Opioid Overdose risks and Buprenorphine| suboxone treatment in the Emergency Department | 703-844-01
Opioid Deaths in The U.S.| trends and Risk Factors 2003-2014
Rates of opioid overdose hospitalizations increased between 2003 and 2014 in the United States, primarily for Caucasians in the South; factors associated with a higher mortality from opioid overdose also include younger age and male gender, according to a study to be presented at the 2018 World Congress on Pain, held September 12-16 in Boston, Massachusetts.
Considering the prevalence of opioid overdose and poisoning in the United States, and the accompanying high rates of addiction and death, researchers analyzed Nationwide Inpatient Sample data on opioid overdose from 2003 to 2014 to identify predictors of mortality, regional disparities, cost of inpatient hospital stay, and yearly trends. The data showed 149,483 patients who were discharged with a primary or secondary opioid poisoning diagnosis (ICD-9 Code 965.xx) in the United States during this time period. Binary logistic regression was used to study region, race, sex, and age as independent predictors of mortality.
Trends and Predictors of Mortality for US Opioid Overdoses from 2003 to 2014
Most opioid overdose patients were male and lived in the Southern United States (39.3%).
Rates of opioid overdose hospitalizations increased between 2003 and 2014 in the United States, primarily for Caucasians in the South; factors associated with a higher mortality from opioid overdose also include younger age and male gender, according to a study to be presented at the 2018 World Congress on Pain, held September 12-16 in Boston, Massachusetts.
Considering the prevalence of opioid overdose and poisoning in the United States, and the accompanying high rates of addiction and death, researchers analyzed Nationwide Inpatient Sample data on opioid overdose from 2003 to 2014 to identify predictors of mortality, regional disparities, cost of inpatient hospital stay, and yearly trends. The data showed 149,483 patients who were discharged with a primary or secondary opioid poisoning diagnosis (ICD-9 Code 965.xx) in the United States during this time period. Binary logistic regression was used to study region, race, sex, and age as independent predictors of mortality.
Of the 149,220 patients admitted for opioid overdose, 2.6% died. The median age of these overdose patients was 47 years old, and 81.1% were Caucasian. Most opioid overdose patients were male and lived in the Southern United States (39.3%). The Northeast had 17.5% of opioid overdose cases, compared with 21.3% in the West and 21.9% in the Midwest. Yearly hospital admissions for opioid overdose have increased over the study timespan, from 7864 overdoses in 2003 to 15,165 overdoses in 2014. The total cost per inpatient admission also increased to $37,281 in 2014 compared with $17,156 in 2003.
Study investigators concluded that "further prospective studies are warranted to better understand the increasing [opioid overdose] admission rates, and an effective, targeted approach should be developed for [use] within the higher mortality demographic."
Reference
Gupta S, Sung V. Hospitalizations for opioid overdoses in the United States from 2003-2014. Trends from the Nationwide Inpatient Sample and Predictors of Mortality. Presented at the World Congress on Pain 2018; September 12-16, 2018; Boston, MA. Poster 65409.
Predictors of Opioid overdose in users
Having a hepatitis C virus (HCV) infection, witnessing a friend or others experiencing a drug overdose, and having a history of frequent buprenorphine treatment are factors that may predict the risk for opioid drug overdose in high-risk opioid users, according to a study published in Addictive Behaviors.
Participants were recruited from an ongoing study in which the efficacy of distributing naloxone kits for reducing opioid overdose was assessed (N=247). Heroin and prescription opioid use were reported by 86.5% of participants, and all patients had reported current or past opioid misuse within 6 months of enrollment. The researchers sought to identify medical, psychosocial, and opioid use characteristics that were predictive of opioid overdose.
Patient characteristics data were obtained from responses on the baseline 30-item Opioid Use Questionnaire, which assessed chronic medical conditions, past and current opioid misuse, sexually transmitted infections (STIs), buprenorphine treatment frequency, and intensive outpatient and rehabilitation treatment history. Participants and family members or friends attended a baseline appointment and naloxone training.
Individuals who were white comprised a significant majority of individuals reporting a past opioid overdose when compared with blacks (96.2% vs 3.8%, respectively; P =.005). More participants who had experienced an opioid overdose in the past 6 months reported using heroin vs prescription opioids only (95.2% vs 4.8%, respectively; P =.001). Participants with a friend who had died from an overdose were also more likely to experience an overdose themselves (89.6% vs 10.4%; P=.001).
In the adjusted analysis, the patient characteristic most associated with experiencing a nonfatal opioid overdose was witnessing a friend overdose (odds ratio [OR] 4.21; 95% CI, 1.99-8.89). Witnessing others overdose (OR 1.42; 95% CI, 1.11-1.82) and having a chronic HCV infection (OR 2.44; 95% CI, 1.20-4.97) were also associated with a higher risk of reporting a prior opioid overdose. Reporting a higher buprenorphine treatment frequency was associated with a greater odds of opioid overdose (OR 1.55; 95% CI, 1.17-2.07), and reporting a high frequency of methadone treatments was associated with a reduction in overdose odds (OR 0.67; 95% CI, 0.49-0.91).
The study was limited by its potential for recall and social desirability bias because of the self-reported nature of the collected participant data.
"Given the high rates of nonfatal opioid overdose, this suggests the need for expanded overdose training and distribution of naloxone," concluded the study authors.
Reference
Schiavon S, Hodgin K, Sellers A, et al. Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users [published online May 30, 2018]. Addict Behav. doi: 10.1016/j.addbeh.2018.05.029
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Emergency Department-Initiated Buprenorphine/Naloxone Beneficial When Prolonged
Buprenorphine/naloxone treatment initiated in the emergency department (ED) and prolonged for 10 weeks in primary care improved treatment engagement and reduced opioid use compared with referral or brief intervention.1
"This study represents a new paradigm for ED-initiated treatment of opioid use disorder with referral for ongoing care," stated lead investigator Gail D'Onofrio, MD, in an interview with Clinical Pain Advisor. She noted that the approach tested in the study, in which an ED clinician initiates treatment and refers patients for follow-up, is similar to that used in other chronic disorders such as hypertension or hyperglycemia. Opiate use disorder was found to be more prevalent in patients who had presented to emergency departments than in the general population.2
The study presented a long-term follow-up of outcomes from the investigators' previous work published in JAMA.3 The JAMA study randomly assigned 329 opioid-dependent patients to 1 of 3 interventions: screening and referral to treatment (referral); screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); or screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10 weeks of continued buprenorphine/naloxone treatment (buprenorphine).
Results of this study showed that at 30 days after treatment randomization, patients in the buprenorphine group were more likely to be involved in addiction treatment than those who received the other interventions. In addition, self-reported illicit opioid use and use of inpatient addiction treatment services were less prevalent in patients who had been prescribed buprenorphine than in patients in the other 2 groups.
The current study involved 88% of the same patients (n=329) who contributed data at a minimum of 1 follow-up assessment conducted at 2, 6, and/or 12 months after the ED intervention. Results showed that at 2 months, engagement in addiction treatment was more common in the buprenorphine group (68/92 [74%]; 95% CI, 65-83) than in those who received referral (42/79 [53%]; 95% CI, 42-64) or brief intervention (39/83 [47%]; 95% CI, 37-58; P <.001). Patients randomly assigned to buprenorphine had fewer self-reported days of illicit opioid use (1.1; 95% CI, 0.6-1.6) compared with the referral group (1.8; 95% CI, 1.2-2.3) or the brief intervention group (2.0; 95% CI, 1.5-2.6; P =.04]. No statistically significant differences for those outcomes were present at 6- or 12-month follow-ups.
Dr D'Onofrio told Clinical Pain Advisor that her research group hoped to offer alternative best practices to emergency physicians, who are not typically involved with continued care of patients with opioid use disorders. "Most EDs observe patients after recovery from overdose, but discharge them with at best a list of programs in the community for help. They do not make direct linkages to treatment programs or providers and do not initiate buprenorphine, similar to when patients present with any other problem related to opioid use disorder," she said.
Summary and Clinical Applicability
The researchers noted that despite its limitations, the study indicates that ED-initiated buprenorphine/naloxone treatment combined with referral for ongoing treatment in primary care is effective at increasing participation in addiction treatment and reducing self-reported illicit opioid use while treatment is continued. "For 27% of the enrolled ED patients, the index ED visit represented their first treatment contact," they wrote. "Thus, the ED visit is an opportunity to engage patients with opioid use disorder in effective medication-assisted treatment."
Limitations
The study was conducted at only 1 ED and 1 site for primary care, both in the same academic medical center, and thus may not be generalizable to other settings.
Thirty-nine patients of the original cohort were not included in the follow-up.
Data on engagement in addiction treatment were based on self-reports and not confirmed with providers.
Engagement in treatment was assessed at designated times, potentially leading to an underestimation, as patients may have been involved in treatment at other times.
References
D'Onofrio G, Chawarski MC, O'Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention [published online February 13, 2017]. J Gen Intern Med. doi: 10.1007/s11606-017-3993-2
Wu L-T, Swartz MS, Wu Z, Mannelli P, Yang C, Blazer DG. Alcohol and drug use disorders among adults in emergency department settings in the United States. Ann Emerg Med. 2012;60(2):172-180. doi: 10.1016/j.annemergmed.2012.02.003
D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi: 10.1001/jama.2015.3474
