, Orbassano, Turin 10043, Italy; Dipartimento di Chimica, Università degli Studi di Torino, via P. Giuria 7, Turin 10125, Italy. 

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