[Discrepancies in the number of deaths from an acute reaction to psychoactive substances recorded in Spain]

[Classification of mental disorders in the Intensive Care Unit]

PURPOSE

To determine the incidence and characteristics of mental disorders (MD) in the Intensive Care Unit (ICU), and to define a classification system adapted to the ICU environment.

DESIGN

A retrospective, descriptive analysis.

SETTING

Intensive Care Unit, Arnau de Vilanova Hospital in Lérida (Spain).

PATIENTS

All patients with MD admitted during 5-year period (January, 1 2004 to December 31, 2008).

MAIN VARIABLES

General variables included clinical-demographic data, diagnostic variables, procedures, severity score, length of stay and mortality. Specific variables included psychiatric history, screening for substance abuse, psychiatric assessment, monitoring and transfer to a psychiatric center. Classification of the MD was as follows: 1) acute substance intoxication (SI); 2) suicide attempts (SA); and 3) MD associated with the main diagnosis (AMD).

RESULTS

A total of 146 patients had MD (7.8%); they were predominantly male (74%) and were younger than the general ICU population (43.9 vs. 55.3 years, p<0.001). The ICU stays of the patients with MDs were shorter (4 days vs. 7 days, p<0.001), and there was less hospital mortality (17.1 vs. 25%, p<0.05). They also showed a higher incidence of pneumonia (19.9 vs. 13.8%, p<0.05), but no differences in the level of severity were observed. The SI group (24.7%) contained the highest number of young people; the SA group (36.3%) showed a predominance of women; and the AMD (39%) group had the longest stays and the highest mortality. Psychiatric consultation was carried out mainly in the SA group (62.3%).

CONCLUSIONS

MD is a relatively common problem in the ICU. Collaboration with the Psychiatry Department seldom occurs, but must be encouraged to develop fully integrated management of critical patients with MD.

Proximity to the US-Mexico border: a key to explaining geographic variation in US methamphetamine, cocaine and heroin purity

AIMS

Although illicit drug purity is a widely discussed health risk, research explaining its geographic variation within a country is rare. This study examines whether proximity to the US-Mexico border, the United States' primary drug import portal, is associated with geographic variation in US methamphetamine, heroin and cocaine purity.

DESIGN

Distances (proximity) between the US-Mexico border and locations of methamphetamine, cocaine and heroin seizures/acquisitions (n = 239,070) recorded in STRIDE (System to Retrieve Information from Drug Evidence) were calculated for the period of 1990-2004. The association of drug purity with these distances and other variables, including time and seizure/acquisition size, was examined using hierarchical multivariate linear modeling (HMLM).

SETTING

Coterminous United States.

FINDINGS

Methamphetamine, cocaine and heroin purity generally decreased with distance from the US-Mexico border. Heroin purity, however, after initially declining with distance, turned upwards-a U-shaped association. During 2000-04, methamphetamine purity also had a U-shaped association with distance. For each of the three drugs, temporal changes in the purity of small acquisitions (<10 g) were typically more dynamic in areas closer to the US-Mexico border.

CONCLUSIONS

Geographic variance in methamphetamine, cocaine and heroin purity throughout the coterminous United States was associated with US-Mexico border proximity. The U-shaped associations between border-distance and purity for heroin and methamphetamine may be due to imports of those drugs via the eastern United States and southeast Canada, respectively. That said, areas closer to the US-Mexico border generally had relatively high illicit drug purity, as well as more dynamic change in the purity of small ('retail level') drug amounts.

Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain

AIMS

To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city.

DESIGN

All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models.

FINDINGS

The study recruited 5049 patients, which provided 23,048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record.

CONCLUSIONS

The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.

[Estimating mortality attributed to illegal drug use in Spain]

BACKGROUND AND OBJECTIVE

The impact of illegal drug consumption on general mortality in Spain is unknown. We aimed to quantify this impact for the period 1994-2000.

SUBJECTS AND METHOD

Number of directly drug-related deaths from HIV among injecting drug users as well as others -- both taken from the General Mortality Register (GMR). Next, corrections were made, multiplying the aforementioned figures by the percentage of injecting drug users in the AIDS register in the first case, and by the underestimation index in the second. This index was calculated comparing the GMR with the specific drug-related register in certain areas.

RESULTS

In Spain, mortality from illegal drug use fell from 22.7 per 100,000 inhabitants, aged 15-49 years (16.4% of all deaths) in 1996 to 8.9/100,000 in 2000 (7.8% of all deaths), meaning a 58% decrease in general mortality. In 2000, drug-related deaths surpassed AIDS mortality in the group of men aged 15-49 years.

CONCLUSIONS

Illegal drug use continues to be an important cause of death among young people in Spain. Overdose is the most likely primary cause of death in drug consumers.

Role of individual and contextual effects in injury mortality: new evidence from small area analysis

OBJECTIVE

To analyse the role of individual and contextual variables in injury mortality inequalities from a small area analysis perspective, looking at the data for the city of Barcelona (Spain) for 1992-98.

SETTING

Barcelona (Spain).

METHODS

All injury deaths in residents older than 19, which occurred in the period 1992-98 were included (n=4393). Age and sex specific mortality rates were calculated for each educational level and each cause of death (traffic injuries, falls, drug overdose, suicide, other injuries). The contextual variables included were the proportion of men unemployed, and the proportion of men in jail, in each neighbourhood. Multilevel Poisson regression models were fitted using data grouped by age, educational level, and neighbourhood for each sex.

RESULTS

Death rates were higher in males, at the extremes of the age distribution (under 44 and over 74 years), and for lower educational levels. The results of the Poisson multilevel models indicate that inequalities by educational level follow a gradient, with higher risks for the population with no schooling, after having adjusted for the contextual variables of the neighbourhood. Such inequalities were more important in the youngest age group (20-34 years), as relative risk of 5.41 (95% confidence interval (CI) 3.9 to 7.4) for all injury causes in males and 4.38 (95% CI 2.3 to 8.4) in females. The highest relative risks were found for drug overdose. There was a contextual neighbourhood effect (the higher the deprivation, the higher the mortality) after having taken into account individual variables.

CONCLUSION

The findings underscore the need to implement injury prevention strategies not only at the individual level taking into account socioeconomic position, but also at the neighbourhood level.

Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration

AIMS

To examine risk factors associated with non-fatal heroin overdose, particularly frequency and route of heroin administration.

DESIGN

Data from cross-sectional surveys were analysed as a case-control and as a case cross-over design.

SETTING AND PARTICIPANTS

2556 subjects treated for heroin dependence in 164 outpatient facilities in Spain.

MEASUREMENTS

Prevalence of overdose involving emergency care in the 12 months before treatment admission. CASE CONTROL DESIGN: Odds ratio (OR) adjusted by logistic regression. CASE-CROSSOVER DESIGN: Estimated relative risk (RR) of transient risk of injecting heroin.

FINDINGS

The prevalence of overdose was 10%. In the case control analysis the cumulative risk of overdose increased as the frequency of heroin use decreased. However, among daily heroin users this risk increased as the frequency of heroin injection rose, with an OR of 6.0 (95% CI: 3.9-9.6) for daily injectors versus non-injectors. Sniffers had a higher risk than smokers among non-daily users, but not among daily users. Other factors associated with increased risk of overdose were: tranquilizers, alcohol or cocaine use, living in certain regions and being long-term HIV+ 0. In the case-crossover analysis, the RR for injecting heroin versus using other routes immediately before overdose was 15.9 (95% CI: 9.5-26.6), and was much higher for non-daily heroin users than for daily users.

CONCLUSIONS

These findings suggest that the rapid entry of a large quantity of heroin into the blood (as occurs when injecting) involves a high risk of overdose, especially when the heroin tolerance level is low (as occurs in sporadic users).

Trends in young adult mortality in three European cities: Barcelona, Bologna and Munich, 1986-1995

OBJECTIVE

In recent decades, in most European countries young adult mortality has risen, or at best has remained stable. The aim of this study was to describe trends in mortality attributable to the principal causes of death: AIDS, drug overdose, suicide and motor vehicle traffic accidents, among adults aged between 15 and 34 years in three European cities (Barcelona, Bologna and Munich), over the period 1986 to 1995.

METHODS

The population studied consisted of all deaths that occurred between 1986 and 1995 among residents of Barcelona, Bologna and Munich aged from 15 to 34 years. Information about deaths was obtained from mortality registers. The study variables were sex, age, the underlying cause of death and year of death. Causes of death studied were: drug overdose, AIDS, suicide and motor vehicle traffic accidents. Age standardised mortality rates (direct adjustment) were obtained in all three cities for the age range 15-34. To investigate trends in mortality over the study period Poisson regression models were fitted, obtaining the average relative risk (RR) associated with a one year increment.

RESULTS

Young adult mortality increased among men in Barcelona and Bologna (RR per year: 1.04, 95% confidence intervals (95%CI): 1.03, 1.06 in Barcelona and RR:1.03, 95%CI:1.01, 1.06 in Bologna) and among women in Barcelona (RR:1.02, 95%CI: 1.01, 1.04), with a change in the pattern of the main causes of death attributable to the increase in AIDS and drug overdose mortality. In Munich, the pattern did not change as much, suicides being the main cause of death during the 10 years studied, although they have been decreasing since 1988 (RR:0.92, 95%CI:0.88, 0.96 for men and 0.81, 95%CI: 0.75-0.87 for women).

CONCLUSION

The increase in AIDS mortality observed in the three European cities in the mid-80s and mid-90s has yielded substantial changes in the pattern of the main causes of death at young ages in Barcelona and Bologna. Munich presented a more stable pattern, with suicide as the main cause of death.

[Exactness of mortality statistics by external and natural causes of death with medico-legal intervention in Catalonia, 1996]

OBJECTIVE

Deaths due to external and natural causes with forensic intervention require medical-legal autopsy. In order to be included in the mortality statistics the results are reported in the statistical document MNP52. The accuracy of cause of death depends on the characteristics of the document, the point at which it is completed (after the death or after the autopsy) and the person that completes it. The objective is to determine the accuracy of external and natural causes of death with forensic intervention, reported in the official statistical documents by a medical-legal autopsy report of these deaths occurred in Catalonia in 1996.

METHODS

Two samplings were undertaken--one for natural causes and another for external causes--that were stratified by sex and judicial district. The information sources were the Mortality Register of Catalonia for the statistical documents and the criminal courts for the medical-legal autopsy, toxicological and pathological reports. We calculated the index of agreement, the sensitivity or detection rate (DR) and the positive predictive value of confirmation rate (CR), and their respective 95% confidence intervals.

RESULTS

The index of agreement was 72.3% (IC 95%: 68.7-75.9). The DR for external causes groups was 65.9% (60.6-71.2) and the CR was 69% (63.6-71.2). For natural causes the DR was 79.4% (74.7-84.2) and the CR was 75.5% (70.7-80.5).

CONCLUSION

In deaths with forensic intervention, the official statistical documents do not correctly report external causes of death, and statistics for natural causes of death approach acceptable levels of accuracy. The results are mainly due to deficits in reporting and certifying these causes in the official statistics.