Journal of Critical Care 37 (2017) 259–260
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Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes We read with interest the article by Pfister et al [1], entitled “Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes.” In a retrospective study, Pfister and colleagues studied adult patients admitted to the intensive care unit (ICU) due to opioid overdose (OD). Of 178 adult patients, 107 (60%) were women. The median age was 41 years. Oxycodone and hydrocodone were the 2 most commonly misused opioids, and tobacco smoking, chronic pain, and alcoholism were the most frequent comorbidities identified in the investigation. Pfister et al conclude that OD is a common cause of ICU admission and affects a relatively young population. We would like to commend Pfister et al for an insightful report on illuminating epidemiology and outcomes of OD leading to ICU admission. However, we also would like to point out that the present study did not address an important issue: that is, many of these overdose patients admitted to the ICU might choose to do so intentionally. Self-harm is largely underrecognized in the general population [2]. An estimated 2 million Americans purposely harm themselves every year. That is about 30 times the published rate of suicide attempts in the United States and 140 times the rate of “successful” suicides [3]. Understanding the differences between unintentional and intentional overdoses is essential to clarify prevention strategies [4]. Information gained from nonfatal cases may, therefore, be generalized to fatal cases. It is well established that nonfatal unintentional OD is associated with future OD [5]), and suicide attempts are associated with suicide [4]. Thus, the study and prevention of unintentional and intentional ODs should be a public health priority. Rockett and Caine [6] argue that establishing an individual's intention to die has been a central element separating suicides from fatal self-harming acts that are labeled “accidents” or “unintentional” deaths. Rockett et al [7] believe that this is a false dichotomy at the level of populations which masks the overall magnitude of fatalities arising from deliberate, self-destructive behaviors. This dichotomy is responsible for muting the urgency for demanding effective preventive interventions and is particularly problematic as the nation experiences a persisting and growing epidemic of opioid and other drug-poisoning deaths [6]. Recently, Curtin and colleagues [8] reported that suicide rates in the United States had increased almost steadily from 1999 through 2014. The most frequent suicide method in 2014 for males involved the use of firearms (55.4%), while poisoning was the most frequent method for females (34.1%). From 1999 through 2014, the age-adjusted suicide rate increased 45% for females and 16% for males [8]. In a recent article by Szymanski and colleagues [9], the authors investigated the drug type and current risk factors in suicide deaths by
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reviewing records from New Mexico's Office of the Medical Investigator database between 2008 and 2012. Of 342 suicide cases due to suicide overdoses, psychiatric illness was present in 72% of cases, and chronic pain was seen in 27.2% cases. Szymanski et al also allude to a dilemma: although it is well recognized that chronic pain alone is associated with an increase in suicidal thoughts and attempts and can be considered a predictor for suicide, most overdose deaths associated with chronic pain are deemed accidental in manner [9]. There is abundant evidence in literature of alcohol use disorders, opioid use disorders, and intravenous drug use on suicide [10]. In a report entitled “Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies” [10], Wilcox and colleagues [10] estimated that mortality ratios for suicide after standardization were seen in alcohol use disorder (979; 95% confidence interval [CI], 898-1065; P b .001), opioid use disorder (1351; 95% CI, 1047-1715; P b .001), intravenous drug use (1373; 95% CI, 1029-1796; P b .001), and mixed drug use (1685; 95% CI, 1473-1920; P b .001). The patient demographics of the study by Pfister et al demonstrates a high prevalence of comorbidities, for example, tobacco usage, having chronic pain, alcohol usage, and having depression in 48%, 44%, 39%, and 29%, respectively. The authors also comment on the unexpected finding that white women in their fifth decade were the most common patients to require ICU stays, in contrary to previous data showing men are more likely to visit emergency departments for opioid OD than women [11,12]. It is unclear whether in the study by Pfister et al, chronic pain is significantly more prevalent in women and if their chronic pain might be the underlying reason for their OD. In summary, research such as that presented in this investigation is important; however, focus needs to be directly on implementation of preventive measures, which ultimately save lives. It is clearly easier to distinguish intentions from nonfatal OD because information is much more obtainable in survivors and can be generalized in many aspects with potential future OD. This focus not only is important but also would make the present investigation much more valuable for clinicians, as they attempt to provide best practice solutions for this very difficult and challenging population. External funding None. Conflict of interest None.
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Letter / Journal of Critical Care 37 (2017) 259–260
Xiulu Ruan, MD Department of Anesthesiology, Louisiana State University Health Science Center, 1542 Tulane Ave, New Orleans, LA 70112 Corresponding author. Tel.: +1 504 568 2315 E-mail address:
[email protected] Jin Jun Luo, MD, PhD1 EMG/Neuromuscular Medicine, Temple University School of Medicine 3401 North Broad St, Suite C525, Philadelphia, PA 19140 E-mail address:
[email protected] Alan David Kaye, MD, PhD2 Department of Anesthesiology, Louisiana State University Health Science Center, 1542 Tulane Ave, New Orleans, LA 70112 E-mail address:
[email protected]
http://dx.doi.org/10.1016/j.jcrc.2016.08.029
1
Tel.: +1 215 707 3915.
2
Tel.: +1 504 568 2315.
References [1] Pfister GJ, Burkes RM, Guinn B, Steele J, Kelley RR, Wiemken TL, et al. Opioid overdose leading to intensive care unit admission: epidemiology and outcomes. J Crit Care 2016;35:29–32. [2] Ruan X, Bydalek K, Chiravuri S. Deliberate self-harm following bariatric surgery. JAMA Surg 2016;151:585. [3] Fortescue EB. Mercy. JAMA 2015;314:1231–2. [4] Britton PC, Bohnert AS, Wines JD, Conner KR. A procedure that differentiates unintentional from intentional overdose in opioid abusers. Addict Behav 2012;37:127–30. [5] Britton PC, Wines JD, Conner KR. Non-fatal overdose in the 12 months following treatment for substance use disorders. Drug Alcohol Depend 2010;107:51–5. [6] Rockett IR, Caine ED. Self-injury is the eighth leading cause of death in the United States: it is time to pay attention. JAMA Psychiatry 2015;72:1069–70. [7] Rockett IR, Kapusta ND, Coben JH. Beyond suicide: action needed to improve selfinjury mortality accounting. JAMA Psychiatry 2014;71:231–2. [8] Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 19992014. NCHS Data Brief 2016. [9] Szymanski LJ, Aurelius MB, Szymanski SA, Lathrop SL. Suicidal drug overdoses in New Mexico: a 5-year retrospective review. J Forensic Sci 2016. [10] Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend 2004;76:S11–9. [11] Hasegawa K, Brown DF, Tsugawa Y, Camargo CA. Epidemiology of emergency department visits for opioid overdose: a population-based study. Mayo Clin. Proc., vol. 89. Elsevier; 2014. p. 462–71. [12] Hasegawa K, Espinola JA, Brown DF, Camargo CA. Trends in US emergency department visits for opioid overdose, 1993-2010. Pain Med 2014;15:1765–70.
