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INTRODUCTION: Estimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8% to 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical services (EMS) has increased since 2015. METHODS: We conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 and 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or drug(s). RESULTS: From 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50-79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023. CONCLUSION: Drug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.

Fentanyl-mixed and substituted heroin is well-documented, but less is known about unintentional fentanyl use among people using stimulants. To determine the prevalence of and racial and ethnic disparities in unintentional fentanyl use among people experiencing a medically attended opioid overdose, we reviewed 448 suspected non-fatal overdose cases attended by a community paramedic overdose response team in San Francisco from June to September 2022. We applied a case definition for opioid overdose to paramedic records and abstracted data on intended substance use prior to overdose. Among events meeting case criteria with data on intended substance use, intentional opioid use was reported by 57.3%, 98.0% of whom intended to use fentanyl. No intentional opioid use was reported by 42.7%, with most intending to use stimulants (72.6%), including methamphetamine and cocaine. No intentional opioid use was reported by 58.5% of Black, 52.4% of Latinx, and 28.8% of White individuals (p = 0.021), and by 57.6% of women and 39.5% of men (p = 0.061). These findings suggest that unintentional fentanyl use among people without opioid tolerance may cause a significant proportion of opioid overdoses in San Francisco. While intentional fentanyl use might be underreported, the magnitude of self-reported unintentional use merits further investigation to confirm this phenomenon, explore mechanisms of use and disparities by race and ethnicity, and deploy targeted overdose prevention interventions.

Severe cases of hydrocarbon aspiration requiring Extracorporeal Membrane Oxygenation (ECMO) are rarely reported in pediatrics, and 90% of hospitalized patients have a relatively benign clinical course. We describe a 14 month-old female with accidental hydrocarbon ingestion and aspiration due to organic makeup brush cleaner that suffered severe ARDS and multiorgan failure, successfully managed with ECMO and surfactant. She was decannulated after a total of 72 hours on ECMO, extubated on hospital day 15 (HD 15), and discharged home in her normal state of health after one month in the hospital. ECMO and adjunctive therapies such as surfactant may be helpful in the management of severe hydrocarbon pneumonitis and there are limited reports of ECMO as a supportive method for these pediatric patients.

IntroductionDeaths from drug overdoses are rising dramatically in the United States. Treatment for opioid use disorders may include behavioral treatments as well as medications for opioid use disorders (MOUD). Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), other advanced practice registered nurses (APRNs), and physician assistants (PAs) and required a training and a federal waiver until recently. The number of NP MOUD prescribers grew steadily over the past decade, but research has identified state-level scope of practice regulations as a barrier to NP MOUD prescribing. This article explores the contributions of, and remaining barriers faced by NP and other APRN MOUD prescribers. We describe qualitative findings from a study of NPs and other key stakeholders involved in MOUD treatment in four states with two differing levels of regulatory structure.MethodsIn this qualitative study, we conducted site visits and semi-structured interviews with NPs and other APRNs, physicians, clinic managers, and regulators in four states including New Mexico and West Virginia (full practice authority for NPs), and Ohio and Michigan (which require physician supervision). Interview notes were entered into a qualitative software package and coded and reviewed by two members of the research team. Data were grouped into key themes.ResultsA total of 76 participants participated in individual or small group interviews in the four states. We found key themes and several subthemes that describe NP practice in MOUD. Participants described key contributions of NP engagement in MOUD, including increasing access, serving rural areas, the unique role of psychiatric NPs, and the value of the nursing model of care in working with people with substance use disorders (SUD). Participants also identified barriers including scope of practice regulations, other regulatory barriers, stigma, and lack of supportive services to address psychosocial needs.ConclusionsThe waiver requirements were eliminated at the end of 2022 in federal budget legislation. Other barriers for NP and other APRN prescribers remain and should be addressed in practice, and in state and federal regulations. Research needs to explore the impact of the waiver elimination on MOUD prescribing and access to services.

BACKGROUND: Both increases and decreases in patients prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined. OBJECTIVE: To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days. DESIGN: Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors. PARTICIPANTS: All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients). MAIN MEASURES: Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME). KEY RESULTS: Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk. CONCLUSIONS: Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

BACKGROUND: The overdose crisis driven by synthetic opioids continues to escalate in the USA. We evaluated the efficacy of multiple manufacturing lots of a fentanyl test strip (FTS) to detect fentanyl and fentanyl analogs and assessed cross-reactivity with possible interferences. METHODS: Drug standards were dissolved in water in a laboratory setting and serially diluted. Drug dilutions were tested using five different manufacturing lots of BTNX Rapid Response (20 ng/mL cutoff) lateral flow chromatographic immunoassay strips to assess lot-to-lot variability for FTS sensitivity and cross-reactivity for the analytes of interest. RESULTS: All five manufacturing lots cross-reacted with fentanyl and eleven fentanyl analogs. Diphenhydramine, lidocaine, MDMA, and methamphetamine were found to cause false positives with the strips. There was notable lot-to-lot variability in the sensitivity of the strips for fentanyl, fentanyl analogs, and known interferences. DISCUSSION: FTS remains an important overdose prevention tool, but lot-to-lot variability in performance complicates robust instructions that balance the prevention of false positives and false negatives. Continued lot-to-lot performance assessment is recommended to ensure health education for FTS remains accurate. More sophisticated drug checking technologies and services are needed in the community landscape to augment personal FTS use to facilitate informed consumption and overdose risk mitigation.

BACKGROUND: Illicitly manufactured fentanyls and stimulants are implicated in the escalating US mortality from drug overdose. San Francisco, California (SF) has seen declining fentanyl injection while smoking has increased. Beliefs and behaviors surrounding this development are not well understood. METHODS: The study used rapid ethnography to explore fentanyl and methamphetamine use in SF. The team conducted semi-structured interviews (n = 34) with participants recruited from syringe service programs. Video-recorded smoking sequences (n = 12), photography and daily field notes supplemented interview data. RESULTS: Difficulty injecting and fear of overdose motivated transitions from injecting to smoking. Fentanyl was extremely cheap-$10/gram-with variability in quality. Foil was the most commonly used smoking material but glass bubbles, bongs and dabbing devices were also popular. No reliable visible methods for determining fentanyl quality existed, however, participants could gauge potency upon inhalation, and developed techniques to regulate dosage. Several participants reported at least hourly use, some reporting one or more grams of daily fentanyl consumption. Smoking was also very social, with people sharing equipment, drugs and information. Participants raised concerns about hygiene and overdose risk to others arising from shared equipment. Reportedly potent fentanyl residue accumulated on smoking materials and was commonly shared/traded/stolen or consumed accidentally with diverse preferences for its use. CONCLUSION: Our data highlight fentanyl residue as a new overdose risk with potential mismatch between the potency of the residual drug and the recipients tolerance. Further, large doses of fentanyl are being consumed (estimated at approximately 50 mg of pure fentanyl/day). Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists. However, SF overdose mortality hit a record high in 2023. Recommendations to reduce fentanyl smoking overdose risks through pacing, greater awareness of dosages consumed and checking tolerance of residue recipients are potentially viable interventions deserving further exploration.

BackgroundMortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.MethodsWe conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.ResultsWe found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.ConclusionThis study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

This protocol outlines a proposed scoping review to characterize evidence on implementation and quality improvement (QI) strategies that aim to improve equitable, evidence-informed care delivery for pregnant and birthing people with substance use disorder (SUD) in acute care. Untreated SUD during pregnancy is associated with an increased risk of overdose and severe maternal morbidity. Acute care settings are one important place to deliver equitable, evidence-informed clinical care. While clinical practice guidelines for substance use treatment and care of pregnant and birthing people with SUD exist, there are gaps in implementation. Our population of interest is pregnant and birthing people with SUD in an acute care setting. We will include US-based studies that describe or evaluate implementation or QI strategies, including experimental, observational, and descriptive studies published from 2016 to 2023. The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews and registered at OSF (registration number: BC4VZ). We will search MEDLINE (PubMed), CINAHL Complete (EBSCO), Scopus (Elsevier), and APA PsychInfo (Ovid) for published studies. Conference proceedings and Perinatal Quality Collaborative websites will be searched for grey literature. Two reviewers will independently screen then extract studies that meet inclusion criteria using a data extraction tool. The completion of this scoping review will help illuminate strengths and gaps in research and practice that aim to inform substance use treatment and care in acute care settings for pregnant and birthing people with SUD.

BackgroundAgainst the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis.Harm reduction and overdose prevention in housingIn response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts.ConclusionEmerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

Objectives: Widespread health service disruptions resulting from the COVID-19 pandemic coincided with a dramatic increase in overdose deaths among people who use drugs (PWUD) in Vancouver, Canada. Those with a history of injection drug use are known to be at heightened risk of substance-associated harms. Drug use patterns and associated sociodemographic and health care utilization trends have been understudied in this population since the pandemic onset. We sought to understand patterns of drug use initiation and/or re-initiation among people with a history of injection drug use (IVDU). Methods: Data were obtained from three harmonized prospective cohort studies of PWUD in Vancouver. Participants with a lifetime history of IVDU who responded to a survey between June 2021 and May 2022 were included. The primary outcome variable was a composite of substance use initiation and re-initiation over the study period, labelled as drug (re)-initiation. A multivariable generalized linear mixed-effects model was used to examine factors associated with self-reported (re)-initiation of substance use over the past six months. Results: Among 1061 participants, the median age was 47 years at baseline and 589 (55.5%) identified as men. In total, 183 (17.2%) participants reported initiating and/or re-initiating a drug, with 44 (4.1%) reporting new drug initiation and 148 (14.0%) reporting drug re-initiation (9 participants responded 'yes' to both). Overall, unregulated stimulants (e.g., crystal methamphetamine and cocaine) were the most common drug class (re-)initiated (n = 101; 55.2%), followed by opioids (n = 74; 40.4%) and psychedelics (n = 36; 19.7%). In the multivariable analysis, (re-)initiation of drug use was independently associated with recent IVDU (adjusted odds ratio [AOR] 2.62, 95% confidence interval [CI] 1.02, 6.76), incarceration (AOR 3.36, CI 1.12, 10.14) and inability to access addiction treatment (AOR 4.91, 95% CI 1.22, 19.75). Conclusions: In an era impacted by the intersecting effects of the COVID-19 pandemic and the overdose crisis, nearly one in five PWUD with a history of IVDU began using a new drug and/or re-started use of a previous drug. Those who reported drug (re-)initiation exhibited riskier substance use behaviours and reported difficulty accessing treatment services. Our findings underscore the need to provide additional resources to support this high-risk population. [ABSTRACT FROM AUTHOR]

Aim Design, setting and participants Measurements Findings Conclusion This study: (1) estimated the effect of early discontinuation of medication for opioid use disorder (MOUD) on overdose probability and (2) measured the relationship between patient characteristics and early discontinuation probability for each MOUD type.This was a retrospective cohort using electronic health record data from the US Veterans Healthcare Administration. Participants were veterans initiating MOUD with buprenorphine (BUP), methadone (MET) or extended‐release naltrexone (XR‐NTX) from fiscal years 2012–19. A total of 39 284 veterans met eligibility with 22 721 (57.8%) initiating BUP, 12 652 (32.2%) initiating MET and 3911 (10.0%) initiating XR‐NTX.Measurements (1) determined whether the veteran experienced an overdose in the 365 days after MOUD initiation (primary) and (2) early discontinuation of MOUD, defined as discontinuation before 180 days (secondary). We assumed that unobserved patient characteristics would jointly influence the probability of discontinuation and overdose. and estimated the joint distribution with a bivariate probit model.We found that 9.0% of BUP initiators who experienced an overdose above the predicted 3.9% had no veteran‐discontinued BUP early; findings for XR‐NTX were similar, with 12.2% of initiators overdosing above the predicted 4.5%, but this was statistically inconclusive. We found no relationship between early discontinuation and overdose for MET initiators, probably due to the high risk of both events. The patient characteristics included in our post‐estimation exploratory analysis of early discontinuation varied by MOUD type, with between 14 (XR‐NTX) and 25 (BUP) tested. The only characteristics with at least one level showing a statistically significant change in probability of early discontinuation for all three MOUD types were geography and prior‐year exposure to psychotherapy, although direction and magnitude varied.Early discontinuation of buprenorphine, and probably extended‐release naltrexone, appears to be associated with a greater probability of experiencing a fatal or non‐fatal overdose among US veterans receiving medication for opioid use disorder (MOUD); methadone does not show the same association. There is no consistent set of characteristics among early discontinuers by MOUD type. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsDiscussionConclusionCo-use of stimulants and opioids is often deliberate. However, the possibility remains that some people are unintentionally consuming fentanyl. To advance understanding of overdose risk, we examined the rate of concordance between self-reported fentanyl use and corresponding urine toxicology screen results.Between August 2022–August 2023, 411 participants (adults who reported any non-medical drug use in the past three months) in Nevada and New Mexico completed a cross-sectional survey, of whom 64% (n = 270; the analytical sample) also completed a urine toxicology screen, which detects fentanyl use in the past three days. Positive predictive value, negative predictive value, sensitivity, and specificity were calculated using self-reported past three-day fentanyl use (yes/no) and urine toxicology screen results for the presence of fentanyl (positive/negative).Of the 270 participants who provided a urine sample, 268 are included in the descriptive statistics (two with inconclusive urine toxicology screen results were excluded). Of the 268 participants, 146 (54.5%) had a fentanyl-positive urine toxicology screen result, 122 (45.5%) had a fentanyl-negative urine toxicology screen result, 137 (51.1%) reported past three-day fentanyl use, and 130 (48.5%) reported no past three-day fentanyl use. Only 6.9% of those with a fentanyl-positive urine toxicology screen did not report recent fentanyl use. The sensitivity of self-reported fentanyl use was 93%, specificity was 97%, positive predictive value was 97%, and negative predictive value was 92%.The rate of unanticipated exposure to fentanyl (that is, positive urine screen and negative self-report) in this sample was low, at 6.9%. This runs counter to the national narrative that there is widespread unknown contamination of fentanyl in the drug supply.Future research is needed to further explore how people who use multiple substances interpret their overdose risk and what harm reduction methods they employ. [ABSTRACT FROM AUTHOR]

Background: Opioid-related fatalities are a leading cause of death in Ohio and nationally, with an increasing number of overdoses attributable to fentanyl. Rapid fentanyl test strips can identify fentanyl and some fentanyl analogs in urine samples and are increasingly being used to check illicit drugs for fentanyl before they are used. Fentanyl test strips are a promising harm reduction strategy; however, little is known about the real-world acceptability and impact of fentanyl test strip use. This study investigates fentanyl test strip distribution and education as a harm reduction strategy to prevent overdoses among people who use drugs. Methods: The research team will recruit 2400 individuals ≥ 18 years with self-reported use of illicit drugs or drugs purchased on the street within the past 6 months. Recruitment will occur at opioid overdose education and naloxone distribution programs in 16 urban and 12 rural Ohio counties. Participating sites will be randomized at the county level to the intervention or non-intervention study arm. A brief fentanyl test strip educational intervention and fentanyl test strips will be provided to participants recruited from sites in the intervention arm. These participants will be eligible to receive additional fentanyl test strips for 2 years post-enrollment. Participants recruited from sites in the non-intervention arm will not receive fentanyl test strip education or fentanyl test strips. All participants will be followed for 2 years post-enrollment using biweekly, quarterly, and 6-month surveys. Primary outcomes include (1) identification of perceived barriers and facilitating factors associated with incorporating fentanyl test strip education and distribution into opioid overdose education and naloxone distribution programs; (2) differences in knowledge and self-efficacy regarding how to test drugs for fentanyl and strategies for reducing overdose risk between the intervention and non-intervention groups; and (3) differences in non-fatal and fatal overdose rates between the intervention and non-intervention groups. Discussion: Findings from this cluster randomized controlled trial will contribute valuable information about the feasibility, acceptability, and impact of integrating fentanyl test strip drug checking in rural and urban communities in Ohio and help guide future overdose prevention interventions. Trial registration: ClinicalTrials.gov NCT05463341. Registered on July 19, 2022. https://clinicaltrials.gov/study/NCT05463341 [ABSTRACT FROM AUTHOR]

The given text is a compilation of case reports and studies related to toxicology and poisoning. It covers a range of topics, including medication overdoses, adverse effects of substances, and the management of toxic exposures. The document provides valuable insights into the complexities of toxicology and highlights the importance of prompt and individualized treatment approaches. It can be a useful resource for library patrons conducting research in this field. [Extracted from the article]

Background: Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. Methods: This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. Discussion: Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. Trial Registration: ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to describe rates and toxicological findings of unintentional opioid and stimulant toxicity deaths, 2012–2021. Methods: The dataset included accidental deaths determined by the Coroner to be due to opioids or stimulants. We calculated annual crude mortality rates and described combinations of drugs identified in toxicological examinations of these deaths. We described temporal trends in the detection of specific opioids, stimulants, benzodiazepines (including novel benzodiazepines), gabapentinoids and z‐drugs in deaths due to opioids and stimulants. Results: Mortality rates increased over time, reaching their peak in 2020 and remaining high in 2021. In deaths due to opioids, there was a decline in the proportion of deaths involving pharmaceutical opioids after 2019, and a corresponding increase in the proportion of deaths with fentanyl detected. Benzodiazepines were often present in deaths due to opioids, with novel benzodiazepines increasing rapidly from 2019 onwards. Cocaine was the most frequently detected drug in deaths due to stimulants, but amphetamine/methamphetamine was detected in around half of all stimulant deaths from 2016 onwards. Discussion and Conclusions: Despite availability of a multitude of overdose prevention interventions, mortality rates due to drug toxicity have increased in Québec. Toxicological findings of these deaths suggest concerning shifts in the illicit drug market, with Québec potentially having entered a new era of elevated overdose mortality. Intervention scale‐up is essential, but unlikely to be sufficient, to reduce drug‐related mortality. Policy reform to address the root causes of drug toxicity deaths, including an unpredictable drug supply, strained health systems and socio‐economic precarity, is essential. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your awareness of the categories, risks and effects of various new psychoactive substances • To recognise the challenges involved in identifying new psychoactive substances • To consider psychosocial and pharmacological interventions that you could use with people who misuse new psychoactive substances. The use of new psychoactive substances is a growing concern across healthcare services in the UK. To date, more than 1,000 types of new psychoactive substances have been identified and they have a wide range of effects, potency and mechanisms of action, which can result in overdose and death. This article reviews the challenges experienced by nurses including in identifying new psychoactive substances, their associated risks and various psychosocial and pharmacological interventions. Currently, evidence surrounding the appropriate nursing interventions required for the misuse of new psychoactive substances is limited. Further research and training opportunities are required for nurses to manage service users who present having taken new psychoactive substances, particularly in hospital, substance misuse and mental health settings. [ABSTRACT FROM AUTHOR]

Background: Stimulant‐related overdoses have increased dramatically, with almost 50% of overdoses in the United States now involving stimulants. Additionally, harm‐reduction approaches are increasingly seen as key to reducing the negative impact of substance use. Contingency management (CM), the provision of financial incentives for abstinence, is the most effective treatment for stimulant use disorder, but historically has not been widely implemented. Many recent, large‐scale implementation efforts have relied upon foundational CM protocols that may not sufficiently account for recent increases in the prevalence and lethality of stimulant use nor the growing preference for harm reduction versus abstinence‐only frameworks. Argument: We argue the need to (1) consider whether and how CM protocols might be modified to address rising stimulant use and harm reduction frameworks and (2) make CM widely accessible so that it can reduce population‐level stimulant use while ensuring that it is delivered with fidelity to its basic principles. Proposed changes include changing CM reinforcement schedules to emphasize treatment engagement and reductions in use in addition to abstinence, changing guidelines on the duration of and re‐engagement in CM, investing in research on virtual CM, incentivizing providers and health systems to deliver CM, making it easier to purchase and use point‐of‐care drug screens, using direct‐to‐consumer marketing to increase demand for CM and adapting CM to the community in which it is being implemented. Conclusions: Our proposed modifications to contingency management (CM) protocols and accessibility may more effectively address rising stimulant use and align CM more closely with harm‐reduction frameworks. Given the urgent need to reduce overdose deaths, developing and testing modified CM protocols may need to rely upon methods other than randomized controlled trials. Efforts to disseminate CM widely to reduce population‐level stimulant use must be balanced with the need to maintain fidelity to CM's basic principles. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: This commentary seeks to evaluate existing knowledge about the relationship between brain injury (BI) and overdose (OD), to unify distant bodies of literature, and to enhance prevention and treatment for opioid OD among individuals with BI. Background: There is a hidden epidemic of undiagnosed BI in the United States. Due to lack of screening, the vast majority of BI sufferers do not know they have a BI. Not only are those with BI at elevated risk for opioid use, misuse, and opioid use disorder, but also they are at elevated risk for OD. Conversely, those with OUD and those who experienced an OD, are more likely to sustain BI. Key Findings/Conclusions: The existing literature suggests that primary strategies to reduce ABI (Acquired Brain Injury)/TBI (Traumatic Brain Injury) harms involve addressing: screening, stigma, racial disparities, and popular misconceptions about OD. The association between TBI and OD is an underexamined public health issue, exacerbated by the bidirectional nature of the relationship. Not only is TBI a risk factor for opioid OD; opioid OD was also found to be a major cause of ABI, which can have lifelong effects similar to Alzheimer's disease. Screening tools for BI were underutilized and inconsistently implemented across reviewed studies. Enhanced screening population wide is a promising intervention, complemented with expanded treatment and research. Black individuals face worse outcomes in BI and treatment outcomes. Anti-racist strategies must fight inequity while addressing social and structural drivers of overdose and BI within the opioid and opioid overdose crises. [ABSTRACT FROM AUTHOR]

Article #1 discusses a clinical trial that examined the effects of delaying intubation in comatose patients with acute poisoning. The study found that delaying intubation was safe and resulted in lower rates of ICU admission and complications. However, the lack of deaths suggests that more research is needed, particularly involving confirmed overdoses. Article #2 explores lead exposure in veterinary workers who handle lead shielding during radiography. The study found that the use of lead shielding is associated with lead exposure, but wearing disposable gloves can significantly reduce this exposure. However, the study had limitations, such as potential bias from the questionnaire and the lack of evaluation of hand washing. Article #3 focuses on the use of angiotensin II (AT2) for treating refractory shock. While AT2 has shown improvement in blood pressures, its impact on mortality is still unclear. The study aims to determine if adding AT2 improves 30-day mortality in patients with severe, refractory shock. However, the study is retrospective and underpowered, so further research is needed to establish its effectiveness. The study found that there was no significant difference in mortality between the AT2 group and the control group, and baseline characteristics differed between the two groups. Overall, the study concluded that AT2 was not associated with improved mortality or organ dysfunction in patients with severe shock. [Extracted from the article]

The Toxicology Investigators Consortium (ToxIC) was launched as a prospective multi-center registry of cases who receive medical toxicology consultations. Now, with over 100,000 cases, the Core Registry continues to address many medical toxicology research questions and has served as the foundation for multiple sub-registries, including the North American Snakebite Registry and the Medications for Opioid Use Disorder sub-registry. ToxIC also has evolved a portfolio of non-registry-based projects utilizing medical toxicology physician site principal investigators who enroll patients through emergency departments, irrespective of whether they received a medical toxicology consultation. These studies include the FDA-ACMT COVID-19 ToxIC Pharmacovigilance Project, which identifies adverse drug reactions related to the treatment of COVID-19, the Fentalog Study a toxico-surveillance study of suspected opioid overdose cases, the Drug Overdose Toxico-Surveillance Reporting Program which enrolls either suspected stimulant or opioid overdose cases, and the just being launched Real-World Examination of Naloxone for Drug Overdose Reversal project. Given ToxIC's experience in multi-center studies and its well-developed infrastructure, it is well-positioned to provide a nimble response on the part of the medical toxicology community to addressing evolving toxicological threats, drug and chemical toxicosurveillance, and other important medical toxicology priorities. [ABSTRACT FROM AUTHOR]