Dataset Information

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

ABSTRACT:

Background

Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.

Methods

In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented.

Results

We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors.

Interpretation

Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated.

SUBMITTER: Lowe A

PROVIDER: S-EPMC5378545 | biostudies-literature | 2017 Jan-Mar

REPOSITORIES: biostudies-literature

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Publications

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

Lowe Amanda A Hamilton Michael M Greenall BScPhm MHSc Julie J Ma Jessica J Dhalla Irfan I Persaud Nav N

CMAJ open 20170101 1

<h4>Background</h4>Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.<h4>Methods</h4>In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Commi ...[more]

PMID: 28401133

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Project description:BackgroundHospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death.Methods and findingsWe conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results.ConclusionsDischarge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.

Project description:BackgroundBenzodiazepine-positive overdoses increased between 2019 and 2021 in Tennessee. We sought to determine the changes in the number and characteristics of prescription and illicit benzodiazepine-positive fatal drug overdoses during this period.Materials and methodsA statewide study was conducted to determine changes in the number and characteristics of benzodiazepine-positive drug overdose decedents using 2019-2021 data from the Tennessee State Unintentional Drug Overdose Reporting System. The analyses were limited to Tennessee residents aged ≥ 18 years. A benzodiazepine-positive overdose was defined as any benzodiazepine on toxicology, regardless of the presence of other substances. Frequencies were generated to compare demographics, circumstances, prescription history, and toxicology between 2019 and 2021 for illicit and prescription benzodiazepine-positive fatal overdoses.ResultsBetween 2019 and 2021, 1666 benzodiazepine-positive unintentional or undetermined fatal drug overdoses out of 5916 total overdoses that occurred among adult Tennessee residents with available toxicological information. Prescription benzodiazepines were identified in 80.7% of deaths, whereas illicit benzodiazepines were identified in 12.0% of deaths. Many decedents had an anxiety disorder (45.5%), while over half of all decedents had a history of substance use disorder (52.3%). Most benzodiazepine-positive overdoses involved fentanyl (71.3%).ConclusionsThis analysis can inform local and regional public health workers to implement focused prevention and intervention efforts for people with co-occurring mental health conditions and substance use disorders to curb overdose epidemics among persons using benzodiazepines in Tennessee. Public health campaigns should focus on educating people on appropriate prescription medication use and the dangers of obtaining substances illicitly. Given the high proportion of opioids in this population, further education also is needed on the dangers of polysubstance drug use. The differences between prescription and illicit benzodiazepine-positive fatal overdoses indicate the need to develop substance-specific prevention and treatment strategies.

Project description:IntroductionThis project studied pain control and the development of adverse events before, during, and after the administration of hydromorphone hydrochloride for various interventional radiology (IR) procedures.MethodsWe performed a retrospective analysis of 100 patients (men = 58; women = 42) sedated with peri-procedural intravenous (IV) hydromorphone in association with various IR procedures. We stratified the procedures as follows: abscess drainages (M = 8; F = 8), arteriograms (M = 1; F = 0), biliary interventions (M = 3; F = 2), bone biopsies (M = 2; F = 2), non-bone biopsies (M = 26; F = 19), non-tunneled venous catheters (M = 1; F = 1), tunneled venous catheters (M = 7; F = 5), embolization (M = 4; F = 0), IVC filter placement (M = 1; F = 1), nephrostomy tube placement (M = 1; F = 4), and percutaneous nephrolithotomy tube placements (M = 4; F = 0). We recorded the pre-, intra-, and post-procedure pain scores [numeric rating scale (NRS) with 0 = no pain to 10 = most pain] for each of the stratifications. We also recorded the total dose of hydromorphone and midazolam hydrochloride received by each gender, as well as whether any men or women received either naloxone hydrochloride or any antiemetic. Lastly, the investigators recorded the development of hypotension following hydromorphone administration and/or hypoxia as well as the need for opioid-induced intensive care unit (ICU) admission. The investigators used unpaired, two-tailed t tests, and either Yates-corrected Chi-squares or two-tailed Fisher's exact tests for continuous and categorical variables, respectively. The difference was statistically significant if p < 0.05.ResultsThere was no significant difference between men and women for either mean age (M = 50 years; F = 53.4 years) or mean pre-procedural pain scores (M = 1.31; F = 0.55). There was no statistically significant difference in numbers of men or women for each procedure stratification. The highest mean pre-procedure pain score was in men undergoing percutaneous nephrostomy tube placement (mean 5, SD 0). The highest mean intra-procedure pain score was in men undergoing abscess drainages (mean 2, SD 2.3). The highest mean post-procedure pain score was in men undergoing abscess drainages (mean 1.5, SD 3.5). The only mean scores that were significantly different between men and women were in pre- (M = 2.5; F = 0.6; p = 0.006) and intra-procedural (M = 2; F = 0.5; p = 0.0001) pain scores for abscess drainages. There was no statistically significant difference in the dose of either hydromorphone (M = 1.3; F = 1.3) or midazolam (M = 1.3; F = 1.3) administered. There was no statistically significant difference in opioid-induced nausea (M = 1; F = 3). One female experienced hypotension and one male experienced hypoxia within 6 h of hydromorphone administration. There were neither opioid-related ICU admissions nor naloxone administrations.ConclusionsThis preliminary study indicates that IV hydromorphone ± midazolam may be a safe and effective analgesic and sedative combination for adult patients undergoing IR procedures.

Project description:BackgroundIntrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery.MethodsIn this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded.ResultsThere was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200).ConclusionsAlthough the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.

Dataset Information

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

Background

Methods

Results

Interpretation

Publications

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

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