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Open Access

Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis

Jessica Moe, Mei Chong, Bin Zhao, Frank X. Scheuermeyer, Roy Purssell and Amanda Slaunwhite
March 17, 2021 9 (1) E242-E251; DOI: https://doi.org/10.9778/cmajo.20200169
Jessica Moe
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Mei Chong
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Bin Zhao
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Frank X. Scheuermeyer
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Roy Purssell
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Amanda Slaunwhite
Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul’s Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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    Figure 1:

    Kaplan–Meier plot for crude probability of survival, according to disposition, after visits to the emergency department for overdose-related reasons.

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    Figure 2:

    Kaplan–Meier plot for probability of survival, according to combined variable of disposition and overdose-related or non-overdose-related

Tables

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    Table 1:

    Characteristics associated with overdose-related and non-overdose-related visits to emergency departments in British Columbia, 2015–2016

    CharacteristicPatient group and reason for visit; no. (%) of patients*
    All patientsDischargedLeft against medical advice
    Overdose
    n = 3593
    Non-overdose
    n = 216 453
    Overdose
    n = 3133
    Non-overdose
    n = 187 932
    Overdose
    n = 150
    Non-overdose
    n = 7960
    Index visits to ED
    Health authority
     Interior Health73 (2.0)23 432 (10.8)66 (2.1)20 028 (10.7)2 (1.3)765 (9.6)
     Fraser Health1900 (52.9)93 487 (43.2)1652 (52.7)81 882 (43.6)42 (28.0)3694 (46.4)
     Vancouver Coastal Health1407 (39.2)51 274 (23.7)1234 (39.4)44 539 (23.7)96 (64.0)1903 (23.9)
     Island Health67 (1.9)38 952 (18.0)60 (1.9)33 638 (17.9)1 (0.7)1200 (15.1)
     Northern Health137 (3.8)8578 (4.0)113 (3.6)7208 (3.8)8 (5.3)371 (4.7)
     Unknown9 (0.3)730 (0.3)8 (0.3)637 (0.3)1 (0.7)27 (0.3)
    Arrival by ambulance2966 (82.5)33 062 (15.3)2585 (82.5)23 525 (12.5)139 (92.7)1261 (15.8)
    Canadian Triage and Acuity Scale
     1 (resuscitation)128 (3.6)1429 (0.7)73 (2.3)425 (0.2)5 (3.3)7 (0.1)
     2 (emergent)1096 (30.5)31 827 (14.7)888 (28.3)23 023 (12.3)35 (23.3)426 (5.4)
     3 (urgent)2147 (59.8)100 094 (46.2)1968 (62.8)86 752 (46.2)103 (68.7)3393 (42.6)
     4 (less urgent)189 (5.3)73 596 (34.0)174 (5.6)69 851 (37.2)6 (4.0)2679 (33.7)
     5 (nonurgent)19 (0.5)5415 (2.5)19 (0.6)4997 (2.7)0 (0.0)353 (4.4)
     Unknown14 (0.4)4092 (1.9)11 (0.4)2884 (1.5)1 (0.7)1102 (13.8)
    Visit length of stay, h, median (IQR)3.5 (2.2–5.9)2.8 (1.7–4.5)3.5 (2.2–5.8)2.8 (1.7–4.3)3.5 (2.2–5.8)2.8 (1.7–4.3)
    Disposition after index visit
     Discharged3133 (87.2)187 932 (86.8)––––
     Left against medical advice150 (4.2)7960 (3.7)––––
     Admitted or transferred310 (8.6)20 561 (9.5)––––
    Patients
    Sex, female1098 (30.6)108 524 (50.1)939 (30.0)95 837 (51.0)33 (22.0)3724 (46.8)
    Age, yr, median (IQR)35.0 (27.0–46.0)41.0 (28.0–56.0)35.0 (27.0–46.0)42.0 (28.0–56.0)35.0 (27.0–46.0)42.0 (28.0–56.0)
    Age group, yr
     14–351836 (51.1)83 451 (38.6)1618 (51.6)75 016 (39.9)74 (49.3)3815 (47.9)
     36–551458 (40.6)72 846 (33.7)1268 (40.5)64 063 (34.1)63 (42.0)2732 (34.3)
     56–74299 (8.3)60 156 (27.8)247 (7.9)48 853 (26.0)13 (8.7)1413 (17.8)
    Material deprivation quintile†
     1 (most deprived)391 (16.6)37 873 (19.6)331 (16.3)33 318 (19.7)21 (25.6)1297 (18.7)
     2289 (12.3)37 265 (19.3)238 (11.7)32 714 (19.4)11 (13.4)1263 (18.3)
     3347 (14.7)36 920 (19.1)301 (14.8)32 212 (19.1)12 (14.6)1265 (18.3)
     4445 (18.9)38 403 (19.9)392 (19.3)33 381 (19.8)12 (14.6)1375 (19.9)
     5 (least deprived)883 (37.5)42 981 (22.2)771 (37.9)37 144 (22.0)26 (31.7)1719 (24.8)
    Elixhauser index with mental health
     02606 (72.5)197 785 (91.4)2379 (75.9)179 940 (95.7)128 (85.3)7586 (95.3)
     1451 (12.6)10 313 (4.8)339 (10.8)4920 (2.6)10 (6.7)234 (2.9)
     ≥ 2536 (14.9)8355 (3.9)415 (13.2)3072 (1.6)12 (8.0)140 (1.8)
    Elixhauser index without mental health
     03287 (91.5)201 901 (93.3)2909 (92.9)181 496 (96.6)144 (96.0)7748 (97.3)
     1187 (5.2)8478 (3.9)145 (4.6)4251 (2.3)2 (1.3)145 (1.8)
     ≥ 2119 (3.3)6074 (2.8)79 (2.5)2185 (1.2)4 (2.7)67 (0.8)
    Psychiatric comorbidities
     Anxiety561 (15.6)11 032 (5.1)478 (15.3)9035 (4.8)10 (6.7)501 (6.3)
     Depression611 (17.0)13 113 (6.1)499 (15.9)10 379 (5.5)18 (12.0)590 (7.4)
     Schizophrenia364 (10.1)2928 (1.4)319 (10.2)1658 (0.9)12 (8.0)135 (1.7)
     Personality disorders195 (5.4)992 (0.5)161 (5.1)582 (0.3)3 (2.0)45 (0.6)
    ≥ 1 prescription medication in 365 d before index visit
     Opioids for analgesia1232 (34.3)47 502 (21.9)1048 (33.5)40 325 (21.5)54 (36.0)1666 (20.9)
     Opioid agonist therapy1375 (38.3)3985 (1.8)1215 (38.8)2997 (1.6)73 (48.7)411 (5.2)
     Benzodiazepines and z-drugs‡1094 (30.4)32 867 (15.2)934 (29.8)26 845 (14.3)31 (20.7)1280 (16.1)
     Antidepressant and antipsychotic medications1976 (55.0)44 193 (20.4)1702 (54.3)35 988 (19.1)74 (49.3)1920 (24.1)
    Incarceration in 365 d before index visit788 (21.9)2422 (1.1)708 (22.6)1887 (1.0)33 (22.0)230 (2.9)
    Health care encounters in 365 d before index visit, median (IQR)
     Hospitalization0.0 (0.0–1.0)0.0 (0.0–0.0)0.0 (0.0–1.0)0.0 (0.0–0.0)0.0 (0.0–1.0)0.0 (0.0–0.0)
     Ambulance1.0 (0.0–1.0)0.0 (0.0–0.0)1.0 (0.0–1.0)0.0 (0.0–0.0)1.0 (0.0–1.0)0.0 (0.0–0.0)
     Physician visits§15.0 (5.0–39.0)8.0 (3.0–15.0)14.0 (5.0–38.0)7.0 (3.0–14.0)14.0 (5.0–38.0)7.0 (3.0–14.0)
     No. of physicians§10.0 (5.0–18.0)7.0 (3.0–11.0)10.0 (4.0–18.0)6.0 (3.0–11.0)10.0 (4.0–18.0)6.0 (3.0–11.0)
     ED visits2.0 (0.0–5.0)0.0 (0.0–0.0)2.0 (0.0–5.0)0.0 (0.0–0.0)2.0 (0.0–5.0)0.0 (0.0–0.0)
    • Note: ED = emergency department, IQR = interquartile range.

    • ↵* Except where indicated otherwise.

    • ↵† Data for material deprivation were missing for the following numbers of patients: 1238 of all patients with an overdose-related visit, 23 011 of all patients with a non-overdose-related visit, 1100 of patients who were discharged after an overdose-related visit, 19 163 of patients who were discharged after a non-overdose-related visit, 68 of patients who left against medical advice after an overdose-related visit and 1041 of patients who left against medical advice after a non-overdose-related visit.

    • ↵‡ For example, zolpidem and zopiclone.

    • ↵§ Community or outpatient.

    • View popup
    Table 2:

    Crude mortality proportions among persons with overdose-related and non-overdose-related visits to the emergency department, overall and by disposition status

    Disposition and time frame, moType of visit; % of patients who died (95% CI)
    Overdose-relatedNon-overdose-related
    Overall (any disposition)
     10.8 (0.6–1.2)0.4 (0.4–0.4)
     31.8 (1.4–2.3)0.7 (0.7–0.8)
     63.5 (2.9–4.1)1.1 (1.1–1.1)
     125.4 (4.7–6.2)1.7 (1.6–1.8)
    Not admitted*
     10.7 (0.4–1.0)0.1 (0.1–0.1)
     31.6 (1.3–2.1)0.3 (0.3–0.3)
     63.4 (2.8–4.0)0.6 (0.5–0.6)
     125.3 (4.6–6.1)1.0 (1.0–1.1)
    Discharged to home or place of residence
     10.6 (0.4–1.0)0.1 (0.1–0.1)
     31.6 (1.2–2.1)0.3 (0.3–0.3)
     63.3 (2.7–3.9)0.6 (0.5–0.6)
     125.1 (4.4–6.0)1.0 (1.0–1.1)
    Left against medical advice
     12.0 (0.7–6.1)0.2 (0.1–0.3)
     32.0 (0.7–6.1)0.4 (0.3–0.6)
     65.3 (2.7–10.4)0.7 (0.5–0.9)
     128.0 (4.6–13.7)1.3 (1.1–1.6)
    Admitted or transferred
     12.3 (1.1–4.7)2.9 (2.7–3.2)
     33.6 (2.0–6.3)4.6 (4.3–4.9)
     64.8 (3.0–7.9)6.1 (5.8–6.4)
     126.5 (4.2–9.8)8.2 (7.8–8.6)
    • Note: ED = emergency department, CI = confidence interval.

    • ↵* “Not admitted” is a combined category for those who were discharged and those who left against medical advice.

    • View popup
    Table 3:

    Adjusted and unadjusted 12-month mortality hazard ratios for persons with overdose-related versus non-overdose-related visits to the emergency department who were either discharged with approval or left against medical advice

    ModelType of model; hazard ratio (95% CI)
    Adjusted*Unadjusted
    Type of visit and disposition
     Non-overdose-related and discharged1.0 (Ref.)1.0 (Ref.)
     Non-overdose-related and left against medical advice1.4 (1.2–1.7)8.3 (4.7–14.6)
     Overdose-related and discharged3.5 (3.0–4.2)1.3 (1.0–1.6)
     Overdose-related and left against medical advice7.1 (4.0–12.5)5.2 (4.5–6.1)
     Additional contrasts
      Overdose-related v. non-overdose-related visits among those who left against medical advice5.0 (2.7–9.1)6.5 (3.6–11.8)
      Left against medical advice v. discharged among those with overdose-related visits2.0 (1.1–3.6)1.5 (0.9–2.9)
    Age group, yr
     14–351.0 (Ref.)1.0 (Ref.)
     36–552.0 (1.7–2.3)2.1 (1.8–2.4)
     56–744.5 (4.1–5.1)5.2 (4.7–5.9)
    Sex
     Male v. female1.7 (1.6–1.9)1.9 (1.7–2.1)
    Elixhauser index with mental health
     01.0 (Ref.)1.0 (Ref.)
     13.8 (3.3–4.3)5.6 (4.9–6.5)
     ≥ 28.0 (7.1–9.0)10.9 (9.4–12.6)
    • Note: CI = confidence interval, Ref. = reference group.

    • ↵* Adjusted for age, sex, comorbidity and disposition (discharged or left against medical advice).

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Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis
Jessica Moe, Mei Chong, Bin Zhao, Frank X. Scheuermeyer, Roy Purssell, Amanda Slaunwhite
Jan 2021, 9 (1) E242-E251; DOI: 10.9778/cmajo.20200169

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Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis
Jessica Moe, Mei Chong, Bin Zhao, Frank X. Scheuermeyer, Roy Purssell, Amanda Slaunwhite
Jan 2021, 9 (1) E242-E251; DOI: 10.9778/cmajo.20200169
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