Trends in Hospitalizations for Serious Infections Among People With Opioid Use Disorder in Ontario, Canada

Abstract

Objectives Opioid use among people who inject drugs can lead to serious complications, including infections. We sought to study trends in rates of these complications among people with an opioid use disorder (OUD) and the sequelae of those hospitalizations. Methods We analyzed all inpatient hospitalizations for serious infections (infective endocarditis [IE], spinal infections, nonvertebral bone infections, and skin or soft tissue infections) among people with OUD in Ontario between 2013 and 2019. We reported the population adjusted rate of hospitalizations for serious infections annually, stratified by type of infection and prevalence of prior opioid agonist therapy and hydromorphone prescribing. We reported characteristics of hospitalizations and 30–day mortality in the most recent 2 years. Results Among people with OUD there was a 167% increase in rates of IE (7.7-20.6 per million residents; P < 0.01), a 394% increase in rates of spinal infections (3.4–16.8 per million residents; P < 0.01), a 191% increase in rates of nonvertebral bone infections (8.9 to 25.9 per million residents; P < 0.01), and a 147% increase in infections of the skin or soft tissue (32.1–79.4 per million residents; P < 0.01) over 7 years in Ontario. Death in-hospital and within 30 days of discharge was highest among those with IE (11.5% and 15.9%, respectively), and lower among those with other infections (<5%). Conclusions Rates of serious infections among people with OUD are rising, placing a significant burden on patients. These findings suggest that early intervention and treatment of infections in this population are needed to prevent downstream harm.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis

“…As all patients in our study had IDU-IE, we cannot say from these data whether injecting pharmaceutical opioid tablets increases risk for serious bacterial infections more than injecting heroin or fentanyl. While one study identified an association between controlled-release hydromorphone prescriptions and IDU-IE in Ontario [ 64 ], a small minority of patients with IDU-IE in Ontario have recent prescriptions for hydromorphone [ 6 , 64 ]. Increasing rates of serious injection drug use-associated bacterial infections have been observed in many jurisdictions [ 4 , 5 ], and in Ontario appear to parallel transitions in the drug supply towards increasing use of illicitly-manufactured fentanyl [ 6 ].…”

“…While one study identified an association between controlled-release hydromorphone prescriptions and IDU-IE in Ontario [ 64 ], a small minority of patients with IDU-IE in Ontario have recent prescriptions for hydromorphone [ 6 , 64 ]. Increasing rates of serious injection drug use-associated bacterial infections have been observed in many jurisdictions [ 4 , 5 ], and in Ontario appear to parallel transitions in the drug supply towards increasing use of illicitly-manufactured fentanyl [ 6 ]. Known risk factors for serious injecting-related infections include more frequent injecting (which has been associated with fentanyl and with stimulants), re-use of contaminated needles and filters, and subcutaneous injecting [ 65 ].…”

“…North America's complex opioid-related public health crisis is associated with increasing rates of injection drug use [1], and a rapidly rising incidence of injecting-related bacterial and fungal infections, including injection drug use-associated infective endocarditis (IDU-IE) [2][3][4][5][6]. Hospitalization for IDU-IE is a "reachable moment" to effectively engage patients in addiction treatment and harm reduction care, including opioid agonist treatment (OAT; e.g.…”

Opioid agonist treatment and risk of death or rehospitalization following injection drug use–associated bacterial and fungal infections: A cohort study in New South Wales, Australia

“…Injection drug use–associated bacterial and fungal infections (e.g., skin and soft-tissue infections, endocarditis, osteomyelitis, septic arthritis, and epidural abscess) are associated with significant morbidity and mortality among people who inject drugs (PWID) and are costly for healthcare systems [ 1 – 6 ]. The incidence of hospitalization for injecting-related infections is increasing in many parts of the world, including Australia [ 7 ], Canada [ 2 , 8 , 9 ], South Africa [ 10 ], the United Kingdom [ 11 ], the United States of America [ 12 – 16 ], and India [ 17 ].…”

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“…Injection drug use-associated bacterial and fungal infections (e.g., skin and soft-tissue infections, endocarditis, osteomyelitis, septic arthritis, and epidural abscess) are associated with significant morbidity and mortality among people who inject drugs (PWID) and are costly for healthcare systems [1][2][3][4][5][6]. The incidence of hospitalization for injecting-related infections is increasing in many parts of the world, including Australia [7], Canada [2,8,9], South Africa [10], the United Kingdom [11], the United States of America [12][13][14][15][16], and India [17].…”