Overdose Emergency Department Visits Research Articles

Trends in recurrent overdose and treatment initiation following emergency department visits for opioid overdose between 2016 and 2021

BackgroundOverdose remains a pressing public health concern in the United States, particularly with the emergence of fentanyl and other potent synthetic opioids in the drug supply. We evaluated trends in recurrent overdose and opioid use disorder (OUD) treatment initiation following emergency department (ED) visits for opioid overdose to inform response efforts. MethodsThis retrospective cohort study used electronic health record and statewide administrative data from Rhode Island residents who visited EDs for opioid overdose between July 1, 2016, and June 30, 2021, a period with fentanyl predominance in the local drug supply. The primary outcome was recurrent overdose in the 365 days following the initial ED visit. OUD treatment initiation within 180 days following the initial ED visit was considered as a secondary outcome. Trends in study outcomes were summarized by year of the initial ED visit. ResultsAmong 1745 patients attending EDs for opioid overdose, 20 % (n=352) experienced a recurrent overdose within 365 days, and this percentage was similar by year (p=0.12). Among patients who experienced any recurrent overdose, the median time to first recurrent overdose was 88 days (interquartile range=23–208), with 85 % (n=299/352) being non-fatal. Among patients not engaged in OUD treatment at their initial ED visit, 33 % (n=448/1370) initiated treatment within 180 days; this was similar by year (p=0.98). ConclusionsFollowing ED visits for opioid overdose in Rhode Island from 2016–2021, the one-year risk of recurrent overdose and six-month treatment initiation rate remained stable over time. Innovative prevention strategies and improved treatment access are needed.

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits.

Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

Acetaminophen overdose: analysis of 2018 US nationwide emergency database.

Recognized risk factors for acetaminophen overdose include alcohol, opioids, and mood disorders. The aim of this study is to assess additional risk factors for acetaminophen overdose evaluated in the emergency department (ED). A retrospective study was performed using the 2018 US Nationwide Emergency Department Sample (NEDS). All adult ED visits for acetaminophen overdose were included in the study group and those without it were taken as control. STATA, 16.1 was used to perform multivariable logistic regression analysis and adjusted odds ratios (ORadj) were reported. We identified 27,792 ED visits for acetaminophen overdose. Relative to non-acetaminophen ED visits, this group was younger (median age 32 vs 47years; p < 0.0001), more oftenfemale (66.1% vs 57.0%; p < 0.0001), had higher ED charges ($3,506 vs $2,714; p < 0.0001), higher proportion of alcohol-related disorders (15.8% vs 3.5%; p < 0.0001), anxiety disorders (30.2% vs 8.3%; p < 0.0001), cannabis use (8.7% vs 1.4%; p < 0.0001), hematology/oncology diagnoses (13.3% vs 10.9%; p < 0.0001), mood disorders (52.4% vs 7.9%; p < 0.0001), opioid-related disorders (4.1% vs 1.0%; p < 0.0001), and suicide attempt/ideation (12.2% vs 1.1%; p < 0.0001). Multivariable analysis showed alcohol-related disorders (ORadj 2.67), anxiety disorders (ORadj 1.24), cannabis (ORadj 1.63), females (ORadj 1.45), Income Q3 (ORadj 1.09), hematology/oncology diagnoses (ORadj 1.40), mood disorders (ORadj 10.07), opioid-related disorders(ORadj 1.20), and suicide attempt/ideation (ORadj 1.68) were associated with acetaminophen overdose. In addition to previously recognized risks, our study demonstrated thatcannabis use and hematologic/oncologic comorbidities were more common among acetaminophen-overdose ED visits. These newfindings are concerning because of rapid legalization of cannabis and the increasing incidence of cancerworldwide. Additionalinvestigation into these risksshould be a priorityfor clinicians, policymakers, and researchers.

Affordable housing through the Low-Income Housing Tax Credit program and opioid overdose emergency department visits

IntroductionThe United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk. MethodsWe used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014. ResultsBetween 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00). ConclusionsGiven the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose.

Estimating the uncertain effect of the COVID pandemic on drug overdoses.

U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both. We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends. Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods. The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

Characteristics of Nonfatal Opioid Overdose in Emergency Department Patients Surviving to Discharge or Hospital Admission.

Emergency department (ED) presentations for opioid overdose have risen significantly over the past decade. Many of these visits result in hospital admission with substantial public health and economic consequences. Much is unknown about the patient and hospital characteristics associated with discharge versus inpatient admission for these patients. We investigated patient and hospital characteristics associated with nonfatal ED visits for opioid overdose associated with hospital admission. Using 2016 data from the Nationwide Emergency Department Sample (NEDS), we performed a cross sectional analysis and identified a weighted estimate of adult patients presenting to EDs across the U.S. with ICD-10 diagnoses consistent with opioid overdose. Disposition, sex, age, expected payer, income quartile, geographic region, type of opioid ingested, co-ingestions, urban/ rural designation and teaching status of hospital were examined. Logistic regression (proc surveylogistic) was used to identify predictors of hospital admission for overdose. Odds ratios and their associated 95% confidence intervals are reported. In 2016 there were 263,621 adult ED presentations for opioid overdose, and 25.5% of them were admitted to the hospital. Although rates of overdose (per 100,000) were higher in the Northeast (110.6) and Midwest (106.4), admission rates were higher in the South (29.4%) and West (30.7%). Factors associated with hospital admission included female sex, older age, having any type of insurance, non-heroin overdoses and benzodiazepine co-ingestions. Understanding the characteristics associated with inpatient admission of patients presenting to the ED with opioid overdose represents an important area for ongoing and future public health intervention.

Disparities in Emergency Department Visits for Opioid and Stimulant Overdoses in Florida During COVID-19.

Emergency department (ED) visits for drug overdoses increased nationally during COVID-19 despite declines in all-cause ED visits. The study purpose was to compare characteristics of ED visits for opioid and stimulant overdoses before and during COVID-19 in Florida. This study tested for disparities in ED visits for opioid and stimulant overdoses by race/ethnicity, age, and insurance status. The study identified ED visits for opioid and stimulant overdose in Florida during quarters two and three of 2019 and compared them with quarters two and three of 2020. Overall, there was an increase in the number of opioid and stimulant overdoses during COVID-19. Combined with the decline in the number of all-cause ED visits, drug overdoses represented a larger share of ED visits during COVID-19 compared with before COVID-19. The study did not find evidence of disparities by race/ethnicity, as each group experienced similar increases in the likelihood of ED visits involving drug overdoses during COVID-19. Differences emerged according to age and insurance status. ED visits involving those under age 18 were more likely to involve opioid or stimulant overdose, and ED visits among those over age 65 were less likely to involve opioid overdose during COVID-19. ED visits among those with vulnerable insurance status were more likely to involve opioid overdose during COVID-19. Patterns of behavior change during periods of restricted activity due to a pandemic. These changes in behavior change the mix of risks that people face, suggesting the need for a reallocation of population health management resources during pandemics.

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals.

AimsTo examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre‐pandemic, peak, and re‐opening periods of the first wave of the COVID‐19 pandemic, using corresponding weeks in 2019 as a historical control.DesignPopulation‐based retrospective cohort study conducted between September 30, 2018 and September 26, 2020.SettingOntario, Canada.ParticipantsA total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low‐income housed individuals matched on age, sex, rurality, and comorbidity burden.MeasurementsED visits for drug overdoses of accidental and undetermined intent.FindingsAverage rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7–153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7–24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re‐opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44–1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08–1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02–1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period.ConclusionsRecently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re‐opening period of the COVID‐19 pandemic compared with housed people.

Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021

Nonfatal emergency department (ED) visits for opioid overdose are important opportunities to prescribe naloxone and buprenorphine, both of which can prevent future overdose-related mortality. We assessed the rate of this prescribing using national data from August 2019 to April 2021, a period during which US opioid overdose deaths reached record levels. We conducted a retrospective cohort analysis using Symphony Health's Integrated Dataverse, which includes data from 5,800 hospitals and 70,000 pharmacies. Of ED visits for opioid overdose between August 4, 2019, and April 3, 2021, we calculated the proportion with at least 1 naloxone prescription within 30 days and repeated this analysis for buprenorphine. To contextualize the naloxone prescribing rate, we calculated the proportion of ED visits for anaphylaxis with at least 1 prescription for epinephrine-another life-saving rescue medication-within 30 days. Analyses included 148,966 ED visits for opioid overdose. Mean weekly visits increased 23.6% during the period between April 26, 2020 and October 3, 2020 compared with the period between August 4, 2019 to April 25, 2020. Visits declined to prepandemic levels between October 4, 2020 and March 13, 2021, after which visits began to rise. Naloxone and buprenorphine were prescribed within 30 days at 7.4% and 8.5% of the 148,966 visits, respectively. The naloxone prescribing rate (7.4%) was substantially lower than the epinephrine prescribing rate (48.9%) after ED visits for anaphylaxis. Between August 4, 2019, and April 3, 2021, naloxone and buprenorphine were only prescribed after 1 in 13 and 1 in 12 ED visits for opioid overdose, respectively. Findings suggest that clinicians are missing critical opportunities to prevent opioid overdose-related mortality.

Early buprenorphine-naloxone initiation for opioid use disorder reduces opioid overdose, emergency room visits and healthcare cost compare to late initiation

ABSTRACT Background Although the effectiveness of buprenorphine-naloxone (BUP-NX) has been established, real-world evidence on the benefits of early treatment initiation is limited. Objective To evaluate the association between early BUP-NX initiation and health-related outcomes among insured adults with opioid use disorder (OUD). Methods We conducted a cross-sectional analysis using the Optum’s de-identified Clinformatics® Data Mart Database from 2010 to 2018. Patients who initiated BUP-NX within 30 days of OUD diagnosis were classified as early initiators. Patients who initiated BUP-NX later, but within the one-year follow-up, were defined as late initiators. Outcomes included opioid overdose, opioid overdose-related emergency department (ED) visits, and all-cause healthcare cost during the year after OUD diagnosis. We employed generalized linear models to compare outcomes between early and late initiators, adjusting for baseline covariates and accounting for missing information for covariates using multiple imputation. Results A total of 8,388 patients with OUD were identified; mean age was 39.9 years; 36% were female; and 67.6% were early initiators. Early initiators had an estimated 42% lower rate of opioid overdose (adjusted rate ratio (aRR) = 0.58; 95% confidence interval (CI): 0.52, 0.64); 51% lower rate of opioid overdose-related ED visits (aRR = 0.49; 95% CI: 0.44, 0.55); and 31% lower total healthcare cost (adjusted cost ratio = 0.69; 95% CI: 0.66, 0.72), compared to late initiators. Conclusion Compared to late BUP-NX initiation, early initiation was associated with a lower risk of opioid overdose and opioid overdose-related ED visits, and reduced total healthcare cost among insured adult patients with OUD.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

ABSTRACT Background Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. Objective To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. Methods A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. Results Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. Conclusions Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Opioid-related emergencies in New York City after the Great Recession

BackgroundThe rise in opioid-related mortality and opioid-related emergency department (ED) visits has stimulated research on whether broader economic declines, such as the Great Recession, affect opioid-related morbidity. We examine in New York City whether one measure of morbidity—opioid-related ED visits—responded acutely to the large negative “shock” of the Great Recession. MethodsData comprise outpatient “treat and release” opioid-related ED visits in New York City for the 72 months spanning January 2006 to December 2011, taken from the Statewide Emergency Department Database (n = 150,246). We modeled the monthly incidence of opioid-related ED visits using Autoregressive, Integrated, Moving Average (ARIMA) time-series methods to control for patterning in ED visits before examining its potential association with the economic shock of the Great Recession. ResultsNew York City shows a mean of 1761 outpatient ED visits per month for opioid dependence and abuse. Unexpectedly large drops in employment coincide with fewer than expected opioid dependence and abuse ED visits in that same month. The result (coefficient = 0.046, 95% Confidence Interval [CI]: 0.002, 0.090) represents a 0.8% drop in overall incidence of opioid dependence and abuse ED visits during the Great Recession. We, however, observe no association between the Great Recession and ED visits for prescription opioid overdose or heroin overdose, or with inpatient ED visits for opioid dependence and abuse. ConclusionsFindings, if replicated, indicate distinct short-term reductions in opioid-related morbidity following the Great Recession. This result diverges from previous findings of increased opioid use following extended economic downturns.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Emergency Department Visits for Opioid Overdoses Among Patients With Cancer.

Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.

Randomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial

IntroductionEffective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain...

Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review

BackgroundOverdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.MethodsWe retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.ResultsAmong the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97).ConclusionsIn this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

Enhanced Surveillance of Nonfatal Emergency Department Opioid Overdoses in California

ObjectiveTo track and monitor nonfatal emergency department opioid overdoses in California for use in the statewide response in the opioid epidemic.IntroductionThe opioid epidemic is a multifaceted public health issue that requires a coordinated and dynamic response to address the ongoing changes in the trends of opioid overdoses. Access to timely and accurate data allows more targeted and effective programs and policies to prevent and reduce fatal and nonfatal drug overdoses in California. As a part of a Centers for Disease Control and Prevention Enhanced State Opioid Overdose Surveillance grant, the goals of this surveillance are to more rapidly identify changes in trends of nonfatal drug overdose, opioid overdose, and heroin overdose emergency department visits; identify demographic groups or areas within California that are experiencing these changes; and to provide these data and trends to state and local partners addressing the opioid crisis throughout California. Emergency department (ED) visit data are analyzed on an ongoing quarterly basis to monitor the proportion of all ED visits that are attributed to nonfatal drug, opioid, and heroin overdoses as a portion of the statewide opioid overdose surveillance.MethodsCalifornia emergency department data were obtained from the California Office of Statewide Health Planning and Development. Data were (and continue to be) analyzed by quarter as the data become available, starting in quarter 1 (Q1) 2016 through Q1 2018. Quarters were defined as standard calendar quarters; January-March (Q1), April-June (Q2), July-September (Q3), and October-December (Q4). Counts of nonfatal ED visits for all drug overdoses, all opioid overdoses, and heroin overdoses were defined by the following ICD-10 codes in the principle diagnosis or external cause of injury fields respectively; T36X-T50X (all drug), T40.0X-T40.4X T40.6 and T40.69 (all opioid), and T40.1X (heroin). Eligible ED visits were limited to CA residents, patients greater than 10 years of age, initial encounters, and were classified as unintentional overdoses or overdoses of undetermined intent. Overdose ED visits are described by quarter, drug, sex, and age for Q1 2016 – Q1 2018.ResultsOn average, 6,450 emergency department visits in California are attributed to drug overdose every quarter. Between Q1 2016 and Q1 2018, on average 1,785 (range: 1,559-2,011 ED visits) of those visits were due to opioid overdoses and a further 924 (52%) of those ED visits were due to heroin overdoses. About 26-30% of all drug overdose ED visits were for opioid overdoses in California during Q1 2016 – Q1 2018. Quarterly, that is around 6.00-7.64 opioid overdose ED visits for every 10,000 ED visits (Table 1), with about half those (3.09-4.30 ED visits) being heroin overdose ED visits. Males accounted for approximately 52% of all drug overdose ED visits, 65% of all opioid overdose ED visits, and 76% of all heroin overdose ED visits per quarter. Across all quarters, 25-34 year olds had the highest proportion of emergency department visits attributed to opioid and heroin overdose compared to all other age groups. However, 11-24 year olds had the highest proportion of emergency department visits attributed to all drug overdoses compared to all other age groups for all quarters except one. Between Q1 2016 and Q1 2018, the proportion of emergency department visits attributed to all drug overdoses increased by 1.8%, all opioid overdoses increased 3.1%, and heroin overdoses increased by 13.5%.ConclusionsOverall trends for the proportion of all emergency department visits for all drug overdoses and all opioid overdoses are relatively stable over this time period, however the proportion of heroin overdose ED visits shows a more substantial increase between Q1 2016 and Q1 2018. In addition, heroin overdose ED visits account for over half of all opioid overdose ED visits during this time in California. Ongoing surveillance of drug, opioid, and heroin overdose ED visits is a crucial component of assessing and responding to the opioid overdose crisis in California and helps to better understand the demographics of those who could be at risk of a future fatal opioid overdose. Timely data such as these (in addition to prescribing, hospitalization, and death data) can inform local and statewide efforts to reduce opioid overdoses and deaths.

Identification and Assessment of Repeat Drug Overdose Visits at EDs in Virginia

ObjectiveTo identify and assess the characteristics of individuals with repeated emergency department (ED) visits for unintentional opioid overdose, including heroin, and how they differ from individuals with a single overdose ED visit.IntroductionThe Virginia Department of Health (VDH) utilizes syndromic surveillance ED data to measure morbidity associated with opioid and heroin overdoses among Virginia residents. Understanding which individuals within a population use ED services for repeated drug overdose events may help guide the use of limited resources towards the most effective treatment and prevention efforts.MethodsVDH classified syndromic surveillance visits received from 98 EDs (82 hospitals and 16 emergency care centers) between January 2015 and July 2018. An unintentional opioid overdose, which included heroin, was classified based on the chief complaint and/or discharge diagnosis (ICD-9 and ICD-10) using Microsoft SQL Server Management Studio. ED visits were categorized as either a single or a repeat visit, where a repeat visit was defined as two or more separate ED visit records from the same individual. ED visit records were matched to individuals using medical record number. Each match represented a repeat visit for one person. RStudio was used to conduct Pearson’s chi-square tests for sex, race, and 10-year age groups among both visit groups and to assess visit frequency among the repeat visit group.ResultsBetween January 2015 and July 2018, 9,869 ED visits for opioid overdose were identified, of which 734 (7.4%) were repeat visits among 597 individuals occurring among 57 EDs. The proportion of individuals with repeated opioid overdose visits was significantly different compared to the proportion of individuals with a single opioid overdose visit by sex (male 66% vs. 61%) and age group (20-29 years 34% vs 30%) (p &lt; 0.05). No significant difference was found by race. EDs had an average of 10 individuals who had repeated opioid overdose visits, with a range from 1 to 62 individuals. Individuals with repeated opioid overdose visits made on average 2.2 visits to EDs, with a range of 2 to 6 visits. The overdose visit rate among EDs ranged from 0.6 to 51.3 opioid overdoses per 100,000 ED visits, with four EDs having a rate greater than 40 opioid overdose visits per 100,000 ED visits.ConclusionsApproximately 7% of ED visits during the study period for opioid overdose were identified as repeat visits using the medical record number. Individuals with repeated opioid overdose visits differed from those with a single opioid overdose visit with respect to sex and age. Repeated opioid overdose visits were disproportionately higher for males and individuals aged 20-29. Hospital utilization by individuals with repeated opioid overdose visits can provide information on which EDs or communities that may require further attention. Some limitations of this study are that the method utilized to identify individuals may result in an underestimation of repeat visits because limited personally identifying information was used to match visit records, and repeat visits that occurred before and after the study period would not be captured.

Emergency department visits for prescription and synthetic opioid overdoses among patients with cancer.

6579 Background: Patients with cancer may be at high risk of opioid dependence due to physical and psychosocial factors, although little data exists to inform providers and policymakers. Our aim is to examine overdoses from prescription and synthetic opiates leading to emergency department (ED) visits among patients with cancer in the United States. Methods: The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS) was queried for all patient visits with a primary diagnosis of prescription or synthetic opioid overdose between 2006 and 2015. Baseline differences between patients with and without cancer were assessed using chi-square and ANOVA testing. Overdose rates by primary cancer site were normalized using prevalence data from the Surveillance, Epidemiology, and End Results (SEER) Program. Weighted frequencies were used to create national estimates for all data analyses. Results: There were 682,820 weighted ED visits for synthetic opioid overdose, among which 34,547 (5.1%) visits were also associated with a diagnosis of cancer. During this timeframe, ED visits for opioid overdose among patients with cancer increased 2.5-fold, compared to 1.7-fold among those without cancer. 16.5% of patients with cancer had metastatic disease. Patients with cancer presenting for opioid overdose had higher risk of hospital admission (74.8% vs 49.6%), respiratory intubation (13.2% vs 12.2%), mortality (2.1% vs 1.1%), and cost-of-hospital-stay ($32,665 vs $31,824) compared to their non-cancer counterparts (all P &lt; 0.05). Primary cancers with the highest normalized overdose rates (ED visits per 10,000 patients) were esophagus (134), liver &amp; intrahepatic bile duct (124), and cervical cancer (124). Other common cancers had the following normalized overdose rates: lung (105), head and neck (70), and breast (26). Conclusions: Approximately 5% of all ED visits due to prescription and synthetic opioid overdose are among patients with cancer. The rate of increase in ED visits due to opioid overdose from cancer patients was nearly 50% higher than that from non-cancer patients over the 10-year study period. Patients with esophageal, liver, and cervical cancer may be at highest risk.