Fatal Opioid Overdoses During And Shortly After Hospital Admissions In England: A Case-Crossover Study

Author summary Why was this study done?The number of deaths due to poisoning by opioids such as heroin is increasing in England.

The risk of dying due to a drug overdose varies across time, for example, deaths are common in the weeks after the release from prison or discharge from drug treatment.

Hospital patients who use illicit drugs report undertreated pain and opioid withdrawal, and patients have overdosed in hospital toilets and car parks.

Hospital admission and discharge may be an opportunity to help people who use illicit opioids.

What did the researchers do and find?We studied people who died due to a fatal drug overdose in England, where an opioid such as heroin contributed to the death.

We looked at the history of hospital admissions for these individuals, and we assessed whether they were admitted to the hospital at the time of death or had recently been discharged.

We found that fatal opioid overdoses are 4 times more likely in the 2 days after the hospital discharge than at other times, showing that hospital discharge is a high-risk time for people who use illicit opioids.

We also found that some fatal opioid overdoses happened during hospital admissions, but the number was similar or lower than expected among people who use drugs in the community.

What do these findings mean?People who use illicit drugs such as heroin need extra support when being discharged from the hospital.

Interventions that reduce the risk of fatal overdose, such as opioid agonist treatment and overdose response training with take-home naloxone (an antidote for opioid overdose), may be beneficial when provided in the hospital.

Hospitals may need to improve training related to addictions and develop policies to implement these overdose reduction interventions.

BackgroundHospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death.

Methods and findingsWe conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results.

ConclusionsDischarge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.