Batya Swift Yasgur MA LSW

Medscape

Gerry Gajadharsingh writes:

“My previous blog refers to the research that follows regarding opioid addiction, but in the USA. Please refer to my comments at the beginning of my previous blog for my take on the effect in the UK population. Whilst this research focuses very much on recreational opioid abuse and its’ effects on mortality, the UK population focus is much more on opioid abuse in relation to chronic pain. However the worrying scenario is whether or not that translates into increased mortality rates, 10 times higher than the normal population for individuals of the same sex and age.”

Patients with opioid use disorder (OUD) who are seen in the general healthcare setting are more than 10 times more likely to die than their counterparts without OUD, new research shows.

An analysis of electronic health records (EHRs) for more than 2500 patients with OUD who were treated at a major university hospital system showed a crude mortality rate of 48.6 deaths per 1000 person-years — a rate that was more than 10 times higher than the expected death rate in the general population for individuals of the same age and sex. The data covered an 8-year period.

“My original thinking was that the mortality rate could not be very high in the general healthcare setting because general healthcare centers are supposed to have more comprehensive health services, and most people are insured. But when I saw such a high mortality rate, I was shocked,” lead investigator Yih-Ing Hser, PhD, professor of psychiatry and behavioral sciences, David Geffen School of Medicine at the University of California, Los Angeles, told Medscape Medical News.

The study was published online April 20 in the Journal of Addiction Medicine.

 Too Little, Too Late

Treatment of OUD has traditionally been delivered in specialty addiction centers, such as methadone treatment programs, “isolated from the primary care system or general medical systems,” the authors note.

Recent healthcare reforms through the Federal Mental Health Parity and Addiction Equity Act and the Affordable Care Act have led to an expansion of services for substance use disorders (SUDs) in primary care. Although most clinicians in the general healthcare system are aware of the risk for elevated mortality among OUD patients in publicly funded SUD treatment settings, they “do not fully appreciate the mortality risks to their patients,” the authors note.

To investigate the mortality rates of OUD in the general healthcare environment, the researchers studied the EHRs from a large university health system from 2006 to 2014. They identified 2576 patients, who ranged in age from 18 to 64 years at their first OUD diagnosis.

They also obtained mortality data from the National Death Index of the US Centers for Disease Control and Prevention. The duration of follow-up was from either the time of first OUD diagnosis to death or to December 31, 2014, for those still alive.

During the follow-up period (a mean of 3.7 person-years), there were 465 (18.5%) confirmed deaths, yielding an all-cause crude mortality rate of 48.6 per 1000 person-years.

Individuals who died were older at the time of first OUD diagnosis (48.4 vs 39.8 years) and were more likely to be male (41.7% vs 31.6%), black (11.2% vs 6.8%), and uninsured (87.1% vs 51.3%). The mean age of patients at death was 51.0 years (SD = 11.0).

Deceased patients were more likely to have been diagnosed with other co-occurring SUDs (particularly SUDs involving tobacco, alcohol, cannabis, and cocaine). Drug-related problems represented the most common cause of death (19.8%). These included accidental poisoning or drug overdose, intentional poisoning, and alcohol use disorder or drug use disorder.

Physical health problems associated with death included heart disease, respiratory disorders, hepatitis C virus (HCV) infection, liver disease, cancer, and diabetes.

Cardiovascular disease and cancer were the most common physical causes of death (17.4% and 16.8%, respectively), followed by infectious diseases (13.5%, with 12.0% HCV and 0.8% HIV), diseases of the digestive system (12.2%, with 4.9% alcohol-related liver disease), and external causes (6.7%).

HCV (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.62 – 2.46) and alcohol use disorder (HR, 1.27; 95% CI, 1.05 – 1.55) were the two statistically significant and clinically important indicators of overall mortality risk.

Lack of Screening

The overall indirect standardized mortality rate of 10.3 (95% CI, 9.4 – 11.3) represented a mortality risk that was more than 10-fold higher than that of the general population, after adjustment for sex and age.

The researchers call these findings “alarming,” suggesting that they “may reflect several past and current issues with current healthcare delivery systems in identifying and addressing OUD problems.”

“The general healthcare system has not been well studied with regard to substance abuse,” Dr Hser noted.

“Patients in this setting are much older at diagnosis than in publicly funded settings, and they have much higher morbidity and morbid conditions,” she said. “But general healthcare providers are not sufficiently screening for addictions, so it comes very late in the process for the person to receive appropriate interventions.