Misuse of Novel Synthetic Opioids: A Deadly New Trend.

: Novel synthetic opioids (NSOs) include various analogs of fentanyl and newly emerging non-fentanyl compounds. Together with illicitly manufactured fentanyl (IMF), these drugs have caused a recent spike in overdose deaths, whereas deaths from prescription opioids have stabilized. NSOs are used as stand-alone products, as adulterants in heroin, or as constituents of counterfeit prescription medications. During 2015 alone, there were 9580 deaths from synthetic opioids other than methadone. Most of these fatalities were associated with IMF rather than diverted pharmaceutical fentanyl. In opioid overdose cases, where the presence of fentanyl analogs was examined, analogs were implicated in 17% of fatalities. Recent data from law enforcement sources show increasing confiscation of acetylfentanyl, butyrylfentanyl, and furanylfentanyl, in addition to non-fentanyl compounds such as U-47700. Since 2013, deaths from NSOs in the United States were 52 for acetylfentanyl, 40 for butyrylfentanyl, 128 for furanylfentanyl, and 46 for U-47700. All of these substances induce a classic opioid toxidrome, which can be reversed with the competitive antagonist naloxone. However, due to the putative high potency of NSOs and their growing prevalence, it is recommended to forgo the 0.4 mg initial dose of naloxone and start with 2 mg. Because NSOs offer enormous profit potential, and there is strong demand for their use, these drugs are being trafficked by organized crime. NSOs present major challenges for medical professionals, law enforcement agencies, and policymakers. Resources must be distributed equitably to enhance harm reduction though public education, medication-assisted therapies, and improved access to naloxone.

Ultrasound-guided central venous catheterization: A review of the relevant anatomy, technique, complications, and anatomical variations.

Central venous catheterization is a commonly used and important intervention. Despite its regular use it is still associated with a high incidence of complications especially infection and catheter tip embolization. Addition of ultrasound guidance to the technique has shown great improvement to the time and number of attempts for successful catheterization. The preference of vein depends greatly on the situation; subclavian vein is the preferred method overall but internal jugular vein is preferred in patients undergoing cardiac or thoracic surgery. This is especially true for pediatric patients in whom femoral vein catheterization is still preferred despite it carrying a higher risk than other locales. Addition of ultrasound guidance greatly reduces the incidence of arterial puncture and subsequent hematoma formation regardless of location. This is because it allows for visualization of anatomical variation prior to intervention and continual visualization of the needle during the placement. It is noteworthy however, that addition of ultrasound does not prevent complications such as catheter tip embolization as this may occur even with perfect placement. The value of ultrasound usage is undisputable since all studies assessing the difference between it and landmark based methods showed preferable outcome. Reduction of time and number of attempts is sufficient argument to make ultrasound guidance standard practice. Clin. Anat. 30:237-250, 2017. © 2017 Wiley Periodicals, Inc.