Differences in 5-year survival after a 'homeless' or 'housed' drugs-related hospital admission: a study of 15--30-year olds in Scotland

Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances

Background

Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths.

Methods

The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson’s chi-square test, Fisher’s exact test and the Mann-Whitney U test to analyse group differences.

Results

A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death.

Conclusions

The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.

Homelessness as a predictor of mortality: an 11-year register-based cohort study

PURPOSE

The purpose of this study was to examine the association between homelessness and psychiatric disorders, including substance use disorders, on one hand, and cause-specific and all-cause mortality on the other in a high-income country.

METHODS

A historical nationwide register-based cohort study of the Danish population from 15 years of age between 2000 and 2011 was conducted. The association between homelessness, psychiatric disorders, and mortality was analysed by Poisson Regression adjusting for important confounders. Standardised mortality ratios (SMRs) were calculated for people with a history of homelessness compared with the general population using direct age-standardisation.

RESULTS

During 51,892,324 person-years of observation, 656,448 died. People with at least one homeless shelter contact accounted for 173,592 person-years with 4345 deaths. The excess mortality in the population experiencing homelessness compared with the general population was reduced by 50% after adjusting for psychiatric diagnoses, including substance use disorders (mortality rate ratio (MRR) for men 3.30, 95% CI 3.18-3.41; women 4.41, 95% CI 4.14-4.71). Full adjustment including physical comorbidity and socioeconomic factors in a sub-cohort aged 15-29 years resulted in an MRR of 3.94 (95% CI 3.10-5.02) compared with the general population. The excess mortality associated with homelessness differed according to psychiatric diagnosis, sex, and cause of death.

CONCLUSIONS

A mental health or a substance use disorder combined with homelessness considerably increases the risk of death. However, homelessness is also independently associated with high mortality. Differences in the association between homelessness and mortality in men and women suggest the need for sex-tailored interventions.

Desigualdade social em saúde na população em situação de rua na cidade de São Paulo

Descrever as características sociodemográficas, o estado de saúde e o acesso a serviços na população em situação de rua em uma amostra em três albergues do centro da cidade de São Paulo. Amostra de 251 indivíduos: 171 do sexo masculino, 78 do sexo feminino e duas pessoas que se autodenominaram transexuais. Foi aplicado um questionário estruturado contendo dados sociodemográficos, trajetória e tempo de vida na rua, atividade física, discriminação, rede e suporte social, estado de saúde, consumo de álcool ou drogas, violência e acesso a serviços de saúde. Verificou-se o predomínio de adultos do sexo masculino, não brancos, com baixo nível de escolaridade, e com renda mensal menor que 1/2 (meio) salário mínimo. Um terço dos entrevistados já se encontrava nessa situação há mais de cinco anos. 45% dos entrevistados consideraram sua saúde boa ou muito boa. A maioria prefere utilizar as unidades básicas de saúde quando tem necessidade. As precárias condições financeiras e ausência de família somam-se às situações de violência física sofrida. Discriminação, péssimas condições de higiene e incapacidade física ou mental são comuns em suas vidas. O desafio que se coloca para a formulação da política de saúde é incorporar as representações e as práticas de cuidados desses sujeitos, como também dos serviços, como ponto de partida para a organização da assistência.

Gender differences in mortality and risk factors in a 13-year cohort study of street-recruited injecting drug users

BACKGROUND

Injecting drug users (IDUs) are at risk of premature mortality. This study examined gender differences in mortality, risk factors, and causes of death among IDUs.

METHODS

In a 13-year cohort study including 172 street-recruited IDUs from Oslo, Norway in 1997, interview data was merged with the National Cause of Death Registry. Crude mortality rate (CMR) and indirect standardized mortality ratio (SMR) were estimated with 95% confidence intervals (CI). A log-logistic multivariate survival analysis model was estimated for the full sample. For a smaller data set (1.1.1998-31.12.2004) the influence of substitution treatment and prison were assessed using cox regression survival analysis.

RESULTS

Eight females and 37 males died. Acute intoxications were the most common cause of death. Women were more at risk in the short-term, but more protected in the long-term. CMR was 16.0 [95% CI 8.0, 31.9] for women and 26.0 [95% CI 18.0, 35.8]) for men. SMR was 39.4 [95% CI 0.2, 220.8]) for women and 21.3 [95% CI 5.7, 54.1] for men. More women injected heroin (98% vs. 88% [x2 = 3.5, p = 0.063]), used prescription drugs (73% vs. 52% [x2 = 5.6, p = 0.018]) and combined these to inject (45% vs. 26% [x2 = 5.9, p = 0.015]). Mixing prescription drugs in heroin injections, and sex work (only women) were associated with decreased survival time. There were no gender differences in access to substitution treatment, while significantly more men had been in prison (74% vs. 51% [x2 = 7.5, p = 0.006]). The instance of substitution treatment and prison significantly decreased the mortality risk. Prison release increased the risk, but not statistically significantly.

CONCLUSIONS

There were gender differences in mortality and risk factors; sex work and prison were gender specific risk factors. These factors should be investigated further to better design future preventive measures.

Management of drug misusers in Glasgow general hospitals

Purpose

– The purpose of this paper is to ascertain an awareness of the management of the drug misusing guidelines in Glasgow general hospitals.

Design/methodology/approach

– A brief literature review was carried out to establish the available evidence for the guidelines. Additionally, a survey questionnaire was sent out to junior medical staff requesting their views on the drug misusing guidelines.

Findings

– A paucity of evidence relating to drug misusing guidelines was found from the literature. The Glasgow Guidelines appear to be a welcome source of information that is both comprehensive and easily accessible for staff. Junior medical staffs have broadly welcomed the guidance but would appreciate additional support on the management of patients prescribed Suboxone.

Research limitations/implications

– There should be an increase in training and development for junior medical staff regarding the guideline.

Originality/value

– The Glasgow Guidelines are aimed primarily at junior medical staff whose knowledge on drug misusing patients may be scarce. Increased training and awareness should improve the management of drug misusers in general hospitals. Consequently, patients should spent less time in hospital.

Systemic review on drug related hospital admissions - A pubmed based search

BACKGROUND

Drug related admissions have significantly increased over the past few decades. According to various studies on drug related hospital admissions, it was estimated that around 5-10% of hospital admissions were due to drug related problems (DRP), in which 50% of them are avoidable.

OBJECTIVE

The objective of the study was to derive results from various studies conducted on drug related hospital admissions and have an overall view about the incidence, frequency, cost of treatment, major causative drugs, problems for drug related hospital admissions, and preventable drug related admissions and summarize the factors responsible for the occurrence of DRP.

METHOD

Relevant literatures related to 'drug related hospital admissions' were obtained from PubMed database. Articles that were published from October 2007 to September 2012 were collected. All the studies being shown in the search results were considered for the study irrespective of the specialty department.

RESULTS

A total of 366 articles were found based on the keyword 'drug related hospital admission', 'drug related problem admission', and 'adverse drug event admissions' search. Out of which 49 articles were identified to be showing relevance to the study. Non-English, abstract-only articles, and out-patient adverse drug reaction (ADR) studies were filtered from 49 articles. Finally 15 articles were taken up for the study. Systemic analysis was made on these articles and the results were summarized.

CONCLUSION

Most of DRP studies were retrospective, multicenter studies conducted in general populations in Europe. The main objective of the studies was to estimate DRP frequency, incidence, risk factors and trends of DRP hospital admissions. Anti-neoplastic agents, CVS drugs and CNS drugs were related to most of the drug related problems. These studies concluded polypharmacy and older age were the major risk factors for developing drug related problems. It was found that the cost for the management of DRP was directly proportional to severity.

Are health inequalities evident at all ages? An ecological study of English mortality records

BACKGROUND

Inequalities in mortality are often presumed to exist at all ages. Here we examine whether this is true.

METHODS

We conducted an ecological study of mortality in England for 1997-99 using routinely collected public records. We used a (smoothed) single year of age rate of mortality for males and females by the multiple deprivation quintile of their ward of residence, for all and specific causes to assess if inequalities varied by age.

RESULTS

For most ages, a greater mortality risk exists for those living in the most deprived compared with the least deprived quintile of wards. However, during late adolescence there is equality. The equalization occurs at the age of 17-19 years. There is a longer period of 10 years for females and 20 years for males of convergence and then divergence centred on late adolescence and young adulthood. The equalization is driven principally through a heightened exposure to the risk of land transport accidents and a resulting higher than expected rate of mortality for the least deprived rather than a decrease in risk for the most deprived.

CONCLUSIONS

It seems likely that an increase in risk taking associated with late adolescence combined with exposure to a relatively dangerous transport environment leads to large increases in risk for young people in the least deprived parts of England. As a result mortality inequality disappears at this age.