Increasing cancer mortality among opioid-dependent persons in Australia: a new public health challenge for a disadvantaged population

Increased cancer incidence and mortality among people with opioid use-related disorders: A nation-wide cohort study

BACKGROUND AND AIMS

Studies on cancer incidence and mortality among people with opioid use-related disorders are lacking. We aimed to measure cancer-specific incidence, mortality and survival among people diagnosed with opioid use-related disorders in Norway during 2010-18.

DESIGN AND SETTING

This was a cohort study conducted in Norway during 2010-18.

PARTICIPANTS

Individuals (n = 20 710) diagnosed with opioid use-related disorders.

MEASUREMENTS

We conducted a cohort study utilizing a data-linkage of national health and population registers. Information on opioid use-related disorders was extracted from specialized healthcare, malignancies from the Cancer Registry of Norway and deaths from Cause of Death Registry. Cancer incidence and mortality were compared with the general population by calculating sex-specific age-standardized incidence (SIR) and mortality (SMR) ratios. One-year survival rates were computed.

FINDINGS

Compared with the general population, people with opioid use-related disorders were at an increased risk of developing cancer overall [SIR = 1.2, 95% confidence interval (CI) = 1.1-1.3] with a higher than twofold cancer mortality rate (SMR = 2.3, 95% CI = 2.0-2.7). Excess risk was observed for liver (12.6, 95% CI = 9.1-17.0), larynx (4.7, 95% CI = 1.7-10.2), lung (3.5, 95% CI = 2.8-4.3) and pancreas cancer (2.6, 95% CI = 1.6-4.0), whereas reduced risk was found for melanoma (0.5, 95% CI = 0.3-0.9), breast (0.6, 95% CI = 0.4-0.9) and prostate cancers (0.3, 95% CI = 0.1-0.4). Site-specific SMRs were significantly elevated for liver (12.3, 95% CI = 8.5-17.2), lung (3.9, 95% CI = 3.0-5.0), pancreas (3.0, 95% CI = 1.7-4.8) and colon cancers (1.9, 95% CI = 1.1-3.1). The average 1-year survival rate after a cancer diagnosis was low in liver, pancreas and colon cancer, ranging from 10 to 15% less than that of the general population.

CONCLUSIONS

In Norway, cancer incidence and cancer-related mortality appear to be elevated among individuals with opioid use-related disorders.

Coverage of cervical cancer prevention interventions among people in Australia who inject drugs

BACKGROUND

The human papillomavirus (HPV) vaccine and regular (i.e., every five years) cervical screening are essential to prevent cervical cancer. Australia has high overall coverage of both interventions but little is known about coverage among people who inject drugs. and known barriers to preventive care among this population may extend to cervical cancer control measures.

METHODS

Data were obtained from the 2023 Illicit Drug Reporting System interviews, in which people who regularly inject drugs participated. The sample was restricted to people with a cervix, with participants aged 25-74 years eligible for the National Cervical Screening Program and participants born after 1980 eligible for HPV vaccination. Age-standardised prevalence ratios were used to compare coverage among this sample to the Australian general population; other results were summarised descriptively.

FINDINGS

Among participants eligible for screening (n = 243), most (96.7 %) reported lifetime uptake, while 70.2 % had been screened during the past five years, which was similar to the general population (prevalence ratio [PR]: 1.14, 95 % confidence interval [CI]: 0.96-1.31). Among those never or overdue for screening (n = 57), one third (31.7 %) were aware that self-sampling is available and barriers to screening varied, with similar numbers reporting personal (e.g., 'I didn't know I needed to'), logistical (e.g., 'I don't have time'), and test-related reasons (e.g., 'the test is uncomfortable/painful'). Among participants eligible for HPV vaccination (n = 99), coverage was 27.2 %, 38 % lower than the general population (PR: 0.62, 95 % CI: 0.39-0.86).

CONCLUSIONS

Cervical screening coverage among this sample of people who inject drugs was similar to the Australian population. Health promotion messaging that focuses on the availability of self-sampling and the importance of regular screening may improve coverage among those overdue for screening. HPV vaccination was lower than the general population, warranting targeted efforts to offer the vaccine to eligible people who inject drugs.

Barriers to and facilitators of screening for cervical and breast cancer: Experiences of non-adherent women with current or previous drug use

Objective

Women with current or previous drug use (WCPDU) have an increased risk of poor cervical and breast cancer outcomes, and low participation in screening for these cancer forms. The aim of this study was to assess self-reported barriers to and facilitators of cervical and breast cancer screening, among WCPDU.

Methods

A survey based on results from a previous qualitative study about WCPDUs experiences of cancer screening was distributed to WCPDU at six opioid agonist treatment (OAT) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. Data on barriers to and facilitators of cancer screening reported by 222 non-adherent WCPDU was analyzed by descriptive statistics. The barriers were structured according to an established model of healthcare access.

Results

The most frequently reported barriers to cervical as well as breast cancer screening were non-receipt of screening invitations (36 % and 25 %, respectively), trouble remembering the appointment (27 % and 30 %) and other priorities (26 % and 29 %). Common suggested facilitators for both cervical and breast cancer screening were screening access at, e.g., a NEP or OAT clinic (45 % and 40 %) and practical support to attend the screening appointment (40 % and 38 %).

Conclusions

In contrast to general population women, WCPDU report mainly practical barriers to cervical and breast cancer screening. However, NEP participants frequently reported experience of stigma and poor reception as barriers to screening. Interventions to minimize barriers to screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

Screening for breast and cervical cancer among OST patients: a qualitative study of barriers and suggested interventions to increase participation

PURPOSE

Women with current or previous drug use are at risk of poor breast and cervical cancer outcomes. While screening is known to decrease cancer mortality, screening participation is sparsely investigated among drug dependent women. The aim of this study was to explore experiences of breast and cervical cancer screening-including barriers and suggested interventions to promote increased participation-among women in opioid substitution treatment (OST).

METHODS

Three focus group interviews were conducted at one OST clinic in Malmö, Sweden. The interviews were moderated by OST staff, assisted by a researcher. A descriptive qualitative analysis was carried out using a template analysis approach, employing a model of healthcare access to organize the description of barriers.

RESULTS

The 11 participants reported several barriers to screening access, affecting the perceived need of screening and the opportunities to seek and reach screening services. Some barriers appear to be specific to women with previous or current drug use. Suggested interventions were moral and practical support, integrated/specialized delivery of screening services, and enhanced screening invitation procedures.

CONCLUSIONS

The study findings provide insight to difficulties with screening compliance among women with current or previous drug use, and provide a knowledge base for quantitative and intervention studies.

Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study

INTRODUCTION

Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender.

METHODS

This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000-2019), Denmark (2000-2018), and Norway (2010-2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality.

RESULTS

In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark).

CONCLUSION

This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

Participation in screening for breast and cervical cancer among women with current or previous drug use: a survey study

BACKGROUND

Women with current or previous drug use (WCPDU) have an increased risk of poor breast and cervical cancer outcomes. Screening is known to decrease the mortality of these common cancer forms, but screening participation has been sparsely investigated among women with drug dependency. The aim of this study was to assess participation in screening for breast and cervical cancer among WCPDU.

METHODS

We recruited WCPDU to a survey study, from six opioid substitution treatment (OST) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. The survey was constructed according to results from focus group discussions about cancer screening in a sample of women in OST. Survey data were analyzed using descriptive statistics. We analyzed associations between non-compliance to screening and healthcare contact (OST, NEP or none) by logistic regression analysis; unadjusted and adjusted for age, native language, housing situation, educational attainment and main source of income.

RESULTS

A total of 298 women (median age 43 years) responded to the survey. The self-reported compliance with cancer screening recommendations was 29% for breast cancer screening and 41% for cervical cancer screening. Non-compliance with cervical cancer screening was associated with NEP participation in univariate but not multivariate analysis. We did not find an association between non-compliance with breast cancer screening and healthcare contact. Non-compliance with screening for cervical cancer was also associated with unstable housing in univariate and multivariate analyses, and inversely associated with increasing age in a univariate analysis. Non-compliance with breast cancer was associated with unstable housing in a univariate analysis, and inversely associated with not having Swedish as a native language in a multivariate analysis.

CONCLUSION

The self-reported compliance with the national cancer screening programs for breast cancer and cervical cancer of WCPDU is notably lower than in the Swedish general population. Women with unstable housing seem to be particularly vulnerable to non-compliance with cancer screening. Interventions to minimize barriers to cancer screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

Opium Use and the Risk of Liver Cancer: A Case-Control Study

Limited evidence is available to acknowledge the association between opium use and liver cancer. In a case-control study, we recruited 117 cases of primary liver cancer (PLC) and 234 age and sex-matched neighborhood controls from 2016 to 2018. We calculated odds ratios (OR) for opium use and 95% confidence intervals (95% CI), using conditional logistic regressions. Compared with non-users the adjusted OR (AOR, 95% CI) for opium use was 6.5 (95% CI, 2.87-13.44). Compared with people who had no history of use, a strong dose-response effect of opium use was observed by amount of use (AOR, 10.70; 95% CI, 3.92-28.70). Cumulative use of opium also indicated that using over 30 gr-year could increase the PLC risk dramatically (AOR, 11.0; 95% CI, 3.83-31.58). Those who used opium for more than 21 years were highly at risk of PLC (AOR, 11.66; 95% CI, 4.43-30.67). The observed associations were significant even among never tobacco smokers (including cigarette and water-pipe smoking).

PREVENTION RELEVANCE

The results of this study indicate that opium use dramatically increased the risk of liver cancer. Because opioids are increasing for medical and non-medical use globally; accordingly, severe health consequences such as liver cancer have to be investigated widely.

Cardiopulmonary and muscular effects of different doses of high-intensity physical training in substance use disorder patients: study protocol for a block allocated controlled endurance and strength training trial in an inpatient setting

INTRODUCTION

Patients with substance use disorder (SUD) have high prevalence of lifestyle-related comorbidities. Physical exercise is known to yield substantial prophylactic impact on disease and premature mortality, and there seems to be an inverse association between physical fitness and adverse health outcomes. High-intensity training is regarded as most effective for improving physical fitness, but less is known concerning the ideal training dose necessary to achieve clinically relevant effects in these patients. The aim of this study is to compare the effect of low-dose and high-dose, high-intensity training, on physical fitness in patients diagnosed with SUD.

METHODS AND ANALYSIS

This study will recruit 40 in-patients of mixed genders, aged 18-70 years. Participants will be block allocated to low-dose or high-dose training, encompassing 24 high-intensity interval and maximal strength training sessions (3/week × 8 weeks). After a 10 min warm-up, the low-dose group will perform 1×4 min intervals at ⁓90% of maximal heart rate and 2×4 repetitions strength training at ⁓90% of 1 repetition maximum. The high-dose group will perform 4×4 min intervals at ⁓90% of maximal heart rate and 4×4 repetitions strength training at ⁓90% of 1 repetition maximum. Clinical measurements and physical tests will be conducted at baseline, midway and on completion and a questionnaire on physical activity will be administered at baseline.

ETHICS AND DISSEMINATION

This protocol is in accordance with the Standard Protocol Items: Recommendations for Interventional Trials statement. All participants will sign a written informed consent. The Regional Committee of Medical Research Ethics, Norway has approved the study. A study of this kind is warranted, and the results will be published in an open access journal to ensure public access, and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04065334.

Drug use disorder and risk of incident and fatal prostate cancer among Swedish men: a nationwide epidemiological study

Purpose

Prostate cancer is the second most common cancer in men and a leading cause of cancer mortality worldwide. Men with drug use disorders (DUD) may potentially be at high risk for prostate cancer mortality because of delayed diagnosis and/or undertreatment. In this study, we aimed to investigate prostate cancer incidence, mortality, and stage at time of diagnosis among men with DUD compared to the general male population in Sweden.

Methods

We performed a follow-up study based on Swedish national register data for the period January 1997–December 2016. The study was based on 1,361,532 men aged 50–75 years at inclusion, of whom 9,259 were registered with DUD. Cox regression analysis was used to compute adjusted hazard ratios (HRs) for incident and fatal prostate cancer, and cancer stage at time of diagnosis, associated with DUD.

Results

DUD was associated with a slightly increased risk of incident prostate cancer (HR: 1.07, 95% confidence interval [CI] 1.00–1.14, p = 0.048) and substantially higher risk of fatal prostate cancer (HR: 1.59, 95% CI 1.40–1.82, p < 0.001), adjusted for age, socioeconomic factors, and comorbidities related to tobacco smoking and alcohol use disorder. No association was found between DUD and prostate cancer stage at diagnosis.

Conclusions

Men with DUD have an increased risk of fatal prostate cancer, possibly related to undertreatment in this patient population. Our findings should raise attention among medical staff and decision-makers towards a disadvantaged group of men in need of easily accessible prostate cancer evaluation and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01513-2.

Perceived healthcare stigma among patients in opioid substitution treatment: a qualitative study

Background

People with substance use disorders (SUD) including patients in opioid substitution treatment (OST) are subject to stigma, and have generally poor health and barriers towards seeking healthcare. Experience of stigma might negatively affect healthcare seeking, but this topic is sparsely investigated. The aim of this study was to explore OST patients’ past and present experiences of substance use stigma in healthcare settings, in order to provide insight into the challenges that people with opioid use disorder may face when using health services, and the strategies they use to cope with them.

Methods

Six focus groups with 23 OST patients were moderated by OST staff, and conducted with a questioning route focusing on health literacy. Experiences associated with stigma and its consequences that were spontaneously brought up by participants were assessed in a secondary analysis using a thematic approach.

Results

Experiences of stigma from a wide range of healthcare settings were reported. Medical records and patients’ oral information regarding substance use, OST medication or hepatitis C infection were identified as circumstances bringing unwanted attention to the SUD. Participants reported various forms of poor treatment, believed to reflect views of people with SUD as morally culpable, intimidating, curious, untrustworthy and less valuable than other patients, sometimes with tangible effects on the quality of healthcare. Stigma in healthcare settings affected healthcare seeking behaviors, and could result in patients concealing their OST status or substance use history.

Conclusion

This study highlights several aspects of perceived healthcare stigma that can shed light on difficulties that OST patients might experience when navigating the healthcare system. The results implicate a need to investigate attitudes towards OST patients, and the aptitude to deal with patients with SUD, among healthcare professionals, as well as a need for interventions addressing knowledge deficits and issues tied to values and patient reception among healthcare staff.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00417-3.

Risk of cancer in individuals with alcohol and drug use disorders: a registry-based study in Reggio Emilia, Italy

Aims of this population-based cohort study was to compare the overall and site-specific cancer incidence in individuals with alcohol or drug use disorders with incidence of the general population, and to estimate excess cancer risk in a subgroup of individuals who have hepatitis C virus or HIV infection. The study included 4373 residents of Reggio Emilia province diagnosed with alcohol or drug use disorders during the period from 1 January 1985 to 31 December 2014. All newly diagnosed cancers registered from 1 January 1996 to 31 December 2014 were taken into account to calculate the standardised incidence ratio (SIR) of cancers of any site and of site-specific cancers. SIR of cancer at any site was 1.6 (95% confidence interval [CI] 1.4-1.9). Anogenital cancers were associated with the highest excess risk (SIR=11.9; 95% CI 4.9-28.5), followed by oesophageal (SIR=9.5; 95% CI 3.6-25.3) and cervical cancer (SIR=8.6; 95% CI 2.8-26.7). Excess risk of all cancer sites, except for breast cancer, was observed among individuals with alcohol use disorders and of all cancer sites, except breast and kidney cancers, among individuals with drug use disorders. Among hepatitis C virus-positive individuals, cancer at any site risk was 1.9 (95% CI 1.2-3.1) and among HIV-infected individuals it was 3.3 (95% CI 1.8-5.7). Individuals with alcohol and drug use disorders face a higher risk of various cancers. Effective interventions to prevent or reduce the harm of substance abuse and risky behaviours in this population are warranted.

QuitNic: A Pilot Randomized Controlled Trial Comparing Nicotine Vaping Products With Nicotine Replacement Therapy for Smoking Cessation Following Residential Detoxification

Introduction

The QuitNic pilot trial aimed to test the feasibility of providing a nicotine vaping product (NVP) compared with combination nicotine replacement therapy (NRT) to smokers upon discharge from a smoke-free residential substance use disorder (SUD) treatment service.

Methods

QuitNic was a pragmatic two-arm randomized controlled trial. At discharge from residential withdrawal, 100 clients received telephone Quitline behavioral support and either 12-week supply of NRT or an NVP. Treatment adherence and acceptability, self-reported abstinence, cigarettes smoked per day (CPD), frequency of cravings, and severity of withdrawal symptoms were assessed at 6 and 12 weeks. Results are reported for complete cases and for abstinence outcomes, penalized imputation results are reported where missing is assumed smoking.

Results

Retention on was 63% at 6 weeks and 50% at 12 weeks. At 12 weeks, 68% of the NRT group reported using combination NRT while 96% of the NVP group used the device. Acceptability ratings for the products were high in both groups. At 12 weeks, 14% of the NVP group and 18% of the NRT group reported not smoking at all in the last 7 days. Mean CPD among continued smokers decreased significantly between baseline to 12 weeks in both groups; from 19.91 to 4.72 for the NVP group (p < .001) and from 20.88 to 5.52 in the NRT group (p < .001). Cravings and withdrawal symptoms significantly decreased for both groups.

Conclusions

Clients completing residential withdrawal readily engaged with smoking cessation post-treatment when given the opportunity. Further research is required to identify the most effective treatments postwithdrawal for this population at elevated risk of tobacco-related harm.

Trial registration number

ACTRN12617000849392

Implications

This pilot study showed that smoking cessation support involving options for nicotine replacement and Quitline-delivered cognitive behavioral counseling is attractive to people after they have been discharged from SUD treatment. Both nicotine vaping products and nicotine replacement therapies were highly acceptable and used by participants who reported reductions in cravings for cigarettes and perceptions of withdrawal symptoms and reductions in number of cigarettes smoked. Some participants self-reported abstinence from cigarettes—around one in five reported having quit smoking cigarettes at 12 weeks postdischarge. The results have significant public health implications for providing quit support following discharge from SUD treatment.

Cervical cancer among Swedish women with drug use disorders: A nationwide epidemiological study

BACKGROUND/AIM

Cervical cancer incidence and mortality has decreased after introduction of national screening in Sweden, but women with drug use disorders (DUD) are less likely to participate in screening programs. We aimed to investigate cervical cancer incidence and mortality among women with DUD compared to the general female population in Sweden.

METHODS

We conducted a cohort study based on Swedish national register data for the period January 1997-December 2015. Data was collected for 3,838,248 women aged 15-75 years of whom 50,858 had DUD. Adjusted hazard ratios (HRs) for incident and fatal cervical cancer were calculated for women with and without DUD using Cox regression analysis.

RESULTS

DUD was significantly associated with incident cervical cancer (HR = 1.39, 95% confidence interval [CI] 1.39-1.61), but not fatal cervical cancer (HR = 1.25, 95% CI: 0.91-1.71), after adjusting for age, educational attainment, social welfare, region of residence, marital status and HIV infection.

CONCLUSION

Women with DUD were thus identified as a risk group for incident cervical cancer, which calls for attention from clinicians and policy makers. It is possible that non-attendance in cancer screening and other healthcare seeking barriers may affect the risk of incident cervical cancer among women with DUD but more research on this topic is needed.

The association of prescription opioid use with incident cancer: A Surveillance, Epidemiology, and End Results-Medicare population-based case-control study

BACKGROUND

Cancer is the second leading cause of death globally, and researchers seek to identify modifiable risk factors Over the past several decades, there has been ongoing debate whether opioids are associated with cancer development, metastasis, or recurrence. Basic science, clinical, and observational studies have produced conflicting results. The authors examined the association between prescription opioids and incident cancers using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. A complex relation was observed between prescription opioids and incident cancer, and cancer site may be an important determinant.

METHODS

By using linked SEER cancer registry and Medicare claims from 2008 through 2013, a case-control study was conducted examining the relation between cancer onset and prior opioid exposure. Logistic regression was used to account for differences between cases and controls for 10 cancer sites.

RESULTS

Of the population studied (n = 348,319), 34% were prescribed opioids, 79.5% were white, 36.9% were dually eligible (for both Medicare and Medicaid), 13% lived in a rural area, 52.7% had ≥1 comorbidity, and 16% had a smoking-related diagnosis. Patients exposed to opioids had a lower odds ratio (OR) associated with breast cancer (adjusted OR, 0.96; 95% CI, 0.92-0.99) and colon cancer (adjusted OR, 0.90; 95% CI, 0.86-0.93) compared with controls. Higher ORs for kidney cancer, leukemia, liver cancer, lung cancer, and lymphoma, ranging from lung cancer (OR, 1.04; 95% CI, 1.01-1.07) to liver cancer (OR, 1.19; 95% CI, 1.08-1.31), were present in the exposed population.

CONCLUSIONS

The current results suggest that an association exists between prescription opioids and incident cancer and that cancer site may play an important role. These findings can direct future research on specific patient populations that may benefit or be harmed by prescription opioid exposure.

Untargeted Metabolomics: Biochemical Perturbations in Golestan Cohort Study Opium Users Inform Intervention Strategies

Objective: Over 50 million people worldwide are estimated to use opioids, of which ~30 million use opiates (opium and its derivatives). Use of opiates has been associated with a variety of adverse complications such as neurological and behavioral outcomes, addiction, cancers, diabetes, and cardiovascular disease. While it is well known that opiates exert their neurobiological effects through binding with mu, kappa, and delta receptors to exert analgesic and sedative effects, mechanistic links to other health effects are not well understood. Our study focuses on the identification of biochemical perturbations in Golestan Cohort Study (GCS) opium users.

Methods: We used untargeted metabolomics to evaluate the metabolic profiles of 218 opium users and 80 non-users participating in the GCS. Urine samples were obtained from adult (age 40–75) opium users living in the Golestan Province of Iran. Untargeted analysis of urine was conducted using a UPLC-Q-Exactive HFx Mass Spectrometry and a 700 MHz NMR Spectrometry.

Results: These GCS opium users had a significantly higher intake of tobacco and alcohol and a significantly decreased BMI compared with non-users. Metabolites derived from opium (codeine, morphine, and related glucuronides), nicotine, and curing or combustion of plant material were increased in opium users compared with non-users. Endogenous compounds which differentiated the opium users and non-users largely included vitamins and co-factors, metabolites involved in neurotransmission, Kreb's cycle, purine metabolism, central carbon metabolism, histone modification, and acetylation.

Conclusions: Our study reveals biochemical perturbations in GCS opium users that are important to the development of intervention strategies to mitigate against the development of adverse effects of substance abuse.

Drug use disorder and risk of incident and fatal breast cancer: a nationwide epidemiological study

Purpose

Breast cancer is one of the most common cancer forms in women and it is often detected by screening. However, women with drug use disorders (DUD) are less likely to be reached by screening programs. In this study, we aimed to investigate breast cancer incidence, mortality and stage at time of diagnosis among women with DUD compared to the general female population in Sweden.

Methods

We performed a follow-up study based on Swedish national register data for the period January 1997–December 2015. The study was based on 3,838,248 women aged 15–75 years, of whom 50,858 were registered with DUD. Adjusted hazard ratios (HRs) for incident and fatal breast cancer, and cancer stage at time of diagnosis, were calculated for women with and without DUD using Cox regression analysis.

Results

DUD was associated with incident breast cancer (HR 1.08, 95% confidence interval [CI] 1.02–1.14, p = 0.0069), fatal breast cancer (HR 1.60, 95% CI 1.42–1.82, p < 0.001), and stage IV breast cancer, i.e. metastasis at diagnosis (HR 2.06, 95% CI 1.44–2.95, p < 0.001).

Conclusions

Women with DUD were identified as a risk group for incident, fatal and metastasized breast cancer, which calls for attention from clinicians and policy makers. Cancer screening attendance and other healthcare seeking barriers are likely to affect the risk increase among women who use drugs; however, more research is needed on the underlying mechanisms.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05998-4) contains supplementary material, which is available to authorized users.

Impact of Opioid Use in Hematological Malignancies: Clinical, Immunological and Concomitant Aspects

Opioid agents play a unique role in pain and symptom management for cancer patients. Research shows that opiate use, especially when associated with underlying cancer, has significant effects on hematological parameters. These changes may lead to greater risk for immunosuppression, tumor growth and progression of metastatic processes. The aim of this review is to explore the effects of opiates on various metabolic and biological processes, as well as the hematopoietic system, especially in cancer patients. Our findings demonstrate that the tumor-promoting effects of opiates remain contradictory, as both growth-promoting and anti-tumor effects have been observed. However, available data suggest that opiates can facilitate the proliferation and migration of tumor cells, and understanding of this process on cancer treatment is tremendously important.

Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality

The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.

Opium use and subsequent incidence of cancer: results from the Golestan Cohort Study

BACKGROUND

Evidence is emerging for a role of opiates in various cancers. In this study, we aimed to investigate the association between regular opium use and cancer incidence.

METHODS

This study was done in a population-based cohort of 50 045 individuals aged 40-75 years from northeast Iran. Data on participant demographics, diet, lifestyle, opium use, and different exposures were collected upon enrolment using validated questionnaires. We used proportional hazards regression models to estimate hazard ratios (HRs) and corresponding 95% CIs for the association between opium use and different cancer types.

FINDINGS

During a median 10 years of follow-up, 1833 participants were diagnosed with cancer. Use of opium was associated with an increased risk of developing all cancers combined (HR 1·40, 95% CI 1·24-1·58), gastrointestinal cancers (1·31, 1·11-1·55), and respiratory cancers (2·28, 1·58-3·30) in a dose-dependent manner (ptrend<0·001). For site-specific cancers, use of opium was associated with an increased risk of developing oesophageal (1·38, 1·06-1·80), gastric (1·36, 1·03-1·79), lung (2·21, 1·44-3·39), bladder (2·86, 1·47-5·55), and laryngeal (2·53, 1·21-5·29) cancers in a dose-dependent manner (ptrend<0·05). Only high-dose opium use was associated with pancreatic cancer (2·66, 1·23-5·74). Ingestion of opium (but not smoking opium) was associated with brain (2·15, 1·00-4·63) and liver (2·46, 1·23-4·95) cancers in a dose-dependent manner (prend<0·01). We observed consistent associations among ever and never tobacco users, men and women, and individuals with lower and higher socioeconomic status.

INTERPRETATION

Opium users have a significantly higher risk of developing cancers in different organs of the respiratory, digestive, and urinary systems and the CNS. The results of this analysis show that regular use of opiates might increase the risk of a range of cancer types.

FUNDING

World Cancer Research Fund International, Cancer Research UK, Tehran University of Medical Sciences, US National Cancer Institute, International Agency for Research on Cancer.

Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study

BACKGROUND

Mortality rates and causes of death among individuals in opioid agonist treatment (OAT) vary according to several factors such as geographical region, age, gender, subpopulations, drug culture and OAT status. Patients in OAT are ageing due to effective OAT as well as demographic changes, which has implications for morbidity and mortality. Norway has one of the oldest OAT populations in Europe. Because of the varying mortality rates and causes of death in different subgroups and countries, research gaps still exist. The aims of this study were to describe the causes of death among OAT patients in Norway, to estimate all-cause and cause-specific crude mortality rates (CMRs) during OAT and to explore characteristics associated with drug-induced cause of death compared with other causes of death during OAT.

METHODS

This was a national, observational register study. Data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry were combined with data from medical records. We included all patients in the Norwegian OAT programme who died not more than 5 days after the last intake of OAT medication, between 1 January 2014 and 31 December 2015.

RESULTS

In the 2-year observation period, 200 (1.4%) of the OAT patients died. A forensic or medical autopsy was performed in 63% of the cases. The mean age at the time of death was 48.9 years (standard deviation 8.4), and 74% were men. Somatic disease was the most common cause of death (45%), followed by drug-induced death (42%), and violent death (12%). In general, CMRs increased with age, and they were higher in men and in patients taking methadone compared with buprenorphine. Increasing somatic comorbidity, measured by the Charlson comorbidity index, reduced the odds of dying of a drug-induced cause of death compared with other causes of death.

CONCLUSIONS

Both somatic and drug-induced causes of death were common during OAT. Improved treatment and follow-up of chronic diseases, especially in patients aged > 40 years, and continuous measures to reduce drug-induced deaths appear to be essential to reduce future morbidity and mortality burdens in this population.

Electronic nicotine devices to aid smoking cessation by alcohol- and drug-dependent clients: protocol for a pilot randomised controlled trial

Background

Up to 95% of people entering treatment for use of alcohol or other drugs (AOD) smoke tobacco. Smokers receiving treatment for AOD use are interested in quitting and make quit attempts, but relapse is more common and rapid compared with the general population of smokers. New ways to address smoking in this population are needed. Electronic nicotine devices (ENDs) or electronic cigarettes hold significant potential as both cessation aids and harm reduction support. This study focuses on the potential of ENDs to facilitate smoking cessation and to sustain it in the medium term among people in treatment for AOD use. The aim of this trial is to explore the effectiveness, feasibility and acceptability of ENDs for smoking cessation compared with combination nicotine replacement therapy (NRT) for clients after discharge from a smoke-free AOD residential withdrawal service.

Methods/design

The study is a pragmatic randomised controlled trial. In total, 100 participants will be recruited following admission to a smoke-free residential withdrawal service in Melbourne, Australia. Participants will complete a baseline survey and be randomised to either the END group (n = 50) or the NRT group (n = 50) prior to discharge. Both groups will receive telephone counselling support from quitline. Follow-up measures will be assessed at 6 and 12 weeks following discharge. The primary outcome is continuous abstinence from smoking at 12 weeks post discharge. Secondary outcomes include: 7-day point prevalence from smoking, point prevalence abstinence from all nicotine (including NRT and ENDs), cravings and withdrawal, time to relapse, and treatment adherence (use of NRT, ENDs and quitline).

Discussion

This is the first randomised controlled trial to assess the effectiveness and acceptability of ENDs within a population dependent on AOD, a priority group with very high levels of smoking. The research will test a model of how to incorporate novel smoking cessation support into a period of high treatment receptiveness.

Trial registration

Australian New Zealand Clinical Trial Registry, ACTRN12617000849392. Registered on 8 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2786-1) contains supplementary material, which is available to authorized users.

Causes of Death After Nonfatal Opioid Overdose

Importance

A recent increase in patients presenting with nonfatal opioid overdoses has focused clinical attention on characterizing their risks of premature mortality.

Objective

To describe all-cause mortality rates, selected cause-specific mortality rates, and standardized mortality rate ratios (SMRs) of adults during their first year after nonfatal opioid overdose.

Design, Setting, and Participants

This US national longitudinal study assesses a cohort of patients aged 18 to 64 years who were Medicaid beneficiaries and experienced nonfatal opioid overdoses. The Medicaid data set included the years 2001 through 2007. Death record information was obtained from the National Death Index. Data analysis occurred from October 2017 to January 2018.

Main Outcomes and Measures

Crude mortality rates per 100 000 person-years were determined in the first year after nonfatal opioid overdose. Standardized mortality rate ratios (SMR) were estimated for all-cause and selected cause-specific mortality standardized to the general population with respect to age, sex, and race/ethnicity.

Results

The primary cohort included 76 325 adults and 66 736 person-years of follow-up. During the first year after nonfatal opioid overdose, there were 5194 deaths, the crude death rate was 778.3 per 10 000 person-years, and the all-cause SMR was 24.2 (95% CI, 23.6-24.9). The most common immediate causes of death were substance use-associated diseases (26.2%), diseases of the circulatory system (13.2%), and cancer (10.3%). For every cause examined, SMRs were significantly elevated, especially with respect to drug use-associated diseases (SMR, 132.1; 95% CI, 125.6-140.0), HIV (SMR, 45.9; 95% CI, 39.5-53.0), chronic respiratory diseases (SMR, 41.1; 95% CI, 36.0-46.8), viral hepatitis (SMR, 30.6; 95% CI, 22.9-40.2), and suicide (SMR, 25.9; 95% CI, 22.6-29.6), particularly including suicide among females (SMR, 47.9; 95% CI, 39.8-52.3).

Conclusions and Relevance

In a US national cohort of adults who had experienced a nonfatal opioid overdose, a marked excess of deaths was attributable to a wide range of substance use-associated, mental health, and medical conditions, underscoring the importance of closely coordinating the substance use, mental health, and medical care of this patient population.

A retrospective cohort study of the health of children prenatally exposed to methadone, buprenorphine or naltrexone compared with non-exposed control children

BACKGROUND AND OBJECTIVES

Little is known about the health of children exposed to opioid pharmacotherapies in utero. This study aims to examine the health of children from birth to 5 years of age, who were exposed to methadone, buprenorphine, or naltrexone with non-exposed children.

METHODS

Children were identified by linking the treatment records of women treated with one of the three opioid pharmacotherapies with midwife notifications. Live-born children exposed to methadone (n = 198), buprenorphine (n = 122), naltrexone (n = 67) in utero, and neonates not prenatally exposed to opioids (n = 387) born between 2001 and 2011 in Western Australia were included in the study. The children were then linked to state mortality, hospital, emergency department (ED), mental health, cancer, and reportable diseases from birth up to their 5th birthday.

RESULTS

Overall rates of hospital admission were elevated in all three treatments as compared with the control children, while rates of ED attendances were only significantly elevated in the methadone (p = .002) and naltrexone (p = .044) exposed children. In terms of both hospital and ED attendances, the differences between the exposed and control children was most apparent in the neonatal period. Rates of mental health out-patient attendances were elevated in buprenorphine-exposed children as compared with the control (p = .005).

DISCUSSION AND CONCLUSIONS

The study provides evidence to suggest a disparity in the health of children exposed to opioid pharmacotherapies in utero compared with non-exposed control children.

SCIENTIFIC SIGNIFICANCE

Exposure to opioid pharmacotherapies in utero may influence the health of children beyond the neonatal period. (Am J Addict 2017;26:845-851).

Young Adult Risk Factors for Cancer: Obesity, Inflammation, and Sociobehavioral Mechanisms

INTRODUCTION

The paper assesses social disparities in the burdens of metabolic and inflammatory risks for cancer in the U.S. young adult population and examines psychosocial and behavioral mechanisms in such disparities.

METHODS

Using data of 7,889 individuals aged 12-32 years from the National Longitudinal Study of Adolescent to Adult Health from 1994 to 2009, generalized linear models were used to assess the sex, race/ethnicity, and SES differences in the risks of obesity and inflammation, measured by C-reactive protein. Further tests examined the extent to which social isolation, smoking, physical inactivity, alcohol abuse, and illicit drug use explain social differentials in each biomarker outcome.

RESULTS

Women, blacks, Hispanics, and socioeconomically disadvantaged groups had higher risks of obesity and elevated C-reactive protein, with the SES gradients being more pronounced in female participants. Health-related behaviors showed large variation across sex, race, and SES strata. After adjusting for these behavioral variables, sex, and race disparities in obesity and excess inflammation in blacks diminished, whereas the adolescent SES disparity in obesity remained. The associations of adolescent and young adult SES disadvantage and inflammation were also explained by behavioral mechanisms. Behavioral factors associated with higher risks of obesity and inflammation differed, with the exception of fast food consumption, a risk factor for both.

CONCLUSIONS

This study provides new knowledge of social distribution of early life exposures to physiologic precedents to cancer development later in life with implications for prevention and early intervention of modifiable risky behaviors in adolescents and young adults.

Role of physicians in the management of substance use disorders

Alcohol, tobacco and other drugs are responsible for significant contribution to the global burden of disease and injury. There are several contributions that the physician can make to reduce the burden that substance use contributes to the community, not only clinically but also through leadership and contribution to community dialogue and public policy.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial

Background

The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services.

Methods/design

A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care.

Discussion

If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549. Registered on 3 March 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1401-6) contains supplementary material, which is available to authorized users.

Harm Reduction: Front Line Public Health

Drug use is a public health problem associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care. Harm reduction is a pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life. Harm reduction prioritizes improving the lives of people who use drugs in partnership with those served without a narrow focus on abstinence from drugs. Evidence has shown that harm reduction oriented practice can reduce transmission of blood-borne illnesses, and other injection related infections, as well as preventing fatal overdose.

Association between alcohol and substance use disorders and all-cause and cause-specific mortality in schizophrenia, bipolar disorder, and unipolar depression: a nationwide, prospective, register-based study

BACKGROUND

People with severe mental illness have both increased mortality and are more likely to have a substance use disorder. We assessed the association between mortality and lifetime substance use disorder in patients with schizophrenia, bipolar disorder, or unipolar depression.

METHODS

In this prospective, register-based cohort study, we obtained data for all people with schizophrenia, bipolar disorder, or unipolar depression born in Denmark in 1955 or later from linked nationwide registers. We obtained information about treatment for substance use disorders (categorised into treatment for alcohol, cannabis, or hard drug misuse), date of death, primary cause of death, and education level. We calculated hazard ratios (HRs) for all-cause mortality and subhazard ratios (SHRs) for cause-specific mortality associated with substance use disorder of alcohol, cannabis, or hard drugs. We calculated standardised mortality ratios (SMRs) to compare the mortality in the study populations to that of the background population.

FINDINGS

Our population included 41 470 people with schizophrenia, 11 739 people with bipolar disorder, and 88 270 people with depression. In schizophrenia, the SMR in those with lifetime substance use disorder was 8·46 (95% CI 8·14-8·79), compared with 3·63 (3·42-3·83) in those without. The respective SMRs in bipolar disorder were 6·47 (5·87-7·06) and 2·93 (2·56-3·29), and in depression were 6·08 (5·82-6·34) and 1·93 (1·82-2·05). In schizophrenia, all substance use disorders were significantly associated with increased risk of all-cause mortality, both individually (alcohol, HR 1·52 [95% CI 1·40-1·65], p<0·0001; cannabis, 1·24 [1·04-1·48], p=0·0174; hard drugs, 1·78 [1·56-2·04], p<0·0001) and when combined. In bipolar disorder or depression, only substance use disorders of alcohol (bipolar disorder, HR 1·52 [95% CI 1·27-1·81], p<0·0001; depression, 2·01 [1·86-2·18], p<0·0001) or hard drugs (bipolar disorder, 1·89 [1·34-2·66], p=0·0003; depression, 2·27 [1·98-2·60], p<0·0001) increased risk of all-cause mortality individually.

INTERPRETATION

Mortality in people with mental illness is far higher in individuals with substance use disorders than in those without, particularly in people who misuse alcohol and hard drugs. Mortality-reducing interventions should focus on patients with a dual diagnosis and seek to prevent or treat substance use disorders.

FUNDING

The Lundbeck Foundation.

Opioid use and risk of liver fibrosis in HIV/hepatitis C virus-coinfected patients in Canada

OBJECTIVES

Opioid use and opioid-related mortality have increased dramatically since the 1990s in North America. The effect of opioids on the liver is incompletely understood. Some studies have suggested that opioids cause liver damage and others have failed to show any harm. HIV/hepatitis C virus (HCV)-coinfected persons may be particularly vulnerable to factors increasing liver fibrosis. We aimed to describe opioid use in an HIV/HCV-coinfected population in Canada and to estimate the association between opioid use and liver fibrosis.

METHODS

We conducted a cross-sectional descriptive analysis of the Canadian Co-infection Cohort Study data to characterize opioid use. We then conducted a longitudinal analysis to assess the average change in aspartate aminotransferase-to-platelet ratio index (APRI) score associated with opioid use using a generalized estimating equation with linear regression. We assessed the progression to significant liver fibrosis (APRI ≥ 1.5) associated with opioid use with pooled logistic regression.

RESULTS

In the 6 months preceding cohort entry, 32% of the participants had received an opioid prescription, 28% had used opioids illicitly and 18% had both received a prescription and used opioids illicitly. Neither prescribed nor illicit opioid use was associated with a change in the median APRI score [exp(β) 0.99 (95% confidence interval (CI) 0.82, 1.12) and exp(β) 0.95 (95% CI 0.81, 1.10), respectively] or with faster progression to liver fibrosis [hazard odds ratio (HOR) 1.20 (95% CI 0.73, 1.67) and HOR 1.09 (95% CI 0.63, 1.55), respectively].

CONCLUSIONS

Although opioids were commonly used both legally and illegally in our cohort, we were unable to demonstrate a negative impact on liver fibrosis progression.

Mortality among older adults with opioid use disorders in the Veteran's Health Administration, 2000-2011

BACKGROUND

The population of people with opioid use disorders (OUD) is aging. There has been little research on the effects of aging on mortality rates and causes of death in this group. We aimed to compare mortality in older (≥ 50 years of age) adults with OUD to that in younger (<50 years) adults with OUD and older adults with no history of OUD. We also examined risk factors for specific causes of death in older adults with OUD.

METHODS

Using data from the Veteran's Health Administration National Patient Care Database (2000-2011), we compared all-cause and cause-specific mortality rates in older adults with OUD to those in younger adults with OUD and older adults without OUD. We then generated a Cox regression model with specific causes of death treated as competing risks.

RESULTS

Older adults with OUD were more likely to die from any cause than younger adults with OUD. The drug-related mortality rate did not decline with age. HIV-related and liver-related deaths were higher among older OUD compared to same-age peers without OUD. There were very few clinically important predictors of specific causes of death.

CONCLUSION

Considerable drug-related mortality in people with OUD suggests a need for greater access to overdose prevention and opioid substitution therapy across the lifespan. Elevated risk of liver-related death in older adults may be addressed through antiviral therapy for hepatitis C virus infection. There is an urgent need to explore models of care that address the complex health needs of older adults with OUD.

Impact of lifetime opioid exposure on arterial stiffness and vascular age: cross-sectional and longitudinal studies in men and women

OBJECTIVE

To characterise and compare the potentiation of arterial stiffness and vascular ageing by opioids in men and women.

DESIGN

Cross-sectional and longitudinal studies of 576 clinical controls and 687 opioid-dependent patients (ODP) on 710 and 1305 occasions, respectively, over a total of 2382 days (6.52 years), 2006-2011. Methodology Radial pulse wave analysis with Atcor SphygmoCor system (Sydney).

SETTING

Primary care.

CONTROLS

General practice patients with non-cardiovascular disorders, and university student controls. ODP: Patients undergoing clinical management of their opioid dependence. CONTROLS had lower chronological ages (CAs) than ODP (30.0±0.5 vs 34.5±0.3, mean±SEM, p<0.0001). 69.6% and 67.7% participants were men, and 16% and 92.3% were smokers (p<0.0001) for controls and ODP, respectively. 86.3%, 10.3% and 3.4% of ODP were treated with buprenorphine (6.98±0.21 mg), methadone (63.04±4.01 mg) or implant naltrexone, respectively. Body mass index (BMI) was depressed in ODP.

INTERVENTIONS

Nil.

PRIMARY OUTCOME MEASURES

Vascular Reference Age (RA) and the ratio of vascular age to chronological age (RA/CA).

SECONDARY OUTCOME MEASURES

Arterial stiffness including Augmentation Index.

RESULTS

After BMI adjustment, RA in ODP was higher as a function of CA and of time (both p<0.05). Modelled mean RA in control and ODP was 35.6 and 36.3 years (+1.97%) in men, and 34.5 and 39.2 years (+13.43%) in women, respectively. Changes in RA and major arterial stiffness indices were worse in women both as a factor (p = 0.0036) and in interaction with CA (p = 0.0040). Quadratic, cubic and quartic functions of opioid exposure duration outperformed linear models with RA/CA over CA and over time. The opioid dose-response relationship persisted longitudinally after multiple adjustments from p=0.0013 in men and p=0.0073 in women.

CONCLUSIONS

Data show that lifetime opioid exposure, an interactive cardiovascular risk factor, particularly in women, is related to linear, quadratic, cubic and quartic functions of treatment duration and is consistent with other literature of accelerated ageing in patients with OD.

Opium use: an emerging risk factor for cancer?

An estimated 16·5 million people worldwide illicitly use opiates, of whom 4 million use raw opium. We did a systematic review to investigate the association between opium use and cancer incidence and mortality. Opium use was associated with an increased risk of cancers of the oesophagus, stomach, larynx, lung, and urinary bladder. Although the present evidence suggests that these associations are possibly causal, further epidemiological studies (particularly prospective studies that collect detailed data about lifetime opium use and control for a broad range of potential confounders) are needed.

Causes of death in a cohort treated for opioid dependence between 1985 and 2005

AIMS

To examine changes in causes of death in a cohort treated for opioid dependence, across time and age; quantify years of potential life lost (YPLL); and identify avoidable causes of death.

DESIGN

People in New South Wales (NSW) who registered for opioid substitution therapy (OST), 1985-2005, were linked to a register of all deaths in Australia.

SETTING

NSW, Australia.

MEASUREMENTS

Crude mortality rates (CMRs), age-sex-standardized mortality rates (ASSRs) and standardized mortality ratios (SMRs) across time, sex and age. Years of potential life lost (YPLL) were calculated with reference to Australian life tables and by calculating years lost before the age of 65 years.

FINDINGS

There were 43 789 people in the cohort, with 412 216 person-years of follow-up. The proportion of the cohort aged 40+ years increased from 1% in 1985 to 39% in 2005. Accidental opioid overdoses, suicides, transport accidents and violent deaths declined with age; deaths from cardiovascular disease, liver disease and cancer increased. Among men, 89% of deaths were potentially avoidable; among women, 86% of deaths were avoidable. There were an estimated 160 555 YPLL in the cohort, an average of 44 YPLL per decedent and an average of 29 YPLL before age 65 years.

CONCLUSIONS

Among a cohort of opioid-dependent people in New South Wales, 1985-2005, almost nine in 10 deaths in the cohort were avoidable. There is huge scope to improve mortality among opioid-dependent people.

Engagement with the criminal justice system among opioid-dependent people: a retrospective cohort study

AIMS

Studies of offending among people who use drugs typically focus upon small and potentially unrepresentative samples. We examined an entire population of opioid-dependent clients' contact with the criminal justice system to develop more accurate population-wide measures of offending among opioid-dependent people in Australia.

DESIGN

Retrospective data linkage study.

SETTING

All entrants to opioid substitution therapy (OST) for opioid dependence in New South Wales, Australia, between 1985 and 2010, with data on court appearances from 1 December 1993 to 31 March 2011.

PARTICIPANTS

All 48 069 valid cohort members who received OST between 1985 and 2010.

MEASUREMENTS

Person-years (PY) of observation and charge rates for major crime categories estimated by sex, age and time.

FINDINGS

A total of 638 545 charges were laid against cohort members between 1993 and 2011. Eight in 10 males (79.7%) and 67.9% of females had at least one charge; rates were 94.15 per 100 PY [95% confidence interval (CI) = 93.89-94.41] among males, and 53.19 per 100 PY (95% CI = 52.91-53.46) among females, and highest at 15-19 years [175.74/100 PY males (95% CI = 174.45-177.03), 75.60/100 PY females (95% CI = 74.46-76.76)] and 20-24 years [144.61/100 PY males (95% CI = 143.70-145.53), 84.50/100 PY females (95% CI = 83.53-85.48)]. The most frequent charges were theft (24.5% of charges), traffic/vehicle (16.3%), offences against justice (10.5%), illicit drug (10.0%), intentional injury (9.9%) and public order offences (8.9%). Overall, 20.8% of the cohort accounted for 67.4% of charges. The most frequently appearing 5.6% of the cohort accounted for 24.3% of costs ($75.5 million).

CONCLUSIONS

Among opioid-dependent people in Australia, a minority account for the majority of the criminal justice contact and levels of offending are not consistent over time, sex or age.

Lifetime opiate exposure as an independent and interactive cardiovascular risk factor in males: a cross-sectional clinical study

Introduction

While several studies have identified an increased incidence of cardiovascular disorders in opiate dependence, neither opiates as a cardiovascular risk factor nor their effect on central arterial function has been considered.

Methods

Pulse wave analysis (SphygmoCor, AtCorMedical Pty Limited, Sydney, NSW, Australia) was undertaken on a cohort of controls and opiate dependent patients and the results compared to their lifetime opiate exposure.

Results

Controls (N = 401) were compared with 465 opiate dependent men. The mean (log) ages were different and were found to be 28.80 ± 0.49 years versus 35.02 ± 0.39 years (P < 0.0001), respectively. Of the opiate dependent group, 87.7% were treated with buprenorphine, 8.8% with methadone, and 3.4% with naltrexone. Multiple regression analysis was used to adjust for chronologic age (CA). At CA of 60 years, the modeled age in the controls was 66.40 years, and that in the addicted group was 73.11 years, an advancement of 6.71 years, or 10.10%. Exacerbations of age dependent changes in central arterial stiffness, central pressures, pulse rate, ejection duration, diastolic duration, and subendocardial perfusion ratio by opiate dependence were all noted (P < 0.05). Current heroin dose, heroin duration, and the dose duration interaction were all significantly related to the vascular (or “reference”) age (RA)/CA ratio (all P < 0.006). After multivariate adjustment, the opiate dose duration was independently predictive of RA (P < 0.02). Opiate dose and/or duration were included in a further 25 terms.

Conclusion

These data show that opiate use is not benign for the male cardiovascular system, but has a dose response relationship to central arterial stiffness and thus cardiovascular aging, acting independently and interactively with established cardiovascular risk factors. These findings imply accelerated organismal aging.

The contributions of viral hepatitis and alcohol to liver-related deaths in opioid-dependent people

BACKGROUND

Mortality rates are elevated among heroin-dependent populations compared to the general population. Liver disease is emerging as an important contributor to mortality as the heroin-dependent population ages. Two major risk factors for liver disease are hepatitis C virus infection and chronic heavy alcohol use. Both of these are highly prevalent among heroin dependent people, but their relative contribution to liver-related mortality is poorly understood.

METHODS

Data recording all prescriptions of opioid substitution treatment in New South Wales, Australia, 1997-2005, were linked to the National Death Index. Crude and standardised mortality rates and standardised mortality ratios were calculated for liver-related and other major causes of death. Frequency counts were obtained for viral hepatitis and alcohol mentions in underlying liver deaths.

RESULTS

There were 208 underlying liver deaths for a CMR of 72.4 per 100,000 py (95% CI 62.9, 82.9), and liver deaths occurred at 9.8 times the general population rate (95% CI 8.5, 11.2). There were increases in liver-related mortality over time. Viral hepatitis was mentioned in three-quarters (n=156, 76%), and alcohol in 43% (n=90) of underlying liver deaths.

CONCLUSIONS

Liver-related deaths were shown to be increasing in this heroin-dependent population, and the majority of these deaths involved chronic viral hepatitis infection. Increased uptake of treatment for hepatitis C virus infection is crucial to reducing the burden of liver-related mortality in this population. Hepatitis B vaccination, and screening of OST patients for alcohol use disorders and delivery of brief interventions as clinically indicated may also be of benefit.

Reduction in arterial stiffness and vascular age by naltrexone-induced interruption of opiate agonism: a cohort study

OBJECTIVE

To prospectively assess if opiate antagonist treatment or the opiate-free status could reverse opiate-related vasculopathy.

DESIGN

Longitudinal Open Observational, Serial 'N of One', over 6.5 years under various treatment conditions: opiate dependence, naltrexone and opiate-free.

SETTING

Primary care, Australia.

PARTICIPANTS

20 opiate-dependent patients (16 males: 16 cases of buprenorphine 4.11±1.17 mg, two of methadone 57.5±12.5 mg and two of heroin 0.75±0.25 g).

INTERVENTION

Studies of central arterial stiffness and vascular reference age (RA) were performed longitudinally by SphygmoCor Pulse Wave Analysis (AtCor, Sydney).

PRIMARY OUTCOMES

Primary outcome was vascular age and arterial stiffness accrual under different treatment conditions.

RESULTS

The mean chronological age (CA) was 33.62±2.03 years. The opiate-free condition was associated with a lower apparent vascular age both in itself (males: p=0.0402 and females: p=0.0360) and in interaction with time (males: p=0.0001 and females: p=0.0004), and confirmed with other measures of arterial stiffness. The mean modelled RA was 38.82, 37.73 and 35.05 years in the opiate, naltrexone and opiate-free conditions, respectively. The opiate-free condition was superior to opiate agonism after full multivariate adjustment (p=0.0131), with modelled RA/CA of 1.0173, 0.9563 and 0.8985 (reductions of 6.1% and 11.9%, respectively).

CONCLUSIONS

Data demonstrate that opiate-free status improves vascular age and arterial stiffness in previous chronic opiate users. The role of opiate antagonist treatment in achieving these outcomes requires future clarification and offers hope of novel therapeutic remediation.

Extent of illicit drug use and dependence, and their contribution to the global burden of disease

This paper summarises data for the prevalence, correlates, and probable adverse health consequences of problem use of amphetamines, cannabis, cocaine, and opioids. We discuss findings from systematic reviews of the prevalence of illicit drug use and dependence, remission from dependence, and mortality in illicit drug users, and evidence for acute and chronic effects of illicit drug use. We outline the regional and global distribution of use and estimated health burden from illicit drugs. These distributions are likely to be underestimates because they have not included all adverse outcomes of drug use and exclude those of cannabis--the mostly widely used illicit drug. In high-income countries, illicit drug use contributes less to the burden of disease than does tobacco but a substantial proportion of that due to alcohol. The major adverse health effects of cannabis use are dependence and probably psychotic disorders and other mental disorders. The health-related harms of cannabis use differ from those of amphetamine, cocaine, and opioid use, in that cannabis contributes little to mortality. Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.

Epidemiologic and Molecular Pathophysiology of Chronic Opioid Dependence and the Place of Naltrexone Extended-Release Formulations in its Clinical Management

Naltrexone implants and depot injections (NI) are a novel form of treatment for opiate dependence (OD). Major questions relate to their absolute and relative efficacy and safety. Opportunely, six recent clinical trial data from several continents have uniformly provided dramatic evidence of the potent, dose-related and highly significant efficacy of NI, with minimal or manageable accompanying toxicity and safety concerns. The opiate-free lifestyle is attained significantly more often with NI adjusted O.R. = 6.00 (95% C.I. 3.86–9.50), P < 10⁻¹⁰. Other drug use and drug craving are also rapidly reduced. The optimum manner in which to commence NI remains to be established. Of particular relevance is the relative safety of NI compared to the chronic opiate agonists (COA) usually employed, as the long-term toxicity of COA is only just being elucidated. Large population-based studies have found elevated rates of cardiovascular disease, six cancers, liver and respiratory disease, and all-cause mortality in COA. Whilst opiates have been shown to trigger numerous molecular pathways, the most interesting is the demonstration that the opiate morphinan’s nucleus binds to the endotoxin groove of the TLR4-MD2 heterodimer. This has the effect of triggering a low grade endotoxaemic-like state, which over time may account for these protean clinical findings, an effect which is reversed by opiate antagonists. This emerging evidence suggests an exciting new treatment paradigm for OD and a corresponding increase in the role of NI in treatment.

The increasing mortality burden of liver disease among opioid-dependent people: cohort study

AIMS

Hepatitis C (HCV) infection is highly prevalent among injection drug users (IDUs) and likely to cause significant mortality over time, but little research attention has focused upon the magnitude of this risk, particularly among ageing users. This study examined trends over time in mortality attributed to liver disease, and in particular contrasting this with other more commonly studied causes of death [acquired immune deficiency syndrome (AIDS), suicide and overdose] among an ageing cohort of heroin-dependent people in Australia.

DESIGN

Data linkage study of methadone treatment entrants with the National Deaths Index.

SETTING

 A cohort entering methadone treatment for heroin dependence in New South Wales, Australia, 1980-85.

PARTICIPANTS

  A total of 2489 people entering methadone treatment for heroin dependence and 54,847 person-years (PY) of follow-up.

MEASUREMENTS

  Linkage of data on all methadone entrants between 1980 and 1985 with data from the Australian National Deaths Index, linked using probabilistic record linkage software.

FINDINGS

There were 8.2 deaths per 1000 PY [95% confidence interval (CI) 7.5-9.0], with standardized mortality ratios (SMRs) of 4.6 (95% CI 4.2-5.0). Almost one in five (17%) of deaths were from underlying liver-related causes, most commonly viral hepatitis. The overall mortality rate for any liver cause was 1.4 deaths per 1000 PY (95% CI 1.1-1.7), 17 times higher than to the general population (95% CI 13.4-21.3), with relative elevations more marked for females (SMR 27.9; 95% CI 17.7-41.9) than males (SMR 14.5; 95% CI 10.8-19.0). Liver mortality increased over time, becoming the most common cause of death by the end of follow-up.

CONCLUSIONS

  Liver disease has become the most common cause of mortality among ageing opioid-dependent people in an ageing Australian cohort. There is an imperative to reduce the long-term risks of HCV and other risks to the liver, including alcohol consumption, which are typically not the major clinical focus for this group.