Fatal opioid overdoses during and shortly after hospital admissions in England: A case-crossover study

Dan Lewer*, Brian Eastwood, Martin White, Thomas D. Brothers, Martin McCusker, Caroline Copeland, Michael Farrell, Irene Petersen

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Hospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death. 

Methods and findings: We conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results. 

Conclusions: Discharge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.

Original languageEnglish
Article numbere1003759
Number of pages15
JournalPLoS Medicine
Issue number10
Publication statusPublished - 5 Oct 2021

Bibliographical note

Funding Information: DL is funded by a National Institute of Health Research Doctoral Research Fellowship [DRF-2018-11-ST2-016]. The views expressed are those of the author(s) and not necessarily those of Public Health England, the NHS, the NIHR or the Department of Health and Social Care. TDB is supported by the Dalhousie University Internal Medicine Research Foundation Fellowship, Killam Postgraduate Scholarship, Ross Stewart Smith
Memorial Fellowship in Medical Research, and Clinician Investigator Program Graduate Stipend (all from Dalhousie University Faculty of Medicine), a Canadian Institutes of Health Research Fellowship (CIHR-FRN# 171259), and through the Research in Addiction Medicine Scholars (RAMS) Program (National Institutes of Health/National Institute on Drug Abuse; R25DA033211). The
funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors have read the journal’s policy and the authors of this manuscript have the following competing interests. MF is Director of the National Drug and Alcohol Research Centre which receives funding from the Australian Federal Government Department of Health. He has also had unrestricted educational grant funding from Indivior, Mundipharma and Seqirius. Other authors declare no competing interests.

Open Access: This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publisher Copyright: © 2021 Lewer et al.

Citation: Lewer D, Eastwood B, White M, Brothers TD, McCusker M, Copeland C, et al. (2021) Fatal opioid overdoses during and shortly after hospital admissions in England: A case-crossover study. PLoS Med 18(10): e1003759.

DOI: https://doi.org/10.1371/journal.pmed.1003759


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