The Opioid Epidemic: a Crisis Disproportionately Impacting Black Americans and Urban Communities.

The heroin epidemic has existed for decades, but a sharp rise in opioid overdose deaths (OODs) jolted the nation in the mid-twenty-teens and continues as a major health crisis to this day. Although the new wave of OODs was initially approached as a rural problem impacting a White/Caucasian demographic, surveillance records suggest severe impacts on African Americans and urban-dwelling individuals, which have been largely underreported. The focus of this report is on specific trends in OOD rates in Black and White residents in states with a significant Black urban population and declared as hotspots for OOD: (Maryland (MD), Illinois (IL), Michigan (MI), and Pennsylvania (PA)), and Washington District of Columbia (DC). We compare OODs by type of opioid, across ethnicities, across city/rural demographics, and to homicide rates using 2013-2020 data acquired from official Chief Medical Examiners' or Departments of Health (DOH) reports. With 2013 or 2014 as baseline, the OOD rate in major cities (Baltimore, Chicago, Detroit, Philadelphia) were elevated two-fold over all other regions of their respective state. In DC, Wards 7 and 8 OODs were consistently greater than other jurisdictions, until 2020 when the rate of change of OODs increased for the entire city. Ethnicity-wise, Black OOD rates exceeded White rates by four- to six-fold, with fentanyl and heroin having a disproportionate impact on Black opioid deaths. This disparity was aggravated by its intersection with the COVID-19 pandemic in 2020. African Americans and America's urban dwellers are vulnerable populations in need of social and political resources to address the ongoing opioid epidemic in under-resourced communities.

Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling study.

BACKGROUND: The syndemic of injection drug use and serious injection-related infections is leading to increasing mortality in the USA. Although outpatient treatment with medications for opioid use disorder reduces overdose risk and recurrent infections, hospitalisation remains common. We evaluated the clinical impact, costs, and cost-effectiveness of hospital-based strategies to address the US opioid epidemic. METHODS: We developed a microsimulation model to compare the cost-effectiveness of: standard hospital care-detoxification for opioids, no addiction consult service (status quo); expanded inpatient prescribing of medications for opioid use disorder, including bridge prescriptions (ie, medication until they can see an outpatient provider) when possible (medications for opioid use disorder with bridge); implementation of addiction consult services within the hospital (addiction consult services alone); and a combined medication for opioid use disorder with addiction consult services strategy (combined). We used clinical trials and observational cohorts to inform model inputs. Outcomes were life-years, discounted costs, incremental cost-effectiveness ratios, hospitalisations, and deaths. We did deterministic sensitivity analyses on key model inputs related to costs and sequelae of drug use and probabilistic sensitivity analysis to further address uncertainty. FINDINGS: Among people who inject opioids in the USA, we estimated that expanding medications for opioid use disorder with bridge prescriptions would reduce hospitalisations and overdose deaths by 3·2% and 3·6%, respectively, and the combination of expanded medications with opioid use disorder along with addiction consult sevices would reduce hospitalisations and overdoses by 5·2% and 6·6%, respectively, compared with the status quo. Mean lifetime costs ranged from US$731 400 (95% credible interval 447 911-859 189 for the medications for opioid use disorder strategy) to $741 200 (470 930-868 551 for the combined strategy) per person. Assuming a willingness-to-pay threshold of $100 000 per life-year gained, medications for opioid use disorder with bridge and combined strategies were cost-effective ($7600 and $14 300, respectively). A scenario that assumed ideal access to harm reduction services came to the same conclusions as the base case and our results were robust in deterministic and probabilistic sensitivity analyses. INTERPRETATION: The combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics. FUNDING: National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.

Association Between State Policies on Improving Opioid Prescribing in 2 States and Opioid Overdose Rates Among Reproductive-aged Women.

BACKGROUND: The opioid overdose epidemic has been declared a public health emergency. Women are more likely than men to be prescribed opioid medications. Some states have adopted policies to improve opioid prescribing, including prescription drug monitoring programs (PDMPs) and pain clinic laws. OBJECTIVE: Among reproductive-aged women, we examined the association of mandatory use laws for PDMPs in Kentucky (concurrent with a pain clinic law) and New York with overdose involving prescription opioids or heroin and opioid use disorder (OUD). STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES: We conducted interrupted time series analyses estimating outcome changes after policy implementation in Kentucky and New York, compared with geographically close states without these policies (comparison states), using 2010-2014 State Inpatient and State Emergency Department Databases. Outcomes included rates of inpatient discharges and emergency department visits for overdoses involving prescription opioids or heroin and OUD among reproductive-aged women. RESULTS: Relative to comparison states, following Kentucky's policy change, we found an immediate postpolicy decrease and a decreasing trend in the rate of overdoses involving prescription opioids, an immediate postpolicy increase in the rate of overdoses involving heroin, and a decreasing trend in the OUD rate (P<0.01); New York's policy change was not associated with the assessed outcomes. CONCLUSIONS: PDMPs and pain clinic laws, such as those implemented in Kentucky, may be promising strategies to reduce the adverse impacts of high-risk opioid prescribing among reproductive-aged women. As states continue efforts to improve inappropriate opioid prescribing, similar strategies as those adopted in Kentucky merit consideration.

Federal and State Action Needed to End the Infectious Complications of Illicit Drug Use in the United States: IDSA and HIVMA's Advocacy Agenda.

In response to the opioid crisis, IDSA and HIVMA established a working group to drive an evidence- and human rights-based response to illicit drug use and associated infectious diseases. Infectious diseases and HIV physicians have an opportunity to intervene, addressing both conditions. IDSA and HIVMA have developed a policy agenda highlighting evidence-based practices that need further dissemination. This paper reviews (1) programs most relevant to infectious diseases in the 2018 SUPPORT Act; (2) opportunities offered by the "End the HIV Epidemic" initiative; and (3) policy changes necessary to affect the trajectory of the opioid epidemic and associated infections. Issues addressed include leveraging harm reduction tools and improving integrated prevention and treatment services for the infectious diseases and substance use disorder care continuum. By strengthening collaborations between infectious diseases and addiction specialists, including increasing training in substance use disorder treatment among infectious diseases and addiction specialists, we can decrease morbidity and mortality associated with these overlapping epidemics.

Trends in Morbidity, Mortality, and Cost of Hospitalizations Associated With Infectious Disease Sequelae of the Opioid Epidemic.

BACKGROUND: Increases in fatal drug poisonings and hepatitis C infections associated with the opioid epidemic are relatively well defined, because passive surveillance systems for these conditions exist. Less described is the association between the opioid epidemic and skin, soft-tissue, and venous infections (SSTVIs), endocarditis, sepsis, and osteomyelitis. METHODS: Michigan hospitalizations between 2016 and 2018 that included an International Classification of Diseases, Tenth Revision, Clinical Modification, code indicating substance use were examined for codes indicative of infectious conditions associated with injecting drugs. Trends in these hospitalizations were examined, as were demographic characteristics, discharge disposition, payer, and cost data. RESULTS: Among hospitalized patients with a substance use diagnosis code, endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations increased by 33%, 35%, 24%, and 12%, respectively between 2016 and 2018. During this time frame, 1257 patients died or were discharged to hospice. All SSTVI hospitalizations resulted in >$1.3 billion in healthcare costs. Public insurance accounted for more than two-thirds of all hospitalization costs. CONCLUSIONS: This study describes a method for performing surveillance for infection-related sequelae of injection drug use. Endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations have increased year over year between 2016 and 2018. These hospitalizations result in significant morbidity, mortality, and healthcare costs and should be a focus of future surveillance and prevention efforts.

Hepatitis C Virus (HCV) Care Continuum Outcomes and HCV Community Viral Loads Among Patients in an Opioid Treatment Program.

BACKGROUND: Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control. METHODS: Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care. RESULTS: Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high. CONCLUSIONS: After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region.

BACKGROUND: Hepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region. METHODS: We developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year. RESULTS: The provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder. CONCLUSIONS: Providers demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.

The escalation of the opioid epidemic due to COVID-19 and resulting lessons about treatment alternatives.

Factors worsening the opioid epidemic during the coronavirus disease 2019 (COVID-19) pandemic provide valuable insight for strategy change where we have historically suffered great loss, bodily and financially.

Tackling the opioid epidemic: Reducing opioid prescribing while maintaining patient satisfaction with pain management after outpatient surgery.

INTRODUCTION: Results of a quality improvement (QI) project to standardize our opioid prescribing practices following five common outpatient general surgery procedures are presented. METHODS: Opioid prescribing habits were reviewed from June to December 2017. QI measures were implemented. We prospectively collected data on opioid prescribing habits and patients' pain management ratings from September 2018 to February 2019. RESULTS: Following implementation, combination pills were less prescribed. More patients were prescribed adjuncts pre- (66% vs. 3%; p < 0.01) and post-operatively (85% vs. 50%; p < 0.01). One-third of pills were prescribed (1363 vs. 4185), with only 520 consumed. Average OME prescribed decreased from 179 to 127 mg (p < 0.001). At follow-up, 52 patients (54%) reported taking 11 pills (1-20) post-operatively for five days. Pain management was rated as good/excellent (88.6%) or fair (9.3%). CONCLUSIONS: Using a pragmatic multimodal approach, decreasing opioid prescriptions at discharge allows for adequate pain management.

Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis.

PURPOSE: To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US). METHODS: This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers. RESULTS: An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]). CONCLUSIONS: In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.

Opioid epidemics.

In this paper, I propose an economic theory that addresses the epidemic character of opioid epidemics. I consider a community in which individuals are heterogenous with respect to the experience of chronic pain and susceptibility to addiction and live through two periods. In the first period they consider whether to treat pain with opioid pain relievers (OPRs). In the second period they consider whether to continue non-medical opioid use to mitigate cravings from addiction. Non-medical opioid use is subject to social disapproval, which depends negatively on the share of opioid addicts in the community. An opioid epidemic is conceptualized as the transition from an equilibrium at which opioid use is low and addiction is highly stigmatized to an equilibrium at which opioid use is prevalent and social disapproval is low. I show how such a transition is initiated by the wrong belief that OPRs are not very addictive. Under certain conditions there exists an opioid trap such that the community persists at the equilibrium of high opioid use after the wrong belief is corrected. Refinements of the basic model consider the recreational use of prescription OPRs and an interaction between income, pain, and addiction.

Statewide collaborative partnerships among American Indian and Alaska Native (AI/AN) communities in California to target the opioid epidemic: Preliminary results of the Tribal Medication Assisted Treatment (MAT) key informant needs assessment.

American Indian and Alaska Native (AI/AN) communities have disproportionately been impacted by the opioid epidemic with the second highest opioid-related overdose death rates compared to other ethnic groups. The diversity among California AI/AN tribes, including regional differences in economic opportunities, tribal affiliation and organization, resources and infrastructure, requires a strong community-based partnership approach to assess global statewide patterns in service availability, acceptability, and utilization, as well as capturing the unique challenges and service needs within each region. This article describes a statewide community-based needs assessment of strengths and weakness among key informants in CA to identify facilitators and barriers to treatment of substance use disorders (SUD) and opioid use disorders (OUD). We conducted structured interviews of 21 healthcare professionals from Urban Indian Health Programs, Tribal clinics and community-based organizations throughout California. The interview assessed (1) barriers to accessing services; (2) risk factors; (3) protective factors; (4) community substance use description; (5) SUD and OUD services available; and (6) service system needs. Findings indicate an overall increase in SUD and OUD in AI/AN communities. Key informants discussed the importance of comprehensive and culturally centered care, wrap-around services, such as treatment of mental health issues alongside substance abuse, and the need for AI/AN-specific treatment facilities that integrate traditional and cultural activities into western health services.

A population-based study of sociodemographic and clinical factors among children and adolescents with opioid overdose.

STUDY OBJECTIVE: An upsurge of high-risk opioid misuse has contributed to the epidemic of opioid overdose in the United States. The primary aim was to report the rate of opioid overdose among the pediatric population and to report demographic and medical differences among POD versus IOD populations. DESIGN: Retrospective descriptive analysis of opioid overdose using the largest pediatric inpatient database in the United States. We performed a Pearson chi-square and Wilcoxon rank sum test to compare differences between cohorts. SETTING: Multi-institutional. PATIENTS: Data were obtained from the Kids' Inpatient Database of the Healthcare Cost and Utilization Project. We used the International Classification of Disease, Ninth Revision codes to extract records of pediatric patients who were admitted for POD or IOD from 2000 to 2012. INTERVENTIONS: None. MEASUREMENTS: None. MAIN RESULTS: The final analysis included 15,884 patients admitted to a United States hospitals with opioid overdose. The rate of POD and IOD has increased steadily from 2000 to 2012. Black, Asian or Pacific Islander, Native American, Multi-race, and Unknown race had higher proportion of POD versus IOD (p < 0.001). Compared to POD, the rate of IOD was highest in Northeast (29.2% versus 14.3%, p < 0.001) and Midwest (31.6%versus 26.1%, (p < 0.001) regions of the country. CONCLUSIONS: Our findings reinforce existing studies that report a continued rise in opioid morbidity and mortality while providing new insights into sociodemographic patterns and comorbidities associated with POD versus IOD.

The Effect of Opioid Dependence on Firearm Injury Treatment Outcomes: A Nationwide Analysis.

BACKGROUND: Both the opioid and gun violence epidemics are recurrent public health issues in the United States. We sought to determine the effect of opioid dependence on gunshot injury treatment outcomes. MATERIALS AND METHODS: Using the 2016 National Readmission Database, patients were included if they had a principal diagnosis of firearm injury. Opioid dependence was identified using appropriate International Classification of Diseases, 10th Revision, Clinical Modification codes. The primary outcome was 30-day all-cause readmission. Secondary outcomes were in-hospital and 1-year mortality, resource utilization, and most common reasons for admission and readmission. Confounders were adjusted for using multivariate regression analysis. RESULTS: A total of 31,303 patients were included, 695 of whom were opioid dependent. Opioid-dependent patients were more likely to be young (35.1 y, range: 33.4-36.7 y) and male (89.9%) compared with patients without opioid dependence. Opioid dependence was associated with higher 30-day readmission rates (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.12-2.50, P = 0.01). However, opioid dependence was associated with lower in-hospital (aOR: 0.16, CI: 0.07-0.38, P < 0.01) and 1-year (aOR: 0.15, CI: 0.06-0.38, P < 0.01) mortality, longer mean length of stay (adjusted mean difference [aMD]: 2.09 d, CI: 0.43-3.76, P = 0.03), and total hospitalization costs (aMD: $6,318, CI: $ 257-$12,380, P = 0.04). Both groups had similar total hospitalization charges (aMD: $$10,491, CI: -$12,618-$33,600, P-value = 0.37). CONCLUSIONS: Opioid dependence leads to higher rates of 30-day readmission and resource utilization among patients with firearm injuries. However, the in-hospital and 1-year mortality rates are lower among patients with opioid dependence secondary to lower injury acuity.

Estimated costs to the Pennsylvania criminal justice system resulting from the opioid crisis.

The opioid crisis has made financial impacts across all levels of the public sector. This report focuses on costs related to the criminal justice system (CJS) in Pennsylvania. Costs impacting 3 principal areas of the CJS are examined: opioid-related arrests, court costs, and incarceration. Analysis of the state-level CJS is our main focus; no local-level costs are included. Through this examination, costs of the opioid crisis for the period of 2007 to 2016 were estimated using opioid costs for 2006 as a baseline. Total costs to the Pennsylvania CJS during this period were over $526 million, with most of that accounted for by state corrections. Opioid-related trends in arrests, court proceedings, and incarceration were not sufficiently well documented to allow for rigorous analysis in earlier periods, and this was the primary limitation to our analysis.

The economic burden of the opioid epidemic on states: the case of Medicaid.

The societal burden of opioid use disorder (OUD) is considerable and contributes to increased healthcare costs and overdose deaths. However, the burden is not well understood. The purpose of this analysis is to estimate the state Medicaid programs' costs for treating OUD and how these costs have changed over time. We used data from the Medicaid Analytic eXtract files from 17 states between 1999 and 2013 to examine the healthcare costs associated with OUD. Inpatient, outpatient, and prescription medication costs related to the treatment of OUD were included, as were excess costs for other healthcare services (eg, general medical care) for individuals with OUD relative to a comparison group of individuals without OUD matched on age, sex, and state. We then extrapolated our results to the entire US Medicaid population using population-based sample weights. All costs were adjusted for inflation and are reported in 2017 US dollars. During our study period, the number of patients who were diagnosed with OUD increased 378%, from 39,109 (0.21% of total Medicaid enrollment) in 1999 to 186,979 (0.60% of total Medicaid enrollment) in 2013 in our 17-state sample. Even after adjusting for inflation, total Medicaid costs associated with OUD more than tripled during this time, reaching more than $3 billion in 2013, from $919 million in 1999. Most of this growth was due to excess non-OUD treatment costs for patients with OUD, which increased 363% over the period; the rate of growth is triple the expenditures for OUD treatment services. When the results were extrapolated to the entire United States, the Medicaid costs associated with OUD increased from more than $2 billion in 1999 to more than $8 billion in 2013. The total cumulative costs that were associated with OUD for this extrapolated 50-state sample over a 15-year time period amounts to more than $72.4 billion. OUD imposes considerable financial burden on state Medicaid programs, and the burden is increasing over time.