Illegal drug-attributable morbidity in Canada 2002

Alcohol and other drugs in suicide in Canada: opportunities to support prevention through enhanced monitoring

The use of alcohol and other drugs has been identified as a significant factor related to suicide through multiple pathways. This paper highlights current understanding of their contributions to suicide in Canada and identifies opportunities for enhancing monitoring and prevention initiatives. Publications from 1998 to 2018 about suicide in Canada and that referred to alcohol or other drugs were identified using PubMed and Google Scholar. A second literature search restricted to articles including results of toxicology testing was conducted by a librarian. We summarised the literature identified on ecological analyses, attributable fractions and deaths, and research including the results of toxicological analyses. Our literature search yielded 5230 publications, and 164 documents were identified for full-text screening. We summarised the findings from 30 articles. Ecological analyses support the association between alcohol sales, annual per capita alcohol consumption and suicide rates. Based on published estimates, approximately a quarter of suicide deaths in Canada are alcohol-attributable, while the estimated attributable fraction for illegal drugs is more variable. Finally, there is a dearth of literature examining the role of acute alcohol and/or drug consumption prior to suicide based on toxicological findings. The proportion of suicide decedents with drugs or alcohol present at the time of death varies widely. While there is evidence on the role of alcohol and drugs in suicide deaths, there is not a large body of research about the acute use of these substances at the time of death among suicide decedents in Canada. Our understanding of the role of alcohol and other drugs in suicide deaths could be enhanced through systematic documentation, which in turn could provide much needed guidance for clinical practice, prevention strategies and policy initiatives.

Somatic Comorbidity and Other Factors Related to Suicide Attempt Among Polish Methadone Maintenance Patients

OBJECTIVES

Fatal and nonfatal suicide attempts are far more common in opioid-dependent individuals than in the general population. More research is needed to understand the specific risk factors for suicidal behaviors in this patient population, particularly outside of the United States and Western Europe. This study investigated the correlates of suicide attempts among Polish patients in methadone maintenance treatment and interpreted results in the context of findings from other countries.

METHODS

The study was based on a sample of 240 individuals recruited from a methadone maintenance clinic in Poland. Participants were interviewed using standardized measures.

RESULTS

Consistent with studies in other countries, sexual abuse, depression, alcohol dependence, and impulsivity were associated with suicide attempt. Additionally, those patients with somatic comorbidity had an increase in odds (odds ratio = 2.6) of suicide attempt.

CONCLUSIONS

The results of our study suggest a potential benefit to treatment approaches that address somatic concerns of methadone-maintenance patients. More research is needed to identify, assess, and understand possible cultural and regional differences between opioid-dependent populations to better tailor prevention strategies.

The burden of disease attributable to cannabis use in Canada in 2012

BACKGROUND AND AIMS

Cannabis use is associated with several adverse health effects. However, little is known about the cannabis-attributable burden of disease. This study quantified the age-, sex- and adverse health effect-specific cannabis-attributable (1) mortality, (2) years of life lost due to premature mortality (YLLs), (3) years of life lost due to disability (YLDs) and (4) disability-adjusted life years (DALYs) in Canada in 2012.

DESIGN

Epidemiological modeling.

SETTING

Canada.

PARTICIPANTS

Canadians aged ≥ 15 years in 2012.

MEASUREMENTS

Using comparative risk assessment methodology, cannabis-attributable fractions were computed using Canadian exposure data and risk relations from large studies or meta-analyses. Outcome data were obtained from Canadian databases and the World Health Organization. The 95% confidence intervals (CIs) were computed using Monte Carlo methodology.

FINDINGS

Cannabis use was estimated to have caused 287 deaths (95% CI = 108, 609), 10,533 YLLs (95% CI = 4760, 20,833), 55,813 YLDs (95% CI = 38,175, 74,094) and 66,346 DALYs (95% CI = 47,785, 87,207), based on causal impacts on cannabis use disorders, schizophrenia, lung cancer and road traffic injuries. Cannabis-attributable burden of disease was highest among young people, and males accounted for twice the burden than females. Cannabis use disorders were the most important single cause of the cannabis-attributable burden of disease.

CONCLUSIONS

The cannabis-attributable burden of disease in Canada in 2012 included 55,813 years of life lost due to disability, caused mainly by cannabis use disorders. Although the cannabis-attributable burden of disease was substantial, it was much lower compared with other commonly used legal and illegal substances. Moreover, the evidence base for cannabis-attributable harms was smaller.

Crude estimates of cannabis-attributable mortality and morbidity in Canada-implications for public health focused intervention priorities

BACKGROUND

Cannabis is the most commonly used drug in Canada; while its use is currently controlled by criminal prohibition, debates about potential control reforms are intensifying. There is substantive evidence about cannabis-related risks to health in various key outcome domains; however, little is known about the actual extent of these harms specifically in Canada.

METHODS

Based on epidemiological data (e.g. prevalence of relevant cannabis use rates and relevant risk behaviors; risk ratios; and annual numbers of morbidity/mortality cases in relevant domains), and applying the methodology of comparative risk assessment, we estimated attributable fractions for cannabis-related morbidity and mortality, specifically for: (i) motor-vehicle accidents (MVAs); (ii) use disorders; (iii) mental health (psychosis) and (iv) lung cancer.

RESULTS

MVAs and lung cancer are the only domains where cannabis-attributable mortality is estimated to occur. While cannabis use results in morbidity in all domains, MVAs and use disorders by far outweigh the other domains in the number of cases; the popularly debated mental health consequences (e.g., psychosis) translate into relatively small case numbers.

CONCLUSIONS

The present crude estimates should guide and help prioritize public health-oriented interventions for the cannabis-related health burden in the population in Canada; formal burden of disease calculations should be conducted.

Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston

OBJECTIVES

We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults.

METHODS

We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences.

RESULTS

Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults.

CONCLUSIONS

In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

What are kids getting into these days? A retrospective chart review of substance use presentations to a Canadian pediatric emergency department

OBJECTIVES

Goals for this study were to characterize the substances being used by youth who presented to an emergency department (ED), their demographic descriptors, and to describe the associated acute morbidity and mortality.

METHODS

We conducted a retrospective review of all youth, ages 10-16 years, who presented to a pediatric ED with complaints related to recreational drug use (n=641) for 2 years ending on December 31, 2009.

RESULTS

The median age of patients was 15 years; 56% were female. Six percent of patients were homeless, and 21% were wards of the state. The most frequent ingestions included ethanol (74%), marijuana (20%), ecstasy (19%), and medications (15%). Over one third of patients had ingested two or more substances. Ninety percent of patients were brought to the ED by the emergency medical services; 63% of these activations were by non-acquaintances. Of the 47% of youth who presented with a decreased level of consciousness, half had a Glasgow Coma Scale less than 13. The Canadian Triage and Acuity Scale score was 1 or 2 for 44% of patients. Sixty-eight percent received IV fluids, 42% received medication, and 4% were intubated. The admission rate was 9%.

CONCLUSIONS

Youth who presented to the ED for substance use represented a socially vulnerable population whose use of recreational substances resulted in high medical acuity and significant morbidity. Improved clinical identification of such high-risk youth and subsequent design of interventions to address problematic substance use and social issues are urgently needed to complement the acute medical care that youth receive.

Brief emergency department interventions for youth who use alcohol and other drugs: a systematic review

OBJECTIVE

Brief intervention (BI) is recommended for use with youth who use alcohol and other drugs. Emergency departments (EDs) can provide BIs at a time directly linked to harmful and hazardous use. The objective of this systematic review was to determine the effectiveness of ED-based BIs.

METHODS

We searched 14 electronic databases, a clinical trial registry, conference proceedings, and study references. We included randomized controlled trials with youth 21 years or younger. Two reviewers independently selected studies and assessed methodological quality. One reviewer extracted and a second verified data. We summarized findings qualitatively.

RESULTS

Two trials with low risk of bias, 2 trials with unclear risk of bias, and 5 trials with high risk of bias were included. Trials evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other drug-positive youth (n = 1) and universal BIs for youth reporting recent alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of ED-based BIs, and variation in outcome measurement and poor study quality precluded firm conclusions for many comparisons. Universal and targeted BIs did not significantly reduce alcohol use more than other care. In one targeted BI trial with high risk of bias, motivational interviewing (MI) that involved parents reduced drinking quantity per occasion and high-volume alcohol use compared with MI that was delivered to youth only. Another trial with high risk of bias reported an increase in abstinence and reduction in physical altercations when youth received peer-delivered universal MI for cannabis use. In 2 trials with unclear risk of bias, MI reduced drinking and driving and alcohol-related injuries after the ED visit. Computer-based MI delivered universally in 1 trial with low risk of bias reduced alcohol-related consequences 6 months after the ED visit.

CONCLUSIONS

Clear benefits of using ED-based BI to reduce alcohol and other drug use and associated injuries or high-risk behaviours remain inconclusive because of variation in assessing outcomes and poor study quality.

Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel

Prevalence of substance use and substance use disorders in Israel is similar to those in other developed countries. The aim of this study was to examine attitudes of physicians in Israel towards nicotine, alcohol and drug use and dependence. A national sample of physicians from different fields of medical specialty (n = 208, response rate 26%) responded to a 50-item questionnaire. Questions included general questions regarding substance use and addictions, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. The poor response rate in this survey dictates caution in interpretation the results. However, they suggest that among medical specialties, psychiatrists had higher levels of self-reported competency in treating addictions and lower rates of moralism towards addictions. Across substances, the highest rates of moralism and lowest ratings of treatment efficacy were directed towards individuals with alcohol dependence. Physicians generally reported experiencing lower levels of satisfaction and higher levels of aggression when treating individuals with alcohol or drug dependence compared with other patients. Physicians' attitudes towards addictions have a significant role in the care that clients with addictions receive. Medical education programs in Israel should devote provisions towards educating physicians about addictions.

Changes in somatic disease incidents during opioid maintenance treatment: results from a Norwegian cohort study

Objectives To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design Retrospective cohort study. Setting OMT programme in two Norwegian counties. Participants 200 OMT patients, participation rate 71.2%. Main outcome measures Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out.

Instruments to detect alcohol and other drug misuse in the emergency department: a systematic review

CONTEXT

Alcohol and other drug (AOD) misuse by youth is a significant public health concern. Unanticipated treatment for AOD-related morbidities is often sought in hospital emergency departments (EDs). Screening instruments that rapidly identify patients who require further diagnostic evaluation and/or brief intervention are critically important.

OBJECTIVE

To summarize evidence on screening instruments that can assist emergency care clinicians in identifying AOD misuse in pediatric patients.

METHODS

Fourteen electronic databases (including Medline, Embase, and PsycINFO) and reference screening were used. Psychometric and prospective diagnostic studies were selected if the instrument focused on detecting AOD misuse in patients aged 21 years or younger in the ED. Two reviewers independently assessed quality and extracted data. Validity and reliability data were collected for psychometric studies. Instrument performance was assessed by using sensitivity, specificity, and positive (LR(+)) and negative (LR(-)) likelihood ratios. Meta-analysis was not possible because of clinical and measurement heterogeneity.

RESULTS

Of the 1545 references initially identified, 6 studies met inclusion criteria; these studies evaluated 11 instruments for universal or targeted screening of alcohol misuse. Instruments based on diagnostic criteria for AOD disorders were effective in detecting alcohol abuse and dependence (sensitivity: 0.88; specificity: 0.90; LR(+): 8.80) and cannabis use disorder (sensitivity: 0.96; specificity: 0.86; LR(+): 6.83).

CONCLUSIONS

On the basis of the current evidence, we recommend that emergency care clinicians use a 2-question instrument for detecting youth alcohol misuse and a 1-question instrument for detecting cannabis misuse. Additional research is required to definitively answer whether these tools should be used as targeted or universal screening approaches in the ED.

Maternal welfare, morbidity and mortality 6-15 years after a pregnancy complicated by alcohol and substance abuse: a register-based case-control follow-up study of 524 women

BACKGROUND

A register-based retrospective case-control study to investigate the long-term morbidity, mortality, and welfare among women with alcohol and/or substance misuse identified during pregnancy.

METHODS

Cohort of 524 women followed-up ante- and perinatally 1992-2001 at special out-patient clinics of maternity hospitals in the capital area of Finland. The control group of 1792 women with no evidence of alcohol or substance misuse was matched for maternal age, parity, date of birth and hospital of index delivery. Both groups were followed-up until end of 2007.

RESULTS

7.9% (42/524) of the cases and 0.2% (4/1792) of the controls had died by the end of the median follow-up of 9 years (OR 38, 95% CI 14-108). The cases displayed significant morbidity requiring in-patient care in the areas of mental disorders (AOR 8.8, 95% CI 6.5-11.9), viral (AOR 23.5, 95% CI 8.8-62.7) and bacterial (AOR 6.1, 95% CI 3.5-10.4) infections, skin diseases (AOR 3.9, 95% CI 2.0-7.8) and injury and poisoning (AOR 4.2, 95% CI 3.1-5.6). The cases displayed more out-patient visits (OR 2.7, 95% CI 2.7-2.8). Their mean length of hospital stay was longer compared to controls (10.3 vs. 4.4 days, p<0.001). The risk of pension granted due to a disorder, disease or disability (OR 8.8, 95% CI 6.0-13.0) and the risk for minimum unemployment benefit were higher compared to controls (OR 2.1, 95% CI 1.8-2.5).

CONCLUSIONS

These women display significant long-term morbidity, mortality and loss of productivity after delivery. The results emphasize the importance of adequate postnatal follow-up and treatment for misuse.

Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study

Background

The long-term impact of opioid maintenance treatment (OMT) on morbidity and health care utilization among heroin addicts has been insufficiently studied. The objective of this study was to investigate whether health care utilization due to somatic disease decreased during OMT, and if so, whether the reduction included all kinds of diseases and whether a reduction was related to abstinence from drug use.

Methods

Cohort study with retrospective registration of somatic disease incidents (health problems, acute or sub-acute, or acute problems related to chronic disease, resulting in a health care contact). Medical record data were collected from hospitals, Outpatients' Departments, emergency wards and from general practitioners (GPs) and prospective data on substance use during OMT were available from 2001 onwards. The observation period was five years before and up to five years during OMT. The cohort consisted of 35 out of 40 patients who received OMT between April 1999 and January 2005 in a Norwegian district town. Statistical significance concerning changes in number of incidents and inpatient and outpatient days during OMT compared with the pre OMT period was calculated according to Wilcoxon signed rank test. Significance concerning pre/during OMT changes in disease incidents by relation to the type of health service contacts, as well as the impact of ongoing substance use during OMT on the volume of contacts, was calculated according to Pearson chi-square and Fisher's exact tests.

Results

278 disease incidents were registered. There was a reduction in all incidents by 35% (p = 0.004), in substance-related incidents by 62% (p < 0.001) and in injection-related incidents by 70% (p < 0.001). There was an insignificant reduction in non-fatal overdose incidents by 44% (p = 0.127) and an insignificant increase in non-substance-related incidents by 13% (p = 0.741). Inpatient and outpatient days were reduced by 76% (p = 0.003) and 46% (p = 0.060), respectively. The disease incidents were less often drug-related during OMT (p < 0.001). Patients experienced a reduction in substance-related disease incidents regardless of ongoing substance use, however there was a trend towards greater reductions in those without ongoing abuse.

Conclusion

Although as few as 35 patients were included, this study demonstrates a significant reduction in health care utilization due to somatic disease incidents during OMT. The reduction was most pronounced for incidents related to substance use and injection. Inpatient and outpatient days were reduced. Most probably these findings reflect somatic health improvement among heroin addicts during OMT.