April 2023"Original Research: Marked Increase in Amphetamine-Related Emergency Department Visits and Inpatient

Marked Increase in Amphetamine-Related Emergency Department Visits and Inpatient Admissions in Toronto, Canada, 2014–2021Accroissement marqué des visites au service d’urgence liées aux amphétamines et de l’hospitalisation de patients à Toronto, Canada, 2014–2021Vitor S. Tardelli, MD MS^1,2,3*

, Samantha Johnstone, BA^1*, Bin Xu, PhD⁴, Soyeon Kim, PhD^5,6, Helena K. Kim, MD PhD⁷, David Gratzer, MD^7,8

, Tony P. George, MD FRCPC^1,7

, Bernard Le Foll, MD PhD MCFP (AM)^3,5 and David J. Castle, MD, FRANZCP^1,7

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The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie
2023, Vol. 68(4) 249‐256
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/07067437221125302
TheCJP.ca | LaRCP.caimg3

AbstractBackground: We report emergency department and inpatient amphetamine-related trends focusing on co-occurring substance use and psychiatric diagnoses at the Centre for Addiction and Mental Health, the largest mental health teaching hospital in Canada.Methods: We describe yearly trends in amphetamine-related Centre for Addiction and Mental Health emergency department visits and inpatient admissions out of all emergency department visits and inpatient admissions between 2014 and 2021, along with proportions of concurrent substance-related admissions and mental/psychotic disorders emergency department visits and inpatient admissions among amphetamine-related contacts; joinpoint regression analyses assessed changes in amphetamine-related emergency department visits and inpatient admissions.Results: Amphetamine-related emergency department visits rose from 1.5% in 2014 to 8.3% in 2021, with a peak of 9.9% in 2020. Amphetamine-related inpatient admissions rose from 2.0% to 8.8% in 2021, with a peak of 8.9% in 2020. Significant increasing trends in the percentage of amphetamine-related emergency department visits happened especially between the second and the fourth quarter of 2014 (quarterly percent change = +71.4, P <0.01). Similarly, the percentage of amphetamine-related inpatient admissions increased mostly between the second quarter of 2014 and the third quarter of 2015 (quarterly percent change = +32.6, P <0.01). The proportion of concurrent opioid-related contacts among amphetamine-related emergency department visits and inpatient admission increased markedly between 2014 and 2021; psychotic disorders in amphetamine-related inpatient admissions more than doubled from 2015 to 2021.Discussion: Prevalence of amphetamine use, mostly from methamphetamine, has been increasing in Toronto as have cooccurring psychiatric disorders and opioid use. Our findings highlight the need for increases in accessible efficacious treatments for complex populations with polysubstance use and co-occurring disorders.Contexte:: Nous rapportons des tendances liées au service d’urgence et aux patients hospitalisés en lien avec les amphétamines, qui sont axées sur l’utilisation de substances et les diagnostics psychiatriques co-occurrents au Centre de toxicomanie et de santé mentale (CAMH), le plus grand hôpital d’enseignement en santé mentale au Canada.Méthodes: Nous décrivons les tendances annuelles des visites liées aux amphétamines au service d’urgence du CAMH et les hospitalisations de patients issues de toutes les visites au service d’urgence et les hospitalisations de patients entre 2014 et 2021, de même que les proportions d’hospitalisations co-occurrentes liées aux substances et aux visites au service d’urgence pour des troubles mentaux/psychotiques et les hospitalisations de patients parmi des contacts liés aux amphétamines; des analyses de régression joinpoint ont évalué les changements des visites au service d’urgence liées aux amphétamines et des hospitalisations de patients.Résultats: Les visites au service d’urgence liées aux amphétamines sont passées de 1,5% en 2014 à 8,3% en 2021, avec une pointe de 9,9% en 2020. Les hospitalisations de patients liées aux amphétamines ont augmenté de 2,0% à 8,8% en 2021, avec une pointe de 8,9% en 2020. Des tendances croissantes significatives du pourcentage des visites au service d’urgence liées aux amphétamines se sont manifestées particulièrement entre le deuxième et le quatrième trimestre de 2014 (variation trimestrielle en pourcentage [VTP] =+71,4, p < ,01). De même, le pourcentage des hospitalisations de patients liées aux amphétamines s”est accru surtout entre le deuxième trimestre de 2014 et le troisième trimestre de 2015 (VTP =+32.6, p < ,01). La proportion de contacts co-occurrents liés aux opioïdes parmi les visites au service d’urgence liées aux amphétamines et l’hospitalisation de patients ont augmenté de façon marquée entre 2014 et 2021; les troubles psychotiques dans les hospitalisations de patients liées aux amphétamines ont plus que doublé de 2015 à 2021.Discussion: La prévalence de l’utilisation d’amphétamines, surtout de méthamphétamine, a augmenté à Toronto tout comme les troubles psychiatriques co-occurrents et l’utilisation d’opioïdes. Nos résultats soulignent le besoin d’augmenter les traitements efficaces accessibles pour les populations complexes de l’utilisation de poly-substances et de troubles co-occurrents.Keywords
methamphetamine, longitudinal studies, hospitals, comorbidityIntroductionThe prevalence of methamphetamine use has been steadily increasing globally, coinciding with similar increases in methamphetamine use disorder and other associated harms (e.g., overdose, emergency department [ED] visits, bloodborne illnesses, and death).¹ Concurrently, rates of simultaneous opioid and methamphetamine use have also seen a dramatic increase.² Co-use may be particularly risky, as it increases the risk of overdose,³ potentially due to stimulant effects “masking” opioid effects or vice versa, resulting in individuals using higher dosages of each.^{4, 5} Individuals with substance use disorders may perceive a benefit to co-use, including methamphetamine prolonging the experience of opioid intoxication or opioids reducing the negative side effects of methamphetamine (e.g., to sleep or reduce withdrawal).⁶ Inspecting the trends of a mental health hospital’s ED and inpatient (IP) visits related to methamphetamine use and co-occurring opioid and psychiatric disorders will be relevant to clinicians and harm reduction service providers.Much of the available evidence in this area comes from the United States,⁷ Australia,⁸ and British Columbia, Canada.³ Despite a 390% increase in methamphetamine-related treatment demand in the province of Ontario from 2012–2017¹ there is very little literature on local trends, and even less on co-occurring mental or other substance use disorders. It has been noted in previous studies that regional patterns can be quite variable,³ being impacted by available resources and the local drug supply. Thus, it is important to analyse geographical overdose “hot spots.” Accordingly, we report ED and IP trends related to methamphetamine use and co-occurring drug use with an emphasis on co-occurring psychiatric diagnoses at the Centre for Addiction and Mental Health (CAMH), Canada’s largest Mental Health teaching Hospital, located in Toronto, Ontario.MethodsSampleOur sample included 90,276 ED visits and 28,834 IP admissions at CAMH between April 2014 and December 2021. This timeframe was chosen due to the availability of standardized data. All data were provided by the CAMH Reporting and Analytics and Performance Improvement sector.Data CollectionWe describe yearly proportions of amphetamine-related ED visits and IP admissions out of all ED visits and IP admissions throughout the study period. All the diagnostic categories reported came from the CAMH electronic medical records filed by ED and IP physicians using the ICD-10.⁹ Amphetamine-related ED visits and IP admissions contained an F15 code including the word “amphetamine”. We also report yearly proportions of amphetamine-related ED visits and IP admissions with concurrent opioid-related diagnoses (all F11 codes). We further report alcohol-related diagnoses (all F10 codes) cannabis-related diagnoses (all F12 codes); other drug-related diagnoses (all F codes except for amphetamine and alcohol codes) to control for potential confounds of general increases in drug use; any psychiatric diagnosis (codes F20–29, F30–39, F40–49, F60–69); and psychotic diagnoses (F20–F29). For this data, we reported the yearly proportion of each of the diagnosis categories described out of all amphetamine-related ED visits and IP admissions. We will use the term “amphetamine-related” visits to refer to the data collected by CAMH, following the institution’s categorization of hospital contacts. Since it is widely known that the trends involving amphetamines are mostly fueled by the increase in the use of methamphetamines, we will use the term “methamphetamine” when not referring specifically to the CAMH internal data.Statistical AnalysisWe used the Joinpoint Trend Analysis Software version 4.8.0.1¹⁰ for statistical analysis. Joinpoint regression models were used to assess the statistical significance of apparent changes in quarterly trends of amphetamine-related ED visits and IP admission. Joinpoint analysis fits a selected data trend into the most parsimonious model allowed by the data (ref – joinpoint software). Trend lines were connected by joinpoints and the significance of each segment was determined using a regression model. The number of joinpoints in each model was determined according to permutation tests (comparing models with different numbers of joinpoints) performed by the software. The trends are described in average quarterly percent changes (QPCs) obtained from a logarithmic-linear model.ResultsBetween April 2014 and December 2021, CAMH had a total of 90,276 ED visits and 28,834 IP admissions. Of those, 5,390 ED visits and 1,773 IP admissions were amphetamine-related, accounting for 6.0% and 6.1% respectively. Sample demographics in 2014 and 2021 are reported in Table 1.Amphetamine-Related ContactsLooking at yearly trends, the proportion of amphetamine-related ED visits out of all ED visits increased from 1.5% in 2014 to 8.3% in 2021, with a peak of 9.9% in 2020. In turn, the amphetamine-related IP admissions among all IP admissions ranged from 2.0% in 2014 to 8.8% in 2021, again peaking in 2020 at 8.9% (see Figure 1).With respect to quarterly trends, the proportion of amphetamine-related ED visits among all ED visits increased from 0.5% in the second quarter of 2014 to 8.0% in the fourth quarter of 2021. The highest proportion of amphetamine-related ED visits was 12.1% in the second quarter of 2020. In turn, amphetamine-related IP admissions among all IP admissions ranged from 1.3% in the second quarter of 2014 to 8.9% in the fourth quarter of 2021, with a peak of 10.3% in the second quarter of 2020.Tab1Fig1Joinpoint analyses were used to identify if there are significant deviations in the overall trend during certain quarterly periods between 2014 and 2021. We observed significant increasing trends in the percentage of amphetamine-related ED visits between the second quarter of 2014 and the fourth quarter of 2014 (QPC = +71.4, P <0.01) and between the fourth quarter of 2014 and the third quarter of 2016 (QPC = + 15.4, P <0.01); after that, there was a non-significant mild increase between the third quarter of 2016 and the third quarter of 2019, followed by a nonsignificant increase between the third quarter of 2019 and the second quarter of 2020 and a nonsignificant decrease in the between the second quarter of 2020 and the fourth quarter of 2021 (see Figure 2). The percentage of amphetamine-related IP admissions increased significantly between the second quarter of 2014 and the third quarter of 2015 (QPC = +32.6, P <0.01) and between the third quarter of 2015 and the fourth quarter of 2021 (QPC =+3.0, P <0.01; see Figure 3).Yearly Proportion of Concurrent Substance use DisordersThe proportion of opioid-related ED visits, among the amphetamine-related visits, increased from 8.2% in 2014 and peaked at 19.8% in 2021, with the lowest proportion in 2015 (4.1%). In comparison, the proportion of alcohol-related ED visits, among the amphetamine-related visits ranged from 15.6% in 2014 and peaked at 17.5% in 2021, with the lowest proportion of alcohol-related ED visits among amphetaminerelated visits at 8.5% in 2015. In turn, the proportion of cannabis-related ED visits, among the amphetamine-related visits ranged from 12.3% in 2014 and peaked at 14.7% in 2021, with the lowest proportion of cannabis-related ED visits at 6.5% in 2015. The proportion of amphetamine-related ED visits including other drug codes (excluding alcohol) ranged from 54.9% in 2014 to 35.8% in 2021. The lowest proportion of ED visits related to other drugs among amphetamine-related visits was of 15.9% in 2018, whereas the highest was observed in 2014 (see Figure 4).With respect to IP admissions, the proportion of opioid-related admissions, among amphetamine-related admissions nearly doubled from 17.1% in 2014 to a peak of 33.8% in 2021. The lowest proportion of opioid-related IP admissions among amphetamine-related visits was of 13.2% in 2015. Conversely, the proportion of alcohol-related admissions among amphetamine-related admissions was 26.3% in 2014 and decreased to 18.5% in 2021, with a peak of 27.6% in 2016 and lowest proportion seen in 2015 (18.4%). In turn, the proportion of cannabis-related IP admissions among amphetamine-related admissions ranged from a peak of 32.9% in 2014 to 27.1% in 2021, with the lowest proportion at 17.4% in 2019. Finally, the proportion related to other drugs (except for alcohol) among amphetamine-related admissions ranged from 52.6% in 2014 to 52.0% in 2021, with the lowest proportion being 42.6%, in 2019, and the highest in 2017 (56.8%) (see Figure 5).Fig2Fig3Fig4Fig5
Yearly Proportion of Concurrent Mental DisordersThe proportion of ED visits with any co-occurring mental disorder among amphetamine-related visits ranged from 25.4% in 2014 to 55.4% in 2021. The lowest figure was seen in 2015 (18.4%), and the highest in 2020 (57.1%; See Figure 5). The proportion of amphetamine-related ED visits with a psychotic disorder ranged from 22.1% in 2014 and 27.3% in 2021, with the lowest proportion in 2018 (15.5%), and the highest in 2020 (29.6%). Relatedly, the proportion of amphetamine-related IP admissions with any co-occurring mental disorder ranged from 63.2% in 2014 to 72.2% in 2021, with the lowest proportion in 2018 (62.9%), and the highest in 2015 (77.2%). Comparatively, the proportion of amphetamine-related IP visits with a co-occurring psychotic disorder nearly doubled from 15.8% in 2014 to 35.1% in 2021. The lowest proportion of psychotic disorders among amphetamine-related IP admissions was in 2014, and the highest in 2020 (36.2%).DiscussionOur findings suggest that Toronto has seen a concerning increase in rates of methamphetamine use paralleling trends seen in the United States,^{7, 11} Australia,⁸ and British Columbia³ and is therefore in need of a corresponding increase in healthcare capacity to respond to growing treatment needs.⁸ Moreover, when inspecting amphetamine-related visits with co-occurring substance use disorders, we found a substantial increase in visits with co-occurring opioid use from 2014 to 2021 relative to visits with co-occurring alcohol, cannabis, or other drug use, which remained relatively stable. These findings support the potential “twin epidemics” emergence of co-occurring methamphetamine and opioid use.⁷ Continuing to monitor the regional trends is imperative for health care providers to facilitate appropriate allocation of resources. While Toronto has seen shifts in attitudes towards harm reduction and an increase in treatment initiatives for opioid use,¹² there remain limited options for individuals who use methamphetamine.¹³ Lack of service is concerning given the increasingly fentanyl-contaminated illegal stimulant supply in the US¹⁴ and Canada,¹⁵ resulting in increasing trends of deaths involving concurrent stimulants and fentanyl, particularly from 2015 onwards.^{14, 16}Notably, our findings also suggest a dramatic increase in individuals presenting with co-occurring psychotic disorders in the context of amphetamines admitted to IP that was not mirrored in ED visits, potentially indicating more severe psychotic presentations such that most individuals who present with co-occurring methamphetamine use and psychosis require admission to the hospital.¹⁷ It is well-known that acute heavy methamphetamine use is associated with the emergence of psychotic-like symptoms (e.g., paranoia and auditory hallucinations), while prolonged use may result in methamphetamine-induced psychotic disorder that remits during abstinence or, in individuals with pre-existing vulnerabilities, exacerbation of a full psychotic disorder that may not remit even during abstinence.¹⁶ Furthermore, methamphetamine use is also associated with depressive and anxious disorders as well as increases in agitation and aggression.^{18, 19} Our findings demonstrate the high psychological burden experienced by individuals who use methamphetamine and further emphasize the need for interventions capable of addressing co-occurring methamphetamine use and mental illness. Unfortunately, much of the extant literature on available treatments excludes individuals with co-occurring mental illnesses, particularly psychosis, leaving it difficult to determine the effectiveness of existing therapeutic interventions.Finally, it should be noted that methamphetamine-related IP and ED admissions peaked in the second quarter of 2020 (April to June), shortly after Ontario’s first coronavirus disease 2019 (COVID-19) lockdown. While not a focus of the present study, this trend parallels findings from other trends data indicating a substantial increase in methamphetamine use,²⁰ opioid overdoses, and utilization of harmreduction and medical system services at the onset of the COVID-19 pandemic.²¹LimitationsLimitations are noted. The data comes from administrative documents from ED and IP units. As such, the quality of the reports is highly dependent on each provider and is potentially subject to reporting bias. The timeframe of the study was limited by changes in data collection methods, and data from before 2014 would therefore not be comparable. Finally, we did not account for multiple visits from repeated individuals when reporting trends.Conclusions and Future DirectionsOur findings suggest that methamphetamine use is a growing problem in the Greater Toronto Area. Affected individuals are in need of targeted interventions, such as evidence-based treatment and increased access to harm reduction initiatives. Moreover, research into the psychological and neurological harms of methamphetamine use needs to be explored in the context of co-occurring opioid use and other substance use, warranting overdose prevention measures for individuals with problematic use of methamphetamine. Finally, research into potential treatments for methamphetamine use needs to take into account that the vast majority of individuals who use methamphetamine also present with other co-occurring substance use disorders and mental disorders.Authors’ NoteBernard Le Foll, Departments of Family and Community Medicine, Pharmacology and Toxicology, Psychiatry, Institute of Medical Sciences and Dalla Lana School of Public Health; University of Toronto.Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bernard Le Foll has obtained funding from Pfizer Inc. (GRAND Awards, including salary support) for investigatorinitiated projects. Le Foll has obtained funding from Indivior for a clinical trial sponsored by Indivior. Le Foll has in-kind donations of cannabis products from Aurora Cannabis Enterprises Inc. and studies medication donations from Pfizer Inc. (varenicline for smoking cessation) and Bioprojet Pharma. He was also provided a coil for a Transcranial magnetic stimulation (TMS) study from Brainsway. Le Foll has obtained industry funding from Canopy Growth Corporation (through research grants handled by the Centre for Addiction and Mental Health and the University of Toronto), Bioprojet Pharma, Alcohol Countermeasure Systems (ACS), Alkermes, and Universal Ibogaine. Lastly, Le Foll has received in-kind donations of nabiximols from GW Pharmaceuticals for past studies funded by CIHR and NIH. He has participated in a session of a National Advisory Board Meeting (Emerging Trends BUP-XR) for Indivior Canada and has been a consultant for Shinogi. He is supported by CAMH, Waypoint Centre for Mental Health Care, a clinician-scientist award from the department of Family and Community Medicine of the University of Toronto and a Chair in Addiction Psychiatry from the department of Psychiatry of the University of Toronto. All other authors have no competing interests to disclose.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.ORCID iDsVitor S. Tardelli

https://orcid.org/0000-0001-6040-7708David Gratzer

https://orcid.org/0000-0002-4578-0050Tony P. George

https://orcid.org/0000-0003-1645-9767David J. Castle

https://orcid.org/0000-0002-3075-1580References

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¹ Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Canada² Departamento de Psiquiatria, Universidade Federal de Sao Paulo, Sao Paulo, Brazil³ Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, Canada⁴ CAMH Reporting and Analytics/Performance Improvement, Toronto, Canada⁵ Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Canada⁶ Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada⁷ Department of Psychiatry, University of Toronto, Toronto, Canada⁸ Centre for Addiction and Mental Health, Toronto, ON, Canada* Those authors contributed equally to this work.Corresponding author:
Vitor S. Tardelli, MD MS, Translational Addictions Research Laboratory, Department of Psychiatry, University of Toronto, 100 Stokes Street, 3rd Floor, Toronto, ON Canada M6J 1H4
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