“There’s a lot of things that lead to organ donation,” says Jean Emond, the head of transplantation at New York Presbyterian/Columbia Medical Center. “None are great.”
“Accidents,” he continues. “Strokes. Overdoses have always been a significant part of the overall supply. But in the last three to five years”—years that coincide with the surging opioid epidemic—”they’ve become very noticeable.”
Data from the federal Organ Procurement and Transplant Network (OPTN), provided to Opioid Watch by the United Network of Organ Sharing (UNOS), show that the number of organ donors who died from overdose increased from 84 in 2001 to 1,370 last year. (UNOS is the private, nonprofit organization that coordinates organ transplants on behalf of the federal government.)
Put another way, such individuals constituted just 1.4 percent of all transplant donors in 2001, while last year they accounted for 13.3 percent—nearly a tenfold increase.
The numbers get even more dramatic when one focuses on organs rather than donors—since a donor often donates more than one organ. The number of organs donated due to fatal overdose grew from 149 in 2000 to 3,533 in 2016— a 24-fold increase—according to a Johns Hopkins School of Medicine study published in the Annals of Internal Medicine on Tuesday, which also relies on OPTN data.
As for kidneys—the most widely sought transplant organ—the number sourced from overdose victims more than doubled in the past five years, from 869 in 2013 to 2,071 last year, according to UNOS.
“They’re numbers we’re grateful for, but not ones we take joy in,” says Jeffrey Veale, a transplant surgeon at the UCLA Ronald Reagan Medical Center in Los Angeles.
“I hear the stories from families when I go to pick up the organs,” Veale says. “A dad with a back injury, for instance, who needed to go back to work and so kept upping his dose of pain killers.”
Waiting lists for transplant organs have actually waned over the past five years, dropping from a peak of 123,851 at the end of 2014 to 115,759 at the end of last year—a nearly 7 percent drop, according to data provided by UNOS. A spokesperson for the group cautions, however, that while the increase in overdose victims was a contributor to the decline, it was not the exclusive one, and a change in kidney allocation policy also affected the numbers.
A very troubling fact, though—the subject of both the recent Johns Hopkins research and a study published in Tranplantation last July, led by Michael Volk of the Transplantation Institute of Loma Linda University—is that not all organs made available by overdose victims are used.
“The [US Centers for Disease Control and Prevention] has defined a group of 28 history categories that they view as carrying increased risk for infectious disease,” explains Emond. “Incarcerated people, for instance. Prostitutes. Injection-drug use.”
Surgeons must inform the potential recipient that he or she is being offered an “increased-risk” organ, as they are labeled.
“What’s frustrating for us,” continues Emond, “is that when you have these conversations, it upsets them. Frightens them. Even though the organ donor is tested with molecular tests for hepatits B, hepatitis C, and HIV. The increased risk is often about one in 10,000, while there’s a one in five chance of dying without a transplant.” (The greatest risk, he says, is presented by donors who die with a needle still in their arm. But even then, he says, the likelihood of infection is slim—between 0.5 and 1 percent.)
The warnings do appear to deter some people from accepting available transplant organs. According to the recent Johns Hopkins study, led by Christine Durand and Mary Bowring, only 1.8 percent of organs from trauma victims were rejected, compared to 5.2 percent of organs from overdose victims.
Those rejecting increased-risk organs may be making a poor wager. Still another Johns Hopkins study, published last November in the American Journal of Transplantation, found that only 31 percent of those who turned down increased-risk kidneys had yet received a normal-risk kidney five years later. And those who did take an increased-risk kidney were 33 percent less likely to die during the period one to six months after accepting it, and 48 percent less likely thereafter, compared to those who passed up the opportunity.
So-called “increased risk” organs do not necessarily increase the risk of mortality. According to the Volk study, survival rates for recipients of a pancreas, liver or heart from a drug user were actually comparable to those for recipients from donors with no history of drug use.
People who die of opioid overdoses are often otherwise healthy, Volk and his colleagues concluded, and typically die of insufficient oxygen to the brain. Any remaining drugs in the organs are flushed away before transplant.
In an interview, Volk says transmission of infectious disease is rare in transplants and that even if, in the rare case, an organ recipient is infected with an infectious disease, those can usually be treated and managed. Organ failure, in contrast, typically results in death or—in the case of kidney patients—a compromised life on dialysis several times a week. Volk is the medical director of the liver transplantation program at Loma Linda University.
Rates of use of increased-risk organs vary around the country, from 20 percent to 100 percent. Volk attributes disparities to the comfort levels of surgeons and transplant team members.
“What that tells us,” co-author Daniel Kaul told a University of Michigan publication last October, “is there may be a different understanding of true risk associated with this label — from one center to another and even within a center, from one organ specialty to another.” Kaul is the medical director of transplant infectious disease at the University of Michigan.
Livers were an exception, according to the study. The rate at which increased-risk livers were accepted was similar to those that did not carry that label.
There’s a simple explanation for that. “For kidneys, patients can continue on dialysis, which, though uncomfortable, can keep them alive,” explains David Klassen, the chief medical officer at UNOS. “There’s no such alternative for liver disease,” he says.
The Volk study found that if all organs labeled increased risk were not so labeled, an additional 300 organs might be transplanted each year in the U.S.
While it’s unlikely that the increased risk label will be removed, more such organs could be transplanted with better patient and doctor education about the risks and benefits, Volk says.
Christine Durand, who led the recent Johns Hopkins study, sees an additional argument in favor of making use of increased-risk organs: the dignity and wishes of the deceased and their families.
“In the transplant community,” she says in an email, “we have the responsibility to honor the gift made by all organ donors and their families. If we fail to keep that promise, then we add to the tragedy of the lives lost.”
Though the increase in opioid overdose donors has made more organs available, says Klassen, efforts to sign up more donors continue in earnest.
“We don’t want to use one crisis to solve another,” he says. “As physicians we want to solve them both.”