Fatal and Non-Fatal Drug Overdoses: Relationship to Cardiovascular Arrhythmias

The United States lost approximately 107,600 citizens to overdose deaths in 2021,¹ with 1 US overdose death occurring every 5 minutes.² Marked by the opioid overdose deaths beginning in the 1990s, exacerbated by heroin and now illicit or unauthorized fentanyl distribution, the US overdose death rate has risen for over 2 decades. Opioid use in the United States and Canada exceeds the opioid need by 3150% and 3090%, respectively.³ Many overdose deaths are often attributable to multiple drugs. These other drugs are often obtained on the internet or black market. Because they are being mixed with fentanyl, unknown to the user, the net effect is the United States is losing an entire generation of citizens, especially those of racial minorities.⁴ 

What pharmacologic-pathophysiologic interaction may be leading to this profound loss of life? The answer may be in causing or exacerbating cardiac arrhythmias. Methamphetamine (86% increase), opiates (74% increase), cocaine (61% increase) and marijuana (35% increase) have been associated with increases in the risk of developing atrial fibrillation.⁵ Some of these agents have been linked to increases in QTc prolongation, a marker of delayed cardiac myocyte repolarization that may lead to ventricular arrhythmias.^6-7 In addition, e-cigarettes, which have increased in use, have recently been linked to atrial fibrillation in mice.⁸ 

These data are a call to pharmacists worldwide. Have a counseling meeting with your patients. Discuss the risks of opiates, how to prevent unintended overdoses, and emergency measures to take if symptoms of respiratory or cardiac depression occur. This is especially important in those patients who have had experienced an overdose and recovered, as those persons are at increased risk of another overdose event. We can make a difference in the lives of our patients!

References:

1. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. Centers for Disease Control and Prevention, National Center for Health Statistics. Updated February 9, 2022. Accessed December 2, 2022. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm  
2. Stobbe M. US overdose deaths hit record 107,000 in 2021, CDC says. Stat News. May 11, 2022. Accessed December 2, 2022. https://www.statnews.com/2022/05/11/us-overdose-deaths-record-107000-2021-cdc/
3. Paola S. Fentanyl use skyrockets. AJP. June 10, 2022. Accessed December 2, 2022. https://ajp.com.au/news/fentanyl-use-skyrockets/
4. Joseph A. As overdose deaths exploded during the pandemic, racial disparities widened, CDC report shows. Stat News. July 19, 2022. Accessed December 2, 2022. https://www.statnews.com/2022/07/19/overdose-deaths-exploded-2020-pandemic-racial-disparities-widened/
5. Lin AL, Nah G, Tang JJ, Vittinghoff E, Dewland TA, Marcus GM. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation. Eur Heart J. Published online October 18, 2022. doi:10.1093/eurheartj/ehac558
6. Haning W, Goebert D. Electrocardiographic abnormalities in methamphetamine abusers. Addiction. 2007;102 Suppl 1:70-5. doi:10.1111/j.1360-0443.2006.01776.x
7. Beckman KJ, Parker RB, Hariman RJ, Gallastegui JL, Javaid JL, Bauman JL. Hemodynamic and electrophysiological actions of cocaine effects of sodium bicarbonate as an antidote in dogs. Circulation. 1991;83:1799-1807. doi:10.1161/01.CIR.83.5.1799
8. Carli AP, Arab C, Salatini R, et al. E-cigarettes and their lone constituents induce cardiac arrhythmia and conduction defects in mice. Nat Commun. 2022;13(1):6088. doi:10.1038/s41467-022-33203-1