Prescription opioid abuse based on representative postmortem
toxicology
Hjelt Institute, Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
ABSTRACT
Opioids are important medications for pain and opioid maintenance treatment. Increasing use and abuse
of prescription opioids has, however, caused worldwide concern. Our aim was to estimate the ratio
between prescription opioid abuse and total use, based on representative postmortem toxicology. Our
material included all the medico-legally examined deaths in Finland during 2010–2011 involving
positive findings involving buprenorphine, codeine, fentanyl, methadone, oxycodone, or tramadol. We
studied drug abuse by age group, with ‘‘abuse’’ meaning licit opioids used illicitly as narcotics. Drugabuse history, drug injecting, or laboratory findings of illicit drugs defined an abuser case. We then
compared abuser cases and other opioid-related cases between the opioids with the number of fatal
poisonings, accidents, suicides, alcohol findings, concomitant opioid use, and median postmortem blood
opioid concentrations. Opioid findings numbered 2499 in 2088 cases. Drug abuse involved 545 opioidpositive cases, which in Finland represented 0.5% of those deceased. The proportion of abuser cases
among all opioid-related cases for buprenorphine was 85.5%, for methadone 82.4%, for tramadol 29.4%,
for codeine 16.3%, for fentanyl 14.5%, and for oxycodone 6.9%. Abuse in age-groups >60 was rare.
Concomitant other opioid findings were more frequent in abuser- than in other cases for codeine,
oxycodone, and tramadol, whereas alcohol findings were more frequent in buprenorphine, codeine, and
fentanyl abuse. Buprenorphine and methadone were most often related to drug abuse. Every other
opioid studied involved some abuse, and especially tramadol. Abuse and fatal poisonings were
concentrated in men aged 20–49.
1. Introduction
Opioids, although effective and important pain relievers and
medications for opioid maintenance treatment, are abused as
narcotics. Although illicit cocaine and heroin use has decreased,
unintentional drug overdose deaths have increased, as has the
consumption of opioid analgesics [1]. In the United States,
prescription drug abuse is a major challenge in public health [2]
and has become the fastest-growing drug problem [1]. Easy
availability of prescription opioids maintains the abuse problem
and has resulted in an opioid-abuse trend [3]. This increasing drug
abuse contributes to more drug-related crimes, social and health
problems, hospitalisation, and mortality. The abuse problem is
worldwide, with South Asia, for example, confronting a struggle
with inadequate treatment of pain, widespread opioid abuse, and
insufficient access to opioid maintenance treatment [4].
Reporting opioid-related harm internationally is crucial for the
monitoring and prevention of opioid epidemics in Europe [5]. Compared to North America, consumption of prescription opioids in
Europe has been, thus far, considerably lower [2,5,6]. In France,
prescription drug abuse especially concerns buprenorphine in
connection with opioid maintenance treatment, morphine used as
an analgesic, and to some degree, methadone and codeine [7]. In the
UnitedKingdom,tramadoldeathshavenotablyincreased[8,9].Deaths
related to tramadol are often unintentional, and coadministration of
psycholeptics or alcohol raises the risk for fatalities [9]. German
researchers, in contrast, have concluded that risk for tramadol misuse
orabuse anditsprevalenceinclinical practiceis low,andtheyfearthat
strict restrictions for tramadol prescription would lead to inadequate
treatment of pain [10]. Pain treatment in today’s Europe seems,
however, not to be inferior to that of North America, despite Europe’s
lower opioid consumption [2].
In Finland, nearly all opioid abuse during recent years has
involved prescription opioids [11]. The one most abused is
buprenorphine; heroin use is currently very rare. The latest
estimate of problematic drug abuse in Finland dates back to 2005,
when 0.52–0.69% of the population aged 15–55 faced social orhealth problems due to drugs [11]. Problematic opioid abuse
accounted for 0.13–0.18% [11]. The consumption of opioids has
remained rather stable during recent years with only a slight
increase from 15 defined daily doses (DDD)/1000 inhabitants/day
in 2005 to 16.5 DDD/1000 inhabitants/day in 2010 and 2011
[12]. In 2005, fatal opioid poisonings numbered 126 [13], and in
2011, 189 [14]. No current estimate of the magnitude of opioid
abuse exists, but in Finland, as well, abuse of prescription
medications is increasing: during 2010–2011, 48% of the pregabalin and 19% of the gabapentin postmortem cases were
attributable to drug abuse, and 90% of pregabalin and gabapentin
abuse included concomitant opioids [15].
The purpose of this study is to evaluate the proportion of abuser
cases to other opioid-related cases for the most common
prescription opioids in Finland during 2010–2011, based on
medico-legal cause-of-death investigations. The reason for our
choosing autopsy cases as study material is Finland’s high medicolegal autopsy rate; postmortem toxicology during the study years
involved 13% of all deaths, giving a more representative sample of
the population than in other countries. The comprehensive
postmortem database allows distinctive epidemiological research,
because it also includes individuals not usually participating in
self-reporting surveys, and the results are based on actual
laboratory analysis. We compare the differences between prescription opioids in terms of age, cause and manner of death,
concomitant alcohol and other opioid use, and opioid concentration in postmortem femoral blood, to create an abuser profile for
each drug.
health problems due to drugs [11]. Problematic opioid abuse
accounted for 0.13–0.18% [11]. The consumption of opioids has
remained rather stable during recent years with only a slight
increase from 15 defined daily doses (DDD)/1000 inhabitants/day
in 2005 to 16.5 DDD/1000 inhabitants/day in 2010 and 2011
[12]. In 2005, fatal opioid poisonings numbered 126 [13], and in
2011, 189 [14]. No current estimate of the magnitude of opioid
abuse exists, but in Finland, as well, abuse of prescription
medications is increasing: during 2010–2011, 48% of the pregabalin and 19% of the gabapentin postmortem cases were
attributable to drug abuse, and 90% of pregabalin and gabapentin
abuse included concomitant opioids [15].
The purpose of this study is to evaluate the proportion of abuser
cases to other opioid-related cases for the most common
prescription opioids in Finland during 2010–2011, based on
medico-legal cause-of-death investigations. The reason for our
choosing autopsy cases as study material is Finland’s high medicolegal autopsy rate; postmortem toxicology during the study years
involved 13% of all deaths, giving a more representative sample of
the population than in other countries. The comprehensive
postmortem database allows distinctive epidemiological research,
because it also includes individuals not usually participating in
self-reporting surveys, and the results are based on actual
laboratory analysis. We compare the differences between prescription opioids in terms of age, cause and manner of death,
concomitant alcohol and other opioid use, and opioid concentration in postmortem femoral blood, to create an abuser profile for
each drug.
Prescription opioid abuse based on representative postmortemtoxicologyHjelt Institute, Department of Forensic Medicine, University of Helsinki, Helsinki, FinlandABSTRACTOpioids are important medications for pain and opioid maintenance treatment. Increasing use and abuseof prescription opioids has, however, caused worldwide concern. Our aim was to estimate the ratiobetween prescription opioid abuse and total use, based on representative postmortem toxicology. Ourmaterial included all the medico-legally examined deaths in Finland during 2010–2011 involvingpositive findings involving buprenorphine, codeine, fentanyl, methadone, oxycodone, or tramadol. Westudied drug abuse by age group, with ‘‘abuse’’ meaning licit opioids used illicitly as narcotics. Drugabuse history, drug injecting, or laboratory findings of illicit drugs defined an abuser case. We thencompared abuser cases and other opioid-related cases between the opioids with the number of fatalpoisonings, accidents, suicides, alcohol findings, concomitant opioid use, and median postmortem bloodopioid concentrations. Opioid findings numbered 2499 in 2088 cases. Drug abuse involved 545 opioidpositive cases, which in Finland represented 0.5% of those deceased. The proportion of abuser casesamong all opioid-related cases for buprenorphine was 85.5%, for methadone 82.4%, for tramadol 29.4%,for codeine 16.3%, for fentanyl 14.5%, and for oxycodone 6.9%. Abuse in age-groups >60 was rare.Concomitant other opioid findings were more frequent in abuser- than in other cases for codeine,oxycodone, and tramadol, whereas alcohol findings were more frequent in buprenorphine, codeine, andfentanyl abuse. Buprenorphine and methadone were most often related to drug abuse. Every otheropioid studied involved some abuse, and especially tramadol. Abuse and fatal poisonings wereconcentrated in men aged 20–49.1. IntroductionOpioids, although effective and important pain relievers andmedications for opioid maintenance treatment, are abused asnarcotics. Although illicit cocaine and heroin use has decreased,unintentional drug overdose deaths have increased, as has theconsumption of opioid analgesics [1]. In the United States,prescription drug abuse is a major challenge in public health [2]and has become the fastest-growing drug problem [1]. Easyavailability of prescription opioids maintains the abuse problemand has resulted in an opioid-abuse trend [3]. This increasing drugabuse contributes to more drug-related crimes, social and healthproblems, hospitalisation, and mortality. The abuse problem isworldwide, with South Asia, for example, confronting a strugglewith inadequate treatment of pain, widespread opioid abuse, andinsufficient access to opioid maintenance treatment [4].Reporting opioid-related harm internationally is crucial for themonitoring and prevention of opioid epidemics in Europe [5]. Compared to North America, consumption of prescription opioids inEurope has been, thus far, considerably lower [2,5,6]. In France,prescription drug abuse especially concerns buprenorphine inconnection with opioid maintenance treatment, morphine used asan analgesic, and to some degree, methadone and codeine [7]. In theUnitedKingdom,tramadoldeathshavenotablyincreased[8,9].Deathsrelated to tramadol are often unintentional, and coadministration ofpsycholeptics or alcohol raises the risk for fatalities [9]. Germanresearchers, in contrast, have concluded that risk for tramadol misuseorabuse anditsprevalenceinclinical practiceis low,andtheyfearthatstrict restrictions for tramadol prescription would lead to inadequatetreatment of pain [10]. Pain treatment in today’s Europe seems,however, not to be inferior to that of North America, despite Europe’slower opioid consumption [2].In Finland, nearly all opioid abuse during recent years hasinvolved prescription opioids [11]. The one most abused isbuprenorphine; heroin use is currently very rare. The latestestimate of problematic drug abuse in Finland dates back to 2005,when 0.52–0.69% of the population aged 15–55 faced social orhealth problems due to drugs [11]. Problematic opioid abuseaccounted for 0.13–0.18% [11]. The consumption of opioids hasremained rather stable during recent years with only a slightincrease from 15 defined daily doses (DDD)/1000 inhabitants/dayin 2005 to 16.5 DDD/1000 inhabitants/day in 2010 and 2011[12]. In 2005, fatal opioid poisonings numbered 126 [13], and in2011, 189 [14]. No current estimate of the magnitude of opioidabuse exists, but in Finland, as well, abuse of prescriptionmedications is increasing: during 2010–2011, 48% of the pregabalin and 19% of the gabapentin postmortem cases wereattributable to drug abuse, and 90% of pregabalin and gabapentinabuse included concomitant opioids [15].The purpose of this study is to evaluate the proportion of abusercases to other opioid-related cases for the most commonprescription opioids in Finland during 2010–2011, based onmedico-legal cause-of-death investigations. The reason for ourchoosing autopsy cases as study material is Finland’s high medicolegal autopsy rate; postmortem toxicology during the study yearsinvolved 13% of all deaths, giving a more representative sample ofthe population than in other countries. The comprehensivepostmortem database allows distinctive epidemiological research,because it also includes individuals not usually participating inself-reporting surveys, and the results are based on actuallaboratory analysis. We compare the differences between prescription opioids in terms of age, cause and manner of death,concomitant alcohol and other opioid use, and opioid concentration in postmortem femoral blood, to create an abuser profile foreach drug.health problems due to drugs [11]. Problematic opioid abuseaccounted for 0.13–0.18% [11]. The consumption of opioids hasremained rather stable during recent years with only a slightincrease from 15 defined daily doses (DDD)/1000 inhabitants/dayin 2005 to 16.5 DDD/1000 inhabitants/day in 2010 and 2011[12]. In 2005, fatal opioid poisonings numbered 126 [13], and in2011, 189 [14]. No current estimate of the magnitude of opioidabuse exists, but in Finland, as well, abuse of prescriptionmedications is increasing: during 2010–2011, 48% of the pregabalin and 19% of the gabapentin postmortem cases wereattributable to drug abuse, and 90% of pregabalin and gabapentinabuse included concomitant opioids [15].The purpose of this study is to evaluate the proportion of abusercases to other opioid-related cases for the most commonprescription opioids in Finland during 2010–2011, based onmedico-legal cause-of-death investigations. The reason for ourchoosing autopsy cases as study material is Finland’s high medicolegal autopsy rate; postmortem toxicology during the study yearsinvolved 13% of all deaths, giving a more representative sample ofthe population than in other countries. The comprehensivepostmortem database allows distinctive epidemiological research,because it also includes individuals not usually participating inself-reporting surveys, and the results are based on actuallaboratory analysis. We compare the differences between prescription opioids in terms of age, cause and manner of death,concomitant alcohol and other opioid use, and opioid concentration in postmortem femoral blood, to create an abuser profile foreach drug.
การแปล กรุณารอสักครู่..
![](//thimg.ilovetranslation.com/pic/loading_3.gif?v=b9814dd30c1d7c59_8619)