Overdose-Associated Admissions Among People Who Inject Opioids at a County Safety-Net Hospital Following Implementation of a Syringe Services Program

Syringe service programs (SSPs) are an evidence-based harm reduction strategy that reduce dangerous sequelae of injection drug use among people who inject drugs (PWID) such as overdose. SSP services include safer injection education and community-based naloxone distribution programs. This study evaluates differences in overdose-associated hospital admissions following implementation of the first legal SSP in Florida, based in Miami-Dade County. Methods We performed a retrospective analysis of hospitalizations for injection drug-related sequelae at a county hospital before and after the implementation of the SSP. An algorithm utilizing ICD-10 codes for opioid use and sequelae was used to identify people who inject opioids (PWIO). Florida Department of Law Enforcement Medical Examiners Commission Report data was used to analyze concurrent overdose death trends in Florida counties. Over the study vs. A total of 26 PWIO and the impact of take-home naloxone programs on hospitalizations. (10) One study of a community take-home naloxone distribution program that operates independent of an SSP found no reduction in emergency department visits or deaths(12). We present a study analyzing the early effects of the IDEA-SSP on incidence of admissions associated with opioid overdose at a county safety-net hospital in south Florida.


Background
Syringe service programs (SSPs) are an evidence-based harm reduction strategy that reduce dangerous sequelae of injection drug use among people who inject drugs (PWID) such as overdose.
SSP services include safer injection education and community-based naloxone distribution programs.
This study evaluates differences in overdose-associated hospital admissions following implementation of the first legal SSP in Florida, based in Miami-Dade County.

Methods
We performed a retrospective analysis of hospitalizations for injection drug-related sequelae at a county hospital before and after the implementation of the SSP. An algorithm utilizing ICD-10 codes for opioid use and sequelae was used to identify people who inject opioids (PWIO). Florida Department of Law Enforcement Medical Examiners Commission Report data was used to analyze concurrent overdose death trends in Florida counties.

Results
Over the 25-month study period, 302 PWIO admissions were identified; 146 in the pre-index vs. 156 in post-index. A total of 26 admissions with PWIO overdose were found; 20 pre-index and 6 post-index (p=0.0034).

Conclusions
Declining overdose-associated admissions among PWIO suggests early impacts following SSP implementation.

Introduction:
In 2017, the Centers for Disease Control and Prevention announced drug overdose mortality hit a record high, with 70,237 Americans dying from overdose.
In 2016, Florida enacted the Infectious Disease Elimination Act, allowing a single pilot syringe services program (SSP) in Florida; the University of Miami IDEA SSP (IDEA). In the year following establishment of IDEA in Miami, approximately 518 PWID enrolled in services, and 795 kits of two 4 mg dose naloxone were distributed to participants. In addition to sterile needles and other injection supplies, participants in the IDEA-SSP are provided with education on safe injection practices. They are also instructed in the use of tester shots (sampling small amounts of a newly acquired drug before using the entire dose), using drugs with trusted friends, and spreading awareness of locations of previous overdose and bad batches-batches with unusually potent or otherwise toxic effects. (4) In addition to exchanging syringes, SSPs provide comprehensive harm reduction services to people who inject drugs (PWID). These services include community distribution of take-home naloxone kits. overdose reversals were reported.(7) Of the overdose reversals reported, 82.8% of individuals that used naloxone to save a life were PWID. Other research shows that PWID deploy take-home naloxone to save a life at a rate nearly ten times that of laypeople who do not use drugs -emphasizing the need to prioritize people who use drugs in naloxone distribution efforts.(8) However, PWID continue to face barriers to naloxone access, including cost and stigma.
Multiple systematic reviews have found take-home naloxone programs to be both safe and effective, leading to increased survival rates among participants and decreases in overdose mortality rates more broadly. (9)(10)(11) Although systemic analyses have found take-home naloxone programs are effective in reducing overdose deaths among program participants, there are few studies that assess the impact of take-home naloxone programs on hospitalizations. (10) One study of a community takehome naloxone distribution program that operates independent of an SSP found no reduction in emergency department visits or deaths (12). We present a study analyzing the early effects of the IDEA-SSP on incidence of admissions associated with opioid overdose at a county safety-net hospital in south Florida.

Methods:
We conducted a retrospective review of hospitalized patients' data at Jackson Memorial Hospital  Table 2). IRI included endocarditis, bacteremia/sepsis, osteomyelitis, abscesses and/or cellulitis diagnoses.
Medical records were abstracted for demographic information, length of stay (LOS), insurance status, and discharge status.

Additionally, we independently analyzed publicly available Florida Department of Law Enforcement
Medical Examiner Commission reports from 2012-2017 to identify state and regional trends in opioidrelated mortality to compare to our local findings. (Fig. 1) Analysis Descriptive statistics and frequency distributions for demographics, insurance status, and hospital use variables were utilized. Hospital use variables included discharge status and LOS for each hospitalization. Categorical data were described with numbers and percentages. Comparisons between pre-and post-index in frequencies of clinical and social demographic characteristics were analyzed by Chi-square or Fisher's exact test. Because some continuous variables, such as age and LOS, were not normally distributed, the Wilcoxon Rank-Sum test was used for the comparisons. The results were reported as median and interquartile range. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC).

Results: Demographics
Of 1360 opioid-related admissions to JMH over the 25-month study period, 302 PWIO admissions were identified; 146 in the pre-index vs. 156 in post-index (Table 1)   However, following SSP implementation, while number of PWIO in our cohort did not change, overdoses reported in PWIO decreased significantly. The temporal association suggests that the IDEA-SSP community distribution of take-home naloxone may have produced early effects in mitigating overdose-associated morbidity and mortality.
Several statewide opioid epidemic interventions were implemented before and directly following the study period, including a concerted law enforcement effort to close "pill mills", the mandated use of Committee. Informed consent was not obtained from participants and a consent waiver was granted.
Data were de-identified prior to analysis.

Consent for publication: Not Applicable
Availability of data and materials: The de-identified dataset is available as Supplementary Title of data: JMH PWIO Description of data: This data consists of the 302 admission of people who inject opioids that we analyzed in this manuscript. Table 2 File