One-Year Association of Drug Possession Law Change With Fatal Drug Overdose in Oregon and Washington

Importance

Two states modified laws to remove or substantially reduce criminal penalties for any drug possession. The hypothesis was that removing criminal penalties for drug possession may reduce fatal drug overdoses due to reduced incarceration and increased calls for help at the scene of an overdose.

Objective

To evaluate whether decriminalization of drug possession in Oregon and Washington was associated with changes in either direction in fatal drug overdose rates.

Design, Setting, and Participants

This cohort study used a synthetic control method approach to examine whether there were changes in drug possession laws and fatal drug overdose rates in Oregon and Washington in the postpolicy period (February 1, 2021, to March 31, 2022, in Oregon and March 1, 2021, to March 31, 2022, in Washington). A counterfactual comparison group (synthetic controls) was created for Oregon and Washington, using 48 states and the District of Columbia, that did not implement similar policies during the study period (January 1, 2018, to March 31, 2022). For 2018-2021, final multiple cause-of-death data from the National Vital Statistics System (NVSS) were used. For 2022, provisional NVSS data were used. Drug overdose deaths were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14.

Exposures

In Oregon, Measure 110 went into effect on February 1, 2021. In Washington, the Washington Supreme Court decision in State v Blake occurred on February 25, 2021.

Main Outcome

Monthly fatal drug overdose rates.

Results

Following the implementation of Measure 110, absolute monthly rate differences between Oregon and its synthetic control were not statistically significant (probability = 0.26). The average rate difference post Measure 110 was 0.268 fatal drug overdoses per 100 000 state population. Following the implementation of the policy change in Washington, the absolute monthly rate differences between Washington and synthetic Washington were not statistically significant (probability = 0.06). The average rate difference post Blake was 0.112 fatal drug overdoses per 100 000 state population.

Conclusions and Relevance

This study found no evidence of an association between legal changes that removed or substantially reduced criminal penalties for drug possession in Oregon and Washington and fatal drug overdose rates. Additional research could examine potential other outcomes as well as longer-term associations with fatal drug overdose overall and across racial and ethnic groups.

Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality

BACKGROUND

Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects.

METHODS

We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply.

RESULTS

In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73.

CONCLUSIONS

Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.

Low-Threshold Buprenorphine via Community Partnerships and Telemedicine-Case Reports of Expanding Access to Addiction Treatment During COVID-19

BACKGROUND

To reduce coronavirus disease 2019 (COVID-19) spread, federal agencies eased telemedicine restrictions including audio-only appointments. These changes permitted clinicians to prescribe buprenorphine to patients with opioid use disorder (OUD) without in-person or audio/video assessment. Our clinic utilized existing community collaborations to implement protocols and extend outreach. We describe 3 patients with OUD who engaged with treatment through outreach with trusted community partners and low-threshold telemedicine.

CASE PRESENTATIONS

Patient 1-a 40-year-old man with severe OUD who injected heroin and was living outside. A weekend harm reduction organization volunteer the patient previously knew used her mobile phone to facilitate an audio-only intake appointment during clinic hours. He completed outpatient buprenorphine initiation. Patient 2-a 48-year-old man with severe opioid and methamphetamine use disorders who injected both and was living in his recreational vehicle. He engaged regularly with syringe services program (SSP), but utilized no other healthcare services. Initially, an SSP worker connected him to our clinic for audio-only appointment using their landline to initiate buprenorphine; a harm reduction volunteer coordinated follow-up. Patient 3-a 66-year-old man with moderate OUD used non-prescribed pill opioids without prior buprenorphine experience. He lived over 5 hours away in a rural town. He underwent virtual appointment and completed home buprenorphine initiation.

CONCLUSION

These 3 cases illustrate examples of how policy changes allowing for telemedicine buprenorphine prescribing can expand availability of addiction services for patients with OUD who were previously disengaged for reasons including geography, lack of housing, transportation difficulties, and mistrust of traditional healthcare systems.

Low-barrier buprenorphine during the COVID-19 pandemic: A rapid transition to on-demand telemedicine with wide-ranging effects

Low barrier addiction clinics increase access to medications to treat substance use disorders, while emphasizing harm reduction. The Harm Reduction and BRidges to Care (HRBR) Clinic is an on demand, low barrier addiction clinic that opened in October 2019. In the first three months of operation (November through January 2020), HRBR saw steadily increasing numbers of patients.

Oregon saw its first case of novel coronavirus in February, and declared a state of emergency and enacted a formal “Stay at Home” order in March. That same month, the DEA announced that patients could be initiated on buprenorphine through telemedicine visits without an in-person exam. Within a week of being granted the ability to see patients virtually, HRBR had transitioned to over 90% virtual visits, while still allowing patients without technology to access in-person care. Within four weeks, the clinic expanded hours significantly, established workflows with community harm reduction partners, and was caring for patients in rural areas of the state.

In response to the COVID-19 crisis, the HRBR clinic was able to quickly transition from in-person to almost completely virtual visits within a week. This rapid pivot to telemedicine significantly increased access to care for individuals seeking low-threshold treatment in multiple contexts. Overarching institutional support, grant funding and a small flexible team were critical. HRBR's increased access and capacity were only possible with the Drug Enforcement Agency loosening restrictions around the use of telehealth for new patients. Keeping these altered regulations in place will be key to improving health and health care equity for people who use drugs, even after the pandemic subsides. Further research is needed in to whether addiction telemedicine impacts medication diversion rates, continued substance use, or provider practices.

Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018

BACKGROUND

Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are particularly morbid and mortal consequences of injection drug use.

METHODS

We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018.

RESULTS

From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001).

CONCLUSIONS

In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.

'…to whom it will be extremly Usefull.' Dr William Cullen's adoption of James Watt's copying machine

Dr William Cullen (1710-1790) was a leading physician of the Enlightenment era. As professor in Edinburgh he became the most influential teacher of theoretical and practical medicine in 18th century Britain. A renowned private practitioner, Cullen systematically archived his postal 'consultations', now held by the Royal College of Physicians of Edinburgh. Initially Cullen preserved his replies as transcriptions, but from April 1781 he began using a mechanical copier, newly devised by the Scottish engineer James Watt. This paper describes the development, promotion and functioning of Watt's copier and considers Cullen's own adoption of the machine. It is suggested that with Cullen's adoption of Watt's copier, medical record keeping entered a new historical phase comparable with the recent digital revolution.

‘Any Style But Gothic': Building a Home for the Royal College of Physicians of Ireland

On 15 July 1864 the Royal College of Physicians of Ireland held its first business meeting in its newly built home at 6 Kildare Street, Dublin. Although the Royal College of Physicians of Ireland had been in existence for over 200 years this was the first occasion that a College meeting had been held in a building owned by the College.

This paper looks at the history behind the construction of a home for the Royal College of Physicians of Ireland. It will examine why it took over 200 years for the Physicians to find a permanent home, how they ended up with the building they did, and what they borrowed from the Royal College of Physicians in Edinburgh in the process.