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Background and Objectives: The involvement of xylazine, a veterinary drug, in West Virginia (WV) human drug-related deaths was examined., Methods: WV drug deaths from 2019 (when xylazine was first identified) to mid-2021. Characteristics including toxicology findings were compared between xylazine and nonxylazine deaths., Results: Of 3292 drug deaths, 117 involved xylazine, and the proportions of deaths with it have increased (1% [2019] to 5% [mid-2021)]. Xylazine decedents had more cointoxicants, with fentanyl (98%) predominant followed by methamphetamine. Xylazine decedents had a significantly greater history of drug or alcohol misuse and hepatic disease., Conclusions and Scientific Significance: In one of the largest analyses of xylazine-involved deaths in a predominantly rural state, identification of xylazine was increasing with multiple cointoxicants (especially fentanyl), and was present in a few deaths with only one other substance involved. Health professionals should be aware of possible enhanced toxicity from xylazine ingestion especially since naloxone does not reverse xylazine's adverse effects., (© 2022 The American Academy of Addiction Psychiatry (AAAP).)

Background: To quantify how alcohol, polysubstance use and other factors influence opioid concentrations in drug-related deaths in West Virginia (WV), United States., Methods: Multiple linear regression models were employed to identify relationships among alcohol, other factors, and the concentrations of four commonly identified opioids (fentanyl, hydrocodone, oxycodone, methadone), accounting for demographic, toxicological and comorbid characteristics in WV drug-related deaths from 2005 to 2018., Results: Alcohol concentrations of 0.08% or above were associated with significant reductions in blood concentrations of fentanyl (27.5%), hydrocodone (30.5%) and methadone (32.4%). Significantly lower predicted concentrations of all opioids studied were associated with multiple opioid vs. single opioid presence, with predicted concentration reductions ranging from 13.7% for fentanyl to 65-66% for hydrocodone and oxycodone. Benzodiazepine presence was associated with small, non-statistically significant changes in opioid concentrations, while stimulant presence was associated with statistically significant reductions in hydrocodone and oxycodone concentrations., Conclusions: Co-ingestion of alcohol, multiple opioids or stimulants were associated with significantly decreased predicted concentrations of commonly identified opioids in drug deaths. Further evidence is provided for enhanced risks from polysubstance use with opioids, which has important public health implications., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: To describe and analyze the involvement of fentanyl and fentanyl analogs (FAs) in drug-related deaths in West Virginia (WV), United States., Methods: Retrospective analyses of all WV drug-related deaths from 2005 to 2017 were performed, including comparisons of demographic and toxicological characteristics among total deaths, deaths in which fentanyl/FAs were present, deaths in which they were absent, heroin-related deaths, and prescription opioid-related deaths., Results: Most of the 8813 drug-related deaths were overdoses, with about 11% resulting from transportation/other injuries in which drugs were contributors. Prescription opioid presence (without fentanyl) decreased by 75% from 2005-14 to 2015-17 (3545 deaths to 859 deaths, respectively), while fentanyl involvement in the deaths increased by 122% between these periods (487 to 1082 deaths). Ten FAs were identified (427 instances) after 2015. Alprazolam and ethanol were among the top five most frequently identified substances across years. Fentanyl, heroin and cocaine replaced oxycodone, diazepam and hydrocodone in the top five beginning in 2015. Few decedents had a prescription for fentanyl after 2015, with fewer prescriptions also present for other controlled substances identified., Conclusions: Fentanyl, rapidly emerging FAs, and other illicit drugs in recent years pose a serious health threat even though prescription opioid-related deaths decreased over the same time period., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored., (© 2015 American Academy of Forensic Sciences.)

Background and Objective: Unintentional drug poisoning deaths represent a major health concern, particularly in rural areas. Although alprazolam is frequently detected in drug-related deaths, characterization of its involvement is limited. Our objective was to compare the characteristics of alprazolam-related deaths with nonalprazolam deaths in a predominantly rural state., Methods: A comprehensive forensic drug database (FDD) was developed in 2005 to compile demographic, toxicology, and co-morbidity information from all West Virginia (WV) drug-related deaths. All FDD data from 2005 to mid-November 2007 were analyzed., Results: Alprazolam contributed to 204 (17.0%) of the 1,199 drug-related deaths and was identified in 7.2% of the 363 deaths occurring during 2005 and in 27.5% of the 422 deaths entered in the database during 2007. At least one other drug, predominantly an opioid, was identified in 97.5% of the alprazolam cases, with concurrent benzodiazepines also found. Compared to nonalprazolam deaths, alprazolam decedents were significantly more likely to be obese and to have preexisting cardiovascular disease, but were less likely to have documented substance abuse. An alprazolam prescription existed in 52.5% of the alprazolam deaths, with 77.6% having a prescription for all drugs identified., Conclusions: Alprazolam was a contributing cause of death in a substantial and increasing number of drug-related deaths. Prescriptions for alprazolam and the other drugs detected were often present in these cases., Scientific Significance: Controlled substance monitoring programs should be routinely used as one mechanism to help prevent potential drug misuse/abuse. Our findings provide a baseline for ongoing alprazolam-related death surveillance., (Copyright © American Academy of Addiction Psychiatry.)

Background: Prescription drug abuse is a major health concern nationwide, with West Virginia having one of the highest prescription drug death rates in the United States. Studies are lacking that compare living subjects with persons who died from drug overdose for evidence of doctor and pharmacy shopping for controlled substances. The study objectives were to compare deceased and living subjects in West Virginia for evidence of prior doctor and pharmacy shopping for controlled substances and to identify factors associated with drug-related death., Methods: A secondary data study was conducted using controlled substance, Schedule II-IV, prescription data from the West Virginia Controlled Substance Monitoring Program and drug-related death data compiled by the Forensic Drug Database between July 2005 and December 2007. A case-control design compared deceased subjects 18 years and older whose death was drug related with living subjects for prior doctor and pharmacy shopping. Logistic regression identified factors related to the odds of drug-related death., Results: A significantly greater proportion of deceased subjects were doctor shoppers (25.21% vs. 3.58%) and pharmacy shoppers (17.48% vs. 1.30%) than living subjects. Approximately 20.23% of doctor shoppers were also pharmacy shoppers, and 55.60% of pharmacy shoppers were doctor shoppers. Younger age, greater number of prescriptions dispensed, exposure to opioids and benzodiazepines, and doctor and pharmacy shopping were factors with greater odds of drug-related death., Conclusions: Doctor and pharmacy shopping involving controlled substances were identified, and shopping behavior was associated with drug-related death. Prescription monitoring programs may be useful in identifying potential shoppers at the point of care.

Purpose: To assess the similarities between pharmacists' and pharmacy patrons' views of pharmacists' roles and to explore the extent to which persons actually see pharmacists assuming certain roles., Method: Cross-sectional survey was administered to pharmacists and patients who were filling prescriptions or seeking nonprescription medications in 9 community pharmacies in Morgantown, West Virginia. The survey assessed 11 routine patient care services. Main outcome measures include opinions of pharmacists and patients about responsibility for providing 11 routine care services and the extent to which these services are provided., Results: Pharmacists and patients had similar opinions about services that pharmacists should provide for 7 of the 11 services evaluated. For the other 4 items for which opinions were divergent, the mean scores for the extent to which pharmacists provide these services indicated that pharmacists do not always provide these services., Conclusion: Pharmacy patrons might not attribute certain patient-related functions to pharmacists because pharmacists do not frequently perform these routine care-related services in actual practice. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

The study sought to explore the attitudes of community pharmacists, university-based pharmacists, and pharmacy students before and after exposure to computerized systems of on-line information services. A 42-item attitudinal survey was administered to 21 community pharmacists, 7 university clinical pharmacist faculty, and 17 senior pharmacy students, prior to and at the end of a year of access to Grateful Med and BRS Colleague. Few significant differences were noted among the participants at baseline. No significant interaction-effect differences for type of participant or system used were found. Participants were generally positive about computers in general, the accuracy of on-line information services, their impact on knowledge and confidence, and their usefulness for pharmacists.