Astronomical Rise in Amphetamine-Related Hospitalizations, Costs

Batya Swift Yasgur, MA, LSW

October 22, 2018

Amphetamine-related hospitalizations more than tripled from 2003 through 2015, and related costs hospital costs rose fivefold, new research shows.

Investigators used hospital discharge data of a nationally representative sample of more than 1.2 million US adults and found that during the 13-year period from 2003 through 2015, amphetamine-related hospitalizations rose from 59,600 to more than 206,000.

The number of hospitalizations that involved both opioids and amphetamines was six times higher in 2015 than in 2003.

Amphetamine-related hospital costs jumped from $436 million in 2003 to $2.17 billion in 2015.

"We believe the majority of these hospitalizations are likely related to illicit methamphetamine," lead author Tyler Winkelman, MD, clinician-investigator, Division of General Internal Medicine, Hennepin Healthcare Center for Patient and Provider Experience, Hennepin Healthcare Research Institute, and assistant professor, Departments of Medicine and Pediatrics, University of Minnesota, Minneapolis, told Medscape Medical News.

"Serious, problematic amphetamine use may be an emerging public health problem, and as the United States continues to grapple with the opioid epidemic, prevention and treatment practices should be developed that can be applied to substance use issues beyond opioid use disorders alone," he said.

The study was published online October 19 in JAMA Network Open.

New Surge

"Largely overshadowed by the opioid epidemic, deaths from psychostimulants increased more than 250% between 2008 and 2015 after a period of declining amphetamine use," the authors write.

Although amphetamine use — primarily illicit methamphetamine hydrochloride — surged in the early 2000s, it began to decline in the mid-2000s as precursors to methamphetamine production were restricted.

Preliminary evidence suggests that since then, amphetamine-related use of treatment facilities and emergency departments (EDs) has again increased.

Nationally representative surveys are designed to be the key source of information regarding the prevalence of the use of substances, but they have not indicated a concurrent increase in methamphetamine use among community-dwelling individuals in the United States. This differs from reports based on other data sources, the authors note.

Trends in amphetamine-related hospitalizations and associated costs "have not been defined, but they could serve to clarify important population-level trends in serious amphetamine use and its implications for health," they write.

To clarify this discrepancy, the researchers used data from the National Inpatient Sample, part of the Healthcare Cost and Utilization Projects sponsored by the Agency for Healthcare Research and Quality, to examine three key issues: the frequency of amphetamine-related hospitalizations over time; hospital-related factors, such as length of stay (LOS) and in-hospital mortality among those patients hospitalized with and those hospitalized without a diagnosis of amphetamine use; and costs associated with amphetamine-related hospitalizations.

The sample included all amphetamine-related hospitalizations between January 1, 2003, and December 31, 2015, of US adults aged 18 years or older (n = 1, 292,300; 41.9% women; mean age, 35.5 years [95% confidence interval (CI), 37.4 - 37.7 years]).

Because use of opioids and other substances also increased during this period, the researchers examined the number of amphetamine-related hospitalizations associated with co-occurring diagnoses related to opioids or other substances (eg, alcohol, cannabis, cocaine, hallucinogens, tranquilizers, or hypnotics).

However, they only examined hospitalizations with a diagnosis code for amphetamine dependence, abuse, or poisoning in the first position.

The number of amphetamine-related hospitalizations was assessed in each year by hospital region.

The researchers also compared trends in amphetamine-related hospitalizations to trends in other substance use–related hospitalizations during the study period.

"Amphetamine-related hospitalization" was defined as a hospitalization in which "a clinician identified current amphetamine dependence or abuse, or amphetamine poisoning, as one of the issues relevant to the hospital stay."

The researchers used weighted frequencies to describe the characteristics of hospitalizations with and those without an amphetamine-related diagnosis.

Age, Race, Ethnicity All Factors

Amphetamine-related hospitalizations were more likely than other hospitalizations to be associated with age <65 years (98.0% vs 58.0%; P < .001), male sex, (60.3% [95% CI, 59.7% - 60.8%] vs 41.1% [95% CI, 40.9% - 41.3%]), and residence in the western United States (58.5% [95% CI, 55.9% - 61.0%] vs 18.9% [95% CI, 18.0% - 19.8%]).

Native American race/ethnicity was three times more common among amphetamine-related hospitalizations than among other hospitalizations. Hispanic race/ethnicity was also more common; African American race/ethnicity was less common.

One quarter of amphetamine-related hospitalizations were associated with alcohol or cannabis use, and 1 in 5 were associated with opioid use.

Among amphetamine-related hospitalizations, substance use and mental health disorders accounted for nine of the top 15 primary diagnoses. Skin and subcutaneous tissue infections and cardiovascular comorbidities were also common.

Between 2003 and 2005, the number of amphetamine-related hospitalizations increased from 59,684 to 83,873, "consistent with known methamphetamine trends in the mid-2000s," the authors report.

By 2008, these hospitalizations had declined to 55,447 (95% CI, 44,936 - 65,959) but subsequently rose by >270%, to 206,180 (95% CI, 189,188 - 223,172), between 2008 and 2015.

More than half of these hospitalizations were associated with ≥1 additional substances throughout the study period. In 2015, 64.1% of amphetamine-related hospitalizations were associated with ≥1 additional substances.

In 2015, there were more than six times (537%) the number of hospitalizations involving both opioids and amphetamines compared to 2003.

Primary hospital diagnoses related to amphetamine use increased ninefold, from 1234 in 2008 to 11,780 in 2015.

Compared with changes in other substance-related hospitalizations between 2008 and 2015, amphetamine-related hospitalizations increased "to a substantially larger degree," the authors report.

For example, hospitalizations with an amphetamine-related diagnosis in any position increased 245.2%, compared with 45.9% for opioid-related hospitalizations and 24.8% for hospitalizations related to any substance.

Socioeconomic, Geographic Differences

Although amphetamine-related hospitalizations more than doubled in all US census regions between 2008 and 2015, they were substantially higher in the western United States and were lowest in the Northeast United States, compared with Southern and Midwestern regions.

Adjusted mean LOS was ≥1 days longer, and transfer rates to another facility were significantly higher (P < .001) for amphetamine-related hospitalizations, compared with other hospitalizations.

Amphetamine-related hospitalizations were associated with a 29% higher mortality rate, compared to other hospitalizations — possibly "associated with known cardiovascular effects of amphetamine use," the authors suggest.

Although costs per hospitalization were statistically significantly lower among amphetamine-related hospitalizations compared with other hospitalizations, total hospital costs related to amphetamines increased substantially, from $436 million in 2003 to $2.17 billion by 2015.

Between 2013 and 2015, the costs of hospitalizations for an amphetamine-related diagnosis covered by Medicaid jumped from $563 million to $1.25 billion. This represented approximately 57.6% of hospital costs for amphetamine-related hospitalizations in 2015.

However, among the uninsured population, amphetamine-related hospital costs decreased from $335 million in 2013 to $244 million in 2015.

"Amphetamine-related hospitalizations increased over 270% between 2008 and 2015, and, although opioid-related hospitalizations were more common, amphetamine-related hospitalizations increased to a much larger degree," said Winkelman.

"After accounting for population growths, amphetamine hospitalizations grew 245% between 2008 and 2015, whereas opioid-related hospitalization increased only by 46%," he added.

He noted that amphetamine-related hospitalizations were more likely to be covered by Medicaid and to have occurred in the western United States.

"Amphetamine-related hospitalizations in our study were associated with socioeconomic characteristics and geographic patterns consistent with trends in methamphetamine use," he said.

Beyond Opioids

Commenting on the study for Medscape Medical News, Wilson Compton, MD, deputy director, National Institute on Drug Abuse, who was not involved with the study, said the findings "add significantly to our knowledge of how devastating methamphetamine has become for many parts of the country.

"The increased costs, estimated to be over $2 billion in 2015, constitute a remarkable finding," he said.

"While all of our attention has been on opioids, this other significant public health concern [amphetamine use] has been growing," Compton added.

He emphasized that clinicians should "be aware that this is a growing problem and work with treatment programs so that they have appropriate facilities to refer patients to if they have stimulant-related disorders, just as they would for other substances."

Winkelman pointed out that the majority of amphetamine-related hospitalizations were associated with at least one additional substance.

"Individuals who are hospitalized for amphetamine-related complications should be screened for additional substance use and referred to substance use treatment — although, unlike opioids, no pharmacologic treatment options currently exist for amphetamine use disorders," he added.

This study was supported in part by a career development award from Hennepin Healthcare. Dr Winkelman received grants from Hennepin Healthcare during the conduct of the study and is a staff physician at the Hennepin County Adult Detention Center. The other authors' disclosures of relevant financial relationships are listed in the original article. Dr Compton has disclosed no relevant financial relationships.

JAMA Network Open. Published online October 19, 2018. Full text

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