“Alarming” Death Rate in Primary care for Opiate Abusers

Patients with opioid use disorder (OUD) who are seen in the general healthcare setting are more than 10 times more likely to die than their counterparts without OUD, new research shows.
An analysis of electronic health records (EHRs) for more than 2500 patients with OUD who were treated at a major university hospital system showed a crude mortality rate of 48.6 deaths per 1000 person-years — a rate that was more than 10 times higher than the expected death rate in the general population for individuals of the same age and sex. The data covered an 8-year period.
“My original thinking was that the mortality rate could not be very high in the general healthcare setting because general healthcare centers are supposed to have more comprehensive health services, and most people are insured. But when I saw such a high mortality rate, I was shocked,” lead investigator Yih-Ing Hser, PhD, professor of psychiatry and behavioral sciences, David Geffen School of Medicine at the University of California, Los Angeles, told Medscape Medical News.
The study was published online April 20 in the Journal of Addiction Medicine.

Too Little, Too Late

Treatment of OUD has traditionally been delivered in specialty addiction centers, such as methadone treatment programs, “isolated from the primary care system or general medical systems,” the authors note.
Recent healthcare reforms through the Federal Mental Health Parity and Addiction Equity Act and the Affordable Care Act have led to an expansion of services for substance use disorders (SUDs) in primary care. Although most clinicians in the general healthcare system are aware of the risk for elevated mortality among OUD patients in publicly funded SUD treatment settings, they “do not fully appreciate the mortality risks to their patients,” the authors note.
To investigate the mortality rates of OUD in the general healthcare environment, the researchers studied the EHRs from a large university health system from 2006 to 2014. They identified 2576 patients, who ranged in age from 18 to 64 years at their first OUD diagnosis.
They also obtained mortality data from the National Death Index of the US Centers for Disease Control and Prevention. The duration of follow-up was from either the time of first OUD diagnosis to death or to December 31, 2014, for those still alive.
During the follow-up period (a mean of 3.7 person-years), there were 465 (18.5%) confirmed deaths, yielding an all-cause crude mortality rate of 48.6 per 1000 person-years.
Individuals who died were older at the time of first OUD diagnosis (48.4 vs 39.8 years) and were more likely to be male (41.7% vs 31.6%), black (11.2% vs 6.8%), and uninsured (87.1% vs 51.3%). The mean age of patients at death was 51.0 years (SD = 11.0).
Deceased patients were more likely to have been diagnosed with other co-occurring SUDs (particularly SUDs involving tobacco, alcohol, cannabis, and cocaine). Drug-related problems represented the most common cause of death (19.8%). These included accidental poisoning or drug overdose, intentional poisoning, and alcohol use disorder or drug use disorder.
Physical health problems associated with death included heart disease, respiratory disorders, hepatitis C virus (HCV) infection, liver disease, cancer, and diabetes.
Cardiovascular disease and cancer were the most common physical causes of death (17.4% and 16.8%, respectively), followed by infectious diseases (13.5%, with 12.0% HCV and 0.8% HIV), diseases of the digestive system (12.2%, with 4.9% alcohol-related liver disease), and external causes (6.7%).
HCV (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.62 – 2.46) and alcohol use disorder (HR, 1.27; 95% CI, 1.05 – 1.55) were the two statistically significant and clinically important indicators of overall mortality risk.

Lack of Screening

The overall indirect standardized mortality rate of 10.3 (95% CI, 9.4 – 11.3) represented a mortality risk that was more than 10-fold higher than that of the general population, after adjustment for sex and age.
The researchers call these findings “alarming,” suggesting that they “may reflect several past and current issues with current healthcare delivery systems in identifying and addressing OUD problems.”
“The general healthcare system has not been well studied with regard to substance abuse,” Dr Hser noted.
“Patients in this setting are much older at diagnosis than in publicly funded settings, and they have much higher morbidity and morbid conditions,” she said. “But general healthcare providers are not sufficiently screening for addictions, so it comes very late in the process for the person to receive appropriate interventions.
“Even when patients with OUD are identified, these clinicians may not have the resources to treat them, because general systems usually do not have addiction specialists on board,” she added.
The responsibility does not lie solely with individual practitioners.
“The timing is perfect, because the 21st Century Cures Act that former President Obama signed is now dispersed throughout the states to improve access to medication-assisted treatment. Policy makers and healthcare systems in each state need to start talking with each other and come up with a better plan to improve the infrastructure, train the physicians, and provide support when they need it,” she said.

More Training Needed

Commenting on the study for Medscape Medical News, Daniel G. Tobin MD, assistant professor of medicine, Yale University School of Medicine, and medical director of adult primary care, the Saint Rafael Campus, Yale–New Haven Hospital, described the study as “meaningful” but recommended caution when interpreting the findings.
“The study analyzed data from electronic medical records and identified people with opioid use disorder based on coding, which is a study limitation, because the coding had to be done correctly,” said Dr Tobin, who was not involved with the study.
“If clinicians did not include the diagnosis in the chart or did not code correctly, the number of opioid users might be underrepresented in the data,” he said, “leading to an overestimation of mortality rates in OUD in the general healthcare setting,” he explained.
Nevertheless, he said, “the study does show that having this diagnosis is associated with a high risk of mortality, and that the mortality is not necessarily due to overdose, which is the general conception of mortality from OUD.
“Since the patients in the study were identified roughly 5 years later than in addiction centers, these 5 additional years can lead to many health problems. I agree with the authors’ conclusion that the later the diagnosis is made, the more damage is done, so one interesting take-away is that we have to diagnose and treat OUD as soon as possible,” he said.
He agreed that more money, training, and infrastructure are necessary. “Not only do individual doctors need to take ownership, but there also has to be some infrastructure support so it becomes a routine part of primary care.”
Dr Hser added that clinicians in primary care settings can be an important force in shaping the nation’s effort to effectively address the opioid epidemic, but they need a lot of help. “They should get adequate training and get connected with an appropriate network that can help overcome many barriers that we are facing in treating addiction.”

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