Recent increase in detection of alprazolam in Victorian heroin-related deaths.

OBJECTIVES: To examine the rate of detection of alprazolam among cases of heroin-related death (HRD) in Victoria, including the relationship between alprazolam supply and HRDs. DESIGN AND SETTING: Population-based study of community alprazolam supply in Victoria and HRDs reported to the Victorian coroner from January 1990 to December 2010. MAIN OUTCOME MEASURES: Number of prescriptions for alprazolam supplied; defined daily dose (DDD) per 1000 population per 04 of alprazolam; number of cases of HRD in which alprazolam was detected through postmortem toxicological testing. RESULTS: Alprazolam supply increased by 1426%, from 0.42 DDD/1000/04 in 1990, to 6.41 in 2010. For every 1 unit increase in DDD/1000/04, the proportion of cases of HRD in which alprazolam was detected increased at an incidence rate ratio of 2.4 (95% CI, 2.1-2.8; P < 0.001). Alprazolam was detected among increasing proportions of HRDs, from 5.3% in 2005 to a peak of 35.3% in 2009. CONCLUSION: The increase in detection of alprazolam among cases of HRD, particularly since 2005, and the disproportionate increase in prescribing of the high-dose 2 mg formulation compared with other formulations suggest a need to examine alprazolam prescribing and to identify inappropriate prescribing and the circumstances of diversion from licit to illicit use.

Over-the-counter codeine analgesic misuse and harm: characteristics of cases in Australia and New Zealand.

AIM: To describe the characteristics of clients addicted to over-the-counter (OTC) codeine analgesics presenting to an Auckland open-access clinic, and to compare them to clients admitted to a New Zealand detoxification unit, and in the Australian community. METHOD: Cross-sectional study of clients presenting to a regional, open-access detoxification clinic covering the Greater Auckland area between 1 January and 31 March 2010. RESULTS: Fifteen clients were analysed, and compared to 77 similar clients identified in Victoria and five other Australian States, and 7 clients admitted to a New Zealand detoxification unit. Cases in each cohort were consistent with those in the published literature, and appear to be similar to each other both demographically and in terms of the high average tablets consumption (49-65 tablets per day), the serious non-steroidal anti-inflammatory drug (NSAID) adverse drug reactions identified, and the long duration of misuse. Many had a history of alcohol or other drug use and mental health disorder. CONCLUSIONS: This study has identified that controls on OTC codeine analgesics in both countries were not sufficient to limit non-medical use of these products. As a result, cases identified in these two countries escalated the number of self-administered tablets taken daily for misuse, resulting in codeine dependence and serious NSAID toxicity secondary to this dependence.

Increasing deaths involving oxycodone, Victoria, Australia, 2000-09.

OBJECTIVE: In light of an emerging epidemic identified in the United States and Canada, to identify trends in fatal drug toxicity involving oxycodone and the demographic characteristics and indicators of socioeconomic disadvantage of the deceased. STUDY DESIGN: Population-based observational study in Victoria, Australia. POPULATION: Decedents whose death was reported to the Victorian Coroner between 2000 and 2009 and where oxycodone was detected. MAIN OUTCOME MEASURES: Association between supply of oxycodone and deaths. Demographic characteristics of decedents. Rate ratios of the rural or metropolitan location and socioeconomic indicators of disadvantage of the deceased. RESULTS: Supply to Victoria has increased nine-fold from 7.5 mg per capita in 2000 to 67.5 mg per capita in 2009. Detection of oxycodone in deaths reported to the Victorian Coroner has increased from 4 (0.08/100,000 population) in 2000 to 97 (1.78/100,000 population) in 2009-a 21-fold increase in deaths. Of the 320 cases described, 53.8% (172) were the result of drug toxicity. Of these, 52.3% were unintentional and 19.8% intentional self-harm; the remaining 27.9% are either still under investigation by the coroner or intent is unknown. Drug toxicity deaths were overrepresented in both rural areas and areas indexed with high levels of disadvantage. CONCLUSIONS: The substantial increase in the number of deaths involving oxycodone is strongly and significantly associated with the increase in supply. Most drug toxicity deaths involving oxycodone were unintentional. This newly identified trend in fatalities in Victoria supports concerns that a pattern of increasing deaths involving oxycodone is emerging globally.

Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases.

OBJECTIVE: To investigate morbidity related to misuse of over-the-counter (OTC) codeine-ibuprofen analgesics. DESIGN AND SETTING: Prospective case series collected from Victorian hospital-based addiction medicine specialists between May 2005 and December 2008. MAIN OUTCOME MEASURES: Morbidity associated with codeine-ibuprofen misuse. RESULTS: Twenty-seven patients with serious morbidity were included, mainly with gastrointestinal haemorrhage and opioid dependence. The patients were taking mean daily doses of 435-602 mg of codeine phosphate and 6800-9400 mg ibuprofen. Most patients had no previous history of substance use disorder. The main treatment was opioid substitution treatment with buprenorphine-naloxone or methadone. CONCLUSIONS: Although codeine can be considered a relatively weak opioid analgesic, it is nevertheless addictive, and the significant morbidity and specific patient characteristics associated with overuse of codeine-ibuprofen analgesics support further awareness, investigation and monitoring of OTC codeine-ibuprofen analgesic use.

Improving the management of chronic non-malignant pain and reducing problems associated with prescription opioids.

New guidelines and a multidisciplinary approach have the potential to help patients in need while minimising inappropriate use of opioids.