Evolving Trends in US Mortality from Opioid Overdose: Heroin and Beyond

OBJECTIVE

Our objective was to explore evolving trends in US drug overdose mortality, overall and by age, sex, race, urbanization, and geography from 1999-2020.

METHODS

This is a descriptive epidemiologic study. We used the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research and Multiple Cause of Death files from the National Center for Health Statistics. We used crude and age-adjusted cause of death and mortality rate ratios as measures of effects and 95% confidence limits to test for significance.

RESULTS

From 1999-2020, drug overdoses caused 1,013,852 deaths and 4.3-fold increase in mortality rate ratios. Subgroup findings were sex (4.5 men, 4.0 women), race (4.6 White, 3.9 Black or African American, 4.0 Asian or Pacific Islanders, 5.1 Native Americans or Alaskan Natives), age (highest 5.6 in 25-34 years, lowest 1.1 in 75-84, and 0.77 in 85+), geography (highest 6.0 in Midwest, lowest 2.6 in West), and urbanization (highest 6.2 in non-metro, lowest 3.7 in metro).

CONCLUSIONS

Drug overdoses in the United States from 1999-2020 increased 4.3-fold, with the highest increase in White and Native American or Alaskan Native populations, and Midwest and non-metro areas. The data create preventive and therapeutic challenges, including restrictions on pharmaceutical industries and enhanced efforts by health care providers in safer prescribing. Addiction care should be integrated into all clinical practices, regardless of specialty, and into undergraduate, graduate, and continuing medical education. Targeted interventions are needed to adequately assess patients and provide care. Analytic studies designed a priori are necessary to test hypotheses formulated from these data.

Opioid overdose deaths and the expansion of opioid agonist treatment: a population-based prospective cohort study

BACKGROUND AND AIM

Effective policies to reduce drug-related overdoses remain a public health priority. We aimed to estimate the causal effects of a national opioid agonist treatment (OAT) program on population level drug fatalities.

DESIGN

Population-based prospective cohort study exploiting supply driven variation in treatment uptake across cohort-age groups generated by the introduction and scale-up of a national OAT program. A Poisson difference-in-differences model with an intention-to-treat design was used to assess how treatment uptake altered the age profile of risks and infer treatment effects on drug fatalities.

SETTING

Norway, from 1996 through 2016.

CASES

The data include a total of 5634 drug-related overdose deaths and cover the introduction of the Norwegian OAT program in 1998 and its initial growth period, reaching 12 286 ever-treated recipients by 2016.

MEASUREMENTS

Fatal opioid-related overdoses were defined as deaths with a primary cause assigned an International Classification of Diseases 10th Revision (ICD-10) code F11, or X42, X44, X62 or X64 in combination with T40.0-T40.4. Other non-opioid related fatal overdoses were defined by a primary cause registered as F12, F14, F15, F16 or F19, or X42, X44, X62 or 64 in combination with T40.5-T40.9.

FINDINGS

An additional 887 deaths (95% credibility interval [CI] = 265-1563) would have been expected in the absence of OAT, which implies one death avoided per 111 (95% CI = 61-342) treatment-exposed person-years. At scale, the program reduced annual overdose mortality by 27% in 2016 (95% CI = 10%-41%) relative to a no-OAT counterfactual, corresponding to 99 fewer expected fatal overdoses (95% CI = 28-180) in 2016. Analysing fatal opioid-related and other drug overdoses separately found similar numbers for avoided opioid-related fatalities (921, with 95% CI = 373-1526) and no treatment effects on non-opioid related fatalities (-38, with 95% CI = -193-154).

CONCLUSION

The introduction and rapid scale-up of a national opioid agonist treatment program in Norway was associated with substantial and plausibly causal reductions in drug fatalities.

Changes in substance supply and use characteristics among people who use drugs (PWUD) during the COVID-19 global pandemic: A national qualitative assessment in Canada

BACKGROUND

People who use drugs (PWUD) may be at an increased risk of experiencing negative effects related to COVID-19. Border and non-essential service closures may have placed PWUD at an increased risk of experiencing unintended consequences regarding drug consumption and supply patterns, as well as related outcomes. However, the extent of these effects upon this population is unknown. The current study examined how COVID-19 has impacted substance use supply and use characteristics among a national cohort of PWUD in Canada.

METHODS

We conducted semi-structured one-on-one telephone-based interviews with 200 adult PWUD across Canada who were currently using a licit or illicit psychoactive substance at least weekly, and/or currently receiving opioid agonist treatment (OAT). Thematic analyses were conducted using qualitative software.

RESULTS

PWUD attributed adverse changes to their substance use frequency, supply, use patterns, and risk behaviors and outcomes to COVID-19. Many participants noted supply disruptions with the majority indicating a decrease in potency and availability, and an increase in the price of substances since COVID-19. Nearly half of participants specified that they had increased their substance use, with some experiencing relapses. In terms of changes to risk level, many participants perceived they were at a greater risk for experiencing an overdose.

CONCLUSION

This study demonstrated the impacts of COVID-19 on PWUD, including a significant disruption substance supply. For many, these changes led to increased use and substitution for toxic and adulterated substances, which ultimately amplified PWUD's risk for experiencing related harms, including overdoses. These findings warrant the need for improved supports and services, as well as accessibility of safe supply programs, take home naloxone kits, and novel approaches to ensure PWUD have the tools necessary to mitigate risk when using substances.

Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses

Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.

Lifetime Risk of Death From Firearm Injuries, Drug Overdoses, and Motor Vehicle Accidents in the United States

BACKGROUND

News media and policy makers frequently discuss deaths from firearms, drug overdoses, and motor vehicle accidents. However, this information is generally presented as absolute numbers or annual rates. Cumulative lifetime risk may be an additional useful metric for understanding the impact of these causes of death.

METHODS

Data on all-cause firearm, drug overdose, and motor vehicle accident deaths were obtained from the US Centers for Disease Control and Prevention (CDC) for the year 2018. Age-specific death rates were used to estimate the cumulative risk of firearm, drug overdose, and motor vehicle accident deaths from birth to age 85 after accounting for other causes of death.

RESULTS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents was 0.93% (95% confidence interval [CI], 0.92%-0.94%), 1.52% (95% CI, 1.51%-1.53%), and 0.92% (95% CI, 0.91%-0.93%), respectively. Black males had a 2.61% (95% CI, 2.55%-2.66%) lifetime risk of firearm death, indicating that 1 out of 38 black males will die from firearms if current death rates persist. Residents of West Virginia had a 3.54% lifetime risk of drug overdose death, equivalent to 1 out of every 28 residents dying from overdoses.

CONCLUSIONS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents is substantial and varies greatly across demographic subgroups and states.

Intubation in acute alcohol intoxications at the emergency department

BACKGROUND

Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury.

METHODS

We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations' characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury.

RESULTS

Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0-2.2] vs. 1.6 g/kg [IQR1.1-2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011).

CONCLUSIONS

Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.