The opioid-abuse epidemic is a problem that continues to persist world-wide. As such, appropriately evaluating and treating such patients is crucial, especially when considering the various complications that may arise. In rare cases, opioid overdoses can be complicated by compartment syndrome, rhabdomyolysis, and acute renal failure. All three of these complications can result in life threatening emergencies. We present a case of a 38-year-old male who was brought to the emergency department after reportedly being found lying on the ground for an unknown period of time from suspected heroin overdose. He was initially treated with 2 milligrams (mg) of intramuscular naloxone en route via emergency medical services with appropriate response. Shortly after arrival to the emergency department, the patient complained of severe right lower extremity pain, paresthesia and paralysis. Patient developed acute lower extremity compartment syndrome that was further complicated by rhabdomyolysis and acute renal failure. While emergency medicine physicians are familiar with the common complications of heroin overdose including mental status changes, respiratory depression and gastrointestinal symptoms, they must also be familiar with the less common ones. Notably, acute compartment syndrome. Compartment syndrome is ultimately a clinical diagnosis and warrants emergent surgical consultation. Every patient presenting to the emergency department warrants a complete, thorough physical examination to evaluate for any and all life-threatening conditions, regardless of the presenting complaint.

UNASSIGNED: To differentiate the severity of acute opioid toxicity and describe both the clinical and physiological features associated with heroin overdose in a cohort of witnessed overdose cases.
UNASSIGNED: Witnessed heroin overdose cases over a 12-month period (30 June 2018 - 30 June 2019) at the Medically Supervised Injecting Room (MSIR) in Melbourne, Australia were examined. The severity of acute opioid toxicity was classified according to the level of clinical intervention required to manage the overdose cases where an escalating level of care was provided. Heroin overdose cases were classified into one of three graded severity categories and a fourth complicated heroin overdose category.
UNASSIGNED: A total of 1218 heroin overdose cases were identified from 60,693 supervised injecting visits over the study period. On the spectrum of toxicity, 78% (n = 955) of overdose cases were classified as Grade 1 severity, 7% (n = 83) as Grade 2 severity, and 13% (n = 161) as Grade 3 acute opioid toxicity severity cases, as well as 2% (n = 19) classified as complicated heroin overdose cases. The median onset time for heroin overdose cases was 17 min (IQR 11-28 min) from the time the individual was ready to prepare and inject heroin until clinical intervention was initiated.
UNASSIGNED: We demonstrated that heroin overdose is a dynamic illness and cases differ in the severity of acute opioid toxicity. The risk of airway occlusion including positional asphyxia was an early and consistent feature across all levels of toxicity, while exaggerated respiratory depression together with exaggerated depression of consciousness was increasingly observed with greater levels of toxicity. We also demonstrated the importance of early intervention in overdose cases, where in a large cohort of heroin overdose cases there were no fatal outcomes, a very low hospitalisation rate and most cases were able to be managed to clinical resolution on-site.

Heroin-related mortality is a complex phenomenon involving several factors that make an individual more susceptible to opioid toxicity. Among these, pre-existing pathological conditions play an important role. The current paper reviewed 51 autopsied cases performed over the last 30 years, each subject (\"frequent heroin user\") having taken heroin intravenously alone before death. For each case, total blood morphine concentration determined by gas chromatography-mass spectrometry (GC-MS) was obtained from the archives. For histopathological evaluation we examined microscopic sections of the heart, lung, brain, liver and kidney, and for each organ a score table with a numerical value from 1 to 5, as an indicator of increasing severity, was drawn up. Finally, we created a scoring system based on the Injury Severity Score (ISS), generated by the sum of the squares of the three highest organ scores. We investigated the relationship between total blood morphine value (mg/l) and pathological score by inserting the two variables in a linear regression model: Score = a + b·Morphinemia (p-value <0.001). The results demonstrated a statistically significant correlation between the two variables: individuals with low total blood morphine values tended to have a higher pathological score. Our study provides useful assessment tools for forensic practice, confirming the need to combine two important disciplines in drug death investigation: forensic pathology and toxicology.

Take-home naloxone, a key response to heroin overdose, may be compromised by the way in which overdose cases are coded in EMS dispatch systems as call-takers direct callers at cardiac arrest events against using any medication. We examined the ways in which confirmed heroin overdose cases attended by ambulances are coded at dispatch to determine whether incorrect coding of overdoses as cardiac arrests may limit the use of take-home naloxone.
We conducted a retrospective analysis of coded ambulance clinical records collected in Victoria, Australia from 2012-2017. Counts of heroin overdose cases were examined by dispatch coding (heroin overdose, cardiac/respiratory arrest and \'other\'), along with age, sex, GCS and respiratory rate. Data were analysed using chi-square and Poisson regression for quarterly counts, adjusting for age, sex and patient GCS.
A total of 5637 heroin overdose cases were attended over the period 2012-2017 (71.4% male, 36.4% aged under 35 years). Almost half (n = 2674, 47.4%) were coded as cardiac/respiratory arrest at dispatch, with 36.8% (n = 2075) coded as heroin overdose and 15.7% (n = 886) coded as other/unknown.
Almost half of the heroin overdoses were dispatched according to a protocol that would preclude the use of take-home naloxone prior to ambulance arrival and this changed little over the period in which take-home naloxone programs were operating in Victoria, Australia. EMS should move as quickly as possible to newer versions of dispatch systems that enable the use of naloxone in cases of obvious opioid overdose that may be classified as cardiac/respiratory arrest.

OBJECTIVE: To evaluate the association between psychiatric comorbidities, substance use disorders and heroin overdose-related hospitalizations (HOD). Next, to understand the demographic trend of HOD hospitalizations and comorbidities.
METHODS: Using the Nationwide Inpatient Sample (NIS), we included 27,442,808 child and adolescent hospitalizations, and 1432 inpatients (0.005%) were managed primarily for HOD. The odds ratio (OR) of the association of variables in HOD inpatients were measured using a logistic regression model.
RESULTS: Adolescents had 56 times higher odds (95% CI 43.36-73.30) for HOD-related hospitalizations compared to 4.6% children under 11 years. About three-fifth of the HOD inpatients were male, and they had 1.5-fold higher odds (95% CI 1.30-1.64) compared to 43% females in the study population. Whites were considerably higher in proportion (81%) than other race/ethnicities. A greater portion of HOD inpatients (40%) were from high-income families. Most common comorbid psychiatric disorders were mood (43.8%) and anxiety (20.4%). The prevalent comorbid substance use disorders were opioid (62.4%), tobacco (36.8%) and cannabis (28.5%) use disorders.
CONCLUSIONS: HOD-related hospitalizations were predominant in males, White and older adolescents (12-18 years). Prescription opioids are the bridge to heroin abuse, thereby increasing the vulnerability to other substance abuse. This requires more surveillance and should be explored to help reduce the heroin epidemic in children.

暂无摘要。

Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.
The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.
There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.
This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Drug overdose is the leading cause of accidental death in the United States. Nationally, opioids are the primary drugs associated with accidental overdoses. In response to increasing overdose deaths, 40 states and the District of Columbia have enacted Good Samaritan Laws (GSLs). Generally, these policies attempt to encourage witnesses or those experiencing an overdose to call 911 by providing limited immunity from arrest, charge and/or prosecution of possession of narcotics. The aim of the current study is to evaluate the effectiveness of New York State\'s 911 GSL.
We exploit a difference in state law between New York State, where the policy was adopted in 2011, and New Jersey, where the policy was not adopted until 2013, to provide a reasonable comparison condition. We examine variation in accidental opioid overdose emergency department visits and inpatient admissions from 2010 to 2012 across 270 hospitals in New York and New Jersey at the quarterly level controlling for hospital fixed effects and time trends using State Emergency Department Databases (SEDD) and State Inpatient Databases (SID).
Accidental opioid overdose emergency department visits and inpatient hospital admissions were increasing in both New York and New Jersey. After the enactment of New York\'s 911 GSL, emergency department visits and inpatient hospital admissions for accidental heroin overdoses increased differently in New York and New Jersey, with an incident rate ratio (IRR) of 1.34 (95% CI = 1.00, 1.86). The results were inconclusive for accidental non-heroin opioid overdoses (IRR = 0.98, 95% CI = 0.86, 1.13).
Accidental heroin overdose emergency department visits and inpatient hospital admissions increased in New York State after the enactment of the 911 GSL, consistent with the intended effect of the GSL. Preliminary evidence suggests that either persons who use heroin and/or those around them were impacted by the policy change.

Background: The aim of this study was to investigate the safety of the management of non-fatal heroin overdose in the out-of-hospital environment; irrespective of whether or not naloxone had been administered. Heroin toxicity-related deaths as well as heroin intoxication-related traumatic deaths following patient-initiated refusal of transport were investigated. Methods: Heroin-related deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated and data linkage to pre-hospital Emergency Medical Services performed, in order to identify whether the death was related to the last episode of care by paramedics. The number of non-fatal heroin overdose events over the study period were also examined. Results and discussion: There were a total of 3921 heroin-related attendances by paramedics during the study period, including 2455 cases that involved treatment but where the patient was not transported to hospital. There were also 243 heroin-related deaths identified over the study period and 93% (n = 225) of those cases were matched with Ambulance Victoria electronic patient care records. Data linkage revealed 31 heroin-related deaths where there had been a recent presentation with a non-fatal heroin overdose to paramedics; however, none of these deaths were related to that episode of care, including for 11 individuals that were treated on scene by paramedics but not transported to the hospital. Conclusions: This study demonstrated that the treatment of uncomplicated heroin overdose in the out-of-hospital environment was safe in terms of mortality, irrespective of whether or not naloxone had been administered. In all of the non-fatal heroin toxicity cases attended by paramedics, whether or not transported to hospital, death occurred as a result of a subsequent and unrelated heroin overdose.

This article reports on the first implementation of an online opioid-overdose prevention, recognition and response training for laypeople. The training was disseminated nationally in November 2014. Between 2000 and 2014, U.S. opioid deaths increased by 200%. The importance of complementary approaches to reduce opioid overdose deaths, such as online training, cannot be overstated.
A retrospective evaluation was conducted to assess perceived knowledge, skills to intervene in an overdose, confidence to intervene, and satisfaction with the training.
Descriptive statistics were used to report sample characteristics, compare experiences with overdose and/or naloxone between subgroups, and describe participants\' satisfaction with the trainings. Z-ratios were used to compare independent proportions, and paired t-tests were used to compare participant responses to items pre- and posttraining, including perceived confidence to intervene and perceived knowledge and skills to intervene successfully.
Between January and October 2015, 2,450 laypeople took the online training; 1,464 (59.8%) agreed to be contacted. Of these, 311 (21.2% of those contacted) completed the survey. Over 80% reported high satisfaction with content, format and mode of delivery and high satisfaction with items related to confidence and overdose reversal preparedness. Notably, 89.0% of participants felt they had the knowledge and skills to intervene successfully posttraining compared to 20.3% pretraining (z = -17.2, p <.001). Similarly, posttraining, 87.8% of participants felt confident they could successfully intervene compared to 24.4% pretraining (z = -15.9, p <.001).
This study demonstrates the effectiveness of the GetNaloxoneNow.org online training for laypeople.