Background Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces. Methods This was a retrospective cohort study (April 1st, 2013 to March 31st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use. We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1st, 2014 to March 31st, 2015. Results In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37–43 years; 60.9–63.0% male), whose ED visits and hospitalizations were higher than comparison groups. In all provinces, cluster analyses identified subgroups with “extreme” and “moderate” frequent visits (median 13–19 versus 4–6 visits/year). “Extreme” versus “moderate” subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups. Conclusions Subgroups of people with “extreme” (13–19 visits/year) and “moderate” (4–6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the “extreme” subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.
Objectives: We aimed to understand trends in opioid overdoses, naloxone dosing, and overdose reversal from 2014 to 2017 at Insite, a community-supervised consumption site in Vancouver, British Columbia. Methods: We performed a retrospective cohort study of patients who overdosed on opioids at Insite. We evaluated yearly trends in total overdoses, naloxone doses administered, and proportions of patients reversed (based on our definitions of “probable” and “confirmed” reversal), with particular attention to trends before and after the emergence of illicit fentanyl in 2015. Results: There was an increase in total overdoses at Insite from 2014–2015 (n=586) to 2016–2017 (n=2033). Overdose reversal data were limited by a large proportion of patients for whom there was not enough information to adjudicate whether reversal occurred, and therefore were marked “unspecified” [n=1537/2619 (58.7%)]. Within these limitations, fewer patients were reversed after 2015 (44.1% in 2016, 29.7% in 2017) than before (47.8% in 2014, 55.1% in 2015) (χ2=73.1, P<0.001). Despite this, naloxone doses remained unchanged between 2014–2015 and 2016–2017 {median: 0.4 mg [interquartile range (IQR): 0.4–0.8 mg] for both, P=0.21}. Insite staff administered higher doses to patients not successfully reversed [median: 0.8 mg (IQR: 0.4–0.8 mg)] compared with those reversed [median: 0.4 mg (IQR: 0.4–0.8 mg)] (P=0.021), and to patients offered transfer to hospital [median: 0.8 mg (IQR: 0.4–0.8 mg)] compared with those discharged home [median: 0.4 mg (IQR: 0.4–0.8 mg)] (Kruskal-Wallis H=288.7, P<0.001). Conclusion: Overdose numbers at Insite increased and fewer patients were successfully reversed following the emergence of illicit fentanyl in 2015, but naloxone doses remained unchanged, suggesting that traditional naloxone dosing does not optimally reverse overdoses caused by fentanyl. Our study supports an alternative approach to naloxone dosing in patients with suspected ultrapotent opioid toxicity and in communities with high fentanyl prevalence. Objectifs: Nous avons cherché à comprendre les tendances en matière de surdoses d’opioïdes, de dosage de naloxone et de renversement des effets de surdosage de 2014 à 2017 à Insite, un site communautaire de consommation supervisée à Vancouver, en Colombie-Britannique (C.-B.). Méthodes: Nous avons réalisé une étude de cohorte rétrospective des patients ayant fait une surdose d’opioïdes à Insite. Nous avons évalué les tendances annuelles du total des surdoses, des doses de naloxone administrées et des proportions de patients qui ont renversé les effets de surdosage (selon nos définitions de “probable” et “confirmée”), en accordant une attention particulière aux tendances avant et après l'émergence du fentanyl illicite en 2015. Résultats: Il y a eu une augmentation du nombre total de surdoses à Insite entre 2014-2015 (n=586) et 2016-2017 (n=2033). Les données sur le renversement des effets de surdosage étaient limitées par une grande proportion de patients pour lesquels il n’y avait pas assez d’informations pour juger si le renversement des effets de surdosage avait eu lieu, et ont donc été marquées “ non spécifié “ (n=1537/2619 [58,7%]). Dans le cadre de ces limitations, moins de patients ont été renversé après 2015 (44,1% en 2016, 29,7% en 2017) qu’avant (47,8% en 2014, 55,1% en 2015) (χ2=73,1, P<0,001). Malgré cela, les doses de naloxone sont restées inchangées entre 2014-2015 et 2016-2017 (médiane de 0,4 mg [IQR 0,4-0,8 mg] pour les deux, P=0,21). Le personnel d’Insite a administré des doses plus élevées aux patients dont le renversement n’a pas réussi (médiane de 0,8 mg [IQR 0,4-0,8 mg]) par rapport à ceux dont le renversement a réussi (médiane de 0,4 mg [IQR 0,4-0,8 mg] (P=0. 021), et aux patients à qui l’on a proposé un transfert à l’hôpital (médiane 0,8 mg [IQR 0,4-0,8 mg]) par rapport à ceux qui ont été renvoyés chez eux (médiane 0,4 mg [IQR 0,4-0,8 mg]) (Kruskal-Wallis H=288,7, P<0,001). Conclusion: Le nombre de surdoses à Insite a augmenté et moins de patients ont renversé les effets de surdosage avec succès après l'émergence du fentanyl illicite en 2015, mais les doses de naloxone sont restées inchangées, ce qui suggère que le dosage traditionnel de la naloxone ne renverse pas de manière optimale les surdoses causées par le fentanyl. Notre étude soutient une approche alternative au dosage de la naloxone chez les patients soupçonnés de toxicité aux opioïdes ultrapuissants et dans les communautés à forte prévalence de fentanyl.
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