PT  - JOURNAL ARTICLE
AU  - Lowder, Evan Marie
AU  - Amlung, Joseph
AU  - Ray, Bradley R
TI  - Individual and county-level variation in outcomes following non-fatal opioid-involved overdose
AID  - 10.1136/jech-2019-212915
DP  - 2020 Apr 01
TA  - Journal of Epidemiology and Community Health
PG  - 369--376
VI  - 74
IP  - 4
4099  - http://jech.bmj.com/content/74/4/369.short
4100  - http://jech.bmj.com/content/74/4/369.full
SO  - J Epidemiol Community Health2020 Apr 01; 74
AB  - Background A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients.Methods Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics.Results 10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019).Conclusion Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.