Increased Organ Availability for Transplantation Related to Opioid Epidemic

A letter to the editor (MR Mehra et al. NEJM 2018; 378: 20: 1943-45) provides a perspective on the increasing availability of organs for transplantation from drug overdoses/opioid epidemic from 2000 to 2016.

Key findings:

  • “The drug-abuse epidemic has been associated with a sharp increase in the recovery of organs from brain-dead donors in the United States but not in Europe. “
  • “The U.S. data indicate that survival among recipients from donors who died from drug intoxication is similar to survival among recipients from donors who died from other causes.”

My take: Opioid use is more likely to place one at risk for needing a liver transplantation due to increase acquistion of hepatitis C infection and is more likely to make a donor available due to drug overdoses.

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Hepatitis C Infections Increasing -Tied to Opioid Crisis

Just when it looked like new treatments could eliminate/cure hepatitis C virus (HCV), it turns out that with the opioid epidemic, HCV infections are increasing at a rapid pace (TJ Liang, JW Ward. NEJM 2018; 378: 1169-71).

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Estimated number of new Hepatitis B and Hepatitis C Infections in the U.S. from CDC Data.

Opioid Epidemic Affecting HCV Infection in Adolescents (as well as adults)

SA Barritt et al. J Pediatr 2018; 192: 159-64. Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse

Background:  “After a sustained decline in new HCV cases, in recent years there has been a significant increase in HCV incidence in adults in many areas, primarily associated with the use and abuse of intravenous heroin and prescription opioids.” This study examines this trend in adolescents.

From abstract:

Study design

We examined hospitalizations in children using the Kids’ Inpatient Database, a part of the Healthcare Cost and Utilization Project. We identified cases using the International Classification of Diseases, 9th edition, codes for HCV infection during 2006, 2009, and 2012. Nonparametric tests for trend were used to calculate trend statistics.

Results

From 2006 to 2012 nationally, the number of hospitalizations of children with HCV increased 37% (2.69 to 3.69 per 10 000 admissions; P < .001). The mean age of children hospitalized was 17.6 years (95% CI, 17.4-17.8). HCV cases among those 19-20 years of age represented 68% of the total HCV diagnoses, with a 54% increase over the years sampled (P < .001 for trend). The burden of HCV in children was highest in whites, those in the lowest income quartile, and in the Northeast and Southern regions of the US (all P < .0001). The prevalence of substance use among children with HCV increased from 25% in 2006 to 41% in 2012 (P < .001).

Conclusion

The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.

My take: Despite the availability of highly effective therapy for hepatitis C, the opioid epidemic undermines any prospect for eliminating hepatitis C infections.

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One in Three Americans Used Prescription Opioids in 2015

NBC News: One in Three Americans Took Prescription Opioid Painkillers in 2015

An excerpt: How many Americans are using prescription opioid painkillers? About one in three.

That’s the stunning number in a new survey released Monday from the National Institute on Drug Abuse, which calculated that a whopping 91.8 million Americans used drugs like OxyContin or Vicodin in 2015.

And nearly five percent of the adults surveyed told researchers they took these drugs without their doctor’s permission, the study reported.  They didn’t get their meds from some seedy drug dealer, either.

“The most commonly reported sources were friends and relatives for free,” the study reported. “Or a physician.”

Heroin Epidemic Causing Surge in Hepatitis C Infections

From NPR: Heroin Epidemic is Driving a Spike in Hepatitis C Cases

An excerpt:

The number of new Hepatitis C cases leaped nearly 300 percent from 2010 to 2015, according to a report released Thursday by the Centers for Disease Control and Prevention. And the CDC points to the likely culprit behind the spike in cases of the infectious disease: the use of heroin and other injection drugs.

And despite the existence of therapies that can cure more than 90 percent of infections, the organization says the disease remains a deadly threat. In 2013, for instance, the CDC says some 19,000 people died of their infections.

From CNN: New Hepatitis C Infections Triple due to Opioid Epidemic

The number of new nationally reported infections with the virus swelled from 850 in 2010 to 2,436 cases in 2015, with the highest rates among young people, mainly 20- to 29-year-olds, who inject drugs, according to a new report released Thursday by the Centers for Disease Control and Prevention.

Opioid Use and Liver Transplantation Outcomes

Not surprisingly, a recent study (HB Randall et al. Liver Transplantation 2017; 23: 305-14) has found that use of opioid medications prior to liver transplantation (LT) increased mortality over 5 years after transplantation.

This retrospective cohort study with data from nearly 30,000 patients correlated outcomes with pre-LT opioid exposure.  Overall, 9.3% of recipients filled opioid prescriptions while on the waiting list. Adjusted hazard ratios for death were 1.28 and 1.52 respectively for opioid use of level 3 and level 4.

In the associated editorial (pg 285-7), the authors note that animal models have shown direct hepatotoxic effects of opioid use, though they speculate that the driver for mortality could be due to “sustained opioid use over time or return to illicit drug use.”

A unrelated commentary by CDC director Tom Frieden (AJC “Protect Ga. families from opioid overdose”, March 18, 2018) explains the scope of the opioid epidemic.  “Since 2000, more than 300,000 of our sons, daughters, brothers, sisters, mothers, fathers, and friends have been killed by opiates.  In 19999, approximately 6,000 Americans died from opiate overdose –including both prescription pain medicines … and heroin.  By 2015 that number increased to more than 33,000.”  This is more than a five-fold increase.

He emphasized that opiates serve as a gateway drug for those addicted to heroin; that is, the majority of those hooked on heroin were started on an opioid medication.

My take: The worsened outcomes of LT due to opioids are unfortunately a tiny part of an enormous tragic problem of the opioid epidemic.

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