Mortality trends in a cohort of opiate addicts, Catalonia, Spain

Palliative care for patients with a substance use disorder and multiple problems: a study protocol

BACKGROUND

The specific palliative care needs and problems of patients with a substance use disorder and multiple problems, and those of their proxies, are under recognized Besides, the organization of palliative care, including the division of health care professionals' responsibilities, is often unclear. Perspectives of patients and proxies are hardly known. We describe the outline of a study designed to explore how palliative care for patients with a substance use disorder is organized in the Netherlands and to explore problems and needs, as well as possible improvements from the healthcare professionals', patients' and proxies' perspective. The aim of this protocol paper is to provide insights in ways to conduct research with vulnerable research participants and to offer a detailed description of the study design. The broader study aims to gain insight in and formulate recommendations on how to improve palliative care for patients with a substance use disorder.

METHODS

A qualitative study with patients, proxies and healthcare professionals. Semi-structured interviews will be held with 10-15 patients who suffer from a severe substance use disorder. They are in a palliative care trajectory and either diagnosed with a chronic or life-threatening disease or, as a result of addictive behavior, a physical deterioration without the prospect of cure. Semi-structured interviews will also be held with 5-10 proxies. Healthcare professionals, volunteers and/or 'experts-by-experience' (n = 24-40) will be participating in semi-structured group interviews. All (group) interviews will be thematically analyzed. Additionally, a strengths, weaknesses, opportunities and threats (SWOT) analysis will be applied to the group interview data with the aim to summarize and concretize the findings.

DISCUSSION

Everyone has a right to an optimal end-of-life phase of life and a dignified dying process. This study will provide valuable knowledge about palliative care for patients with a substance use disorder and explicitly bring to light the needs and problems of the patients and their proxies and healthcare professionals in a palliative care phase.

Effect of ageing and time since first heroin and cocaine use on mortality from external and natural causes in a Spanish cohort of drug users

BACKGROUND

We aimed to assess the effect of ageing and time since first heroin/cocaine use on cause-specific mortality risk and age disparities in excess mortality among heroin (HUs) and cocaine users (CUs) in Spain.

METHODS

A cohort of 15,305 HUs and 11,905 CUs aged 15-49 starting drug treatment during 1997-2007 in Madrid and Barcelona was followed until December 2008. Effects of ageing and time since first heroin/cocaine use were estimated using a competing risk Cox model and the relative and absolute excess mortality compared to the general population through directly age-sex standardized rate ratios (SRRs) and differences (SRDs), respectively.

RESULTS

Mortality risk from natural causes increased with time since first heroin use, whereas that from overdose declined after having peaked in the first quinquennium. Significant effects of time since first cocaine use were not identified, although fatal overdose risk seemed higher in CUs after five years. Mortality risk from natural causes (HUs and CUs), injuries (HUs), and overdoses (CUs) increased with age, the latter without reaching statistical significance. Crude mortality rates from overdoses and injuries remained very high at age 40-59 among both HUs (595 and 217 deaths/100,000 person-years, respectively) and CUs (191 and 88 deaths/100,000 person-years). SRDs from all and natural causes were much higher at age 40-59 than 15-29 in both HUs (2134 vs. 834 deaths/100,000 person-years) and CUs (927 vs. 221 deaths/100,000 person-years), while the opposite occurred with SRRs.

CONCLUSION

The high mortality risk among HUs and CUs at all ages from both external and natural causes, and increased SRDs with ageing, suggest that high-level healthcare and harm reduction services should be established early and maintained throughout the lifetime of these populations.

Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users

BACKGROUND

The aim of the study was to estimate the lethality of opioid overdose among young heroin users.

METHODS

A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.

RESULTS

The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).

CONCLUSIONS

Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.

Cause-specific mortality among people previously hospitalized with opioid-related conditions: a retrospective cohort study

PURPOSE

Although numerous studies have reported on all-cause mortality among opioid users, few have provided estimates for specific causes of death. We report all-cause and cause-specific mortalities for a large cohort of individuals with a history of opioid-related disorders.

METHODS

We used administrative data on people discharged from California hospitals between 1990 and 2005 with diagnoses of opioid dependence, abuse, poisoning, or withdrawal. We calculated crude and standardized cause-specific mortality rates and ratios.

RESULTS

Data included 68,066 individuals and 390,438 person-years of follow-up. There were 13,107 deaths (a crude mortality rate of 33.6 per 1000 person-years). The standardized mortality rate was 37.6 per 1000, and the standardized mortality ratio (SMR) was 4.36 (95% confidence interval [CI], 4.30-4.43). Standardized mortality ratios were greater than 1 for all specific causes except Alzheimer's disease, and were the highest for drug-induced deaths (62.2, 95% CI, 58.2-66.1), human immunodeficiency virus (24.6, 95% CI, 22.3-26.9), and endocarditis (23.2, 95% CI, 15.3-31.3). The broad causes associated with the most excess deaths were drug- or alcohol-induced death (23% of excess deaths), cancer (18%), heart disease (14%), and lower respiratory disease (7%).

CONCLUSIONS

Mortality in this cohort was very high. Most excess deaths were not directly due to drug use, but many were from causes associated with the use of tobacco or alcohol. Mortality for cancers not linked to tobacco or alcohol was also elevated, suggesting that admission for opioid-related causes serves in part as a risk marker for preexisting disease.

A multi-state model to estimate incidence of heroin use

Background

Existing incidence estimates of heroin use are usually based on one information source. This study aims to incorporate more sources to estimate heroin use incidence trends in Spain between 1971 and 2005.

Methods

A multi-state model was constructed, whereby the initial state “heroin consumer” is followed by transition to either “admitted to first treatment” or to “left heroin use” (i.e. permanent cessation or death). Heroin use incidence and probabilities of entering first treatment ever were estimated following a back-calculation approach.

Results

The highest heroin use incidence rates in Spain, around 1.5 per 1,000 inhabitants aged 10–44, occurred between 1985 and 1990; subdividing by route of administration reveals higher incidences of injection between 1980 and 1985 (a mean of 0.62 per 1.000) and a peak for non-injectors in 1990 (0.867 per 1,000).

Conclusions

A simple conceptual model for heroin users’ trajectories related to treatment admission, provided a broader view of the historical trend of heroin use incidence in Spain.

A 25-year follow-up of patients admitted to methadone treatment for the first time: mortality and gender differences

INTRODUCTION

We conducted a follow-up study to evaluate the outcome of a heroin-dependent population 25 years after their first enrollment in methadone maintenance treatment (MMT). We assessed mortality in the sample plus actual drug use, treatment, and medical factors associated with drug dependence, focusing on possible gender differences.

METHODS

Prospective follow-up study of 214 heroin-dependent patients consecutively admitted for MMT between 1980 and 1984 in the Asturias Public Health Service. The standardized mortality ratio (SMR) and 95% confidence interval (CI) were calculated. An ad-hoc protocol on drug misuse and treatment, drug-related morbidity and Clinical Global Impression (CGI) scores were assessed in the survivors' sample.

RESULTS

Information was received on 159 subjects, 106 of whom were deceased. Men accounted for 76.2% of the study cohort. Over the 25-year follow-up period, the SMR was 22.51 (95% CI=22.37-22.64). In the survivors sample, 39.6% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 47.2% and hepatitis B/C in 81.1%; current heroin use was reported by 22.6%. There were no gender differences in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 25-year follow-up compared with 31.1% of males.

CONCLUSIONS

This study confirms the high mortality of heroin addicts even after enrollment in MMT. Severity of the addiction in terms of mortality was similar in both genders. Women who survived the 25-year follow-up were more likely to have stopped using heroin than men.

The relationship between injection and noninjection drug use and HIV disease progression

BACKGROUND

Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression.

METHODS

We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005.

RESULTS

There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use.

CONCLUSIONS

This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

AIMS

To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables.

METHODS

Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random-effects meta-analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta-regressions examined potentially important sources of heterogeneity across studies.

RESULTS

Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. Very high heterogeneity across studies was observed; pooled all-cause CMR was 2.09 per 100 person-years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out-of-treatment periods had higher mortality risk than in-treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication.

CONCLUSIONS

Mortality among opioid-dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non-randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.

Recording of clinical information in a Scotland-wide drug deaths study

The aim of this study was to analyse the nature and extent of data extracted from case files of deceased individuals in contact with services 6 months prior to drug deaths in Scotland during 2003. A cross-sectional descriptive analysis of 317 case notes of 237 individuals who had drug-related deaths was undertaken, using a data linkage process. All contacts made with services in the 6 months prior to death were identified. Information on clinical and social circumstances obtained from social care, specialist drug treatment, mental health, non-statutory services, the Scottish Prison Service and Criminal Records Office was collated. More than 70% (n = 237) were seen 6 months prior to their drug death. Sociodemographic details were reported much more frequently than medical problems, for example, ethnicity (49%), living accommodation (66%), education and income (52%) and dependent children (73%). Medical and psychiatric history was recorded in only 12%, blood-borne viral status in 17% and life events in 26%. This paucity of information was a feature of treatment plans and progress recorded. The 237 drug deaths were not a population unknown to services. Highly relevant data were missing. Improved training to promote in-depth recording and effective monitoring may result in better understanding and reduction of drug deaths.

The toxicology of homicide offenders and victims: A review

ISSUES

The toxicology of homicide offenders and victims, and homicide as a cause of death among psychoactive substance users.

APPROACH

Review of the toxicology of homicide, and homicide as a cause of death among psychoactive substance users.

KEY FINDINGS

A half or more of offenders are intoxicated by a psychoactive substance at the time of the homicide, with alcohol the most commonly reported substance. Levels of substances among victims are comparable with those seen among perpetrators. Among both offenders and victims, levels of substances far exceed population use. Among substance users, homicide specific mortality rates of substance users far exceed population rates. Reducing rates of alcohol and other drug consumption, at national and individual levels, can be expected to substantially reduce rates of, and risk for, homicide.

CONCLUSIONS AND IMPLICATIONS

Psychoactive substances are strongly associated with homicide. One of the major societal benefits that can be derived from active attempts to reduce alcohol and other drug use are reductions in homicide rates.

Mortality and cause of death among 1705 illicit drug users: a 37 year follow up

INTRODUCTION AND AIMS

To examine the overall mortality and causes of deaths of a large cohort of users of illicit drugs in Stockholm over 37 years.

DESIGN AND METHODS

People with substance abuse were identified through records collected by different institutions in Stockholm in 1967. Subjects were followed in registers recording mortality and cause of death and in-patient care stays until 2003.

RESULTS

More than half (n = 860) of the 1705 identified substance abusers died at an average age of 47 years, 25-30 years younger than the general population. The standardised rate ratio (SRR) for mortality was 3.3 among men and 3.5 among women. Incidence of mortality per 1000 person-years was also increased, but somewhat lower for women. The difference between these two measures is mainly explained by a lower mortality among women in general. In-patient care stays with both alcohol and drug-related diagnoses were associated with higher risk of dying among women than men: SRR = 14.5 and SRR = 4.0, respectively. Accidents and suicide were the most common cause of death among the youngest subjects (15-24 years) and cardiovascular diseases and tumours among the oldest (> or =55 years).

DISCUSSION AND CONCLUSIONS

Accidents and suicide, especially at a young age, are two common causes of death that might be prevented by increased awareness in medical personnel, along with better treatment and supportive measures.

Unintentional drug overdose death trends in New Mexico, USA, 1990-2005: combinations of heroin, cocaine, prescription opioids and alcohol

AIMS

To determine the contribution of heroin, prescription opioids, cocaine and alcohol/drug combinations to the total overdose death rate and identify changes in drug overdose patterns among New Mexico subpopulations.

DESIGN

We analyzed medical examiner data for all unintentional drug overdose deaths in New Mexico during 1990-2005. Age-adjusted drug overdose death rates were calculated by sex and race/ethnicity; we modeled overall drug overdose death adjusting for age and region.

FINDINGS

The total unintentional drug overdose death rate in New Mexico increased from 5.6 per 100 000 in 1990 to 15.5 per 100 000 in 2005. Deaths caused by heroin, prescription opioids, cocaine and alcohol/drug combinations together ranged from 89% to 98% of the total. Heroin caused the most deaths during 1990-2005, with a notable rate increase in prescription opioid overdose death during 1998-2005 (58%). During 1990-2005, the 196% increase in single drug category overdose death was driven by prescription opioids alone and heroin alone; the 148% increase in multi-drug category overdose death was driven by heroin/alcohol and heroin/cocaine. Hispanic males had the highest overdose death rate, followed by white males, white females, Hispanic females and American Indians. The most common categories causing death were heroin alone and heroin/alcohol among Hispanic males, heroin/alcohol among American Indian males and prescription opioids alone among white males and all female subpopulations.

CONCLUSIONS

Interventions to prevent drug overdose death should be targeted according to use patterns among at-risk subpopulations. A comprehensive approach addressing both illicit and prescription drug users, and people who use these drugs concurrently, is needed to reduce overdose death.

Effect of education on overall and cause-specific mortality in injecting drug users, according to HIV and introduction of HAART

BACKGROUND

We assessed the impact of education on long-term overall and cause-specific mortality among 6575 injecting drug users (IDUs) according to HIV status and introduction of highly active antiretroviral therapy (HAART).

METHODS

Community-based cohort study of IDUs recruited in three AIDS prevention centres (1987-1996). Causes of death were ascertained in clinical centres and Mortality Registry and classified as AIDS, drug use related, injuries, or liver diseases. Poisson regression models including education and calendar period interaction and adjusted by sex, age, and HIV were used.

RESULTS

In 73 901 person-years of follow-up, there were 1493 deaths (20.2/1000 person-years): 761 related to AIDS, 234 to drug use, 179 to injuries, and 93 to liver diseases. IDUs with university studies had a lower risk of death (RR 0.52; 95% CI 0.36-0.77) than those without studies: this difference was higher after (RR 0.45; 95% CI 0.25-0.80) than before 1997 (RR 0.68; 95% CI 0.41-1.13). Compared to before 1997, while decreases in the risk of AIDS mortality were seen during 1997-2004 for both lower (RR 0.49; 95% CI 0.41-0.58) and higher (RR 0.33; 95% CI 0.23-0.48) educated, only those higher educated experienced a reduction in drug-use mortality (RR 0.54; 95% CI 0.28-1.05) and death from injuries (RR 0.52; 95% CI 0.23-1.21).

CONCLUSIONS

Independently of HIV status, lower education predicts a higher risk of death in IDUs and its impact is stronger after 1997. Education has a protective effect on most causes of death and it cannot be entirely attributable to the access or use of HAART.

Using cohort studies to estimate mortality among injecting drug users that is not attributable to AIDS

BACKGROUND

Injecting drug use (IDU) and associated mortality appear to be increasing in many parts of the world. IDU is an important factor in HIV transmission. In estimating AIDS mortality attributable to IDU, it is important to take account of premature mortality rates from other causes to ensure that AIDS related mortality among injecting drug users (IDUs) is not overestimated. The current review provides estimates of the excess non-AIDS mortality among IDUs.

METHOD

Searches were conducted with Medline, PsycINFO, and the Web of Science. The authors also searched reference lists of identified papers and an earlier literature review by English et al (1995). Crude mortality rates (CMRs) were derived from data on the number of deaths, period of follow up, and number of participants. In estimating the all-cause mortality, two rates were calculated: one that included all cohort studies identified in the search, and one that only included studies that reported on AIDS deaths in their cohort. This provided lower and upper mortality rates, respectively.

RESULTS

The current paper derived weighted mortality rates based upon cohort studies that included 179 885 participants, 1,219,422 person-years of observation, and 16,593 deaths. The weighted crude AIDS mortality rate from studies that reported AIDS deaths was approximately 0.78% per annum. The median estimated non-AIDS mortality rate was 1.08% per annum.

CONCLUSIONS

Illicit drug users have a greatly increased risk of premature death and mortality due to AIDS forms a significant part of that increased risk; it is, however, only part of that risk. Future work needs to examine mortality rates among IDUs in developing countries, and collect data on the relation between HIV and increased mortality due to all causes among this group.

VEdeTTE, a longitudinal study on effectiveness of treatments for heroin addiction in Italy: study protocol and characteristics of study population

The aim of this study was to provide a methodological overview of the study design of the national evaluation large-scale study VEdeTTE and a description of the VEdeTTE study population and to compare enrollments with refusals and the study population with the overall clients at the National Health System (NHS) treatment centers. VEdeTTE is a longitudinal study of heroin addicts recruited in 115 NHS treatment centers in Italy, 1998-2001; 11,903 people were enrolled, 3876 refused to participate; data were analysed on 10,454. Information from refusals was compared to enrollments. The characteristics of the cohort were compared to those of all patients treated in 1999 in Italy. Refusals had a lower educational level and less regular occupational status than those enrolled. Fourteen percent of enrolled patients were women; heroin users in the VEdeTTE study were older than patients attending all NHS treatment centers in Italy; incident cases were less represented. The majority of participants had more than 8 years of education, 33.5% were regularly employed, and only 2% did not have a fixed address. Injectors were 72.3%; 40.6% had a previous overdose, and 14.3% had been imprisoned for life; 15.7% shared injection equipment during the previous 6 months. The proportion of participants reporting heroin use approximately halved from the beginning of the current treatment to the time of the interview. The VEdeTTE study is the biggest cohort of heroin addicts attending treatment centers in Europe. The Italian heroin-addicted population under treatment seems to have low level of education but good social integration. Compared with men, women show a higher severity. Participants show a beneficial effect of treatment.

Drug-related mortality and its impact on adult mortality in eight European countries

OBJECTIVE

To estimate the mortality rates from drug-related deaths and other causes among problem drug users and population attributable risk of death due to opiate use in eight study sites in Europe.

METHODS

Opiate users were recruited from drug treatment centres during the period 1990-1998 and deaths followed up through national or local mortality registries. Gender-specific overall mortality rate, proportion of deaths by cause (drug-related, HIV, other), standardized mortality ratios (SMRs), and the attributable risk fraction (ARF) were estimated.

RESULTS

Crude mortality rates varied from 1 per 100 person-years in the Dublin and London cohorts to 3.8 per 100 person-years in Barcelona. The highest drug-related mortality rate was 10 per 1,000 person-years in Barcelona; the rates were approximately 7 per 1,000 person-years in Denmark, London, Rome, and Vienna, and <3.5 per 1,000 person-years for the others cohorts. The mortality rate for AIDS was <2 per 1,000 person-years in all the cohorts except Lisbon, Rome, and Barcelona, for which it was approximately 6 per 1,000 person-years. The highest SMR among males was 21.1 in Barcelona, and among females the highest SMRs were 53.7 and 37.7 in Barcelona and Rome, respectively. In Denmark the ARF was 5%, whereas it was >10% in all other study sites and 24% in Barcelona.

CONCLUSION

Cohort mortality studies, especially in combination with estimates of prevalence, provide useful insights into the impact of opiate use on mortality across European countries and emphasize how preventing overall and drug-related deaths among opiate users can significantly improve the health of the population.

Socio-economic inequalities in suicide: a European comparative study

BACKGROUND

Social factors have been shown to be predictors of suicide. It is not known whether these factors vary between countries.

AIMS

To present a first European overview of socio-economic inequalities in suicide mortality among men and women.

METHOD

We used a prospective follow-up of censuses matched with vital statistics in ten European populations. Directly standardised rates of suicide were computed for each country.

RESULTS

In men, a low level of educational attainment was a risk factor for suicide in eight out of ten countries. Suicide inequalities were smaller and less consistent in women. In most countries, the greater the socio-economic disadvantage, the higher is the risk of suicide. The population of Turin evidenced no socio-economic inequalities.

CONCLUSIONS

Socio-economic inequalities in suicide are a generalised phenomenon in western Europe, but the pattern and magnitude of these inequalities vary between countries. These inequalities call for improved access to psychiatric care for lower socio-economic groups.

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.

Drug-use pattern, comorbid psychosis and mortality in people with a history of opioid addiction

OBJECTIVE

To compare the 15-year mortality of people with a history of opioid dependence that had achieved stable abstinence, with the mortality associated with continued drug use. Another objective was to study the influence of hospitalization with comorbid psychosis on the 15-year mortality.

METHOD

In 1984, 188 persons (122 men and 66 women) with a history of intravenous narcotics addiction were interviewed about their drug-use pattern. A registry-based follow-up continued through 1999 and mortality was assessed. Three 1984-drug-use categories were formed. In category 1, cohort members had achieved stable abstinence from drug use by 1984. Using Cox multiple regression analysis, we (i) estimated reduced mortality of category 1 drug users, and (ii) studied the influence of hospitalization with comorbid psychosis on mortality.

RESULTS

About 32% had died during the 15-year follow-up. The 15-year mortality associated with stable abstinence was reduced by 56% when compared with the perceived worst drug-use pattern. Hospitalization for comorbid psychosis was not independently associated with mortality in this sample. When drug-use categories were compared with mortality expectations for the general population, the standard mortality rates (SMRs) were clearly elevated. Even in the stably abstinent drug-use category (category 1), SMR was significantly elevated by at least seven-fold in both genders.

CONCLUSION

People who had achieved stable abstinence from injecting narcotics use were at lower risk of premature death than people with continued drug use. A residual observed excess mortality in people who had apparently achieved stable abstinence from drug use is consistent with the view of drug addiction as a chronic disease.

Unintentional methadone-related overdose death in New Mexico (USA) and implications for surveillance, 1998-2002

AIMS

To determine death rates from methadone over time, to characterize methadone-related death and to discuss public health surveillance of methadone-related death.

DESIGN

We analyzed medical examiner data for all unintentional drug overdose deaths in New Mexico, USA, between 1998 and 2002.

MEASUREMENTS

Age-adjusted death rates for methadone-related death, logistic regression models for likelihood of methadone-related death among all unintentional drug overdose deaths and bivariate comparisons within methadone-related death.

FINDINGS

Of 1120 drug overdose deaths during this period, there were 143 (12.8%) methadone-related deaths; the death rate decreased over the time period, averaging 1.6 per 100,000. Of 143 methadone-related deaths, 22.4% were due to methadone alone, 23.8% were due to methadone/prescription drugs (no illicit drugs), 50.3% were due to methadone/illicit drugs and 3.5% were due to methadone/alcohol. These groups were significantly different in demographics, health history and circumstances of death. Of 79 decedents (55.2%) with a known source of methadone, 68 obtained methadone through a physician prescription (31 for methadone maintenance treatment (MMT), 27 for managing pain and 10 had unknown reason for prescription).

CONCLUSIONS

Methadone-related death rates and the proportion of methadone-related death among all drug overdose deaths decreased in New Mexico from 1998 to 2002. It is important for surveillance of methadone-related death to assess multiple drug causes, not just underlying cause. Also, methadone for pain management must be examined alongside MMT and when possible, methadone co-intoxication should be described in the context of other drugs causing death.

Drug-related mortality and fatal overdose risk: pilot cohort study of heroin users recruited from specialist drug treatment sites in London

Fatal overdose and drug-related mortality are key harms associated with heroin use, especially injecting drug use (IDU), and are a significant contribution to premature mortality among young adults. Routine mortality statistics tend to underreport the number of overdose deaths and do not reflect the wider causes of death associated with heroin use. Cohort studies could provide evidence for interpreting trends in routine mortality statistics and monitoring the effectiveness of strategies that aim to reduce drug-related deaths. We aimed to conduct a retrospective mortality cohort study of heroin users recruited from an anonymous reporting system from specialist drug clinics. Our focus was to test whether (1). specialist agencies would agree to participate with a mortality cohort study, (2). a sample could be recruited to achieve credible estimates of the mortality rate, and (3). ethical considerations could be met. In total, 881 heroin users were recruited from 15 specialist drug agencies. The overall mortality rate of the cohort of heroin users was 1.6 (95% confidence interval [CI], 1.1 to 2.2) per 100 person-years. Mortality was higher among males, heroin users older than 30 years, and injectors, but not significantly higher after adjustment in a Cox proportional hazard model. Among the 33 deaths, 17 (52%) were certified from a heroin/methadone or opiate overdose, 4 (12%) from drug misuse, 4 (12%) unascertained, and 8 (24%) unrelated to acute toxic effects of drug use. Overall, the overdose mortality rate was estimated to be at least 1.0 per 100 person-years. The standardized mortality ratio (SMR) was 17 times higher for female and male heroin users in the cohort compared to mortality in the non-heroin-using London population aged 15-59 years. The pilot study showed that these studies are feasible and ethical, and that specialist drug agencies could have a vital role to play in the monitoring of drug-related mortality.

Prevalence and circumstances of opiate overdose among injection drug users in the Russian Federation

Using a self-administered questionnaire, we examined the characteristics of opiate overdose in 16 cities of the Russian Federation. As indicated by responses from 763 injection drug users who took part in this study, 59% experienced an overdose, 81% reported seeing others experiencing an overdose, and 15% stated that they had witnessed a fatal overdose. The most common drug that caused opiate overdose was heroin (74%), although we also found that, in smaller towns, home-produced opiates tended to be a major overdose-causing agent. There were a number of factors that increased the likelihood of overdose, such as mixing opiates with alcohol and tranquilizers or having a longer history of opiate use. We also found that injecting drug users were reluctant to seek medical assistance when their peers experienced an overdose because of the perceived ineffectiveness of ambulance services and fear of police prosecution. At the same time, 57% of respondents admitted that they lacked appropriate skills to treat overdose. We discuss the implications of these findings for overdose prevention programs in Russia.

Estimating prevalence of problem drug use at national level in countries of the European Union and Norway

OBJECTIVES

This paper will present the most recent estimates for problematic drug use in European Member States and explore the problems of comparability.

METHODS

Estimates of problematic drug use, derived according to agreed guidelines, were collected from all EU countries and Norway. Methods included multipliers based on treatment, police, mortality or AIDS/HIV data, the capture-recapture method and the multivariate indicator method. Prevalence estimates were transformed into rates per 1000 population aged 15-64 years.

RESULTS

Target populations varied according to data selection. Estimates for six partially overlapping types of drug use could be identified: 'problem opiate use', 'problem opiate or cocaine use', 'problem amphetamine or opiate use', 'problem drug use', '(current) injecting' and 'life-time injecting'. Rates of injectors ranged from 2.6 in Germany to 4.8 in Luxembourg; rates in Austria, Denmark, Finland, Portugal and the United Kingdom fell within this range. For problem opiate use, a group of high prevalence countries were found with average rates exceeding six cases (Italy, Luxembourg, Spain and the United Kingdom) and a group with lower prevalence with average rates close to three cases (Austria, Germany, Ireland, the Netherlands). Rates obtained for France (problem opiate or cocaine use), Finland and Sweden (problem amphetamine or opiate use) are not directly comparable and fall between these rates.

CONCLUSIONS

Cross-national comparisons should be made with care and estimated target populations may vary greatly between countries. For estimating various forms of problem drug use at national level, a multi-method approach is recommended.

Deaths by unintentional illicit drug overdose in Italy, 1984-2000

AIM

To determine whether there has been an increase in deaths by overdose in Italy, as elsewhere in the Western world, over the past fifteen years.

METHOD

This study's conclusions are based on analysis of official data on overdose deaths attributed to illicit drug addiction and abuse (ICD-9 codes 304 and 305) from 1984 to 2000, drawn from two archives of drug abuse information: the Direzione Centrale per i Servizi Antidroga (DADE) of the Italian Ministry of the Interior (1984-2000), and the Health Statistics held at the Italian Central Statistics Institute (ISTAT) (1984-1997). Mortality rates have been calculated for both genders in the following age groups: 15-24, 25-34, and 35-44 years.

RESULTS

Official data indicate that there has been a steady increase in the number of deaths by overdose in Italy over recent 15 years. This trend has affected both genders, but is more evident among males. Over the whole period females had consistently lower overdose rates than males. In both genders the age group 35-44 was subject to the highest mortality rate increase over the study period, however, the highest overdose rates for both males and females were observed in the 25-34 age group. Consistently higher rates were witnessed in the northern regions of Italy with an overall increase across all latitudes. However, the greatest increase over the study period occurred in the South. In 5190 cases evaluated by the Italian Forensic Toxicology Group, 95.9% of deaths were attributed to heroin, but in about half of these, mixtures of three or more substances (heroin, benzodiazepines, cannabinoids, cocaine, methadone) were found in the deceased at doses that were likely to have contributed to death.

CONCLUSIONS

The increase observed in the rates of death by overdose is likely to be a reflection of increased use of illicit drugs in the general population. Reporting practice by forensic pathologists might explain the extent of attribution of cause of death to heroin. Drop-out from addiction treatment is a commonly observed antecedent of fatal opioid overdose, therefore, caution is required when establishing treatment protocol for patients. Interventions that aim specifically at improving patient compliance with medical and psychiatric therapies should be favoured.

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).

Mortality of opiate users in Vienna, Austria

The purpose of this study was to investigate whether there are differences in overall and cause-specific mortality rates of opiate users in maintenance treatment and of opiate users not in any drug treatment program in Vienna, Austria. A cohort of opiate-users enrolled in maintenance treatment in Vienna and a cohort of individuals involved in opiate-related emergencies from 1995 to 1997 were retrospectively analyzed. The standardized mortality rate of opiate-users enrolled in maintenance treatment was 12.1 and that of individuals involved in opiate-related emergencies was 48.8. Excess mortality was found for all categories for both groups. In the face of the extremely high excess mortality of opiate users involved in opiate-related emergencies, measures have to be taken to get these individuals in drug treatment programs as soon as possible.

Optimal investment in a portfolio of HIV prevention programs

OBJECTIVES

In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes.

METHODS

The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior.

RESULTS

The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit.

CONCLUSIONS

The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

HIV transmission and the cost-effectiveness of methadone maintenance

OBJECTIVES

This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic.

METHODS

We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%.

RESULTS

Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots.

CONCLUSIONS

Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.

[Trends in the number of human immunodeficiency virus infected persons and AIDS cases in Spain: 1980-1998]

BACKGROUND

To describe the trend in the number of HIV-infected persons and the number of AIDS cases in Spain between 1980 and 1998.

SUBJECTS AND METHODS

The following information was used: annual incidence of AIDS taken from the National Registry, AIDS deaths taken from the same registry and from the Registry of Vital Statistics, HIV seroprevalence in studies in sentinel populations, HIV incidence in cohorts of exposed persons, and reports of HIV infections in the registries existing in the autonomous communities. We considered three events of interest--HIV infection, AIDS and death--which were related using back-projection and compartmental models.

RESULTS

HIV spread rapidly in Spain during the years 1980. Transmission subsequently declined by more than 50% to figures that probably do not exceed 6,000 new infections in 1998. The incidence of AIDS increased to more than 7,000 new cases in 1994 and has since declined to some 4,000 cases in 1998. The level of AIDS mortality has always been lower than the incidence; it increased up to 1995 and then dropped to less than half in subsequent years. The number of living persons infected with HIV, including AIDS cases, arose until the early years 1990 and has since remained steady at about 125,000 persons. The number of cases of living persons with AIDS has increased continuously, and is estimated at about 19,000 through the end of 1998.

CONCLUSIONS

The recent trend in new infections, AIDS cases and deaths is favourable, while the number of infected living persons remains very high.

Mortality of HIV-positive and HIV-negative heroin abusers as a function of duration of injecting drug use

OBJECTIVE

To determine the incidence of mortality of injecting drug users as a function of the duration of injecting drugs and HIV status, and to assess how these effects vary according to age at initiation and calendar period (before and after 1992).

METHODS AND DESIGN

Cohort of 376 intravenous heroin users admitted to detoxification between February 1987 and January 1990.

SETTING

Patients referred from outpatient clinics of metropolitan Barcelona. Duration and characteristics of drug use were determined by interviews. Blood samples were collected during admission and analyzed for HIV, CD4+ cell count and different biologic parameters. Assessment of vital status and causes of death were obtained by hospital charts, death certificates, and autopsies.

RESULTS

The study population consisted of 299 men and 77 women, whose mean age at entry was 26 years, mean duration of injecting drug use before admission 6.1 years; HIV seroprevalence at entry 70.2%. By the end of the follow-up (median 5.6 years), 21.8% of individuals had died (26.6% in HIV-positive, and 10.7% in HIV-negative injecting users). Based on Kaplan-Meier estimates, 10%, 20%, and 30% of HIV negative patients died by 8.7, 11.3 and 14.3 years, respectively, after initiating injecting drugs. The corresponding survival times for the seropositives were substantially lower: 6.6, 8.5, and 11.6 years, respectively. Overall, the survival time was significantly (p < .05) decreased by 22% in HIV-positive injecting drug users. Older age at initiation of injecting drug use was significantly (p < .05) associated with mortality in HIV-positive heroin users but it showed the opposite direction among HIV-negative people. Death rates in HIV-positive patients of the same duration of drug use were similar in periods before and after 1992 (relative hazard (RH) = 0.97; 95% confidence interval: 0.58-1.61). Although not statistically significant, the hazard of death in HIV-negative injecting drug users was substantially lower after 1992 (RH = 0.59).

CONCLUSIONS

Before introduction of potent antiretroviral therapies, HIV infection further increased rates of mortality that had already been heightened by injecting drug use. Furthermore, HIV infection modifies the effect of age at initiation and eliminates the seemingly downward trend of mortality in HIV-negative people.

Drug-related mortality in Denmark 1970-93

We analysed drug-related mortality in Denmark with respect to secular trends, gender, and regional variations, for the period 1970 - 93, for all deaths from poisoning and among drug addicts. The study was based on the Register of Causes of Death in Denmark and included 6,229 drug-related deaths, defined by specific combinations of manner of death, underlying cause of death, and contributory cause of death. The main outcome measure is age-specific mortality rate. A total of 63% of the drug-related deaths were registered as unnatural deaths. During the period studied, mortality increased for men in the 25 - 49 year age group and for women in all age groups over 25 years of age. For both men and women, the youngest birth cohorts from the mid-1950s and 1960s suffered much higher mortality than those born before 1950; however, the three youngest birth cohorts had almost the same mortality. During the entire period, mortality in the capital, Copenhagen, was much higher than in the provinces, but in the last years, a more favourable trend has been seen in Copenhagen.

Substance Abuse and Drug-Related Death, Suicidal Ideation, and Suicide: A Review

The high mortality rate among drug users, which is partly due to the HIV epidemic and partly due to drug-related accidental deaths and suicides, presents a major public health problem. Knowing more about prevalence, incidence, and risk factors is important for the development of rational preventive and therapeutic programs. This article attempts to give an overview of studies of the relations between substance abuse, suicidal ideation, suicide, and drug-related death. Research in this field is hampered by the absence of clear definitions, and results of studies are rarely comparable. There is, however, consensus about suicidal ideation being a risk factor for suicide attempts and suicide. Suicidal ideation is also a predictor of suicide, especially among drug users. It is correlated with an absence of family support, with the severity of the psychosocial dysfunctioning, and with multi-drug abuse, but also with requests for treatment. Every clinical examination of a drug user, not only of those who are depressed, should address the possible presence of suicidal ideation, as well as its intensity and duration.

Pre-AIDS mortality from natural causes associated with HIV disease progression: evidence from the European Seroconverter Study among injecting drug users

OBJECTIVES

To study differences in pre-AIDS mortality between European cohorts of injecting drug users (IDU) and to evaluate whether pre-AIDS mortality increased with time since HIV seroconversion and decreasing CD4 count.

METHODS

The study population consisted of 664 IDU with documented intervals of HIV seroconversion from eight cohort studies. Differences in pre-AIDS mortality were studied between European sites; an evaluation of whether pre-AIDS mortality increased with time since HIV seroconversion and decreasing CD4 count was carried out using Poisson regression.

RESULTS

One hundred and seven IDU died, of whom 57 did not have AIDS. Pre-AIDS causes of death were overdose/suicide (49%), natural causes such as bacterial infections/cirrhosis (40%), and unintentional injuries/unknown (11%). Considering pre-AIDS death and AIDS as competing risks, 14.7% were expected to have died without AIDS and 17.3% to have developed AIDS at 7 years from seroconversion. No statistically significant differences in pre-AIDS mortality were found between European regions, men and women, age categories and calendar time periods. Overall pre-AIDS mortality did not increase with time since seroconversion, but did increase with decreasing CD4 count. Evaluating cause-specific mortality, only pre-AIDS mortality from natural causes appeared to be associated with time since seroconversion as well as immunosuppression. For natural causes, the death rate per 100 person-years was 0.13 the first 2 years after seroconversion, 0.73 in years 2-4 [risk relative (RR) to years 0-2, 5.6], 1.83 in years 4-6 (RR, 14.0) and 1.54 for > or = 6 years (RR, 11.7). This rate was 0 for a CD4 cell count > or = 500 x 10(6)/l, 1.06 for 200-500 x 10(6)/l and 4.06 for < 200 x 10(6)/l (RR versus > or = 200 x 10(6)/l, 7.0). In multivariate analysis, both CD4 count and time since seroconversion appeared to be independently associated with death from natural causes; CD4 count appeared to be the strongest predictor (adjusted RR, 5.9).

CONCLUSIONS

A high pre-AIDS mortality rate was observed among IDU. No significant differences were observed across European sites. Pre-AIDS mortality from natural causes but not from overdose and suicide was associated with HIV disease progression.