Opiates or cocaine: mortality from acute reactions in six major Spanish cities. State Information System on Drug Abuse (SEIT) Working Group

Epidemiological Study of Mortality Rate from Alcohol and Illicit Drug Abuse in Iran

Background: The estimate of mortality associated with illicit opiate use provides useful information to those directing and monitoring local, national and international policies and programs. This study investigated the epidemiology of mortality due to the illegal consumption of narcotics and psychotropic substances in the Iran to provide evidence-based public health data for useful programs and actions aimed at preventing drug-related mortality.

Study Design: A cross-sectional study.

Methods: The information regarding all cases of psychotropic positive was collected from Legal Medicine Organization, occurred on Mar 2015 to Feb 2016. Demographic and epidemiological data were extracted from recorded documents. Data were then analyzed in Stata software.

Results: Overall, 2306 died cases from opioid or psychotropic abuse were evaluated. The mean age of the subjects was 36.07±12.61 yr, they were mostly single male, and 88.64% of them had Iranian nationality. The mortality rate from opiate and psychotropic abuse in the whole country was 38.22 per 1,000,000 population. The most common location of death was at home or in another private residence. History of overdose, suicide, hospitalization in psychiatric hospital, staying in prison and substance abuse in the family observed in some people who died from drug abuse.

Conclusions: Mortality rate from substance abuse is more among unmarried young men aged 30-39 yr with low education level also in self-employed. We suggest policies to prevent this person accessing and using drug.

Experiences of Illicit Drug Overdose: An Ethnographic Study of Emergency Hospital Attendances

To date there are few available data relating to drug users' views and experiences of illicit drug overdose. This paper provides in-depth information relating to the experience of overdose that might help to inform and improve prevention of the problem and responses to it. Research was conducted in five hospitals in two Scottish cities during 1997 and 1998. Data were collected from (i) semistructured interviews with 74 drug users who had overdosed in the previous 48 hours and (ii) fieldnotes written during non-participant observation in the hospital setting. Analysis was undertaken using grounded theory (Glaser & Strauss, 1967) and was assisted by the computer software package WinmaxPro. Issues considered relate to the overdose incident; subsequent recovery; treatment received; and behavior in the hospital setting. The findings are discussed and some implications for policy and practice are considered.

Opiate- and cocaine-related fatal overdoses in Luxembourg from 1985 to 2011: a study on gender differences

BACKGROUND/AIM

We analysed gender differences in national fatal overdose (FOD) cases related to opiates and cocaine use between 1985 and 2011 (n = 340).

METHODS

Cross-examination of national data from law enforcement and drug use surveillance sources and of forensic evidence. Bivariate and logistic regression analysis of male/female differences according to sociodemographics, forensic evidence and drug use trajectories.

RESULTS

The burden of deaths caused by FOD on the general national mortality was higher for men (PMR/100=0.55) compared with women (PMR/100=0.34). Compared with their male peers, women were younger at the time of death (t=3.274; p=0.001) and showed shorter drug use careers (t=2.228; p=0.028). Heroin use was recorded more frequently in first drug offences of female victims (AOR=6.59; 95% CI 2.97-14.63) and according to forensic evidence, psychotropic prescription drugs were detected to a higher degree in females (AOR=2.019; 95% CI 1.065-3.827).

CONCLUSION

The time window between the onset of illicit drug use and its fatal outcome revealed to be shorter for women versus men included in our study. Early intervention in female drug users, routine involvement of first-line healthcare providers and increased attention to use of poly- and psychotropic prescription drugs might contribute to prevent premature drug-related death and reduce gender differences.

Cocaine-related admissions to an intensive care unit: a five-year study of incidence and outcomes

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Using latent class analysis (LCA) to analyze patterns of drug use in a population of illegal opioid users

BACKGROUND

The objective of this paper is to empirically determine a categorization of illegal opioid users in Canada in order to describe and analyze drug use patterns within this population.

METHODS

Drug use patterns of 679 eligible illegal opioid users outside treatment from the OPICAN study, a pan-Canadian cohort (recruited March to December, 2002) involving the cities of Toronto, Montreal, Vancouver, Edmonton and Quebec City, were empirically examined using latent class analysis. These latent classes were then further analyzed for associations using chi-square and t-test statistics.

FINDINGS

The opioid and other drug user sample surveyed were categorized into three latent classes. Class 1 (N=256) was characterized by the use of Tylenol 3 and benzodiazepines along with high levels of depression and self-reported pain. Class 2 (N=68) was described by the non-injection use of both heroin and crack while having a high level of homelessness. Class 3 (N=344) was shown to consist of injection drug users of heroin and cocaine exhibiting the highest levels of HIV and Hepatitis C infections amongst the classes.

CONCLUSIONS

Using latent class analysis we found distinct patterns of drug use amongst illegal opioid users differing in terms of type of drugs co-used, social context, and co-morbid pathologies. These data may be useful as the empirical basis for the planning of specific prevention and treatment interventions.

Causes of death among crack cocaine users

OBJECTIVE: The study accompanied 131 crack-cocaine users over a 5-year period, and examined mortality patterns, as well as the causes of death among them. METHOD: All patients admitted to a detoxification unit in Sao Paulo between 1992 and 1994 were interviewed during two follow-up periods: 1995-1996 and 1998-1999. RESULTS: After 5 years, 124 patients were localized (95%). By the study endpoint (1999), 23 patients (17.6%) had died. Homicide was the most prevalent cause of death (n = 13). Almost one third of the deaths were due to the HIV infection, especially among those with a history of intravenous drug use. Less than 10% died from overdose. CONCLUSIONS: The study suggests that the mortality risk among crack cocaine users is greater than that seen in the general population, being homicide and AIDS the most common causes of death among such individuals.

Do young heroin users in Madrid, Barcelona and Seville have sufficient knowledge of the risk factors for unintentional opioid overdose?

To identify the self-perceived reasons for unintentional opioid overdose of young heroin users in three Spanish cities and their agreement with objective risk factors for overdose. Computer-Assisted Personal Interviews (CAPI) were held with 991 street-recruited current heroin users aged 18-30. The general reasons for overdose and the reasons for the last overdose suffered were explored with open-ended (OEQs) and pre-coded questions (PCQs). Limited knowledge of overdose risk factors was defined as mention of fewer than two objective risk factors for unintentional overdose in the OEQ. Univariate, bivariate, and logistic regression methods were used. 77.8% (Seville), 64.9% (Madrid) and 57.2% (Barcelona) of participants have limited knowledge of overdose risk factors. Residence in Seville and not having attended courses or meetings on overdoses were significantly associated with limited knowledge, after adjusting for other factors. The most frequently identified general reasons in OEQ or PCQ were using heroin in large amounts (66.8%), together with tranquilizers (62.0%), adulterated (60.7%), or purer than usual (57.6%). Most reasons were selected more frequently in PCQ than in OEQ, especially rapid injection of the entire dose and using heroin shortly after using tranquilizers or alcohol, by injection, or after a period of abstinence. The results were similar for overdoses suffered by participants. Most young heroin users do not have sufficient knowledge of overdose risk factors, especially the use of heroin by injection, after a period of abstinence, or together with alcohol or methadone. Specific informational or educational programs adapted to the local context are critically needed.

The effect of persistence of cocaine use on 12-month outcomes for the treatment of heroin dependence

AIMS

To determine the effects of cocaine use across the study period on outcomes of treatment for heroin dependence 12 months post-treatment entry.

DESIGN

Longitudinal cohort (12 months). Interviews were conducted at baseline, 3 and 12 months.

SETTING

Sydney, Australia.

PARTICIPANTS

Four hundred ninety-five heroin users recruited for the Australian Treatment Outcome Study and re-interviewed at 12-month follow-up.

FINDINGS

Cocaine was widely used among treatment entrants in NSW, with almost all having a lifetime history of cocaine use and almost half having used in the month preceding baseline. While there was an overall decline in cocaine use across the study period, individual use patterns varied widely. Approximately half of the cohort did not report cocaine use at any data point, with the remainder reporting having used at one (29%), two (12%), or at all three (5%) points. Cocaine use across the study period was an independent predictor of most major treatment outcomes, with more cocaine use points predicting poorer outcome. Persistent cocaine use predicted a higher prevalence of homelessness, heroin use, daily injecting, needle sharing and injection-related health problems at 12 months as well as more extensive recent polydrug use.

CONCLUSIONS

Cocaine use was common among individuals seeking treatment for primary heroin dependence in NSW. Any cocaine use over the study period was associated with poorer outcomes in virtually all areas. Persistent cocaine use over the study period, however, appeared particularly detrimental. Cocaine use among clients should evidently be a cause for concern amongst treatment providers and may warrant being specifically targeted during treatment.

Cohort trends in age of initiation to heroin use

This paper examines gender differences and trends over time in the age of initiation to heroin use. Data from two large surveys: the Sydney component of the ANAIDUS, conducted in 1989, and the ASHIDU, conducted in 1994, were used to examine this issue. Together, these studies contained information on 1,292 individuals who identified themselves as heroin users. Results indicated that, while there were no significant gender differences in age of initiation to heroin use, there was a significant (p < 0.001) time trend in the mean age at which heroin was first used. Specifically, the mean age of first heroin use among individuals born during the interval 1940-1949 was 20.5 years while among those born during 1970-1979 the mean age of first heroin use was 16.5 years. These findings were confirmed by analyses of the National Household Survey. Further analysis of the ASHIDU data indicated that younger age of initiation to heroin use was associated with polydrug use, overdose and crime after the effects of duration of heroin use had been statistically controlled. These findings suggest that there has been both an increase in the willingness of young people to experiment with heroin and an increased availability of the drug over this time. In combination with evidence that there has been an increase in the amount of heroin being imported into Australia, and an increased demand for treatment for opiate dependence, these data suggest that Australia is experiencing an increase in the use of heroin, particularly among youth.

Cocaine-related fatalities in New South Wales, Australia 1993-2002

AIM

To ascertain the demographic characteristics, circumstances of death, toxicological results, and major autopsy findings of cocaine-related fatalities.

DESIGN

Inspection of the coronial records of all cocaine-related deaths that occurred in New South Wales, Australia between 1 January 1993 and 31 December 2002.

SETTING

New South Wales, Australia.

FINDINGS

146 cases were identified. Cocaine was implicated in the direct cause of death in 86% of cases, an antecedent cause in 8% and a significant condition contributing to death in 7%. The mean age of decedents was 34.1 years, and 84% were male. Half were employed, and 26% were in professional employment. The predominant route of administration was injection (86%), however nasal (8%), oral (3%), smoking (1%), and anal (1%) administration were all recorded. The most common location of death was a private home (53%). No intervention occurred prior to death in 82% of cases. The median blood benzoylecgonine concentration was 0.40 mg/L (range 0.00-20.00 mg/L). Cases had a mean of 3.5 drugs, with morphine (79%) the most common co-occurring drug. In 5% of cases cocaine was the sole drug detected. Cardiac pathology was noted in 57% of cases, most commonly coronary artery atherosclerosis (39%) and cardiac hypertrophy (14%). In 15% of cases moderate to severe arterial occlusion was noted. Cerebrovascular pathology was noted in 22% of cases, most commonly cerebrovascular atherosclerosis (10%).

CONCLUSIONS

Cocaine-related deaths are a significant clinical problem in New South Wales.

Deaths from drug abuse in northwestern Spain, 1992 - 97

A total of 338 cases of death from acute reactions to drugs in Galicia (NW Spain) from 1 June 1992 to 31 July 1997 were examined. The average annual mortality rate was close to 70 cases. Male victims (90%) prevailed over female ones, the average age at death being 28.8 years. Most of the victims were habitual users who died in their own homes (40%) or nearby (30%). Polydrug use was the most common pattern, the most frequently detected drugs being opioids (281 cases), followed by alcohol (128 cases), benzodiazepines (92 cases) and cocaine (75 cases). Although the intravenous route prevailed (91%), oral and inhalation consumption of the drugs were also significant--the latter has grown significantly in recent times in relation to opioids and other drugs. How accurate the certificate of death can be depends on how thorough the investigation at the crime scene, autopsy room and laboratory are, as well as appropriate knowledge of the individual's history. The coordinated action of different health care institutions and use of available resources are crucial with a view to obtaining such data.

[Heart failure mortality in Spain, 1977-1998]

INTRODUCTION AND OBJECTIVES

Heart failure is now the third leading cause of cardiovascular death in developed countries and is also an important cause of morbidity and hospitalization that now represents the main cause of admissions among the elderly. In this study we present heart failure mortality trends in Spain developing over the last 20 years.

METHODS

Data on deaths due to heart failure were obtained from files supplied by the Spanish National Institute for Statistics. We present age-adjusted specific mortality rates over time analyzed by sex and geographic area. Poisson regression models were used to estimate trends.

RESULTS

Heart failure is responsible for 4 to 8% of all-cause mortality in men and women, and for 12 to 20% of cardiovascular mortality overall, the the highest rates seen among the elderly and in Andalusia. The lowest rates are found in the Basque Country and some provinces of Castilla-Leon. Rates have tended to decrease over the last 20 years, but the rate of decrease has been slower in women, such that their mortality began to exceeded that of men from 1990 onwards. Mortality among the elderly has not changed significantly but the total number of deaths and morbidity are both increasing.

CONCLUSIONS

Because the Spanish population is aging, we can foresee that chronic heart failure will require greater attention in the future.

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.

Fluctuations in heroin purity and the incidence of fatal heroin overdose

In order to determine the role played by heroin purity in fatal heroin overdoses, time series analyses were conducted on the purity of street heroin seizures in south western Sydney and overdose fatalities in that region. A total of 322 heroin samples were analysed in fortnightly periods between February 1993 to January 1995. A total of 61 overdose deaths occurred in the region in the study period. Cross correlation plots revealed a significant correlation of 0.57 at time lag zero between mean purity of heroin samples per fortnight and number of overdose fatalities. Similarly, there was a significant correlation of 0.50 at time lag zero between the highest heroin purity per fortnight and number of overdose fatalities. The correlation between range of heroin purity and number of deaths per fortnight was 0.40. A simultaneous multiple regression on scores adjusted for first order correlation indicated both the mean level of heroin purity and the range of heroin purity were independent predictors of the number of deaths per fortnight. The results indicate that the occurrence of overdose fatalities was moderately associated with both the average heroin purity and the range of heroin purity over the study period.

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

OBJECTIVE

The National Mortality Register (NMR) is used to monitor and prioritize health problems, but it may underestimate deaths from external causes, among which are deaths from acute reaction to psychoactive substances (ARPS). To evaluate the discrepancies between death from ARPS collected in the NMR and those collected in the specific register of the State Information System for Drug Addiction (SEIT).

METHODS

We evaluated the discrepancy between ARPS deaths in 15-49 years olds registered in the NMR (code E850-858) and deaths from acute reaction to opium and cocaine in the SEIT, in Barcelona, Bilbao, Madrid, Sevilla, Valencia and Zaragoza, between 1984-93.

RESULTS

3,491 ARPS deaths were registered in SEIT, 1,285 in NMR. Varying degrees of discrepancies appeared between the two registers in all six cities. The NMR in Madrid showed 92% fewer deaths than the SEIT, while in Barcelona the NMR figure was 23% lower. Between 1984 and 1993 the differences between registers in all cities, except Madrid and Seville, narrowed (p < 0.01).

CONCLUSIONS

Even though detection of ARPS deaths in the NMR has been improving, it still underestimates the real situation, and is therefore not a useful tool in the evaluation of temporal-spatial variations. To improve detection of ARPS deaths (and those from other external causes) a systematic linkage with data from the coroners' registers must be done.

Fatal poisoning with alcohol and drugs in the Greater Amman County

A study of fatal poisoning due to alcohol and drugs was carried out, to examine the mortality resulting from alcohol and drugs in the Greater Amman County, Jordan. A retrospective review of all autopsy records and certified deaths issued by the Department of Forensic Medicine at Jordan University Hospital in the greater Amman county was undertaken. During the 18 years (1978-1996) 6109 postmortem cases were performed in our department. A total of 60 cases were identified and analyzed according to age, race, sex, manner of death of the victims along with blood alcohol concentration, the drug detected at autopsies, the scene circumstances, and the geographic location of the accident and death.

Jurisdictional trends in opioid overdose deaths, 1988-96

This report analysed data on opioid overdose mortality between 1988 and 1996 to: examine differences between jurisdictions in the rate of fatal opioid overdose and the rate of increase in overdose; and estimate the proportion of all deaths which were attributed to opioid overdose. Australian Bureau of Statistics (ABS) data were obtained on the number of deaths attributed to opioid dependence (ICD 9 codes 304.0, 304.7) and accidental opioid poisoning (ICD 9 codes E850.0, E850.1). The highest rate of fatal overdose occurred in NSW, followed by Victoria. The standardised mortality rate among other jurisdictions fluctuated quite markedly. While the rate of opioid overdose has increased throughout Australia, the rate of increase has been greater in some of the less-populous states and territories than it has in NSW or Victoria. In 1996, approximately 6.5% of all deaths among people aged 15-24 years and approximately 10% of all deaths among those aged 25-34 were due to opioid overdose. During the interval from 1988 to 1996, the proportion of deaths attributed to opioid overdose increased. From 1988 to 1996, the proportion of deaths attributed to opioid overdose among individuals aged 25-34 years was approximately one-third that attributed to suicide, but this proportion had increased to approximately one-half by 1996. The rate of increase in the proportion of deaths attributed to opioid overdose was higher than the rate of increase in the proportion of deaths attributed to suicide.

Association of cardiovascular disease risk factors with socioeconomic position during childhood and during adulthood

OBJECTIVE

To investigate strength of associations between risk factors for cardiovascular disease and socioeconomic position during childhood and adulthood.

DESIGN

Cross sectional analysis of status of cardiovascular risk factors and past and present social circumstances.

SUBJECTS

5645 male participants in the west of Scotland collaborative study, a workplace screening study.

MAIN OUTCOME MEASURES

Strength of association between each risk factor for cardiovascular disease (diastolic blood pressure, serum cholesterol concentration, level of recreational physical exercise, cigarette smoking, body mass index, and FEV1 score (forced expiratory volume in one second as percentage of expected value) and social class during childhood (based on father's main occupation) and adulthood (based on own occupation at time of screening).

RESULTS

All the measured risk factors were significantly associated with both father's and own social class (P < 0.05), apart from exercise and smoking (not significantly associated with father's social class) and body mass index (not significantly associated with own social class). For all risk factors except body mass index, the regression coefficient of own social class was larger than the regression coefficient of father's social class. The difference between the coefficients was significant for serum cholesterol concentration, cigarette smoking, body mass index, and FEV1 score (all P < 0.001).

CONCLUSIONS

Subjects' status for behavioural risk factors (exercise and smoking) was associated primarily with current socioeconomic circumstances, while status for physiological risk factors (serum cholesterol, blood pressure, body mass index, and FEV1) was associated to varying extents with both past and present socioeconomic circumstances.

Mortality due to acute adverse drug reactions: opiates and cocaine in Barcelona, 1989-93

Drug-related deaths have become a major source of premature mortality. This paper presents an analysis of deaths due to acute adverse drug reactions caused by opiates or cocaine in the city of Barcelona over a 5-year period during which figures were stable. Annual mortality rates due to adverse drug reactions of city residents for the 1989-93 period were estimated to be 15.3 per 100,000 people in the 15-49-year age group. Mortality rates for men (25.0) are consistently higher than mortality rates for women (5.8). Mortality rates by age group show different patterns by gender. Males in the 25-29-year group have the highest mortality rate (62.8), almost doubling the rates for the 20-24 (36.1) and 30-34 (33.3)-year groups. The highest differential in age-specific mortality by gender is seen in the 35-39-year age group, where mortality rates for men (21.5) are eight times higher than for women (2.6 per 100,000). The distribution by place of residence, stratifying data across city neighbourhoods and municipal districts displays wide differences between districts in the mean annual rates, ranking between 77.3 and 8.3 per 100,000, a nine-fold magnitude. Differences are even steeper when we break down data by neighbourhood. Although all areas with high adverse drug reactions mortality are areas of low socio-economic level, a more complex association between deprivation and drug use must exist, as other areas with similarly low socio-economic indicators do not suffer from such high mortality. A cross-tabulation of place of residence and district of death shows that for most adverse drug reaction deaths, death takes place in the district of residence but patterns related to districts who attract drug-related deaths and districts who export them may be observed. These results provide new insights into the epidemiology of substance abuse in Barcelona, where it follows patterns that may be similar to those of other major urban areas in Spain, but also in other Southern European countries.