Association between route of illicit drug administration and hospitalizations for infective endocarditis

Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study

BACKGROUND

Heroin pipe distribution may encourage people who use heroin (PWUH) to transition from injecting to smoking heroin, reducing harms associated with injection drug use. A syringe services program (SSP) in Seattle, Washington, led by people who use drugs developed a heroin pipe distribution program.

METHODS

We conducted a pretest-posttest quasi-experimental study to evaluate the impact of heroin pipe distribution on drug consumption behaviors among PWUH between March and December 2019. SSP clients were surveyed during three weeklong timepoints before and four weeklong timepoints after heroin pipe distribution. Primary outcomes were change in proportion of SSP clients who exclusively injected heroin, exclusively smoked heroin, and both injected and smoked heroin in the past seven days comparing the pre- and post-intervention periods.

RESULTS

Across the seven observation timepoints, 694 unique respondents completed 957 surveys. Multiple responses from a single respondent in a given period were collapsed, resulting in 360 pre-intervention and 430 post-intervention records. Heroin use was reported in over half of pre-intervention (56%, 201/360) and post-intervention records (58%, 251/430). Compared to pre-intervention behaviors, the proportion of respondents who exclusively injected heroin was lower after the start of heroin pipe distribution (32%, 80/251 vs 43%, 86/201, p = 0.02), while the proportion of respondents who both injected and smoked heroin was higher (45%, 113/251 vs 36%, 72/201, p = 0.048). Just under half (44%, 110/251) of respondents who used heroin during the post-intervention period used a heroin pipe obtained from the SSP, of which 34% (37/110) reported heroin pipe distribution had reduced their heroin injection frequency. Self-reported hospitalization for a pulmonary cause was not associated with using a heroin pipe.

CONCLUSIONS

The proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution. Randomized studies with longer follow-up are needed to investigate whether heroin pipe distribution reduces heroin injection and improves health outcomes associated with drug use. Limited intervention exposure, loss to follow-up, and pipe availability from other sources pose methodological challenges to evaluations of route transition interventions in community settings. This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.

The risk of infective endocarditis among people who inject drugs: a retrospective, population-based time series analysis

BACKGROUND

Infective endocarditis is an increasingly common complication among people who inject drugs. We conducted this study to determine whether the removal of traditional controlled-release oxycodone from the Canadian market would be associated with an increase in the use of hydromorphone and an increased risk of infective endocarditis.

METHODS

We conducted a retrospective, population-based time series analysis using the linked health administrative databases of Ontario, Canada. We measured the quarterly risk of admissions for infective endocarditis related to injection drug use and changes in opioid prescription rates from 2006 to 2015. We set the intervention point at the fourth quarter of 2011, when traditional controlled-release oxycodone was removed from the Canadian market.

RESULTS

We observed an increase in the risk of admissions for infective endocarditis related to injection drug use during the study period. Before the intervention point, we observed a mean of 13.4 admissions per quarter, and after the intervention, we observed a mean of 35.1 admissions per quarter. However, no significant change in this risk occurred at the intervention point. Rather, the risk of infectious endocarditis appeared to have increased earlier and in parallel with the rise in hydromorphone prescriptions. Hydromorphone represented 16% of all opioid prescriptions at the start of the observation period and 53% by the end.

INTERPRETATION

The risk of infective endocarditis related to injection drug use is increasing and is temporally associated with increasing prescriptions for hydromorphone. This relation warrants further exploration.

Increasing incidence of IV-drug use associated endocarditis in southern West Virginia and potential economic impact

BACKGROUND

The opioid crisis has disproportionally affected Appalachia. One of the potentially lethal and costly complications associated with IV drug use is infective endocarditis (IE). The goal of this study was to assess the trend and costs of substance abuse associated IE admissions in Southern West Virginia.

METHODS

This is a retrospective analysis of cost, incidence, and geographic patterns of all patients admitted over the last decade with concomitant drug abuse (cocaine, amphetamine, sedative, and other/mixed drug abuse) and IE in the largest tertiary care center for Southern West Virginia. A time series model was used to investigate the effect of drug use on the incidence of IE.

RESULTS

A total of 462 patients were hospitalized with IE and concomitant illicit drug use. IE cases increased from 26 admissions in 2008 to 66 in 2015. Patterns of increases in mixed drug use (DRG most often associated with IV drug use in our center) mirrored increases in IE (P = 0.001). From 2008 to 2015, the total hospital charges were $17 306 464 on 462 cases of illicit drug associated IE. Only a fraction of the billed fees (22%) was collected ($3 829 701).

CONCLUSIONS

The number of patients hospitalized with IE has dramatically increased over the last decade in a pattern that mirrors the increase in mixed drug use. The majority of payers were from underfunded state programs or private pay and thus, only 22% of the hospital charges were paid, leaving a hospital deficit of over $13 476 763 during the study period.