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醫院外與芬太尼相關的藥物過量死亡

 

醫院外與芬太尼相關的藥物過量死亡

資料來源:2023 6 21 日發表在 NEJM.org

 

    致編輯:2022 3 月,美國 12 個月藥物過量死亡人數達到了歷史最高水平,估計有 110,360 人死亡。 大流行期間非法藥物供應的變化導致更多與芬太尼相關的過量死亡。 芬太尼的效力及其起效的速度有可能增加用藥過量死亡率,特別是對於無法及時接受醫療照護的人群。

    我們使用國家衛生統計中心的死因數據來評估 Covid-19 大流行之前發生在醫院外的藥物過量死亡,並與大流行初期(2016 年至 2021 年)發生的死亡進行比較 過量死亡根據是否涉及美沙酮以外的合成阿片類藥物(主要是芬太尼)、另一種不含芬太尼的阿片類藥物或不含阿片類藥物進行分類。 死亡地點被分為醫院外、醫院或其他醫療機構內,我們計算了每百萬美國人口的年死亡發生率。 卜瓦松回歸模型用於計算死亡率的變化。 我們使用連接點統計軟件進行回歸分析,以確定每種藥物類別的院外用藥過量死亡百分比趨勢的變化。 有關研究中使用的方法和數據分析的詳細信息,請參閱補充附錄,該附錄與本信全文可一起在 NEJM.org 上獲取。

1. 按地點和藥物類型劃分的藥物過量死亡趨勢。 圖中顯示了 2016 年至 2021 年每 100 萬美國人口因藥物過量死亡的人數,這一時期涵蓋了 Covid-19 大流行開始之前和之後的幾年。

 

我們發現,在大流行初期,服藥過量死亡人數有所增加,主要是由與芬太尼相關的院外死亡造成的,從 2016 年的每百萬人 46.6 人增加到 2021 年的每百萬人 178.0 人,增加了 282%95 % 信賴區間 [CI]275 289)(圖 1)。 2016 年,所有藥物過量死亡的 74.1% 發生在醫院外,這一比例在 2020 年增至 78.0%2021 年增至 78.6% 2021 年,芬太尼藥物過量死亡的 83.0% 發生在醫院外,而 2021 年不涉及芬太尼的阿片類藥物過量死亡這一比例為 76.1%;以及不包括阿片類藥物的過量死亡為67.8% 芬太尼過量的院外死亡比例有所增加(年度百分比變化,1.6%95% CI1.1 2.0),同時其他阿片類藥物過量的比例保持相似(年度百分比變化,0.1% 95% CI-0.2 0.3)和非阿片類藥物過量(年度百分比變化,-0.3%95% CI-1.1 0.5)。 補充附錄表 S1 S4 提供了有關每年過量用藥死亡、發病率變化和死亡地點的更多數據。

連接點回歸分析 (Joinpoint regression analysis) 確定了大流行第一年和第二年期間每種藥物類別在醫院外發生的服藥過量死亡比例的趨勢變化。 Covid-19 大流行初期,院外用藥過量死亡人數的增加顯示,由於芬太尼的參與不斷增加,藥物過量的嚴重程度有所增加。

 

Molly M. Jeffery,博士,MPP; 瑪麗亞·史蒂文斯,文學碩士,公共衛生碩士 明尼蘇達州羅切斯特梅奧診所。 jeffery.molly@mayo.edu

Gail DOnofrio,醫學博士 ;Edward R. Melnick,醫學博士、M.H.S. ,康乃狄克州紐黑文耶魯大學。

本信的內容完全由作者負責,並不一定代表美國國立衛生研究院的官方觀點。 透過與策略協調辦公室簽署的合作協議 (U24AT009676) 以及與國家藥物濫用研究所簽署的合作協議 (UH3DA047003),得到美國國立衛生研究院 (NIH) 衛生保健系統研究合作實驗室共同基金的支持。 作者提供的披露表格與本信全文可在 NEJM.org 上獲取。

這封信於 2023 6 21 日發表在 NEJM.org 上。

DOI10.1056/NEJMc2304991

 

 

 

 

 

Fentanyl-Associated Overdose Deaths Outside the Hospital

This letter was published on June 21, 2023, at NEJM.org.

 

To the Editor: In March 2022, 12-month drug-overdose fatalities reached their highest recorded level in the United States, with an estimated 110,360 deaths. Changes in the illicit drug supply during the pandemic have resulted in more fentanyl-associated overdose deaths. The potency of fentanyl and the rapidity of onset of its effect have the potential to increase overdose mortality, especially among people who are unable to receive timely medical care.

We used cause-of-death data from the National Center for Health Statistics to evaluate drug-overdose deaths that occurred outside the hospital before the Covid-19 pandemic as compared with deaths that occurred during the early years of the pandemic (2016 through 2021). Overdose deaths were categorized according to whether they involved a synthetic opioid other than methadone (primarily fentanyl), another opioid without fentanyl, or no opioid. The place of death was categorized as outside a hospital or in a hospital or other medical setting, and we calculated the annual incidence of death per million U.S. population. Poisson regression models were used to calculate changes in mortality. We used Joinpoint statistical software to perform regression analysis to identify changes in trends in the percentage of out-of-hospital overdose deaths in each drug category. Details regarding the methods and data analysis used in the study are available in the Supplementary Appendix, available with the full text of this letter at NEJM.org.

Figure 1. Trends in Drug-Overdose Deaths, According to Location and Drug Type. Shown are the number of deaths from drug overdoses per 1 million U.S. population from 2016 through 2021, a period that encompassed the years immediately before and after the start of the Covid-19 pandemic.

 

We found that overdose deaths increased during the early pandemic period and were driven primarily by out-of-hospital deaths that were associated with fentanyl, which increased from 46.6 per million in 2016 to 178.0 per million in 2021, a 282% increase (95% confidence interval [CI], 275 to 289) (Fig. 1). In 2016, 74.1% of all overdose deaths occurred outside the hospital, a percentage that increased to 78.0% in 2020 and 78.6% in 2021. Deaths occurred outside the hospital in 83.0% of fentanyl overdoses in 2021, as compared with 76.1% of opioid-overdose deaths without fentanyl involvement and 67.8% of overdose deaths that did not include opioids. The proportion of out-of-hospital deaths increased for fentanyl overdoses (annual percent change, 1.6%; 95% CI, 1.1 to 2.0) at the same time that the proportions remained similar for other opioid overdoses (annual percent change, 0.1%; 95% CI, −0.2 to 0.3) and nonopioid overdoses (annual percent change, −0.3%; 95% CI, −1.1 to 0.5). Additional data regarding yearly overdose deaths, changes in incidence, and place of death are provided in Tables S1 through S4 in the Supplementary Appendix.

Joinpoint regression analysis identified changes in trend in the proportion of overdose deaths that occurred outside the hospital for each drug category during the first and second years of the pandemic. The increase in out-of-hospital overdose deaths during the early years of the Covid-19 pandemic suggests that drug overdoses had increased in severity because of the increasing involvement of fentanyl. 

 

Molly M. Jeffery, Ph.D., M.P.P. Maria Stevens, M.A., M.P.H. Mayo Clinic Rochester, MN jeffery.molly@mayo.edu Gail D’Onofrio, M.D. Edward R. Melnick, M.D., M.H.S. Yale University New Haven, CT

The content of this letter is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Supported by the National Institutes of Health (NIH) Common Fund of the NIH Health Care Systems Research Collaboratory through a cooperative agreement (U24AT009676) with the Office of Strategic Coordination and by a cooperative agreement (UH3DA047003) with the National Institute on Drug Abuse. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on June 21, 2023, at NEJM.org.

DOI: 10.1056/NEJMc2304991

 

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