The risk of infective endocarditis among people who inject drugs: a retrospective, population-based time series analysis

Weir, Matthew A.; Slater, Justin; Jandoc, Racquel; Koivu, Sharon; Garg, Amit X.; Silverman, Michael

doi:10.1503/cmaj.180694

Cited by 40 publications

(52 citation statements)

References 22 publications

(18 reference statements)

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“…4 Associated health complications, such as hepatitis C infection, HIV infection, and serious injection-related infections, are also increasing. [5][6][7] In addition, as rates of opioid-related death have increased despite decreases in prescription opioid supply, there is an increasing recognition that greater attention must be paid to improving access to effective OUD treatment. 8,9 Medication for opioid use disorder (MOUD) is effective and improves mortality, treatment retention, and remission, but most people with OUD remain untreated.…”

Section: Introductionmentioning

confidence: 99%

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

et al. 2020

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IMPORTANCE Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking.OBJECTIVE To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. DESIGN, SETTING, AND PARTICIPANTS This retrospective comparative effectiveness researchstudy assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims EXPOSURES One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. MAIN OUTCOMES AND MEASURES Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. RESULTS A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone.During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. (continued) Key Points Question What is the real-world effectiveness of different treatment pathways for opioid use disorder? Findings In this comparative effectiveness research study of 40 885 adults with opioid use disorder that compared 6 different treatment pathways, only treatment with buprenorphine or methadone was associated with reduced risk of overdose and serious opioid-related acute care use compared with no treatment during 3 and 12 months of follow-up. Meaning Methadone and buprenorphine were associated with reduced overdose and opioid-related morbidity compared with opioid antagonist therapy, inpatient treatment, or intensive outp...

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Section: Introductionmentioning

confidence: 99%

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

et al. 2020

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“…In June of 2016, a public health emergency was declared in London, Ontario, Canada following an increase in IE (13) and injection-related HIV (14). We identified an association between increasing IVDU associated IE hospitalization and increasing prescriptions of hydromorphone across Ontario (4).…”

Section: Introductionmentioning

confidence: 95%

“…This infectious complication of intravenous drug use (IVDU) is associated with significant morbidity and mortality requiring extensive and costly(1,2) multidisciplinary care (7). PWID are at risk of IE due to: comorbidities of HIV, hepatitis C and skin and soft tissue infections; non-sterile injection practices; and the reuse of injection drug preparation equipment (IDPE) (2,4,(8)(9)(10)(11)(12).…”

Section: Introductionmentioning

confidence: 99%

“…Prescription rates for hydromorphonecontrolled-release (CR) (Hydromorph Contin ®, Purdue Pharma, Pickering, Ontario) in London are in the top quartile in Ontario (4,13,15). Furthermore, studies have shown that the misuse of prescribed opiates such as hydromorphone-CR amplify risk of infections due to the nature of how these substances are prepared for injection (11,(16)(17)(18).…”

Section: Introductionmentioning

confidence: 99%

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Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

Shah

Wong

Ball

et al. 2020

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Background: The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. Details of injection practices leading to IE are not well characterized.Methods: A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were > 18 years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls were recruited from outpatient clinics in patients without IE and addiction clinics in London, Ontario. Results: 33 cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Using clean injection equipment from the provincial distribution network was a protective factor against IE (p<0.001). Furthermore, using lighters during the injection process was also protective for IE (OR 2.5; 95% CI 1.11–5.63). Female sex (OR 3.63; 95% CI 1.58-8.36) and injection into multiple sites (OR 4.31; 95% CI 1.33-13.93) were associated with IE. Injection into the feet (57.6% cases; 36.6% control; p= 0.034) was also associated with IE. Discussion: Our pilot study highlights the importance of distributing clean injection materials for IE prevention. Injection into multiple areas may indicate a greater difficulty in accessing common and safer injection sites such as the arm, and thus multi-site injections may be a surrogate marker for injection-related venous damage in entrenched drug users. Moreover, the use of lighters may be correlated with the best practice of heating preparations of drugs prior to injection, which is known to reduce bacterial burden. Lastly, gender differences in injection techniques, which may place women at higher risk of IE, requires further study.

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“…There has been a rising incidence of infective endocarditis (IE) among people who inject drugs (PWID), paralleling the opioid epidemic in North America (1)(2)(3)(4)(5)(6). This infectious complication of intravenous drug use (IVDU) is associated with significant morbidity and mortality requiring extensive and costly(1,2) multidisciplinary care (7).…”

Section: Introductionmentioning

confidence: 99%

Risk Factors of Infective Endocarditis in Persons Who Inject Drugs

Shah

Wong

Ball

et al. 2020

Preprint

Self Cite

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Background: The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. The coincident rise in IE and change of drug preference to hydromorphone-controlled release (CR) among our PWID population in London, Ontario, intrigued us to study the details of injection practices leading to IE, which have not been well characterized in literature. Methods: A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were >18 years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls without IE were recruited from outpatient clinics and addiction clinics in London, Ontario. Results: 33 cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Multivariable logistic regressions showed that the odds of having IE were 4.65 times higher among females (95% CI 1.85, 12.28; p=.001), and 5.76 times higher among PWID who did not use clean injection equipment from the provincial distribution networks (95% CI 2.37, 14.91; p<.001). Injecting into multiple sites and heating hydromorphone-CR prior to injection were not found to be significantly associated with IE. Hydromorphone-CR was the most commonly injected drug in both groups (90.9% cases; 81.4% controls, p = 0.197). Discussion: Our study highlights the importance of distributing clean injection materials for IE prevention. Furthermore, our study showcases that females are at higher risk of IE, which is contrary to the reported literature. Gender differences in injection techniques, which may place women at higher risk of IE, require further study. We suspect that the very high prevalence of hydromorphone-CR use made our sample size too small to identify a significant association between its use and IE, which has been established in the literature.

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The risk of infective endocarditis among people who inject drugs: a retrospective, population-based time series analysis

Cited by 40 publications

References 22 publications

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

Risk Factors of Infective Endocarditis in Persons Who Inject Drugs

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