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

The risk of repeated suicidal presentations following residential treatment for substance use disorders: A recurrent event analysis using linked administrative data

BACKGROUND

Individuals seeking alcohol and other drug (AOD) treatment consistently experience higher rates of suicidal behaviours and death by suicide when compared to the general population. By linking residential AOD treatment data to administrative healthcare and death datasets, we aimed to examine suicide-related behaviours and identify risk and protective factors for these events following discharge from residential treatment.

METHODS

Participants included 1056 individuals aged 18-69 (M = 32.06, SD = 9.55, male = 696,65.9 %) admitted to three residential treatment facilities in Queensland, Australia from January 1, 2014 to December 31, 2016. Treatment data was linked to administrative hospital, emergency department (ED), mental health service, and Registry of Deaths data 2-years post-discharge. ICD-10 codes were used to identify and analyse suicide-related events.

RESULTS

Within 2-years post-discharge, 175 (16.6 %) individuals had a suicide-related event (n = 298 episodes). The highest proportion of episodes (11.1 %) occurred within 1-month of discharge. Higher risk of a recurrent suicide-related event was associated with receiving a Disability Support Pension (aHR = 1.69 (95%CI:1.10,2.59), two or more previous episodes of residential AOD treatment (aHR = 1.49 (95%CI:1.30,2.15). Completing residential treatment was associated with a lower risk of suicide-related events (aHR = 0.54 (95%CI:0.35,0.83).

LIMITATIONS

The amalgamation of suicidal ideation, attempts, and death into a single outcome oversimplifies their complex nature and interplay. The exclusive focus on one service provider limits generalisability, and data constraints and missingness preclude many analyses.

CONCLUSIONS

Understanding suicidal behaviours and critical risk periods following discharge from residential treatment is crucial for improving continuing care, developing effective suicide prevention, and implementing targeted interventions among this high-risk population.

Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: a cohort analysis

BACKGROUND AND AIM

Medically managed opioid withdrawal (detox) can increase the risk of subsequent opioid overdose. We assessed the association between mortality following detox and receipt of medications for opioid use disorder (MOUD) and residential treatment after detox.

DESIGN

Cohort study generated from individually linked public health data sets.

SETTING

Massachusetts, USA.

PARTICIPANTS

A total of 30 681 opioid detox patients with 61 819 detox episodes between 2012 and 2014.

MEASUREMENTS

Treatment categories included no post-detox treatment, MOUD, residential treatment or both MOUD and residential treatment identified at monthly intervals. We classified treatment exposures in two ways: (a) 'on-treatment' included any month where a treatment was received and (b) 'with-discontinuation' individuals were considered exposed through the month following treatment discontinuation. We conducted multivariable Cox proportional hazards analyses and extended Kaplan-Meier estimator cumulative incidence for all-cause and opioid-related mortality for the treatment categories as monthly time-varying exposure variables.

FINDINGS

Twelve months after detox, 41% received MOUD for a median of 3 months, 35% received residential treatment for a median of 2 months and 13% received both for a median of 5 months. In on-treatment analyses for all-cause mortality compared with no treatment, adjusted hazard ratios (AHR) were 0.34 [95% confidence interval (CI) = 0.27-0.43] for MOUD, 0.63 (95% CI = 0.47-0.84) for residential treatment and 0.11 (95% CI = 0.03-0.43) for both. In with-discontinuation analyses for all-cause mortality, compared with no treatment, AHRs were 0.52 (95% CI = 0.42-0.63) for MOUD, 0.76 (95% CI = 0.59-0.96) for residential treatment and 0.21 (95% CI = 0.08-0.55) for both. Results were similar for opioid-related overdose mortality.

CONCLUSIONS

Among people who have undergone medically managed opioid withdrawal, receipt of medications for opioid use disorder, residential treatment or the combination of medications for opioid use disorder and residential treatment were associated with substantially reduced mortality compared with no treatment.

All-cause and cause-specific mortality rates of patients treated for alcohol use disorders: A meta-analysis

BACKGROUND

Although alcohol use disorders (AUDs) are known to increase the relative risk of all-cause and some cause-specific mortality, the absolute mortality rates of the AUD population are unknown. Such knowledge would benefit planners of the provision of services for this population, including in prioritizing the identification and/or treatment of diseases likely to cause their death.

METHODS

We conducted a systematic review of studies in English, reporting the cause-specific mortality rates among people treated for AUDs. Number of deaths by cause and total person-years of follow-up were extracted. All-cause and cause-specific mortality rates per 1000 person-years were meta-analyzed assuming random effects.

RESULTS

Thirty-one studies were included. Participants were mainly middle-aged males. The quality of studies was generally good. A total of 6768 all-cause deaths in 276,990.7 person-years of follow-up (36,375 patients) were recorded, and the pooled all-cause mortality rate was 27.67/1000 person-years (py) (95% confidence interval [CI]: 23.9, 32.04). The most common cause of death in the AUD population was cardiovascular disease (CVD) (6.9/1000 py; 95% CI: 5.61, 8.49), followed by gastrointestinal deaths (5.63/1000 py; 95% CI: 4.1, 7.74), unnatural deaths (4.95/1000 py; 95% CI: 4.01, 6.09)), neoplasms, respiratory diseases, and substance use disorders.

CONCLUSIONS

Patients with AUDs have increased rates of all-cause and cause-specific mortality compared with the general population. Like the general population, they are most likely to die of CVD. In contrast to the general population, gastrointestinal and unnatural deaths are the next most common causes of death. We believe these facts should be considered when planning health care services for patients with AUDs.

Substance use among persons with homeless experience in primary care

BACKGROUND

Community survey data suggest high prevalence of substance use disorders among currently homeless individuals. There are less data regarding illicit drug and alcohol use problems of homeless-experienced persons engaged in primary care. They may have less severe use and require different care responses from primary care teams.

METHODS

The authors surveyed currently and formerly homeless, i.e., homeless-experienced, persons engaged in primary care at five federally funded programs in the United States, administering the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST definitions of lower, moderate, and high risk were used to assess a spectrum of lifetime and recent substance use, from any use to likely dependence, and to identify sociodemographic and health status characteristics associated with severity of use.

RESULTS

Almost one half of the sample (N = 601) had recently (within the past three months) used alcohol, and one third had recently used an illicit drug. The most commonly used illicit drugs in the past three months were cannabis (19%), cocaine (16%), and opioids (7.5%). Over one half (59%) of respondents had ASSIST-defined moderate- or high-risk substance use. A significant proportion (31%) of those identified as at moderate risk had no recent substance use, but did report past problematic use. Ten percent of the lower-risk group had past problematic use of alcohol. Severity of use was associated with worse health status, but not with housing status or type of homelessness experienced.

CONCLUSIONS

Less severe (moderate-risk) use and past problematic use, potentially indicative of remitted substance use disorders, were more common than high-risk use in this primary care, homeless-experienced sample. These findings highlight the urgency of identifying effective ways to reduce risky substance use and prevent relapse in homeless-experienced persons.

Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review

Drug overdose is a major cause of death among homeless people, but little is known about the characteristics of homeless overdose decedents. We conducted a retrospective record review of 219 adult patients of Boston Health Care for the Homeless Program (BHCHP) who died of drug overdose in 2003-2008. We assessed the substances implicated in overdose and the health and service use characteristics of decedents prior to death. Eighty-one percent of overdose deaths involved opioids and 40% involved multiple drugs. Problem substance use (85%), psychiatric illness (61%), and chronic pain (45%) were common, and 32% had documentation of all three. Half were well-connected to BHCHP, and 35% had a clinic visit within 90 days of death. The complex health histories and frequent health care contacts of homeless drug overdose decedents suggest that clinical facilities may be an important frontline venue for overdose education, naloxone distribution, and integrated substance use treatment programming.

Are overdoses treated by ambulance services an opportunity for additional interventions? A prospective cohort study

AIMS

To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods).

DESIGN

A prospective cohort study.

SETTING

Oslo, Norway.

PARTICIPANTS

A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004.

MEASUREMENTS

Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated.

FINDINGS

Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period.

CONCLUSIONS

Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods.

Factors influencing mortality among alcohol and drug treatment clients in Victoria, Australia: the role of demographic and substance use characteristics

OBJECTIVE

Clinical studies consistently identify alcohol- and drug-related treatment populations as more likely to die prematurely compared with an age-matched general population. However, demographic characteristics and primary drug of concern as predictors of mortality risk following treatment have not been adequately explored. This paper examines relationships between substance use, demographic factors and mortality among alcohol and drug treatment clients.

METHOD

A retrospective cohort incorporating 7 years of data was utilised to examine mortality outcomes in the 2 years following treatment among Victorian clients recorded on the Alcohol and Drug Information Service (ADIS) database by linking partial client identifiers with the National Death Index (NDI). A cohort of 18,686 clients engaged in at least one course of treatment over a 12-month period was included. Analysis was of crude and standardised mortality rates across client groups in terms of the presenting drug of concern for treatment and demographic characteristics.

RESULTS

A higher risk of premature death was associated with older age, being male, not being employed, living alone, medical and psychiatric comorbidity, recent injecting, and a history of intensive drug treatment access. Alcohol treatment clients had the worst prognosis. After adjustment for client characteristics, alcohol treatment clients experienced a significantly higher rate of death compared with other clients.

CONCLUSIONS

Findings from these previously unexplored data highlight the need to increase awareness of the range and magnitude of risks associated with harmful alcohol use, and to identify approaches to enhance treatment effectiveness to reduce negative outcomes following treatment for populations at elevated risk of harm.

The case for chronic disease management for addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Mortality associated with illegal drug use among adults in the United States

OBJECTIVES

To examine all-cause and cause-specific mortality over a 15-year follow-up period in relation to at-baseline reported lifetime use of illegal drugs from five classes (marijuana, cocaine, heroin, hallucinogens, and inhalants) among adults in the United States (US) household population.

METHODS

The study involved 20,983 sample adults who responded to the 1991 National Health Interview Survey Drug and Alcohol Use supplemental questionnaire and also met the eligibility criteria for mortality follow-up. Cox proportional hazards models were estimated to examine the relationships.

RESULTS

Adults who at baseline reported lifetime heroin use were at significantly higher risk of all-cause death over the follow-up period (hazard rate ratio or HR = 2.02; 95% confidence interval or CI 1.26-3.23), compared with those who did not report using drugs from any of the five classes, even after adjusting for age, sex, race, education, marital status, cigarette smoking status, and alcohol use status. Those who at baseline reported lifetime cocaine (no heroin) use had a significantly higher rate of death associated with human immunodeficiency virus diseases over the follow-up period than nonusers of drugs from any of the five classes. Several limitations of the analysis are discussed.

CONCLUSIONS

Further research is needed to understand and track the elevated mortality associated with illegal drug use and the correlates of drug-poisoning deaths.

Association of psychiatric illness and all-cause mortality in the National Department of Veterans Affairs Health Care System

OBJECTIVE

To assess the independent association of seven psychiatric illnesses with all-cause mortality in a representative national sample of veterans, after adjustment for demographic factors, psychiatric and medical comorbidity, obesity, tobacco use, and exercise frequency.

METHODS

Analyses were conducted using data from the 1999 Large Health Survey of Veteran Enrollees (n = 559,985). Cox proportional hazards models were used to examine the relationship of seven psychiatric diagnoses with mortality. Date of all-cause mortality was determined from the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. All-cause mortality rates were calculated as the total number of deaths in each group divided by the person-years of follow-up time in each group.

RESULTS

During the 9-year study period, 27% of the subjects (n = 131,396) died. Each of the psychiatric diagnoses was associated with significantly increased HR for all-cause mortality after adjusting for age, race, and gender. Hazard ratios ranged from 1.02 (95% confidence interval, 1.01, 1.04) for posttraumatic stress disorder to 1.97 (95% confidence interval, 1.89, 2.04) for alcohol use disorders. After adjustment for psychiatric and medical comorbidity, obesity, current smoking and exercise frequency, alcohol and drug abuse and dependence, and schizophrenia were statistically significantly associated with an increased risk of mortality.

CONCLUSIONS

In this study of a large representative national sample of veterans, schizophrenia and alcohol and drug use disorders were independently associated with an increased risk of all-cause mortality over a 9-year period.

Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users

AIMS

Post-discharge monitoring and early reintervention have become standard practice when managing numerous chronic conditions. These two experiments tested the effectiveness of recovery management checkup (RMC) protocols for adult chronic substance users.

INTERVENTION

RMC included quarterly monitoring; motivational interviewing to provide personalized feedback and to resolve ambivalence about substance use; treatment linkage, engagement and retention protocols to increase the amount of treatment received.

PARTICIPANTS AND SETTING

Recruited from sequential addiction treatment admissions, participants in the two experiments were, on average, 36 and 38 years of age, mainly female (59% versus 46%), African American (85% versus 80%) and met past-year criteria for dependence (87% versus 76%).

DESIGN

Participants in both experiments were assigned randomly to the RMC or control condition and interviewed quarterly for 2 years.

MEASUREMENT

The Global Appraisal of Individual Needs (GAIN) was the main assessment instrument.

FINDINGS

RMC participant outcomes were better than control participants in both experiments. Effect sizes were larger in the second experiment in terms of reducing days to readmission (Cohen's d = 0.41 versus d = 0.22), successive quarters in the community using substances (d = -0.32 versus -0.19), past-month symptoms of abuse/dependence (d = -0.23 versus -0.02) and increasing the days of abstinence over 2 years (d = +0.29 versus 0.04).

CONCLUSION

RMC, which provided ongoing monitoring and linkage, is feasible to conduct and is effective for adults with chronic substance dependence.

Health consequences of illegal drug use

PURPOSE OF REVIEW

The aim of this article is to review recent research on the health consequences of illegal drug use and possible risk factors, with a particular focus on prospective evidence.

RECENT FINDINGS

Mortality studies have revealed qualitative and quantitative changes in causes of death among heroin and injecting drug users (IDUs), probably due to increasing exposure to harm reduction programs, the introduction of highly active antiretroviral therapy (HAART), the aging of drug users, and rising concurrent use of illegal drugs and prescription drugs. For morbidity, nonfatal overdose is still one of the most important concerns; likewise the higher prevalence of hepatitis C among non-IDUs and hepatitis A, B, C coinfection. Cannabis use has been consistently reported to be associated with the emergence of psychotic symptoms, yet that seems not to be the case for anxiety and depressive disorders. Use of 3,4 methylenedioxymethamphetamine (MDMA) has been linked with short-term negative effects on cognitive performance (i.e. visual memory). A series of longitudinal studies have shown enduring unfavorable effects of prenatal cocaine and marijuana exposure on children's physical, cognitive, and language development.

SUMMARY

Prospective evidence on illegal drug use in particular subpopulations may be needed to better understand health problems among users at different life stages and the possible long-term effects.

Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death

OBJECTIVE

Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection.

METHOD

Participants were English-speaking IDUs, 18 years of age and older, who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death.

RESULTS

Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23).

CONCLUSIONS

IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.