Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study

Abstract

Study objective: Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. Methods: This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. Results: A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). Conclusion: These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.

Comparison of depression and anxiety among pacemaker and implantable cardioverter‐defibrillator recipients: A cross‐sectional study

“…Depression also increases nocturnal cortisol levels and cortisol awakening responses 11 . Predictors of death among heart patients include increased heart rate responses in a standing position (orthostatic challenge), abnormal heart rate response to premature ventricular contractions, and unusual ventricular depolarizations 12 . Other serious psychological problems among patients with heart diseases include anxiety.…”

Prevalence of Mental Health Disorders among Individuals Enrolled in an Emergency Response Program for Treatment of Opioid Use Disorder

“… 49 Emergency departments not are adequately equipped to manage mental health emergencies 50 and the opioid epidemic is increasing the burden on EDs to provide a solution. 51 , 52 Individuals with mental health emergencies in the ED are triaged, stabilized, and released with a referral to community-based mental health services; 49 , 50 , 53 and this treat-and-refer model has largely continued with SUD emergencies. 49 Although ED-initiated MOUD is a promising approach to addressing the opioid crisis, 24 , 25 without prompt follow up with psychosocial services many patients fall through the cracks.…”

Emergency medical services targeting opioid user disorder: An exploration of current out‐of‐hospital post‐overdose interventions

“…5,6 Because a previous nonfatal overdose is the greatest predictor of future fatality, the time after an overdose may present an integral opportunity to intervene, either out-of-hospital or in the ED. 7 A significant amount of resources has been dedicated to addressing the opioid crisis in all 50 states; the Substance Abuse and Mental Health Services Administration (SAMHSA)…”

“…EDs are especially vital because critical time intervention theory posits that interventions occurring during critical times, such as an overdose, may particularly be useful for engaging vulnerable individuals into treatment 5,6 . Because a previous non‐fatal overdose is the greatest predictor of future fatality, the time after an overdose may present an integral opportunity to intervene, either out‐of‐hospital or in the ED 7 . A significant amount of resources has been dedicated to addressing the opioid crisis in all 50 states; the Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded over $900 million in State Opioid Response Grants.…”