Mortality rates among opioid addicts in a longitudinal study

Injection Drug Use Endocarditis: An Inner-City Hospital Experience

Background

There has been a rise in the incidence of injection drug use and associated infective endocarditis.

Methods

The clinical outcomes of 39 patients admitted with injection drug use-associated infective endocarditis were collected with a mean follow-up of 14 months. The outcomes were compared for patients treated medically with those undergoing surgical intervention. Re sults: The mean age was 39 ± 11 years; 54% were female. Thirty-two patients (82%) had native and 7 (18%) prosthetic infective endocarditis. The tricuspid valve was affected in 17 patients (43%), the mitral in 10 (26%), the aortic in 4 (10%), and multiple valves in 8 (20%). Sixteen (41%) patients underwent surgery, and 23 (59%) were treated with medical therapy. The indications for surgery included heart failure, systemic emboli, recurrent infection, and vegetation size ≥10 mm. Patients undergoing surgery had a higher rate of paravalvular abscess (25% vs 0%, P = 0.02), valve perforation (37% vs 11%, P = 0.04), and mitral valve involvement (44% vs 13%, P = 0.06), whereas medically treated patients had higher tricuspid valve involvement (61% vs 19%, P = 0.02). During follow-up, 26% of medical and 31% of surgical cohort patients died (P = 0.7). Mortality was highest (54%) among those who continued medical management despite an indication for surgery. Univariate predictors of mortality were age (odds ratio [OR] 1.09, 95% confidence interval [CI]: 1.01-1.17; P = 0.02), heart failure (OR 6.9; 95% CI: 1.24-37.49; P = 0.02), septicemia (OR 4.40; 95% CI:0.99-19.54; P = 0.05), and shock (OR 10.8; 95% CI: 1.68-69.92; P = 0.01).

Conclusions

Despite contemporary therapy, patients with injection drug use-associated infective endocarditis remain at high risk of complications and poor clinical outcomes. These findings highlight the need for developing new care pathways and a team approach for effective management.

Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse

Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.

Impact of workplace injury on opioid dependence, abuse, illicit use and overdose: a 36-month retrospective study of insurance claims

OBJECTIVES

To examine the impact of workplace injury on opioid dependence, abuse and overdose (opioid-related morbidity) and if severity of injury increases the hazard of these health effects.

METHODS

We used MarketScan databases to follow injured and propensity score matched non-injured workers, both without prior opioid-related diagnoses. Using a Cox proportional hazard model, we examined the impact of workplace injury on opioid-related morbidity.

RESULTS

The hazard of opioid-related morbidity for injured workers was 1.79 times than that of matched non-injured workers (95% CI 1.89 to 3.60). For medical-only and lost-time injured workers, it was respectively 1.54 (95% CI 1.02 to 2.32) and 2.91 (95% CI 1.75 to 4.84) times that of non-injured workers.

CONCLUSIONS

Reducing workplace injury or severity of workplace injury, as well as efforts to ensure appropriate opioid prescribing for injured workers, may help to reduce the societal costs of opioid use.

Association of History of Injection Drug Use with External Cause-Related Mortality Among Persons Linked to HIV Care in an Urban Clinic, 2001-2015

High mortality rates among persons with HIV with a history of injection drug use (PWID) are thought to be driven in part by higher rates of external cause-related mortality. We followed 4796 persons aged 18-70 engaged in continuity HIV care from 2001 to 2015 until death or administrative censoring. We compared cause-specific (csHR) and subdistribution hazards (sdHR) of death due to external causes among PWID and persons who acquired their HIV infection through other routes (non-IDU). We standardized estimates on age, sex, race, and HIV-related health status. The standardized csHR for external cause-related death was 3.57 (95% CI 2.39, 5.33), and the sdHR was 3.14 (95% CI 2.16, 4.55). The majority of external cause-related deaths were overdose-related and standardized sdHR was 4.02 (95% CI 2.40, 6.72). Absolute rate of suicide was low but the csHR for PWID compared to non-IDU was most elevated for suicide (6.50, 95% CI 1.51, 28.03). HIV-infected PWID are at a disproportionately increased risk of death due to external causes, particularly overdose and suicide.

Infective endocarditis: trends, surgical outcomes, and controversies

The number of hospitalizations and surgical cases of infective endocarditis (IE) are increasing. The aim of this study was to review these trends, surgical outcomes, and controversies related to IE. A search of MEDLINE of studies published between 1960 and 2018 was conducted. Search terms included "infective endocarditis", "history of", "trend", "epidemiology", "outcome", "medical management", "surgery", "indication", and "re-operative surgery", or any combination thereof. The United States has the highest incidence of IE in the world at 15 per 100,000 people, with increases in incidence due to the aging population as well as increasing rates of intravenous drug use (IVDU). National guidelines support early surgical intervention in specific clinical settings in both left and right-sided IE. However, only 11% of the evidence used in formulating guidelines for surgical therapy in IE are based on level A evidence. Ongoing controversies include whether to perform surgery in the setting of continued or recurrent IVDU in a patient with a prior valve operation, timing of surgery after acute stroke due to IE, and general indications for surgery for tricuspid valve IE. IE has a surging incidence and increasing burden on the healthcare system in the United States. Multiple controversies exist, and formulating level A evidence and multidisciplinary collaboration will be essential components to effectively treating this complex patient population.

Surgical outcomes of infective endocarditis among intravenous drug users

BACKGROUND

With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may require surgical intervention; however, few data exist about clinical outcomes of these individuals.

METHODS

We evaluated consecutive adult patients undergoing surgery for active IE between 2002 and 2014 pooled from 2 prospective institutional databases. Death and valve-related events, including reinfection or heart valve reoperation, thromboembolism, and anticoagulation-related hemorrhage were evaluated.

RESULTS

Of the 436 patients identified, 78 (17.9%) were current IVDUs. The proportion of IVDUs increased from 14.8% in 2002 to 2004 to 26.1% in 2012 to 2014. IVDUs were younger (aged 35.9 ± 9.9 years vs 59.3 ± 14.1 years) and had fewer cardiovascular risk factors than non-IVDUs. During follow-up (median, 29.4 months; quartile 1-3, 4.7-72.6 months), adverse events among all patients included death in 92, reinfection in 42, valve-reoperation in 35, thromboembolism in 17, and hemorrhage in 16. Operative mortality was lower among IVDUs (odds ratio, 0.25; 95% confidence interval [CI], 0.06-0.71), but overall mortality was not significantly different (hazard ratio [HR], 0.78; 95% CI, 0.44-1.37). When baseline profiles were adjusted by propensity score, IVDUs had higher risk of valve-related complications (HR, 3.82; 95% CI, 1.95-7.49; P < .001) principally attributable to higher rates of reinfection (HR, 6.20; 95% CI, 2.56-15.00; P < .001).

CONCLUSIONS

The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.

Impact of hepatitis C status on 20-year mortality of patients with substance use disorders

Background

The magnitude of the effect of hepatitis C viral infection on survival is still not fully understood. The objective of this study was to determine whether the presence of hepatitis C viral antibodies in 1991 was associated with increased mortality 20 years later within a cohort of patients with substance use disorders. Secondary objectives were to determine other factors that were associated with increased mortality in the cohort.

Methods

A subset of a 1991 study cohort of patients who had presented for detoxification was reexamined 20 years later. The Social Security Death Index was queried to identify which of the original patients had died. Attributes of survivors and non-survivors were compared, with special attention to their hepatitis C status in 1991. The original study and this analysis were conducted in the chemical detoxification unit at Johns Hopkins Bayview (previously Francis Scott Key Hospital), an academic urban hospital. All participants met the criteria for alcohol or opioid dependence at the time of admission in 1991. The primary study outcome was 20-year mortality after initial admission in 1991, with a planned analysis of hepatitis C status.

Results

Twenty years after admission, 362 patients survived and 82 had died. Of the 284 patients who were hepatitis C positive, 228 survived (80 %). Of the 160 patients who were hepatitis C negative, 134 survived (84 %). This absolute risk increase of 4 % was not statistically significant (p = 0.37). Factors associated with increased mortality included male sex, white race, older age, and reported use of alcohol, cocaine, and illicit methadone. Binary logistic regression including hepatitis C status and these other variables yielded an adjusted odds ratio of 0.87 (95 % CI 0.49–1.55); (p = 0.64) for hepatitis C positive 20-year survival.

Conclusions

Hepatitis C positivity was not associated with a statistically significant difference in 20-year survival. The effect of the virus on mortality, if present, is small, relative to the effect of substance use disorders alone.

Risk behavior in opioid-dependent individuals after the administration of a therapeutic dose of methadone

BACKGROUND AND OBJECTIVES

Evidence suggests that methadone may play a protective role in the faulty decision-making in heroin-addicted individuals. This may reduce craving for opioids and the risky decisions associated with active opioid use.

METHODS

We tested the effect of a daily therapeutic dose of methadone on faulty decision-making in eighty (n = 80) individuals with a history of opioid addiction. We used the Iowa Gambling Task (IGT) and compared the score and response time before and after the daily methadone dosing.

RESULTS

The mean net IGT score before methadone dose was 10 (±22) and 22 (±23) after methadone dose (t = 4.23, p = .00006). These results reflect statistically significant improvement in faulty decisions after the administration of the daily methadone dose. The mean response time for the reward cards before methadone dose were 1,856 ms (±871) and 1,465 ms (±851) after methadone dose (t = 2.55, p = .012). The mean response time for the punishment cards before methadone dose were 1,688 ms (±911) and 1,399 ms (±827) after methadone dose (t = 1.86, p = .065). These results reflect statistically significant improvement in response time to a rewarding healthy decisions after the administration of the daily methadone dose.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This is the first study to report the effect of a therapeutic dose of methadone on improving faulty decisions for individuals with a long history of opioids addiction. This study demonstrated that the time to making a healthy decision was significantly shorter as a result of administration of methadone.

Five-year mortality after acute poisoning treated in ambulances, an emergency outpatient clinic and hospitals in Oslo

Background

The long-term mortality after prehospital treatment for acute poisoning has not been studied previously. Thus, we aimed to estimate the five-year mortality and examine the causes of death and predictors of death for all acutely poisoned patients treated in ambulances, the emergency outpatient clinic, and hospitals in Oslo during 2003–2004.

Methods

A prospective cohort study included all adults (≥16 years; n=2045, median age=35 years, male=58%) who were discharged after treatment for acute poisoning in ambulances, the emergency outpatient clinic, and the four hospitals in Oslo during one year. The patients were observed until the end of 2008. Standardized mortality rates (SMRs) were calculated and multivariate Cox regression analysis was applied.

Results

The study comprised 2045 patients; 686 treated in ambulances, 646 treated in the outpatient clinic, and 713 treated in hospitals. After five years, 285 (14%) patients had died (four within one week). The SMRs after ambulance, outpatient, and hospital treatment were 12 (CI 9–14), 10 (CI 8–12), and 6 (CI 5–7), respectively. The overall SMR was 9 (CI 8–10), while the SMR after opioid poisoning was 27 (CI 21–32). The most frequent cause of death was accidents (38%). In the regression analysis, opioids as the main toxic agents (HR 2.3, CI 1.6–3.0), older age (HR 1.6, CI 1.5–1.7), and male sex (HR 1.4, CI 1.1–1.9) predicted death, whereas the treatment level did not predict death.

Conclusions

The patients had high mortality compared with the general population. Those treated in hospital had the lowest mortality. Opioids were the major predictor of death.

Surviving drug addiction: the effect of treatment and abstinence on mortality

OBJECTIVES

We examined the relationships between substance abuse treatment, abstinence, and mortality in a sample of individuals entering treatment. We also estimated overall mortality rates and the extent to which they varied according to demographic, clinical severity, and treatment variables.

METHODS

We used data from a 9-year longitudinal study of 1326 adults entering substance abuse treatment on the west side of Chicago, of whom 131 died (11.0 per 1000 person-years). Baseline predictors, initial and long-term treatment response, and substance use patterns were used to predict mortality rates and time to mortality.

RESULTS

Older age, health problems, and substance use were associated with an increased risk of mortality, and higher percentages of time abstinent and longer durations of continuous abstinence were associated with a reduced risk of mortality. Treatment readmission in the first 6 months after baseline was related to an increased likelihood of abstinence, whereas readmission after 6 months was related to a decreased likelihood of abstinence, suggesting that treatment timing is significant.

CONCLUSIONS

Our findings suggest the need to shift the addiction treatment field from an acute care model to a chronic disease management paradigm and the need for more aggressive screening, intervention, and addiction management over time.

Policing and risk of overdose mortality in urban neighborhoods

BACKGROUND

Accidental drug overdose is a major cause of mortality among drug users. Fears of police arrest may deter witnesses of drug overdose from calling for medical help and may be a determinant of drug overdose mortality. To our knowledge, no studies have empirically assessed the relation between levels of policing and drug overdose mortality. We hypothesized that levels of police activity, congruent with fears of police arrest, are positively associated with drug overdose mortality.

METHODS

We assembled cross-sectional time-series data for 74 New York City (NYC) police precincts over the period 1990-1999 using data collected from the Office of the Chief Medical Examiner of NYC, the NYC Police Department, and the US Census Bureau. Misdemeanor arrest rate-reflecting police activity-was our primary independent variable of interest, and overdose rate our primary dependent variable of interest.

RESULTS

The mean overdose rate per 100,000 among police precincts in NYC between 1990 and 1999 was 10.8 (standard deviation=10.0). In a Bayesian hierarchical model that included random spatial and temporal effects and a space-time interaction, the misdemeanor arrest rate per 1000 was associated with higher overdose mortality (posterior median=0.003, 95% credible interval=0.001, 0.005) after adjustment for overall drug use in the precinct and demographic characteristics.

CONCLUSIONS

Levels of police activity in a precinct are associated with accidental drug overdose mortality. Future research should examine aspects of police-community interactions that contribute to higher overdose mortality.

Methadone maintenance dosing guideline for opioid dependence, a literature review

To date, methadone dosing is still an issue of debate and controversy among clinicians who are involved in methadone maintenance programs. The authors conducted a literature review to update clinicians about this issue and provide recommendations for proper methadone dosing. Studies eligible for inclusion in the review were retrieved from the PubMed database by searching for reports published between 1990 and September 2008 using the major medical subject headings Methadone (all fields) and dose. Only articles written in English were included. Additional reports were identified from the reference lists of retrieved articles and by manual review of the tables of contents of journals on drug of abuse included in the psychiatry and substance abuse subject category listing 2008 of the Journal Citation Reports. Abstracts of medical meetings were excluded. Twenty-four articles were included in the review. Twelve are randomized, controlled, or double-blind clinical trials, 10 are non-randomized and observational studies, and 2 are meta-analyses. Currently, the consensus is to have a goal for methadone dosing in the range of 60 to 100 mg daily. For patients who continue to use illicit opiates while prescribed this dose range, clinicians may consider doses greater than 100 mg daily. However, this is not the current consensus but rather is based on the limited promising data the authors have; it could be considered if the benefits outweigh the risks for some patients.

The effectiveness of methadone maintenance treatment: an overview

This paper reviews the evidence for the effectiveness of methadone maintenance as used in the treatment of opioid dependence. Findings from randomized controlled trials and observational studies suggest that methadone maintenance reduces heroin use, crime, injection-related risk behaviours and premature mortality among people dependent on opioids. The research further suggests that two aspects of treatment are important in ensuring this effectiveness. Methadone treatment is more effective when higher doses (>50 mg) are employed and, overall, the evidence suggests that a treatment goal of successful maintenance on methadone rather than total abstinence is appropriate. The importance of ancillary services in treatment outcome is less clear and is the subject of current research and debate.

Benefits of retention in methadone maintenance and chronic medical conditions as risk factors for premature death among older heroin addicts

BACKGROUND

Methadone maintenance treatment reduces rates of premature mortality in heroin addicts. However, few published studies have addressed the effectiveness of treatment, mortality rates, or causes of death in older (geriatric) patients maintained on methadone. Identifying risk factors for premature mortality and potential targets for early intervention may reduce rates of premature mortality in older patients maintained on methadone.

METHODS

We conducted a retrospective chart review for patients enrolled in the methadone maintenance program at the Atlanta Veterans Affairs Medical Center. We reviewed the charts of 91 patients and collected the following information: demographics (age, gender, marital status, and race); composite score at admission on the Addiction Severity Index (ASI); most recent ASI score for alcohol use, drug use, and medical, psychiatric, family, legal, and employment problems; results of urine drug screens for opiates, cocaine, and benzodiazepines (first 4 screens after admission and last 4 screens); dose and duration of methadone treatment; HIV and hepatitis B and C status; tobacco smoking; presence of diabetes mellitus, hypertension, heart disease, chronic obstructive pulmonary disease, or cancer; history of intravenous drug use; and missed primary care appointments (last five appointments).

RESULTS

A statistically significant association was found between diabetes mellitus and between liver and gastrointestinal cancer and premature mortality in this sample of older patients maintained on methadone (OR=30.79, p=0.008 for diabetes mellitus; OR=19.91, p=0.017 for cancer). Patients who remained in treatment showed statistically significant improvement in ASI scores for problems related to drug use and for psychiatric, medical, and legal problems. They showed a nonsignificant trend toward reduction of problems associated with alcohol use. The group of patients who dropped out of methadone treatment did not show statistically significant improvement on any area of the ASI except family problems. The group who remained in treatment also showed a statistically significant reduction in drug use when results of the first four and last four urine drug screens for opiates, cocaine, and benzodiazepines were compared (p<0.0001 for opiates and cocaine, p=0.02 for benzodiazepines).On the other hand, the group who dropped out of methadone treatment did not show any statistically significant reduction in drug use based on urine screens (p=0.05 for opiates, p=0.38 for cocaine, and p=0.53 for benzodiazepines).

CONCLUSIONS

The results presented here suggest potential targets for intervention related to lifestyle risk factors and comorbid medical conditions, such as nicotine dependence and diabetes mellitus, that may have the potential to improve health outcomes for older patients with opioid dependence.

Mortality and causes of death after hospital-treated self-poisoning in Oslo: a 20-year follow-up

INTRODUCTION

Self-poisoning is a risk factor for premature death and for suicide, but for how long? The aims were to examine the mortality rate, causes of death, and risk factors for mortality and suicide during 20 years.

METHOD

Prospective cohort study including all patients discharged after self-poisoning from all medical departments in Oslo in 1980 (n = 946, 51 % females, median age 31 years). Standardized mortality ratios (SMRs) and Cox regression analysis were used.

RESULTS

During follow-up, 355 (37.5%) of the patients died, SMR 4.6 (95% CI, 4.2-5.1). After 15 years, the SMR was still 3.3 (95% C.I., 2.5-4.2). Sixty-seven (7.1%) committed suicide, SMR 26.7 (95% CI, 21.0-33.9). The risk of death from all causes was significantly higher. Unspecific risk factors for death were found. A suicidal motive was the only risk factor for suicide.

CONCLUSION

The mortality rate implies a poor prognosis in this patient group.

Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis

Background

Infectious disease is often the reason for intravenous drug users being seen in a clinical setting. The objective of this study was to evaluate the appropriateness of treatment and outcomes for this patient population in a hospital setting.

Methods

Retrospective study of all intravenous drug users hospitalized for treatment of infectious diseases and seen by infectious diseases specialists 1/2001–12/2006 at a university hospital. Treatment was administered according to guidelines when possible or to alternative treatment program in case of patients for whom adherence to standard protocols was not possible. Outcomes were defined with respect to appropriateness of treatment, hospital readmission, relapse and mortality rates. For statistical analysis adjustment for multiple hospitalizations of individual patients was made by using a generalized estimating equation.

Results

The total number of hospitalizations for infectious diseases was 344 among 216 intravenous drug users. Skin and soft tissue infections (n = 129, 37.5% of hospitalizations), pneumonia (n = 75, 21.8%) and endocarditis (n = 54, 15.7%) were most prevalent. Multiple infections were present in 25%. Treatment was according to standard guidelines for 78.5%, according to an alternative recommended program for 11.3%, and not according to guidelines or by the infectious diseases specialist advice for 10.2% of hospitalizations. Psychiatric disorders had a significant negative impact on compliance (compliance problems in 19.8% of hospitalizations) in multiple logistic regression analysis (OR = 2.4, CI 1.1–5.1, p = 0.03). The overall readmission rate and relapse rate within 30 days was 13.7% and 3.8%, respectively. Both non-compliant patient behavior (OR = 3.7, CI 1.3–10.8, p = 0.02) and non-adherence to treatment guidelines (OR = 3.3, CI 1.1–9.7, p = 0.03) were associated with a significant increase in the relapse rate in univariate analysis. In 590 person-years of follow-up, 24.6% of the patients died: 6.4% died during hospitalization (1.2% infection-related) and 13.6% of patients died after discharge.

Conclusion

Appropriate antibiotic therapy according to standard guidelines in hospitalized intravenous drug users is generally practicable and successful. In a minority alternative treatments may be indicated, although associated with a higher risk of relapse.

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.

Years of potential life lost among heroin addicts 33 years after treatment

OBJECTIVE

To examine premature mortality in terms of years of potential life lost (YPLL) among a cohort of long-term heroin addicts.

METHOD

This longitudinal, prospective study followed a cohort of 581 male heroin addicts in California for more than 33 years. In the latest follow-up conducted in 1996/97, 282 subjects (48.5%) were confirmed as deceased by death certificates. YPLL before age 65 years was calculated by causes of death. Ethnic differences in YPLL were assessed among Whites, Hispanics, and African Americans.

RESULTS

On average, addicts in this cohort lost 18.3 years (SD=10.7) of potential life before age 65. Of the total YPLL for the cohort, 22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents. The total YPLL and YPLL by death cause in addict cohort were significantly higher than that of US population. The YPLL among African Americans was significantly lower than that among Whites or Hispanics.

CONCLUSION

The YPLL among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.

Cocaine- and opiate-related fatal overdose in New York City, 1990-2000

Background

In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990–2000.

Methods

Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990–2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression.

Results

Overall, among decedents ages 15–64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62–0.82), Black (OR = 4.73, 95% CI 4.08–5.49) or Hispanic (OR = 1.51, 95% CI 1.29–1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06–1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44–0.56) and older age (55–64) (OR = 2.53 95% CI 1.70–3.75)).

Conclusion

As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.

Risk of mortality during four years after substance detoxification in urban adults

The objective of this analysis was to assess the mortality rate and risk factors in adults, with substance dependence, who are not receiving primary medical care (PC). Date and cause of death were identified using the National Death Index data and death certificates for 470 adults without PC over a period of almost 4 years after detailed clinical assessment after detoxification. Factors associated with risk of mortality were determined using stepwise Cox proportional hazards models. Subjects were 76% male, 47% homeless, and 47% with chronic medical illness; 40% reported alcohol, 27% heroin, and 33% cocaine as substance of choice. Median age was 35. During a period of up to 4 years, 27 (6%) subjects died. Median age at death was 39. Causes included: poisoning by any substance (40.9% of deaths), trauma (13%), cardiovascular disease (13.6%), and exposure to cold (9.1%). The age adjusted mortality rate was 4.4 times that of the general population in the same city. Among these individuals without PC in a detoxification unit, risk factors associated with death were the following: drug of choice [heroin: hazard ratio (HR) 6.9 (95% confidence interval (CI) 1.6-31.1]; alcohol: HR 3.7 (95% CI 0.79-16.9) compared to cocaine); past suicide attempt (HR 2.1, 95% CI 0.96-4.5); persistent homelessness (HR 2.4, 95% CI 1.1-5.3); and history of any chronic medical illness (HR 2.1, 95% CI 0.93-4.7). Receipt of primary care was not significantly associated with death (HR 0.85, 95% CI 0.34-2.1). Risk of mortality is high in patients with addictions and risk factors identifiable when these patients seek help from the health care system (i.e., for detoxification) may help identify those at highest risk for whom interventions could be targeted.

The association between change in social network characteristics and non-fatal overdose: results from the SHIELD study in Baltimore, MD, USA

BACKGROUND

Social network factors have been reported to be associated with non-fatal overdose. Yet, few studies have examined how changes in social network characteristics may influence overdose risk. The purpose of this study was to examine the relationship between changes in social network and non-fatal overdose.

METHODS

Data for this study came from 659 participants enrolled in the Self-Help in Eliminating Life-Threatening Diseases (SHIELD) study, who reported details about their non-fatal overdose experience between enrollment and a follow-up visit. Social network characteristics were described at both time points and net change in network composition was calculated.

RESULTS

The sample was predominately male (56%), African-American (96%) and unemployed (78%). Experience of non-fatal overdose between time points was reported by 15%. Older age was associated with non-fatal overdose. Interaction between incarceration status and drug use was statistically significant. Protective factors were having a denser network at baseline and a network that became denser after adjusting for gender, homelessness, incarceration, drug use and total network size.

CONCLUSIONS

Drug users' social networks are an important target for overdose prevention interventions. Further research on overdose risk and movement of specific network members in and out of networks is warranted.

Life Expectancy and Productivity Loss Among Narcotics Addicts Thirty-Three Years After Index Treatment

This study computed the life expectancy of a cohort of male narcotics addicts followed for 33 years and assessed the productivity lost as a result of premature mortality. The future life expectancy was constructed for the narcotics addicts and for a comparable cohort from the general U.S. population. The average future life expectancy of the cohort was 18.84 years compared to 33.48 years for comparable U.S. males (t = 49.49, p < .00001). As a result of this premature mortality, the estimated monetary value of lost productivity was greater than 174 million dollars. The lives of heroin addicts were severely truncated at productive ages resulting in a loss of potential productivity that increases social and economic burdens.

Opiate users' knowledge about overdose prevention and naloxone in New York City: a focus group study

Background

Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions.

Methods

In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program.

Results

Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use.

Conclusion

Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability.

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.

What explains the association between neighborhood-level income inequality and the risk of fatal overdose in New York City?

Accidental drug overdose is a substantial cause of mortality for drug users. Using a multilevel case-control study we previously have shown that neighborhood-level income inequality may be an important determinant of overdose death independent of individual-level factors. Here we hypothesized that the level of environmental disorder, the level of police activity, and the quality of the built environment in a neighborhood mediate this association. Data from the New York City (NYC) Mayor's Management Report, the NYC Police Department, and the NYC Housing and Vacancy Survey were used to define constructs for the level of environmental disorder, the level of police activity and the quality of the built environment, respectively. In multivariable models the odds of death due to drug overdose in neighborhoods in the top decile of income inequality compared to the most equitable neighborhoods decreased from 1.63 to 1.12 when adjusting for the three potential mediators. Path analyses show that the association between income inequality and the rate of drug overdose mortality was primarily explained by an indirect effect through the level of environmental disorder and the quality of the built environment in a neighborhood. Implications of these findings for the reduction of drug overdose mortality associated with the distribution of income are discussed.

The urban built environment and overdose mortality in New York City neighborhoods

Accidental drug overdose continues to be a substantial cause of mortality for drug users. Characteristics of the neighborhood built environment may be important determinants of the likelihood of drug overdose mortality independent of individual-level factors. Using data from the New York City Office of the Chief Medical Examiner, we conducted a multilevel case control study using data on accidental overdose deaths as cases and non-overdose accidental deaths as controls. We used archival data from the New York City Housing and Vacancy Survey and the Mayor's Office of Operations to assess characteristics of neighborhood external (e.g. dilapidation of buildings) and internal (e.g. quality of utilities in houses) built environment. Multilevel analyses were used to assess the relations between the neighborhood built environment and the likelihood of overdose death. Six out of the eight characteristics of the external environment studied and three out of the six characteristics of the internal environment studied were significantly associated with the likelihood of fatal drug overdose in multilevel models after adjusting for individual-level (age, race, sex) and neighborhood-level (income, drug use) variables. Deterioration of the built environment, particularly the external environment, is associated with an increased likelihood of fatal accidental drug overdose. Disinvestment in social resources, psychosocial stressors, neighborhood differences in response to a witnessed overdose, and differences in vulnerability to the adverse consequences of drug use in different neighborhoods may explain the observed associations.

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.

Mortality risk among new onset injection drug users

AIMS

To characterize mortality experience among those who only recently started injection.

DESIGN

Prospective study.

SETTING

Independent study clinic within high drug use neighborhoods.

PARTICIPANTS

In 1988-1989, we enrolled 256 adult injection drug users (IDUs) recruited through street outreach who had initiated injection within the prior 2 years.

MEASUREMENTS

Consenting participants underwent venipuncture for HIV antibody testing and interviews. We prospectively ascertained date and cause of death through follow-up contact and registry linkages. Analyses included standardized mortality ratios (SMRs) with local, state and national mortality data, adjusted for age, gender and race.

FINDINGS

Baseline median age was 30 years, 70% were male, 95% were African-American and 90% injected within the prior 6 months. We identified 69 deaths through October 2000; mortality rate was 3.3/100 person-years. The adjusted SMR with the USA (and Baltimore) as the reference for IDUs was 4.40 (2.43) for 1991-1992, which increased to 8.12 (4.13) by 1993-1994, decreased to 4.43 (2.13) by 1997-1998 and increased slightly to 5.35 (2.79) during 1999-2000. Excluding HIV-related mortality, SMRs remained elevated. Decline in SMRs was not linked to drug abuse treatment.

CONCLUSIONS

These data demonstrate excess mortality among new-onset IDUs compared with demographically similar peers in the general population, indicating the need for interventions to prevent premature death among young IDUs.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998

AIMS

Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City.

DESIGN

We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998.

FINDINGS

Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study.

CONCLUSIONS

There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

Prevention could be less cost-effective than cure: the case of hepatitis C screening policies in France

OBJECTIVES

To access the cost-effectiveness of French recommendations for hepatitis C virus (HCV) screening and the extent to which earlier identification of carriers may or not improve the cost-effectiveness of therapeutic strategies.

METHODS

Cost-effectiveness analysis were performed using decision-tree analysis and a Markov model. Four alternative strategies were compared: no screening and no treatment; initiation of HCV treatment after the diagnosis of cirrhosis; and two alternative strategies refer to the current French policies of HCV testing, i.e., two enzyme immunoblot assay (EIA) tests in series, or a polymerase chain reaction (PCR) analysis after the first positive EIA test. Costs were computed from the viewpoint of the health care system. The analysis has been applied to populations particularly at risk of infection, as well as the general population.

RESULTS

The "wait and treat cirrhosis" strategy was more cost-effective in the general population and in transfusion recipients. The incremental cost-effectiveness ratio of this strategy compared with baseline strategy was 3,476 of euros and Euro15,300 in respective cohorts. Considering the HCV screening strategy, the additional cost would be of Euro4,933 and Euro240,250 per additional year of life saved, respectively. In the intravenous drug user (IDU) population, the "two ElA" screening strategy was the more cost-effective alternative, with an additional cost of Euro3,825 per additional year of life saved.

CONCLUSIONS

HCV screening would be discarded for transfusion recipients but should be encouraged for IDUs and also for the general population, in which the additional cost of screening is an order of magnitude more acceptable.

Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

AIMS

Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends.

DESIGN

We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis.

FINDINGS

Opiates, cocaine and alcohol were the three drugs most commonly attributed as the cause of accidental overdose death by the OCME, accounting for 97.6% of all deaths; 57.8% of those deaths were attributed to two or more of these three drugs in combination. Accidental overdose deaths increased in 1990-93 and subsequently declined slightly in 1993-98. Changes in the rate of multi-drug combination deaths accounted for most of the change in overdose death rates, whereas single drug overdose death rates remained relatively stable. Trends in accidental overdose death rates within gender and racial/ethnic strata varied by drug combination suggesting different patterns of multi-drug use among different subpopulations.

CONCLUSIONS

These data suggest that interventions to prevent accidental overdose mortality should address the use of drugs such as heroin, cocaine and alcohol in combination.

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.

Racial/ethnic disparities in overdose mortality trends in New York City, 1990-1998

Racial/ethnic disparities in health and disease have been present in the United States for the past century. Although differences such as individual access to health care and health-related behaviors account for some of these health disparities, it is likely that a combination of individual and contextual-level factors determine the differential rates of disease between racial/ethnic groups. We studied fatal accidental drug overdose in New York City between 1990 and 1998 to describe differences in racial/ethnic patterns over time and to develop hypotheses about factors that might contribute to these differences. During this period, rates of overdose death were consistently higher among blacks and Latinos compared to whites. In addition, cocaine was more common among black decedents, while opiates and alcohol were more common among Latino and white decedents. Differences in situational factors, such as differential likelihood of activating emergency medical response, may in part explain the consistently higher overdose mortality rates observed among minorities. Further study to determine the individual and contextual factors that explain these observed disparities in overdose death may identify effective areas for public health intervention and provide insight into factors underlying racial/ethnic disparities in other health outcomes.

Suicide among heroin users: rates, risk factors and methods

The current paper examines critically the literature on suicide rates, suicide risk factors and methods employed for suicide among heroin users, and compares these to those of the general population. Heroin users have a death rate 13 times that of their peers, and deaths among heroin users attributed to suicide range from 3-35%. Overall, heroin users are 14 times more likely than peers to die from suicide. The prevalence of attempted suicide is also many orders of magnitude greater than that of community samples. The major general population risk factors for suicide also apply to heroin users (gender, psychopathology, family dysfunction and social isolation). Heroin users, however, have extremely wide exposure to these factors. They also carry additional risks specifically associated with heroin and other drug use. Drugs as a method of suicide play a larger role in suicide among heroin users than in the general population. Heroin, however, appears to play a relatively small role in suicide among this group. Overall, suicide is a major clinical issue among heroin users. It is concluded that suicide is a major problem that treatment agencies face, and which requires targeted intervention if the rates of suicide among this group are to decline.

Naltrexone in the treatment of heroin dependence: relationship with depression and risk of overdose

OBJECTIVE

This article examines the use of naltrexone in the treatment of heroin dependence. The relationship between naltrexone and depression as well as risk of overdose is examined.

METHOD

The existing literature is reviewed along with recent interim data from clinical trials underway in Victoria.

RESULTS

Naltrexone is a recent addition to treatment for heroin dependence in Australia. The relationship between depression and naltrexone has been examined in previous literature. Underlying rates of depression in heroin users are high and treatment may resolve or exacerbate depression. Research to date demonstrates that the addition of naltrexone does not necessarily increase depression in patients. The risk of non-fatal heroin overdose is significantly elevated after naltrexone treatment as a result of reduced tolerance. Data from clinical trials underway in Victoria demonstrate a significantly elevated rate of non-fatal overdose in naltrexone patients compared to those in substitution maintenance treatment. The mortality rate subsequent to naltrexone treatment appears to be equivalent to or greater than that for untreated heroin users. Further research is required.

CONCLUSIONS

Clinicians need to carefully monitor depression in patients, and warn patients of the risks of reduced tolerance to opiates following naltrexone treatment. Agonist treatments such as methadone, LAAM and buprenorphine carry much less risk of overdose.

The impact of a partially effective HIV vaccine on a population of intravenous drug users in Bangkok, Thailand: a dynamic model

Because of the variability of HIV, the first AIDS vaccine is likely to be only partially effective. There is some concern among scientists that a low-efficacy vaccine could worsen the HIV epidemic if vaccinated individuals increase their risk behavior under the false assumption of immunity. To address this concern, we constructed a dynamic compartmental model that simulated the course of the HIV/AIDS epidemic in a population of injection drug users in Bangkok, Thailand. The model calculated long-term HIV prevalence, number of AIDS cases, and total population size for two scenarios: vaccination program versus no vaccination program. We used sensitivity analyses to evaluate the impact of postvaccination risk behavior change on HIV prevalence. A 75% effective vaccine led to a 40-year HIV prevalence of 37% with vaccination and 50% without vaccination. Postvaccination behavior change had only a limited effect on the results with a 75% effective vaccine but a significant effect with a 30% effective vaccine. If 90% of low-risk individuals responded to a 30% effective vaccine with increased high-risk behavior, the benefit of vaccination disappeared. These results agree with analyses of the epidemic among gay men. If injection drug behavior is indeed modifiable, our findings have significant policy and planning implications.

Reductions in non-fatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS)

Few studies have reported changes in rates of overdose after drug misuse treatment. This paper investigates changes in non-fatal overdose between treatment intake and 1 year follow-up among a sample of 753 clients recruited to the National Treatment Outcome Research Study (NTORS). A relatively high rate of overdose (15%) was reported during the 3 months prior to treatment. Variables predictive of overdose at intake to treatment included injecting, frequency of benzodiazepine and cocaine use, quantity of alcohol consumption, and levels of anxiety. At 1 year follow-up, the rate of non-fatal overdose had fallen to 6%. Reduced rates of non-fatal overdose were found for clients treated in both residential and community treatment settings. Reductions in overdose were linked to improvements in frequency of drug use and lower rates of injecting. Clients who overdosed at follow-up showed no improvements in their substance use, except for frequency of crack cocaine use. The risk of non-fatal overdose at 1 year was associated with injecting and multiple drug use. These findings support the view that treatment an important role can play in reducing deaths among drug misusers.

A prospective study of mortality among drug misusers during a 4-year period after seeking treatment

AIMS

The opportunity to study deaths as they occur within the framework of a prospective cohort study is relatively uncommon. This study investigates deaths among drug misusers over a 4-year period, with specific attention to the circumstances and causes of death, and risk factors for mortality. The study also critically examines the recording of drug-related deaths.

DESIGN, SETTING, PARTICIPANTS

Prospective cohort study of 1075 drug misusers recruited to 54 treatment programmes during 1995.

MEASUREMENTS

Data derived from interviews conducted with clients at intake, death certificates and post-mortem examinations.

FINDINGS

The annual mortality rate was 1.2%, about six times higher than that for a general, age-matched population. Fourteen per cent of the deaths were due to self-inflicted injuries, accidents or violence and 18%, were due to medical causes. The majority of deaths (68%) were associated with drug overdoses. Opiates were the drugs most commonly detected during post-mortem examinations. In the majority of cases, more than one drug was detected. Polydrug use and, specifically, heavy drinking, and use of benzodiazepines and amphetamines, were identified as risk factors for mortality. Anxiety and homelessness were also predictive of increased mortality.

CONCLUSIONS

We suggest that drug misusers and those working with drug misusers need to be more alert to the risks of polydrug use, including the combined use of alcohol with illicit drugs. The study revealed inconsistencies in the recording of drug-related deaths on death certificates. The routine recording of all substances detected during toxicological examination would improve the accuracy of death certification.

Experience of heroin overdose among drug users attending general practice

BACKGROUND

Heroin overdose is responsible for significant mortality. It has not previously been highlighted as an important prevention or care issue for general practitioners (GPs) involved in the management of drug misuse.

AIMS

To examine the prevalence and experience of heroin overdose in a population of drug users attending a general practice.

METHOD

A questionnaire-based interview of drug users attending a general practice in Dublin, Ireland.

RESULTS

Twenty-four (73% of estimated total) drug users were interviewed. Although 17 (71%) were on recognised methadone treatment programmes, 10 (42%) were still injecting heroin. A total of 23 (96%) had witnessed an overdose, with 10 (42%) having been victims of overdose themselves. Twenty-two (92%) knew a victim of fatal overdose, with four (17%) having been present at a fatal overdose. The interviews revealed high levels of activity associated with overdose and poor use of preventive measures.

CONCLUSION

The issue of prevention and management of overdose should become a priority for GPs caring for opiate-dependent patients.

Medical consequences of substance abuse

Given the preceding review, differentiating the complications of parenteral drug use, HIV disease, and the toxicity of the drugs such as alcohol or cocaine may be a difficult matter for clinicians. The risk for coexisting morbidities is high. Thus, obtaining accurate and complete medical histories is of paramount importance. Drug-abuse treatment and follow-up medical care after an acute complication often involves multiple health care providers. The integration of primary prevention plans with the reinforcement of drug abstinence requires time, commitment, and the coordination of services. This integration should be a priority for individual patients as well as for public health planning.