Opioid epidemic and liver disease

Abstract

Opioid use in the United States and in many parts of the world has reached epidemic proportions. This has led to excess mortality as well as significant changes in the epidemiology of liver disease. Herein, we review the impact of the opioid epidemic on liver disease, focusing on the multifaceted impact this epidemic has had on liver disease and liver transplantation. In particular, the opioid crisis has led to a significant shift in incident hepatitis C virus infection to younger populations and to women, leading to changes in screening recommendations. Less well characterized are the potential direct and indirect hepatotoxic effects of opioids, as well as the changes in the incidence of hepatitis B virus infection and alcohol abuse that are likely rising in this population as well. Finally, the opioid epidemic has led to a significant rise in the proportion of organ donors who died due to overdose. These donors have led to an overall increase in donor numbers, but also to new considerations about the better use of donors with perceived or actual risk of disease transmission, especially hepatitis C. Clearly, additional efforts are needed to combat the opioid epidemic. Moreover, better understanding of the epidemiology and underlying pathophysiology will help to identify and treat liver disease in this high-risk population.

Fig. 1

Drug overdose deaths in the United States from 1999-2017 among all ages and by type of opioid., , , Figure reproduced from. Opioid overdose deaths were identified using ICD-10 codes X40-X44, X60-X64, X85, Y10-Y14, and multiple cause codes T40.0, T 40.1, T40.2, T40.3, T40.4, T40.6. Drugs included natural/semisynthetic opioids, methadone, heroin, synthetic opioids other than methadone, cocaine, and psychostimulants with abuse potential. Death rates are age-adjusted, and calculated by using age-specific death rates and applying them to the 2000 U.S. standard population age distribution. For each type of opioid, multiple cause of death code was T40.1 for heroin, T40.2 for natural and semisynthetic opioids, T40.3 for methadone, and T40.4 for synthetic opioids excluding methadone, T40.5 for cocaine, and T43.6 for psychostimulants with abuse potential. Deaths may involve more than one drug and are not mutually exclusive.

Fig. 2

Incidence of acute hepatitis C infection by age group – United States, 2001-2016. Figure reproduced from

Fig. 3

Hepatitis C infection among pregnant women at time of delivery – United States, 2015., Figure reproduced with permission from. Data were obtained from National Center for Health Statistics. Maternal HCV infection was indicated from infant birth certificates at the time of delivery. Urbanicity was established using data from 2013 NCHS Urban Rural Classification Scheme for Counties.

Fig. 4

Percentage of overdose-death donors in state-wide donor pool, 2000 and 2018. Donor mechanism of death was categorized as overdose (drug intoxication) using the cause of death from the OPTN database of donors.

Fig. 5

Regional variation in percentage of drug-overdose death donors in 2018.

Fig. 6

Overdose deaths and overdose death donors with organs recovered and transplants performed using ODD organs by organ type, 2000-2018. ODD, overdose-death donors.

Fig. 7

Median deceased donor age by HCV serostatus, from 2012-2016. Figure reproduced with permission from.