Estimating the total mortality among problem drug users

Prescription opioid misuse and its relation to injection drug use and hepatitis C virus infection: protocol for a systematic review and meta-analysis

BACKGROUND

The production, prescription, and consumption of opioid analgesics to treat non-cancer pain have increased dramatically in the USA in the past decade. As a result, misuse of these opioids has increased; overdose and transition to riskier forms of drug use have also emerged. Research points to a trend in transition to drug injection among those misusing prescription opioids, where clusters of acute hepatitis C virus (HCV) infection are now being reported. This systematic review and meta-analysis aims to synthesize the prevalence of prescription opioid misuse in the USA and examine the rate of transition to injection drug use and incident HCV in these new people who inject drugs (PWID).

METHODS/DESIGN

Eligible studies will include quantitative, empirical data including national survey data. Scientific databases will be searched using a comprehensive search strategy; proceedings of scientific conferences, reference lists, and personal communications will also be searched. Quality ratings will be assigned to each eligible report using the Newcastle-Ottawa Scale. Pooled estimates of incidence rates and measures of association will be calculated using random effects models. Heterogeneity will be assessed at each stage of data synthesis.

DISCUSSION

A unique typology of drug use is emerging which is characterized by antecedent prescription opioid misuse among PWID. As the epidemic of prescription opioid misuse matures, this will likely serve as a persistent source of new PWID. Persons who report a recent transition to drug injection are characterized by high rates of HCV seroincidence of 40 per 100 person years or higher. Given the potential for the persistence and escalation of the consequences of prescription opioid misuse in the USA, there is a critical need for synthesis of the current state of the epidemic in order to inform future public health interventions and policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014008870.

Why do patients stay in opioid maintenance treatment?

Opioid maintenance treatment (OMT) successfully improves social functioning and leads to an increase of survival rates, by reducing drug-related mortality and infections. A region-wide anonymous survey was performed to evaluate subjective factors that could potentially contribute to growing numbers of patients in OMT in the city of Berlin, Germany. In the survey, performed in 2011, 46 staff members and 986 patients participated. Both patients and staff members report beneficial effects of OMT on physical and mental health, and reduction of criminality. Patients on average consider the detoxification from OMT more difficult than from heroin. Staff members underestimate the wish of patients to reach abstinence of OMT. We conclude that besides reduced mortality, these subjective factors may contribute to a growing number of patients in OMT. No financial or material support was received in any phase of the study.

Long-term mortality and causes of death among hospitalized Swedish drug users

AIM

To study long-term mortality and causes of death in a cohort of drug users in relation to main type of drug use and HIV-status.

METHODS

A total of 1640 hospitalized drug users in Stockholm was followed up from 1985 to the end of 2007. The mortality was compared with the general Swedish population and hazard ratios (HR) for the main risk indicators were calculated. The causes of death were studied, using information from death certificates.

RESULTS

630 persons died during the observation period. The Standard Mortality Ratio (SMR) was 16.1 (males 13.8, females 18.5). The crude mortality rate was 2.0 % (males 2.2% and females 1.5%). The mortality rate was higher in heroin users than among amphetamine users, HR 1.96, controlled for age and other risk factors. The mortality rate among individuals infected with the human immunodeficiency virus (HIV) was high (4.9 %), HR 2.64, compared with HIV-negative individuals. Most of the deaths were from other causes than acquired immune deficiency syndrome. One-third of deaths (227) were caused by heroin intoxication. The number of deaths from HIV-related causes decreased after 1996, when highly active anti-retroviral therapy was introduced. In all, there were 92 HIV-related deaths. Deaths from natural causes increased during the observation period. The SMR was highest for cardiovascular and gastrointestinal diseases. The results indicate a correlation between amphetamine use and death from cerebral haemorrhage. A high proportion of natural deaths were alcohol-related.

CONCLUSIONS

The death rate among illicit drug users was persistently high. Alcohol consumption was a contributing factor to premature death.

Making sense of differing overdose mortality: contributions to improved understanding of European patterns

The European Monitoring Centre for Drugs and Drug Addiction, EMCDDA, publishes statistics for overdose deaths giving a European mean number, and ranking nations in a national 'league table' for overdose deaths. The interpretation of differing national levels of mortality is more problematic and more complex than is usually recognised. Different systems are used to compile mortality data and this causes problems for cross-national comparisons. Addiction behaviour can only be properly understood within its specific social and environmental ecology. Risk factors for overdose, such as the type of drug consumed, and the route of administration, are known to differ across countries. This paper describes problems associated with ranking and suggests how mortality data might be used in high-level countries aiming at reduction in the number of overdose deaths.

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.

Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression

BACKGROUND & AIMS

The prevalence of chronic hepatitis C (CH-C) remains high and the complications of infection are common. Our goal was to project the future prevalence of CH-C and its complications.

METHODS

We developed a multicohort natural history model to overcome limitations of previous models for predicting disease outcomes and benefits of therapy.

RESULTS

Prevalence of CH-C peaked in 2001 at 3.6 million. Fibrosis progression was inversely related to age at infection, so cirrhosis and its complications were most common after the age of 60 years, regardless of when infection occurred. The proportion of CH-C with cirrhosis is projected to reach 25% in 2010 and 45% in 2030, although the total number with cirrhosis will peak at 1.0 million (30.5% higher than the current level) in 2020 and then decline. Hepatic decompensation and liver cancer will continue to increase for another 10 to 13 years. Treatment of all infected patients in 2010 could reduce risk of cirrhosis, decompensation, cancer, and liver-related deaths by 16%, 42%, 31%, and 36% by 2020, given current response rates to antiviral therapy.

CONCLUSIONS

Prevalence of hepatitis C cirrhosis and its complications will continue to increase through the next decade and will mostly affect those older than 60 years of age. Current treatment patterns will have little effect on these complications, but wider application of antiviral treatment and better responses with new agents could significantly reduce the impact of this disease in coming years.