Evaluating Differences in Opioid and Stimulant Use-associated Infectious Disease Hospitalizations in Florida, 2016–2017

Abstract

Background The opioid epidemic has led to increases in injection drug use (IDU)-associated infectious diseases; however, little is known about how more recent increases in stimulant use have affected the incidence and outcomes of hospitalizations for infections among people who inject drugs (PWID). Methods All hospitalizations of PWID for IDU-associated infections in Florida were identified using administrative diagnostic codes and were grouped by substance used (opioids, stimulants, or both) and site of infection. We evaluated the association between substance used and the outcomes: patient-directed discharge (PDD, or “against medical advice”) and in-hospital mortality. Results There were 22,856 hospitalizations for infections among PWID. Opioid use was present in 73%, any stimulants in 43%, and stimulants-only in 27%. Skin and soft tissue infection was present in 50%, sepsis/bacteremia in 52%, osteomyelitis in 10%, and endocarditis in 10%. PWID using opioids/stimulants were youngest, most uninsured, had the highest rate of endocarditis (16%) and hepatitis C (44%). Additionally, 25% of opioid/stimulant users had PDD versus 12% for those using opioids-only. In adjusted models, opioid/stimulant use was associated with PDD compared to opioid-only use (aRR 1.28, 95% CI 1.17-1.40). Younger age and endocarditis were also associated with PDD. Compared to opioid-only use, stimulant-only use had higher risk of in-hospital mortality (aRR 1.26, 95% CI 1.03-1.46). Conclusion While opioid use contributed to most IDU-associated infections, many hospitalizations also involved stimulants. Increasing access to harm reduction interventions could help prevent these infections, while further research on the acute management of stimulant use disorder-associated infections is needed.

Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014–18

“…While initiation of MOUD was not significantly associated with decreased rates of PDD in this cohort, it is unknown whether patients received appropriate doses of MOUD to prevent withdrawal and control cravings, which can be more challenging in the era of fentanyl [ 42 ]. It is important to note that, overall, the rate of PDD was 18.3%, consistent with other studies in this population [ 9 ]. Whereas we did not explore harm reduction approaches to antibiotic therapy in PWID with OUD in this study, it is imperative that we fulfill our duty as physicians and offer the next best therapy to PWID, including oral antibiotic contingency plans for PDD [ 43 ].…”

“…Because the number of hospitals included for this study is large, with a relatively low number of patients treated per hospital, it was not possible to account for potential between‐hospital clustering. Insurance status was included to approximate socio‐economic status, and other co‐occurring substance use disorders were included as these were previously shown to be associated with endocarditis and osteomyelitis secondary to injection drug use [ 9 ]. All data were analyzed by SAS version 9.4 and IBM SPSS Statistics version 24.…”

“…Concomitantly, the surge in the number of Americans living with opioid use disorder (OUD) has led to significant morbidity and mortality from infectious consequences of injection drug use [ 7 , 8 , 9 ]. In addition to skin and soft tissue infections [ 10 ], people who inject drugs (PWID) are at a higher risk of severe injection‐related infections, such as endocarditis and osteomyelitis [ 7 , 8 , 9 ], both conditions requiring long‐term intravenous (i.v.) antibiotic therapy as the gold standard of treatment [ 11 ].…”

Recurring Severe Injection-related Infections in People Who Inject Drugs and the Need for Safe Injection Sites in Spain

“…As a probable direct consequence, almost 20% of individuals who had a hospital admission presented with episodes of relapse with readmission to the hospital. These rates of PDD are higher than in other studies examining people who inject opiates/stimulants or opiates-only (35). This can be partially explained by the lack of highly effective medication for stimulant use disorder, which does exist for opioid use disorder, the limited expertise in management of stimulant use disorder by doctors in hospital, and by not using a low-threshold approach during hospitalization.…”

Behavioral Risk Factors for HIV Infection in Hospitalized Persons Who Co-use Stimulants and Opioids

“…Unlike cocaine, illicit ATS tend to be less expensive, locally supplied, and have longer lasting stimulant effects [12]. Given the inherent difference in stimulant and opioid pharmacology, varying methods of drug preparation, typical frequency of injection, and psychoactive impact, there is a mounting body of evidence that shows that people with opioid and stimulant co-use have differential infectious disease acquisition compared to those PWID who only use opioids [13][14][15][16]. While this unique population of PWID has been at significant risk for fatal overdose and infections related to drug use including HIV, little is known about the magnitude of its impact on their HIV risk behaviors.…”