Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study

BACKGROUND AND AIMS

Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids.

DESIGN

Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME).

SETTING

Australia.

PARTICIPANTS

People who are prescribed opioids.

MEASUREMENTS

Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up.

FINDINGS

Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400).

CONCLUSION

In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

How to close the gaps between evidence and practice for perioperative opioids

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Characteristics of oxycodone-related ambulance attendances: analysis of temporal trends and the effect of reformulation in Victoria, Australia from 2013 to 2018

BACKGROUND AND AIMS

In Australia, oxycodone has been associated with increasing rates of harm over time, despite reduced use, reformulation to a tamper-resistant form and in contrast to most prescription opioids. We explored characteristics of oxycodone-related ambulance attendances to understand whether presentation characteristics could explain increasing oxycodone harm.

DESIGN

Retrospective study of coded ambulance patient care records related to extramedical oxycodone use, January 2013 to September 2018.

SETTING

Victoria, Australia.

CASES

A total of 2788 oxycodone-related ambulance attendances.

MEASUREMENTS

Primary outcomes were temporal changes in characteristics of oxycodone presentations over time (from 2013 to 2018) and following reformulation. Covariates include demographic characteristics, presentation severity, mental health, substance use and poisoning intent.

FINDINGS

Average age was 41.3 (± 16.4) years with females comprising 56.4% of attendances (n = 2788). The proportion of females in oxycodone-related attendances increased over time [an average increase in the odds ratios of 5% per year (OR) = 1.05, 95% confidence interval (CI) = 1.01-1.10]. Other temporal trends included a reduced likelihood of naloxone administration (OR = 0.92, 95% CI = 0.85-1.00), heroin involvement (OR = 0.81, 95% CI = 0.66-0.99), comorbid mental health symptoms (OR = 0.87, 95% CI = 0.82-0.92) and unknown intent poisoning (OR = 0.91, 95% CI = 0.85-0.96); and a greater risk of alcohol involvement (OR = 1.06, 95% CI = 1.01-1.11), non-opioid extramedical pharmaceutical use (OR = 1.05, 95% CI = 1.01-1.10), comorbid suicidal thoughts or behaviours (OR = 1.10, 95% CI = 1.05-1.15) and past history of psychiatric issues (OR = 1.22, 95% CI = 1.16-1.27). Interrupted time-series analysis showed that reformulation was associated with an immediate effect on sex, severity, accidental poisoning and unknown intent poisoning, although these were not sustained over time. Alcohol involvement in the attendance (OR = 1.43, 95% CI = 1.17-1.74, i.e. an average increase in the odds of 43% per year), Glasgow Coma Scale (OR = 1.28, 95%CI 1.04 - 1.57), a previous history of psychiatric issues (OR = 0.80, 95% CI = 0.70-0.92, i.e. an average decrease in the odds of 20% per year, heroin involvement (OR = 0.22, 95% CI = 0.05 - 0.98) and illicit drug use (OR = 0.45, 95% CI = 0.23 - 0.87) showed statistically significant relative changes following the reformulation.

CONCLUSIONS

The characteristics of oxycodone presentations in Australian ambulances attendances appear to be changing over time, including more female presentations; increasing alcohol use, extramedical use of non-opioid pharmaceuticals and suicidal thoughts or behaviours and decreasing heroin and illicit drug involvement.

A predictive model for serious adverse events in adults with acute poisoning in prehospital and hospital care

OBJECTIVE

The objective of this study was to design a risk model with variables determined before hospital arrival to predict the risk of serious adverse events in patients with acute poisoning.

METHODS

A preliminary prospective, multicentre cohort study of adults with prehospital diagnosis of acute intoxication was conducted. The study was carried out in the Public Health System of the Community of Castilla-Leon (Spain), including seven advanced life support units and five hospitals, between April 1, 2018, and June 30, 2019. People aged >18 years with a main prehospital diagnosis of acute poisoning admitted to a referral hospital on advanced life support were included. The main outcome measure was prehospital and hospital serious adverse events in patients with acute poisoning.

RESULTS

We included 221 patients, with a median age of 47 years (interquartile range: 33-61). The most frequent cause of poisoning was psychopharmaceuticals (111 cases, 49.8%): 38 (17.2%) patients had a serious adverse event, with a hospital mortality of 4.1% (nine cases) in the 30 days after the index event. The final model included age ≥65 years (odds ratio [OR]: 9.59, 95% confidence interval [CI]: 3.48-26.45; p < 0.001), oxygen saturation/fraction of inspired oxygen index ≤300 (OR: 15.03, 95% CI: 5.74-39.33; p < 0.001), and point-of-care lactate ≥4 mmol/L (OR: 7.68, 95% CI: 2.88-20.45; p < 0.001). The poisoning Early Warning Score was constructed from these three variables, and 1 point was assigned to each variable. The area under the curve of the score was 0.896 (95% CI: 0.82-0.96; p < 0.001).

CONCLUSIONS

The poisoning Early Warning Score may help in decision-making and promote early identification of high-risk patients with acute poisoning in the prehospital context.

Coding and classification of heroin overdose calls by MPDS dispatch software: Implications for bystander response with naloxone

BACKGROUND AND AIMS

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.

METHODS

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.

RESULTS

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.

DISCUSSION AND CONCLUSIONS

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.

Regional, national and international datasets: How they improve our understanding of the acute harms associated with prescription medicine misuse

Prescription medicine misuse is a significant problem in many areas of the world. Understanding the acute and chronic harms related to misuse of prescription medicines allows healthcare professionals, drug addiction treatment services and legislative authorities to determine what interventions may be beneficial to reduce these harms and protect individuals and society. However, it is difficult to obtain systematic data on the harms associated with prescription medicine misuse because of how patient visits to clinics and hospitals are recorded and coded in regional or national databases. In this review, we discuss how regional, national and international sources of information can help develop a greater understanding of the prevalence and pattern of acute harms related to prescription medicine misuse using data from ambulance attendances, emergency department presentations and poisons information services.

Comparing rates and characteristics of emergency department presentations related to pharmaceutical opioid poisoning in Australia: a study protocol for a retrospective observational study

INTRODUCTION AND AIMS

Pharmaceutical opioids are an important contributor to the global 'opioid crisis', and are implicated in 70% of Australia's opioid-related mortality. However, there have been few studies which consider the relative contribution of different pharmaceutical opioids to harm.We aim to compare commonly used pharmaceutical opioids in terms of (1) rates of harm, and (2) demographic and clinical characteristics associated with that harm.

METHOD AND ANALYSIS

Observational study of emergency department presentations for non-fatal poisoning related to pharmaceutical opioid use. Data from 2009 to 2019 will be extracted from the Victorian Emergency Minimum Dataset which contains data from public hospitals with dedicated emergency departments in Victoria, Australia's second most populous state. A combination of free-text and International Classification of Diseases 10th Revision codes will be used to identify relevant cases, with manual screening of each case to confirm relevance. We will calculate supply-adjusted rates of presentations using Poisson regression for all pharmaceutical opioid cases identified, separately for nine commonly prescribed pharmaceutical opioids (buprenorphine, codeine, fentanyl, methadone, morphine, oxycodone, oxycodone-naloxone, tapentadol, tramadol), and for a multiple opioid category. We will use multinomial logistic regression to compare demographic and clinical characteristics, such as triage category, across opioid types.

ETHICS AND DISSEMINATION

This work is conducted under approval 21427 from the Monash University Human Research Ethics Committee for ongoing injury surveillance. As per conditions of approval, cells of <5 will not be reported, though zeroes will be preserved. We will present project findings in a peer-reviewed journal article as well as at relevant scientific conferences.

Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Victoria, Australia from 2013 to 2018

BACKGROUND AND AIMS

Despite increases in opioid prescribing and related morbidity and mortality, few studies have comprehensively documented harms across opioid types. We examined a population-wide indicator of extramedical pharmaceutical opioid-related harm to determine if the supply-adjusted rates of ambulance presentations, the severity of presentations or other attendance characteristics differed by opioid type.

DESIGN

Retrospective observational study of coded ambulance patient care records related to extramedical pharmaceutical opioid use, January 2013 to September 2018.

SETTING

Australia CASES: Primary analyses used Victorian data (n = 9823), with available data from other Australian jurisdictions (n = 4338) used to determine generalizability.

MEASUREMENTS

We calculated supply-adjusted rates of attendances using Poisson regression, and used multinomial logistic regression to compare demographic, presentation severity, mental health, substance use and other characteristics of attendances associated with seven pharmaceutical opioids.

FINDINGS

In Victoria, the highest rates of attendance [per 100 000 oral morphine equivalent mg (OME)] were for codeine (0.273/100 000) and oxycodone (0.113/100 000). The lowest rates were for fentanyl (0.019/100 000) and tapentadol (0.005/100 000). Oxycodone-naloxone rates (0.031/100 000) were lower than for oxycodone as a single ingredient (0.113/100 000). Fentanyl-related attendances were associated with the most severe characteristics, most likely to be an accidental overdose, most likely to have naloxone administered and least likely to be transferred to hospital. In contrast, codeine-related attendances were more likely to involve suicidal thoughts/behaviours, younger females and be transported to hospital. Supply-adjusted attendance rates for individual opioids were stable over time. Victorian states were broadly consistent with non-Victorian states.

CONCLUSIONS

In Australia, rates and characteristics of opioid-related harm vary by opioid type. Supply-adjusted ambulance attendance rates appear to be both stable over time and unaffected by large changes in supply.

The National Ambulance Surveillance System: A novel method for monitoring acute alcohol, illicit and pharmaceutical drug related-harms using coded Australian ambulance clinical records

Although harmful consumption of alcohol and other drugs (both illicit and pharmaceutical) significantly contribute to global burden of disease, not all harms are captured within existing morbidity data sources. Indeed, harms occurring in the community may be missed or under-reported. This paper describes the National Ambulance Surveillance System, a unique Australian system for monitoring and mapping acute harms related to alcohol and other drug consumption. Data are sourced from paramedic electronic patient care records provided by ambulance services from across Australia. Coding occurs in a purpose-built system, by a team of specialised research assistants. Alcohol, and specific illicit and pharmaceutical drugs, rather than broad drug classes, are manually coded and the dataset is reviewed and cleaned prior to analysis. The National Ambulance Surveillance System is an ongoing, dynamic surveillance system of alcohol and other drug-related harms across Australia. The data includes more than 140 output variables per attendance, including individual substances, demographics, temporal, geospatial, and clinical data (e.g., Glasgow Coma Scale score, naloxone provision and response, outcome of attendance). The National Ambulance Surveillance System is an internationally unique population-level surveillance system of acute harms arising from alcohol and other drug consumption. Dissemination of National Ambulance Surveillance System data has been used to inform and evaluate policy approaches and potential points of intervention, as well as guide workforce development needs and clinical practice at the local and national level. This methodology could be replicated in other countries.