The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study

Morphine Equivalent Total Dosage as Predictor of Adverse Outcomes in Opioid Prescribing

OBJECTIVE

The objective of this work was to develop a risk prediction model of opioid overdoses and opioid use disorder for patients at first opioid prescription and compare the predictive accuracy of using morphine equivalent total dosage with daily dosage as predictors.

DESIGN

Records from patients aged 18-79 years with opioid prescriptions between January 1, 2016 and June 30, 2019, no prior history of adverse outcomes, and no malignant cancer diagnoses were collected from the electronic health records system of a medium-sized central Ohio health care system (n = 219,276). A Cox proportional hazards model was developed to predict the adverse outcomes of opioid overdoses and opioid use disorder from patient sociodemographic, pharmacological, and clinical diagnoses factors.

RESULTS

573 patients experienced overdoses and 2,571 patients were diagnosed with OUD in the study time frame. Morphine equivalent total dosage of opioid prescriptions was identified as a stronger predictor of adverse outcomes (C = 0.797) than morphine equivalent daily dosage (C = 0.792), with best predictions from a model that includes both predictors (C = 0.803). In the model with both daily and total dosage predictors, patients receiving a high total/low daily dosage experienced a higher risk (HR = 2.17) than those receiving a low total/high daily dosage (HR = 2.02). Those receiving a high total/high daily dosage experienced the greatest risk of all (HR = 3.09).

CONCLUSIONS

These findings demonstrate the value of including morphine equivalent total dosage as a predictor of adverse opioid outcomes and suggest total dosage may be more strongly correlated with increased risk than daily dosage.

Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis

INTRODUCTION

Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD.

METHODS

Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality.

RESULTS

Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09).

DISCUSSION

Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.

Contemporary Trends in Hospitalizations for Comorbid Chronic Liver Disease and Substance Use Disorders

INTRODUCTION

Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics.

METHODS

We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time.

RESULTS

Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors.

DISCUSSION

In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.

Heroin use is associated with liver fibrosis in the Miami Adult Studies on HIV (MASH) cohort

BACKGROUND

People who use opioids and people living with HIV (PLWH) are at increased risk for liver-related morbidity and mortality. Although animal models suggest that chronic opioid use may cause liver damage, research in humans is limited. We aimed to determine whether opioid use, particularly heroin, was associated with liver fibrosis.

METHODS

Cross-sectional analysis of 679 participants (295 HIV/HCV uninfected, 218 HIV mono-infected, 87 HCV mono-infected, 79 HIV/HCV coinfected) from the Miami Adult Studies on HIV (MASH) cohort. Liver fibrosis was assessed via magnetic resonance elastography (MRE) on a 3 T Siemens MAGNETOM Prisma scanner.

RESULTS

A total of 120 (17.7 %) participants used opioids. Liver fibrosis was present in 99 (14.6 %) participants and advanced liver fibrosis in 31 (4.6 %). Heroin use (N = 46, 6.8 %) was associated with HCV-seropositivity, smoking, misuse of prescription opioids, and polysubstance use. The use of heroin, but not misuse of prescription opioids, was significantly associated with liver fibrosis (OR = 2.77, 95 % CI: 1.18-6.50) compared to heroin non-users, after adjustment for confounders including excessive alcohol consumption, polysubstance use and HIV and HCV infections. Both HIV and HCV infections were associated with liver fibrosis, whether virally suppressed/undetectable or viremic.

CONCLUSIONS

Heroin use was independently associated with increased risk for liver fibrosis irrespective of the use of other substances and HIV or HCV infections. Both HIV and HCV were associated with higher risk for liver fibrosis, even among those with suppressed or undetectable viral loads. The exact mechanisms for opioid-induced liver fibrosis remain to be fully elucidated.

Chronic Liver Disease and Silymarin: A Biochemical and Clinical Review

Chronic liver disease (CLD) is an under-recognized epidemic that continues to increase in prevalence and is a major health concern. Silymarin, the active compound of Silybum marianum (Milk thistle), has historically been used in CLD. A significant barrier to silymarin use is its poor bioavailability. Attempts at improving the bioavailability of silymarin have led to a better understanding of formulation methods, pharmacokinetics, dosing, and associated drug interactions. Clinically, silymarin exerts its hepatoprotective effects through antioxidative, antifibrotic, anti-inflammatory, antitoxin, and anticancerous mechanisms of actions. Despite the use of silymarin being extensively studied in alcoholic liver disease, metabolic-associated fatty liver disease, viral hepatitis, and drug-induced liver injury, the overall efficacy of silymarin remains unclear and more research is warranted to better elucidate the role of silymarin in CLD, specifically regarding its anti-inflammatory effects. Here, we review the current biochemical and clinical evidence regarding silymarin in CLD.