Individual and county-level variation in outcomes following non-fatal opioid-involved overdose
Tóm tắt
A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients.
Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics.
10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019).
Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.
Từ khóa
Tài liệu tham khảo
Hedegaard H , Warner M , Miniño AM . Drug overdose deaths in the United States, 1999-2016. Hyattsville, MD: National Center for Health Statistics, 2017. https://www.cdc.gov/nchs/data/databriefs/db294.pdf
Manchikanti, 2012, Opioid epidemic in the United States, Pain Physician, 15, ES9, 10.36076/ppj.2012/15/ES9
Alexander, 2018, Trends in black and white opioid mortality in the United States, 1979–2015, Epidemiology, 29, 707, 10.1097/EDE.0000000000000858
Jalal, 2018, Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016, Science, 361, 10.1126/science.aau1184
Scholl, 2019, Drug and opioid-involved overdose deaths - United States, 2013-2017, Morbidity and Mortality Weekly Report, 67, 1419
Ruhm, 2017, Geographic variation in opioid and heroin involved drug poisoning mortality rates, Am J Prev Med, 53, 745, 10.1016/j.amepre.2017.06.009
Rossen, 2014, Hot spots in mortality from drug poisoning in the United States, 2007–2009, Health Place, 26, 14, 10.1016/j.healthplace.2013.11.005
Monnat, 2018, Factors associated with county-level differences in U.S. drug-related mortality rates, Am J Prev Med, 54, 611, 10.1016/j.amepre.2018.01.040
Haffajee, 2019, Characteristics of US counties with high opioid overdose mortality and low capacity to deliver medications for opioid use disorder, JAMA Netw Open, 2, e196373, 10.1001/jamanetworkopen.2019.6373
Balmert, 2016, Patterns and trends in accidental poisoning deaths: Pennsylvania’s experience 1979-2014, PLoS One, 11, 10.1371/journal.pone.0151655
Hollingsworth, 2017, Macroeconomic conditions and opioid abuse, J Health Econ, 56, 222, 10.1016/j.jhealeco.2017.07.009
Caputi, 2018, Population-level analyses cannot tell us anything about individual-level marijuana-opioid substitution, Am J Public Health, 108, e12, 10.2105/AJPH.2017.304253
Hser, 2015, Long-Term course of opioid addiction, Harv Rev Psychiatry, 23, 76, 10.1097/HRP.0000000000000052
Chatterjee, 2019, Non-Fatal opioid-related overdoses among adolescents in Massachusetts 2012–2014, Drug Alcohol Depend, 194, 28, 10.1016/j.drugalcdep.2018.09.020
MacDougall, 2019, Development and characteristics of the provincial overdose cohort in British Columbia, Canada, PLoS One, 14, 10.1371/journal.pone.0210129
Campbell, 2018, Use of a prescription opioid registry to examine opioid misuse and overdose in an integrated health system, Prev Med, 110, 31, 10.1016/j.ypmed.2018.01.019
Dasgupta N , Funk MJ , Brownstein JS . Comparing unintentional opioid poisoning mortality in metropolitan and non-metropolitan counties, United States, 1999–2003. In: Thomas YF , Richardson D , Cheung I , eds. Geography and drug addiction. Springer Netherlands: Dordrecht, 2008: 175–92.
Wright, 2014, The iatrogenic epidemic of prescription drug abuse: County-level determinants of opioid availability and abuse, Drug Alcohol Depend, 138, 209, 10.1016/j.drugalcdep.2014.03.002
Rigg, 2018, Opioid-related mortality in rural America: geographic heterogeneity and intervention strategies, International Journal of Drug Policy, 57, 119, 10.1016/j.drugpo.2018.04.011
King, 2014, Determinants of increased Opioid-Related mortality in the United States and Canada, 1990–2013: a systematic review, Am J Public Health, 104, e32, 10.2105/AJPH.2014.301966
Gomes, 2011, Geographical variation in opioid prescribing and opioid-related mortality in Ontario, Hcq, 14, 22, 10.12927/hcq.2011.22153
Cerdá, 2017, Prescription opioid poisoning across urban and rural areas: identifying vulnerable groups and geographic areas, Addiction, 112, 103, 10.1111/add.13543
US Census Bureau . 2013-2017 American community survey (ACS) 5-year estimates. Available: https://www.census.gov/programs-surveys/acs/technical-documentation/table-and-geography-changes/2017/5-year.html [Accessed 31 May 2019].
Centers for Disease Control and Prevention,, National Center for Health Statistics . Compressed mortality file 1999-2016 on CDC wonder online database, 2016. Available: https://wonder.cdc.gov/cmf-icd10.html [Accessed 28 May 2019].
Raudenbush SW , Bryk AS . Hierarchical linear models: applications and data analysismethods. 2nd ed. Newbury Park, CA: SAGE, 2002.
Larochelle, 2018, Medication for opioid use disorder after nonfatal opioid overdose and association with mortality, Ann Intern Med, 169, 137, 10.7326/M17-3107
Kim, 2017, Addressing the prescription opioid crisis: potential for hospital-based interventions?, Drug Alcohol Rev, 36, 149, 10.1111/dar.12541
Ray, 2018, Ems naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana, Addiction, 113, 2271, 10.1111/add.14426
A drugmaker tries to cash in on the opioid epidemic, one state law at a time. all things considered, 2017. Available: https://www.npr.org/sections/health-shots/2017/06/12/523774660/a-drugmaker-tries-to-cash-in-on-the-opioid-epidemic-one-state-law-at-a-time [Accessed 8 May 2019].
Lee, 2018, Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial, The Lancet, 391, 309, 10.1016/S0140-6736(17)32812-X
Plebani, 2011, Examining naltrexone and alcohol effects in a minority population: results from an initial human laboratory study, The American Journal on Addictions, 20, 330, 10.1111/j.1521-0391.2011.00138.x
Mattick RP , Breen C , Kimber J , et al . Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews.