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Ochalek TA, Cumpston KL, Wills BK, Gal TS, Moeller FG. Nonfatal Opioid Overdoses at an Urban Emergency Department During the COVID-19 Pandemic. JAMA. 2020;324(16):1673–1674. doi:10.1001/jama.2020.17477
Psychosocial consequences related to coronavirus disease 2019 (COVID-19) may place individuals at a heightened likelihood of opioid overdose or relapse.1,2 In 1 study,2 emergency medical services responses to opioid overdoses in Kentucky were increased in the early weeks following the COVID-19 state emergency declaration compared with the 52 previous days. This increased risk of opioid overdose may be particularly concerning among Black patients, who have been overrepresented in COVID-19–related infections, hospitalizations, and deaths, as well as associated socioeconomic consequences.3-5 Given that emergency departments offer an opportune setting to initiate treatment, this study compared numbers of nonfatal, unintentional opioid-related opioid overdoses presenting to an urban emergency department during the early months of the pandemic relative to the previous year.
Patients with opioid overdoses from March 1 to June 30, 2019, and from March 1 to June 30, 2020, were identified from electronic medical records from the Virginia Commonwealth University based on the following chief concern terms: overdose, opioid, heroin, fentanyl, and altered mental status. Data on opioid overdose fatalities during the second quarter of 2020 were unavailable for analyses because cause-of-death determination is often delayed for months pending toxicology testing and autopsies.2 Intentional opioid overdoses (ie, suicide attempts) and nonopioid-related opioid overdoses (ie, patients who did not receive naloxone or were not reported as suspected opioid overdoses) were also excluded. The number of acute myocardial infarction diagnoses, identified from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I21.9, and the number of total emergency department visits were examined as comparisons during the same time periods.
Manual medical record reviews to abstract patient characteristics were conducted by 2 research team members and discrepancies checked against the electronic medical record. Demographic characteristics included age, sex, race/ethnicity, and insurance status. Visit characteristics included the percentage of patients who received a naloxone prescription to fill at their community pharmacy, received a list of contact information for local treatment resources and/or a referral at discharge, received an addiction medicine consult if admitted, and accessed opioid agonist or antagonist treatment at the institution’s outpatient clinic. Descriptive statistical analyses were performed using SPSS version 27 (IBM). This project was approved by the Virginia Commonwealth University institutional review board and informed consent was waived.
The total number of nonfatal opioid overdose visits increased from 102 between March and June 2019 to 227 between March and June 2020. In contrast, compared with 2019, the total number of acute myocardial infarction diagnoses decreased from 41 to 31 and the number of all emergency department visits decreased from 36 565 to 26 061 in March through June 2020.
Among patients who presented with a nonfatal opioid overdose in March through June 2019 and March through June 2020, the mean ages were 42.2 years and 44.0 years, 71 (70%) and 165 (73%) were male, 64 (63%) and 181 (80%) were Black, and 45 (44%) and 91 (40%) were uninsured, respectively (Table). In terms of visit characteristics in March through June 2019 and March through June 2020, 55 (54%) and 127 (56%) patients received a naloxone prescription and 45 (44%) and 154 (68%) received treatment resources and/or a referral at discharge, respectively. However, only 4 (4%) and 14 (6%) of the 17 (17%) and 46 (20%) admitted patients received an addiction medicine consult, and 3 (3%) and 23 (10%) accessed treatment at the outpatient clinic after overdosing, respectively.
In 1 emergency department in Virginia, a greater number of visits for opioid overdoses was observed in the first 4 months of the COVID-19 pandemic, and Black patients made up a relatively larger proportion of opioid overdose visits compared with the previous year. The study has several limitations. First, these findings were from 1 city’s emergency department in a small sample of patients and may not be generalizable to other locations. Second, the number of opioid overdoses was underestimated because official reporting of fatal opioid overdoses is delayed and because patients who did not present to the emergency department were not included.
These findings demonstrate additional evidence of racial/ethnic disparities in health that have been magnified during the COVID-19 pandemic3-5 and the recent historical protests.5 The reasons for the increase in nonfatal opioid overdoses presenting to the emergency department warrant further investigation.
Corresponding Author: Taylor A. Ochalek, PhD, Virginia Commonwealth University C. Kenneth and Dianne Wright Center for Clinical and Translational Research, Richmond Academy of Medicine Bldg, 1200 E Clay St, Richmond, VA 23298 (email@example.com).
Accepted for Publication: August 25, 2020.
Published Online: September 18, 2020. doi:10.1001/jama.2020.17477
Author Contributions: Drs Ochalek and Gal had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Ochalek, Wills, Moeller.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Ochalek.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Ochalek, Gal.
Administrative, technical, or material support: Wills, Moeller.
Supervision: Ochalek, Cumpston, Moeller.
Conflict of Interest Disclosures: Dr Moeller reported consulting for Indivior PLC, Boehringer Ingelheim, and Astellas and receiving grant support from Indivior PLC and Nektar. No other disclosures were reported.
Funding/Support: This study was supported in part by National Institutes of Health research training grant NIDA T32 DA7027-44; National Institutes of Health grants UL1TR002649, U54DA038999, and NCI P30 CA016059/36; and funding from Indivior PLC and Virginia Catalyst.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.