Mortality trends among heroin users treated between 1975 and 2013 in Northern Italy: Results of a longitudinal study

Association of substance use with suicide mortality: An updated systematic review and meta-analysis

Background

Rates of suicide mortality and substance use have increased globally. We updated and extended existing systematic reviews of the association between substance use and suicide.

Methods

This systematic review and meta-analysis explored the association between substance use and suicide mortality in peer reviewed, longitudinal cohort studies published from 2003 through 2024. Risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled data were analyzed using a quality effects model. Meta-regression was used to assess the effect of moderation by study quality. Asymmetry in funnel plots and Doi plots were used to detect reporting bias.

Findings

The analysis involved 47 studies from 12 countries. Substance misuse (SMR: 5.58, 95 % CI: 3.63-8.57, I2: 99 %) was significantly associated with risk for suicide. Alcohol (SMR: 65.39, 95 % CI: 3.02-19.62, I2: 99 %), tobacco (SMR: 1.83, 95 % CI: 1.20-2.79, I2: 83 %), opioid (SMR: 5.46, 95 % CI: 3.66-8.15, I2: 96 %), cannabis (SMR 3.31, 95 % CI: 1.42-7.70, I2: 95 %), and amphetamine (SMR 11.97, 95 % CI: 3.13-45.74, I2: 99 %) misuse were each linked to higher rates of suicide mortality. The association between substance misuse and suicide was stronger for females (SMR: 12.37, 95 % CI: 7.07-21.63, I2: 98 %) than males (SMR: 5.21, 95 % CI: 3.09-8.78, I2: 99 %) overall and in analyses of specific substances. Further disaggregated data were not available to sufficiently explore for potential health inequities across social factors.

Conclusions

This meta-analysis highlights that substance misuse remains a significant suicide risk factor. It underscores the need for universal and targeted prevention and equitable access to effective interventions.

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011-2020: A national retrospective cohort study

BACKGROUND AND AIMS

Opioid dependence is associated with an increased risk of suicide. Drug-related mortality among people with opioid dependence in Scotland has more than tripled since 2010; less is known about changes in suicide risk. We aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide and to measure trends in suicide rates in those with opioid dependence over time.

DESIGN

Retrospective cohort study.

SETTING

Scotland, UK.

PARTICIPANTS

46 453 individuals in Scotland who received at least one prescription for OAT between 2011 and 2020 with over 304 000 person-years (pys) of follow-up.

MEASUREMENTS

We calculated standardised mortality ratios (SMR) using the age- and sex-specific suicide rates in Scotland for years 2011-2020. We fitted multivariable competing-risk regression models to estimate suicide rates by OAT exposure and to estimate trends over time, adjusting for potential confounders.

FINDINGS

There were 575 deaths classed as suicide among the cohort and the overall suicide rate was 1.89 (95% confidence interval [CI] = 1.74-2.05) per 1000 pys. Age and sex SMR for suicide was 7.05 times (95% CI = 6.50-7.65) higher than in the general population. After adjustment, OAT was shown to be highly protective against suicide, with rates more than three times greater (adjusted hazard ratio: 3.07; 95% CI = 2.60-3.62) off OAT compared with on OAT. Suicide rates decreased over time, falling from 2.57 (95% CI = 2.19-3.02) per 1000 pys in 2011-12 to 1.48 (95% CI = 1.21-1.82) in 2019-20.

CONCLUSION

People with opioid dependence in Scotland appear to have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.

Trends in educational inequalities in smoking-attributable mortality and their impact on changes in general mortality inequalities: evidence from England and Wales, Finland, and Italy (Turin)

BACKGROUND

Socioeconomic mortality inequalities are persistent in Europe but have been changing over time. Smoking is a known contributor to inequality levels, but knowledge about its impact on time trends in inequalities is sparse.

METHODS

We studied trends in educational inequalities in smoking-attributable mortality (SAM) and assessed their impact on general mortality inequality trends in England and Wales (E&W), Finland, and Italy (Turin) from 1972 to 2017. We used yearly individually linked all-cause and lung cancer mortality data by educational level and sex for individuals aged 30 and older. SAM was indirectly estimated using the Preston-Glei-Wilmoth method. We calculated the slope index of inequality (SII) and performed segmented regression on SIIs for all-cause, smoking and non-SAM to identify phases in inequality trends. The impact of SAM on all-cause mortality inequality trends was estimated by comparing changes in SII for all-cause with non-SAM.

RESULTS

Inequalities in SAM generally declined among males and increased among females, except in Italy. Among males in E&W and Finland, SAM contributed 93% and 76% to declining absolute all-cause mortality inequalities, but this contribution varied over time. Among males in Italy, SAM drove the 1976-1992 increase in all-cause mortality inequalities. Among females in Finland, increasing inequalities in SAM hampered larger declines in mortality inequalities.

CONCLUSION

Our findings demonstrate that differing education-specific SAM trends by country and sex result in different inequality trends, and consequent contributions of SAM on educational mortality inequalities. The following decades of the smoking epidemic could increase educational mortality inequalities among Finnish and Italian women.

Factors associated with suicide in people who use drugs: a scoping review

BACKGROUND

Suicide is a significant contributor to global mortality. People who use drugs (PWUD) are at increased risk of death by suicide relative to the general population, but there is a lack of information on associated candidate factors for suicide in this group. The aim of this study was to provide a comprehensive overview of existing evidence on potential factors for death by suicide in PWUD.

METHODS

A scoping review was conducted according to the Arksey and O'Malley framework. Articles were identified using Medline, CINAHL, PsycINFO, SOCIndex, the Cochrane Database of Systematic Reviews and the Campbell Collaboration Database of Systematic Reviews; supplemented by grey literature, technical reports, and consultation with experts. No limitations were placed on study design. Publications in English from January 2000 to December 2021 were included. Two reviewers independently screened full-text publications for inclusion. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

The initial search identified 12,389 individual publications, of which 53 met the inclusion criteria. The majority (87%) of included publications were primary research, with an uncontrolled, retrospective study design. The most common data sources were drug treatment databases or national death indexes. Eleven potential factors associated with death by suicide among PWUD were identified: sex; mental health conditions; periods of heightened vulnerability; age profile; use of stimulants, cannabis, or new psychoactive substances; specific medical conditions; lack of dual diagnosis service provision; homelessness; incarceration; intravenous drug use; and race or ethnicity. Opioids, followed by cannabis and stimulant drugs were the most prevalent drugs of use in PWUD who died by suicide. A large proportion of evidence was related to opioid use; therefore, more primary research on suicide and explicit risk factors is required.

CONCLUSIONS

The majority of studies exploring factors associated with death by suicide among PWUD involved descriptive epidemiological data, with limited in-depth analyses of explicit risk factors. To prevent suicide in PWUD, it is important to consider potential risk factors and type of drug use, and to tailor policies and practices accordingly.

Reversals in past long-term trends in educational inequalities in life expectancy for selected European countries

BACKGROUND

Across Europe, socioeconomic inequalities in mortality are large and persistent. To better understand the drivers of past trends in socioeconomic mortality inequalities, we identified phases and potential reversals in long-term trends in educational inequalities in remaining life expectancy at age 30 (e30), and assessed the contributions of mortality changes among the low-educated and the high-educated at different ages.

METHODS

We used individually linked annual mortality data by educational level (low, middle and high), sex and single age (30+) from 1971/1972 onwards for England and Wales, Finland and Italy (Turin). We applied segmented regression to trends in educational inequalities in e30 (e30 high-educated minus e30 low-educated) and employed a novel demographic decomposition technique.

RESULTS

We identified several phases and breakpoints in the trends in educational inequalities in e30. The long-term increases (Finnish men, 1982-2008; Finnish women, 1985-2017; and Italian men, 1976-1999) were driven by faster mortality declines among the high-educated aged 65-84, and by mortality increases among the low-educated aged 30-59. The long-term decreases (British men, 1976-2008, and Italian women, 1972-2003) were driven by faster mortality improvements among the low-educated than among the high-educated at age 65+. The recent stagnation of increasing inequality (Italian men, 1999) and reversals from increasing to decreasing inequality (Finnish men, 2008) and from decreasing to increasing inequality (British men, 2008) were driven by mortality trend changes among the low-educated aged 30-54.

CONCLUSION

Educational inequalities are plastic. Mortality improvements among the low-educated at young ages are imperative for achieving long-term decreases in educational inequalities in e30.

Morphine may have a role in telomere shortening

Morphine/heroin may increase oxidative stress in drug-dependent persons. The imbalance between oxidative stress and antioxidant defense mechanisms can accelerate the shortening of telomere length. This article reports two sets of data; comparison of relative telomere length between heroin-dependent patients and healthy control group, as well as, investigation of the effect of morphine on the relative telomere length of human SH-SY5Y cells treated by morphine. Study participants were composed of 163 heroin-dependent patients and 166 unrelated healthy controls. SH-SY5Y cells were treated with (5 μM) morphine hydrochloride and incubated for 40 and 60 days. The relative telomere length was calculated as the T/S (telomere/single-copy gene) ratio using 36B4 as a reference for each sample, using quantitative real-time PCR. The mean (± SE) value of relative telomere length was 4.81 ± 0.21 and 6.38 ± 0.23 in leukocytes of heroin-dependent and control groups, respectively. The telomere length was significantly decreased in heroin-dependent participants (t = 4.97; df = 327; P < 0.0001). The relative telomere length in cells treated with morphine for 60 days was 4.50 ± 0.14 and in untreated cells was 5.75 ± 0.08. The difference was highly significant (t  =  7.68; df = 4; P = 0.002). Our present findings indicate that morphine and dependency on heroin are significantly associated with shorter telomeres. The present findings may help to explain some of the adverse effects of drug dependency on health such as accelerating biologic processes related to aging.

A cohort study revealed high mortality among people who inject drugs in Hai Phong, Vietnam

OBJECTIVE

To estimate the residual mortality rate among people who inject drugs (PWID) in a Low-Middle Income Countries context where the HIV epidemic has been controlled and methadone coverage is high.

STUDY DESIGN AND SETTING

PWID from Haiphong, Vietnam, were recruited through three annual respondent-driven sampling surveys that fueled two cohorts of PWID with HIV (n = 761) and without HIV (n = 897), with bi-annual follow-up. Presumed causes of death were ascertained from medical records and/or interviews of participants family.

RESULTS

Among the 1658 participants with a median follow-up of 2 years, 67 and 36 died in the HIV-positive and HIV-negative cohort, respectively, yielding crude mortality rates of 4.3 (95% Confidence interval (CI): 3.3-5.4) per 100 person-years of follow-up (PYFU) and 1.9 (CI: 1.4-2.6) per 100 PYFU. In the HIV-positive cohort, in which 81% of participants had undetectable viral load, the two main causes of death were tuberculosis and HIV-related diseases. In the HIV-negative cohort, the two main causes of death were liver-related diseases and overdose. In a time-dependent multivariable model, "unsuppressed viral load" was associated with increased risk of mortality, whereas "being on methadone" or "being employed" was associated with a lower risk.

CONCLUSION

Despite a very successful HIV and methadone program, the mortality remains high among PWID in Vietnam, largely due to curable infectious diseases such as tuberculosis and viral hepatitis.

Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis

Importance

Mortality among people with opioid dependence is higher than that of the general population. Opioid agonist treatment (OAT) is an effective treatment for opioid dependence; however, there has not yet been a systematic review on the relationship between OAT and specific causes of mortality.

Objective

To estimate the association of time receiving OAT with mortality.

Data Sources

The Embase, MEDLINE, and PsycINFO databases were searched through February 18, 2020, including clinical trial registries and previous Cochrane reviews.

Study Selection

All observational studies that collected data on all-cause or cause-specific mortality among people with opioid dependence while receiving and not receiving OAT were included. Randomized clinical trials (RCTs) were also included.

Data Extraction and Synthesis

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data on study, participant, and treatment characteristics were extracted; person-years, all-cause mortality, and cause-specific mortality were calculated. Crude mortality rates and rate ratios (RRs) were pooled using random-effects meta-analyses.

Main Outcomes and Measures

Overall all-cause and cause-specific mortality both by setting and by participant characteristics. Methadone and buprenorphine OAT were evaluated specifically.

Results

Fifteen RCTs including 3852 participants and 36 primary cohort studies including 749 634 participants were analyzed. Among the cohort studies, the rate of all-cause mortality during OAT was more than half of the rate seen during time out of OAT (RR, 0.47; 95% CI, 0.42-0.53). This association was consistent regardless of patient sex, age, geographic location, HIV status, and hepatitis C virus status and whether drugs were taken through injection. Associations were not different for methadone (RR, 0.47; 95% CI, 0.41-0.54) vs buprenorphine (RR, 0.34; 95% CI, 0.26-0.45). There was lower risk of suicide (RR, 0.48; 95% CI, 0.37-0.61), cancer (RR, 0.72; 95% CI, 0.52-0.98), drug-related (RR, 0.41; 95% CI, 0.33-0.52), alcohol-related (RR, 0.59; 95% CI, 0.49-0.72), and cardiovascular-related (RR, 0.69; 95% CI, 0.60-0.79) mortality during OAT. In the first 4 weeks of methadone treatment, rates of all-cause mortality and drug-related poisoning were almost double the rates during the remainder of OAT (RR, 2.01; 95% CI, 1.55-5.09) but not for buprenorphine (RR, 0.58; 95% CI, 0.18-1.85). All-cause mortality was 6 times higher in the 4 weeks after OAT cessation (RR, 6.01; 95% CI, 4.32-8.36), remaining double the rate for the remainder of time not receiving OAT (RR, 1.81; 95% CI, 1.50-2.18). Opioid agonist treatment was associated with a lower risk of mortality during incarceration (RR, 0.06; 95% CI, 0.01-0.46) and after release from incarceration (RR, 0.09; 95% CI, 0.02-0.56).

Conclusions and Relevance

This systematic review and meta-analysis found that OAT was associated with lower rates of mortality. However, access to OAT remains limited, and coverage of OAT remains low. Work to improve access globally may have important population-level benefits.

Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality

The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.

All-Cause and Cause-Specific Mortality Among People Using Extramedical Opioids: A Systematic Review and Meta-analysis

IMPORTANCE

Extramedical opioid use has escalated in recent years. A better understanding of cause-specific mortality in this population is needed to inform comprehensive responses.

OBJECTIVE

To estimate all-cause and cause-specific crude mortality rates (CMRs) and standardized mortality ratios (SMRs) among people using extramedical opioids, including age- and sex-specific estimates when possible.

DATA SOURCES

For this systematic review and meta-analysis, MEDLINE, PsycINFO, and Embase were searched for studies published from January 1, 2009, to October 3, 2019, and an earlier systematic review on this topic published in 2011.

STUDY SELECTION

Cohort studies of people using extramedical opioids and reporting mortality outcomes were screened for inclusion independently by 2 team members.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by a team member and checked by another team member. Study quality was assessed using a custom set of items that examined risk of bias and quality of reporting. Data were pooled using random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression.

MAIN OUTCOMES AND MEASURES

Outcome measures were all-cause and cause-specific CMRs and SMRs among people using extramedical opioids compared with the general population of the same age and sex.

RESULTS

Of 8683 identified studies, 124 were included in this analysis (100 primary studies and 24 studies providing additional data for primary studies). The pooled all-cause CMR, based on 99 cohorts of 1 262 592 people, was 1.6 per 100 person-years (95% CI, 1.4-1.8 per 100 person-years), with substantial heterogeneity (I2 = 99.7%). Heterogeneity was associated with the proportion of the study sample that injected opioids or was living with HIV infection or hepatitis C. The pooled all-cause SMR, based on 43 cohorts, was 10.0 (95% CI, 7.6-13.2). Excess mortality was observed across a range of causes, including overdose, injuries, and infectious and noncommunicable diseases.

CONCLUSIONS AND RELEVANCE

The findings suggest that people using extramedical opioids experience significant excess mortality, much of which is preventable. The range of causes for which excess mortality was observed highlights the multiplicity of risk exposures experienced by this population and the need for comprehensive responses to address these. Better data on cause-specific mortality in this population in several world regions appear to be needed.

Would You Be Surprised If This Patient Died This Year? Advance Care Planning in Substance Use Disorders

Primary care physicians are increasingly incorporating screening tools for substance use disorders (SUDs) and referral to treatment into their practice. Despite efforts to provide access to treatment, patients with SUDs remain at an increased risk of mortality, both from overdose and from general medical conditions. Advance care planning (ACP) is recommended for patients with chronic, progressive medical conditions such as malignancies or heart failure. Though SUDs are widely acknowledged to be chronic diseases associated with an increased risk of mortality, there has been little discussion on ACP in this population. ACP is a discussion regarding future care, often including selection of a surrogate decision-maker and completion of an advanced directive. ACP has been associated with better quality of end-of-life and care more consistent with patient preferences. Studies in other vulnerable populations have shown that marginalized and high-risk individuals may be less likely to receive ACP. Similarly, patients with SUDs may employ different decision-makers than that defined by law (i.e., friend vs. family member), increasing the importance of discussing patient values and social structure. Physicians should routinely conduct ACP conversations with patients with SUDs, especially those with chronic, progressive medical conditions and/or severe, uncontrolled substance use disorders.

Mortality Rates and Trends Among Bologna Community Mental Health Service Users: A 13-Year Cohort Study

The present study aimed to determine mortality rates and trends among community mental health service users in Bologna (Italy) between 2001 and 2013. Standardized mortality ratios (SMRs) were calculated, and Poisson multiple regression analysis was performed. The cohort comprised 42,357 patients, of which 3556 died. The overall SMR was 1.62 (95% confidence interval = 1.57-1.67). SMRs for natural causes of death ranged from 1.25 to 2.30, whereas the SMR for violent deaths was 3.45. Both serious and common mental disorders showed a significant excess of mortality, although higher rates were found in severe mental disorders, especially in personality disorders. Different from most published studies, the overall SMR slightly decreased during the study period. The present study, though confirming that people with mental disorders present a higher risk of mortality, calls for prevention strategies oriented to all psychiatric diagnoses.