{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T14:17:16Z","timestamp":1790691436435,"version":"4.1.0"},"reference-count":49,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2023,4,19]],"date-time":"2023-04-19T00:00:00Z","timestamp":1681862400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"NIHR-funded programme \u2018Improving Hospital Opiate Substitution Therapy (iHOST)\u2019","award":["NIHR133022"],"award-info":[{"award-number":["NIHR133022"]}]},{"name":"IHR-funded programme \u2018Improving Hospital Opiate Substitution Therapy (iHOST)\u2019","award":["NIHR133022"],"award-info":[{"award-number":["NIHR133022"]}]},{"name":"NIHR Doctoral Research Fellowship","award":["DRF-2018-11-ST2-016"],"award-info":[{"award-number":["DRF-2018-11-ST2-016"]}]},{"name":"Dalhousie University Internal Medicine Research Foundation Fellowship"},{"name":"vCanadian Institutes of Health Research Fellowship","award":["CIHR-FRN#171259"],"award-info":[{"award-number":["CIHR-FRN#171259"]}]},{"name":"Research in Addiction Medicine Scholars (RAMS) Program","award":["R25DA033211"],"award-info":[{"award-number":["R25DA033211"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>We identified 121 coroners\u2019 reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34\u201346); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0283549","type":"journal-article","created":{"date-parts":[[2023,4,19]],"date-time":"2023-04-19T17:29:59Z","timestamp":1681925399000},"page":"e0283549","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":18,"title":["Opioid-related deaths during hospital admissions or shortly after discharge in the United Kingdom: A thematic framework analysis of coroner reports"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3698-7196","authenticated-orcid":true,"given":"Dan","family":"Lewer","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5570-5556","authenticated-orcid":true,"given":"Thomas D.","family":"Brothers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Magdalena","family":"Harris","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1434-7585","authenticated-orcid":true,"given":"Kirsten L.","family":"Rock","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline S.","family":"Copeland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,4,19]]},"reference":[{"key":"pone.0283549.ref001","doi-asserted-by":"crossref","first-page":"e67","DOI":"10.2105\/AJPH.2012.300764","article-title":"All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-Analysis.","volume":"102","author":"J Zlodre","year":"2012","journal-title":"Am J Public Health."},{"key":"pone.0283549.ref002","doi-asserted-by":"crossref","first-page":"1545","DOI":"10.1111\/j.1360-0443.2010.02990.x","article-title":"Meta-analysis of drug-related deaths soon after release from prison: Drug-related deaths after release from prison.","volume":"105","author":"ELC Merrall","year":"2010","journal-title":"Addiction."},{"key":"pone.0283549.ref003","first-page":"357","article-title":"Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies","author":"L Sordo","year":"2017","journal-title":"BMJ"},{"key":"pone.0283549.ref004","doi-asserted-by":"crossref","first-page":"109492","DOI":"10.1016\/j.drugalcdep.2022.109492","article-title":"Increased risk of death immediately after discharge from compulsory care for substance abuse","volume":"236","author":"A Ledberg","year":"2022","journal-title":"Drug and Alcohol Dependence"},{"key":"pone.0283549.ref005","doi-asserted-by":"crossref","first-page":"959","DOI":"10.1136\/bmj.326.7396.959","article-title":"Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study","volume":"326","author":"J. 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The","year":"2002","journal-title":"International Journal of Drug Policy"},{"key":"pone.0283549.ref030","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/s13722-019-0145-5","article-title":"A conceptual model for understanding post-release opioid-related overdose risk.","volume":"14","author":"PJ Joudrey","year":"2019","journal-title":"Addict Sci Clin Pract"},{"key":"pone.0283549.ref031","article-title":"Drug Crime: Statistics for England and Wales.","author":"G Allen","year":"2021","journal-title":"UK House of Commons Library"},{"key":"pone.0283549.ref032","doi-asserted-by":"crossref","first-page":"c5475","DOI":"10.1136\/bmj.c5475","article-title":"Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database","volume":"341","author":"R Cornish","year":"2010","journal-title":"BMJ"},{"key":"pone.0283549.ref033","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1097\/ANS.0000000000000070","article-title":"Toward Cultural Safety: Nurse and Patient Perceptions of Illicit Substance Use in a Hospitalized Setting.","volume":"38","author":"B Pauly","year":"2015","journal-title":"Advances in Nursing Science"},{"key":"pone.0283549.ref034","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1016\/j.annemergmed.2020.02.013","article-title":"Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals","volume":"76","author":"V Eswaran","year":"2020","journal-title":"Annals of Emergency Medicine"},{"key":"pone.0283549.ref035","article-title":"ACMD Naloxone Review.","author":"Advisory Council on the Misuse of Drugs","year":"2022","journal-title":"Advisory Council on the Misuse of 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