Opioid Agonist Treatment and Risk of Mortality During an Opioid Overdose Public Health Emergency: A Population-Based Retrospective Cohort Study

IntroductionOpioid agonist treatment (OAT) is a safe and effective treatment for opioid use disorder (OUD). However, people commonly stop and start OAT and their risk of death is high immediately after stopping. The prevalence of illicitly manufactured fentanyl and other highly potent synthetic opioids have increased in the illicit drug supply globally. Yet, there is limited evidence examining the relationship between OAT and mortality when these contaminants are widely available in the illicit drug supply. Objectives and ApproachWe aimed to compare the risk of mortality on and off OAT in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. We linked five health administrative datasets in British Columbia, Canada, creating a cohort of 55,347 people with OUD who received OAT during a 23-year period (1996 to 2018). We compared the risk of mortality on and off treatment over time, and according to time since starting or stopping treatment and by medication type. Results7,030 of 55,347 (12.7%) OAT recipients died during follow-up. All-cause SMR was substantially lower on OAT (4.6 [4.4 to 4.8]) compared to off OAT (9.7 [9.5 to 10.0]). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 [1.8 to 2.4] times higher than on OAT prior to the introduction of fentanyl, and increased to 3.4 [2.8 to 4.3] at the end of the study period (65% increase in relative risk). Conclusion / ImplicationsThe protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, while the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

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Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study

BMJ ◽

10.1136/bmj.m772 ◽

2020 ◽

pp. m772 ◽

Cited By ~ 6

Author(s):

Lindsay A Pearce ◽

Jeong Eun Min ◽

Micah Piske ◽

Haoxuan Zhou ◽

Fahmida Homayra ◽

...

Keyword(s):

Relative Risk ◽

Illicit Drug ◽

Population Based ◽

Opioid Use Disorder ◽

Drug Supply ◽

Opioid Use ◽

Opioid Agonist ◽

Opioid Agonist Treatment ◽

Risk Of Mortality ◽

Stopping Treatment

Abstract Objective To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. Design Population based retrospective cohort study. Setting Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. Participants 55 347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. Main outcome measures All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. Results 7030 (12.7%) of 55 347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). Conclusions Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

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The Evolving Overdose Epidemic: Synthetic Opioids And Rising Stimulant-Related Harms

Epidemiologic Reviews ◽

10.1093/epirev/mxaa011 ◽

2020 ◽

Cited By ~ 1

Author(s):

Christopher M Jones ◽

Faraah Bekheet ◽

Ju Nyeong Park ◽

G Caleb Alexander

Keyword(s):

Illicit Drug ◽

Opioid Overdose ◽

Prescription Opioids ◽

Drug Supply ◽

Synthetic Opioids ◽

Key Stakeholders ◽

Public Health Challenges ◽

Concomitant Exposure ◽

Over Time ◽

Key Questions

Abstract The opioid overdose epidemic is typically described as having occurred in three waves, with morbidity and mortality accruing over time principally from prescription opioids (1999-2010), heroin (2011-2013) and illicit fentanyl and other synthetic opioids (2014-present). However, the increasing presence of synthetic opioids mixed into the illicit drug supply, including with stimulants such as cocaine and methamphetamine, as well as rising stimulant-related deaths, reflects the rapidly evolving nature of the overdose epidemic posing urgent and novel public health challenges. We synthesize the evidence underlying these trends, consider key questions such as where and how concomitant exposure to fentanyl and stimulants is occurring, and identify actions for key stakeholders regarding how these emerging threats, and continued evolution of the overdose epidemic, can best be addressed.

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Understanding Steps and Challenges to Take-home Naloxone and Buprenorphine/naloxone Implementation in Québec Emergency Rooms: Suboxed Project

10.21203/rs.3.rs-33331/v1 ◽

2020 ◽

Author(s):

Annie Talbot ◽

Rania Khemiri ◽

Luc Londei-Leduc ◽

Christine Robin ◽

Suzanne Marcotte ◽

...

Keyword(s):

At Risk ◽

Emergency Departments ◽

Governance Structure ◽

The United States ◽

Opioid Overdose ◽

Drug Supply ◽

Emergency Rooms ◽

Opioid Agonist ◽

Clinical Algorithm ◽

Opioid Agonist Treatment

Abstract BackgroundDeaths attributable to drug abuse are on the rise across Canada. It is estimated that there were more than 13,900 opioid-related deaths from January 2016 to June 2019 in the country. Emergency departments (EDs) are often on the frontline of care provided to people at risk of opioid overdose within Québec’s healthcare system. A variety of programs to implement take-home naloxone distribution and/or the provision of opioid agonist treatment for ED patients who are at risk for overdose have been created in the United States and in Europe. However, few EDs in Canada have developed protocols for the provision of take-home naloxone and/or opioid agonist treatment by ED doctors.MethodsA clinical algorithm for take home naloxone (THN) and prescription of buprenorphine/naloxone (B/N) was implemented in three EDs of Québec, Canada. This first phase of the SuboxED project required selecting clinical experts, describing the patient population, and creating partnerships with pharmacists and opioid agonist treatment clinics.Results:The clinical experts developed tools based on literature reviews and national and international guidelines. They also created educational tools and trained over 328 ED clinical staff. In addition, SuboxED ensured that a supply of take-home naloxone and B/n was available in the three ED sites for the study.ConclusionImplementing the proposed clinical algorithm for THN and prescription of B/N was challenging: drug supply and ED staff’s buy-in were among the most notable difficulties of SuboxED. Planning training sessions at three different institutions, each with its own governance structure and clinical culture, local realities and harm reduction priorities was complicated. Engaging already overworked ED teams consistently working in a gridlocked environments, revealed in itself to be a difficult endeavour.In the next phase of SuboxED, we will focus on data collection and analysis to evaluate both the implementation of the protocol through a retrospective review of electronic health records and satisfaction surveys of patients and healthcare professionals.Trial registration: noneContribution to the literatureIn the midst of the opioid overdose crisis, initiating a clinical algorithm for take-home naloxone and prescription of B/n in three operationally different Canadian emergency departments was feasible.Implementing a clinical algorithm for take-home naloxone and prescription of B/n is challenging; significant barriers involve drug supply, ED staff buy-in, training, engaging already overworked ED team.

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Non-fatal opioid overdose, naloxone access, and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study

International Journal of Drug Policy ◽

10.1016/j.drugpo.2021.103421 ◽

2021 ◽

pp. 103421

Author(s):

A. Conway ◽

H. Valerio ◽

A. Peacock ◽

L. Degenhardt ◽

J. Hayllar ◽

...

Keyword(s):

Opioid Overdose ◽

Opioid Agonist ◽

Opioid Agonist Treatment

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Impact of Fluid Resuscitation Regimes in Relative Risk of Mortality in Burned Patients

Albanian Journal of Trauma and Emergency Surgery ◽

10.32391/ajtes.v5i2.231 ◽

2021 ◽

Vol 5 (2) ◽

pp. 849-853

Author(s):

Besnik Faskaj ◽

Monika Belba

Keyword(s):

Relative Risk ◽

Statistical Significance ◽

Burn Injuries ◽

University Hospital ◽

Burn Shock ◽

Ringer Lactate ◽

Risk Of Death ◽

Risk Of Mortality ◽

Observational Prospective Cohort Study ◽

The University

Background; Some studies have supported the opinion that patients who get greater volumes of resuscitation fluids are at a higher chance of edema, complications, and probably bad outcomes. In the results of the International Society of Burn Injuries approximately half (49.5%) added colloid before 24h. This study aims to analyze the relative risk for mortality comparing resuscitation in the first 24 hours with Parkland and resuscitation with the use of Colloids. Material and Methods; This was an observational prospective cohort study conducted in the Service of Burns of the University Hospital Centre "Mother Teresa" in Tirana (UHCT), Albania. The study includes adult patients with critical burns > 40% TBSA, hospitalized in the Intensive Care Unit of the service during the period 2014 to 2019. Resuscitation in the first 24 hours is done with Ringer Lactate according to Parkland and with Ringer Lactate with the addition of colloids after 12 hours. Results; The data for organ dysfunction and organ insufficiency were the same in the two groups without statistical significance. Mortality in the RL group was 48% (24 deaths of 50 patients) while in the RL + Colloid rehydrated group was 46% (23 deaths of 50 patients). Patients which have 40-60% burns and are rehydrated with RL + Colloids have a risk of death 0.4 times less than those rehydrated with RL. Conclusions; Resuscitation with Ringer lactate and Colloids in the first 24 hours of thermal damage is a rehydration alternative for the treatment of burn shock. This therapy especially helps patients with major burns > 40% TBSA who during rehydration require large amounts of fluids and are associated with severe plasma hypoalbuminemia. Number Need to Treat (NNT benefit) is 10 so 1 in 10 patients can benefit in lowering the risk of death with RL + Colloid rehydration.

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Rates of opioid agonist treatment prescribing in provincial prisons in Ontario, Canada, 2015–2018: a repeated cross-sectional analysis

BMJ Open ◽

10.1136/bmjopen-2021-048944 ◽

2021 ◽

Vol 11 (11) ◽

pp. e048944

Author(s):

Claire Bodkin ◽

Susan Bondy ◽

Leonora Regenstreif ◽

Lori Kiefer ◽

Fiona Kouyoumdjian

Keyword(s):

General Population ◽

Scale Up ◽

Unmet Need ◽

Opioid Overdose ◽

Opioid Agonist ◽

Access To Treatment ◽

Monthly Basis ◽

Cross Sectional ◽

Opioid Agonist Treatment ◽

Need For Treatment

ObjectiveTo describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.DesignWe used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.SettingProvincial prisons and general population in Ontario, Canada between 2015 and 2018.ParticipantsAdults incarcerated in provincial prisons and people ages 15 years and older in Ontario.Main outcomes and measuresOpioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.ResultsIn prison, 6.9%–8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.ConclusionsThe increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

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Understanding Steps and Challenges to Take-home Naloxone and Buprenorphine/naloxone Implementation in Québec Emergency Rooms: Suboxed Project

10.21203/rs.3.rs-33331/v2 ◽

2020 ◽

Author(s):

Annie Talbot ◽

Rania Khemiri ◽

Luc Londei-Leduc ◽

Christine Robin ◽

Suzanne Marcotte ◽

...

Keyword(s):

At Risk ◽

Governance Structure ◽

The United States ◽

Opioid Overdose ◽

Emergency Rooms ◽

Opioid Agonist ◽

Clinical Algorithm ◽

Opioid Agonist Treatment ◽

System A ◽

Clinical Culture

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Opioid-dependent error processing

Journal of Opioid Management ◽

10.5055/jom.2011.0085 ◽

2017 ◽

Vol 7 (6) ◽

pp. 443-449

Author(s):

James Fellows-Smith, MBBS, MMedSc, MRCPsych, FRANZCP, FAchAM

Keyword(s):

Relative Risk ◽

Methadone Treatment ◽

Error Processing ◽

Opioid Overdose ◽

Community Based ◽

Risk Of Death ◽

Oral Naltrexone ◽

Naltrexone Treatment ◽

Relative Risk Of Death ◽

Methadone Program

Objective: To evaluate error processing in contrasting opioid treatment samples by finding the relative risk of fatal dosing errors leading to opioid overdose in a controlled cohort of detoxified patients with opioid dependence.Methods: Data linkage was performed between the Western Australian deaths register and recorded admissions to the Perth Naltrexone Clinic and community-based methadone program. Death register and corresponding data of coronial findings for all the patients who were treated with rapid opioid detoxification under sedation and oral naltrexone were compared with corresponding data for all the patients who were prescribed methadone over a 2-year period.Results: Data for naltrexone-treated patients (n = 1,097) and community-based methadone-treated patients (n = 2,520) showed mortality rates to be 2.6 percent per year for naltrexone treatment when compared with 0.7 percent for methadone treatment (p 0.001). This was due to 4.3 times the relative risk of death from opioid toxicity for naltrexone-treated patients (p 0.001).Conclusions: Naltrexone increases vulnerability to overdose as enhanced opioid effects following neuroanatomical blockade can reverse behavioral tolerance and lead to greater fatal dosing errors on reinstatement of opioid dependence.

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