Fatal unintentional intoxications with tramadol during 1995-2005

Tramadol is an extensively used centrally acting analgesic and is considered a safe drug devoid of many serious adverse effects of traditional opioids. However, recently, toxicity and an abuse potential of tramadol have been reported. This study examined fatal unintentional tramadol intoxications among Swedish forensic autopsy cases between 1995 and 2005. All fatal intoxications were selected, in which toxic concentrations of tramadol (>1 microg/g femoral blood) had been detected, and where the forensic pathologist considered the intoxication unintentional and the fatal outcome at least partly explained by tramadol. Toxicology analyses, police reports, autopsy protocols and medical records were scrutinized. A total of 17 cases (eleven men and six women) of fatal unintentional tramadol intoxications were identified. For these cases the median age was 44 years (range 18-78 years) and the median tramadol concentration was 2.0 microg/g (range 1.1-12.0 microg/g). Other pharmaceutical substances, illicit drugs or ethanol were detected in addition to tramadol in all of these cases. In fact, intoxication with multiple drugs was considered the cause of death in 10 (59%) cases. However, in seven cases tramadol was the only substance present in toxic concentrations. A history of substance abuse was identified in 14 (82%) subjects and a present tramadol abuse in 8 (47%). These results suggest that fatal intoxications with tramadol may occur unintentionally and that subjects with a history of substance abuse may be at certain risk. Precaution is therefore warranted when prescribing tramadol in such patients.     

Measures to enhance the success of global climate treaties

We analyze important forces that hamper the formation of successful self-enforcing agreements to mitigate global warming from an economic point of view. The analysis combines two modules: (a) an integrated assessment model that captures the feedback between the economy, environmental damages and the climate system and (b) a game theoretic model that determines stable coalitions in the presence of free-riding incentives. We consider two types of measures to enhance the success of international environmental treaty-making: (a) transfers, aiming at balancing asymmetric gains from cooperation; (b) institutional changes, aiming at making it more difficult to upset stability of a treaty. We find that institutional changes may be as important as transfers and should therefore receive more attention in future international negotiations.

Comparative Toxicology of Intentional and Accidental Heroin Overdose*

Abstract: The demographic and toxicological characteristics of deliberate (SUI, n = 50) and accidental (ACC, n = 927) fatal heroin overdose cases were examined. SUI cases were more likely to be female, had lower body mass indices, were more likely to be enrolled in treatment and less likely to have hepatic pathology. The median blood morphine concentration of SUI cases was significantly higher than that of ACC cases (0.70 vs. 0.40 mg/L, p < 0.001). Blood morphine concentrations of >1 mg/L were seen among 38.0% of SUI cases compared to 13.9% of ACC cases. Being a member of the SUI group remained a significant independent predictor of higher morphine concentrations after controlling for the effects of potential confounders (p < 0.001), other significant predictors being the absence of alcohol (p < 0.001), the presence of methadone (p < 0.05), and the presence of cocaine (p < 0.05). The current data are consistent with the view that suicide forms a small, but distinct, category of heroin overdose cases, rather than overdose being a parasuicidal phenomenon per se.     

Clinical and Autopsy Characteristics of Fatal Methamphetamine Toxicity in Australia

Characteristics of death attributed solely to methamphetamine toxicity (MT, n = 93) by forensic pathologists were examined and compared to cases of multiple drug toxicity (MDT, n = 634). The mean age of MT cases was 36.7 years, and 86.0% were male. Strenuous activity was reported in 12.9%. The most common witness observations were: collapse (60.3%), difficulty in breathing (36.2%), and hyperthermia (27.6%). MT cases had higher blood methamphetamine (0.54 vs. 0.11 mg/L) and amphetamine (0.04 vs. 0.02 mg/L) concentrations and lower likelihoods for opioids (12.5% vs. 80.9%), hypnosedatives (27.3 vs. 60.7%), antidepressants (14.8 vs. 29.8%), and antipsychotics (9.1 vs. 19.7%). MT cases had significantly heavier hearts than MDT cases (423.4 vs. 385.8 g) and were more likely to have cardiomegaly (37.1 vs. 20.4%) and replacement fibrosis (25.7 vs. 14.5%). The clinical picture was of a sudden cardiac event in a middle‐aged man with a high methamphetamine concentration. Cardiovascular signs of heavy methamphetamine use are frequently seen.     

Social support and one-year outcomes for women participating in prison-based substance abuse treatment programming

In recent decades, the number of women under criminal justice supervision has increased considerably, many of whom are serving time for drug offenses. Furthermore, women in prison are more likely than their non-institutionalized counterparts to suffer from a substance abuse disorder. While there is a growing body of research concerning women offenders’ drug abuse and treatment needs, few studies have examined the substance abuse treatment outcomes of women in the criminal justice system. Using data from Outcome Evaluation of the Forever Free Substance Abuse Treatment Program, this study compared women’s self-reported drug use twelve months after participation in high-intensity (n = 101) and low-intensity (n = 81) prison-based substance abuse treatment programming (N = 182). Women who perceived high levels of emotional social support were less likely to report substance use at 12-month follow-up. Furthermore, perceptions of emotional social support and treatment intensity interacted in their association with relapse, such that the protective effect of social support was strongest for women who participated in high-intensity programming. The results of the analyses highlight the importance of perceived social support for women with substance abuse disorders who are transitioning from prison-based substance abuse treatment programming to the community.     

Morphine Concentrations in Stomach Contents of Intravenous Opioid Overdose Deaths

Abstract:  Death caused by heroin overdose is almost always the result of intravenous injection of the drug in Australia. We briefly describe a case where a heroin overdose was initially thought to be the result of oral ingestion of the drug, primarily as a result of higher concentrations of morphine in stomach contents than in blood. During the subsequent criminal trial and investigation, however, the issue of the entero-hepatic circulation of morphine was raised as a possible reason for the presence of morphine in the stomach contents. In this study, we report on the distribution of opioids in blood, stomach contents, urine, liver, and bile in 29 deaths caused by intravenous heroin overdose. The mean total and free blood morphine concentrations were 0.60 and 0.32 mg/L , respectively, and the mean stomach contents total morphine concentration was 1.16 mg/kg. All cases had detectable morphine in the stomach contents, and 24 of 29 cases (83%) had higher concentrations of total morphine in stomach contents than in blood. The mean total morphine concentration in bile was c. 100 times that in blood, and the liver total morphine concentration averaged twice that of blood levels. We conclude that the entero-hepatic circulation of morphine and subsequent reflux of duodenal contents back into the stomach can result in the deposition of morphine in gastric contents. Consequently, the relative levels of opioids in blood and stomach contents cannot be used to determine the site of administration of the drug.     

Costs, Output, and Institutional Differentiation in Danish Childcare Policy

Investigating differences in costs due to institutional differentiation is of central importance, since most public sectors struggle with limited resources combined with high demands. Similar public services produced in different institutional set-ups constitute excellent units of observation, since the production costs can be directly compared. An example of such services is found in Denmark, where the municipalities provide two types of public childcare arrangements. All Danish municipalities, to varying degrees, offer the cheaper type, namely day-care homes. It is, however, remarkable that day-care centers and day care in private homes coexist in the same municipality with a cost difference of about 40 percent. Using the framework of rational institutionalism, this article claims that the institutional set-ups in the two kinds of childcare result in different employee strategies, which, together with varying sector strength, lead to widely different costs. The case is established by an analysis of interviews with employees, politicians and users of childcare services, combined with statistical evidence from the Danish municipalities.     

Chinese eyes on Africa: Authoritarian flexibility versus democratic governance

This article seeks to shed more light on the consequences of China's aid to and trade with African states. It attempts to answer two questions: First, does China's ‘no-strings-attached’ policy in Africa constitute a challenge to Western aid paradigms? Second, is there as an emerging state-sponsored Chinese model of ‘effective governance’, guided by a south-south vision of mutuality, equality and reciprocity at work? It is argued that China's Africa watchers are cautious, not wanting to project any false hopes into bilateral relationships with African countries. In the light of China's reform experience, these analysts propose that indigenous contexts should determine what developmental model to choose. China is unwilling to force its experiences of ‘a market economy with Chinese characteristics’ upon other nations. The article concludes by arguing that, although not unproblematic, there is reason to be positive about China's higher profile in Africa.