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

Monitoring Opioids in Europe: The Need for Shared Definitions and Measuring Drivers of Opioid Use and Related Harms

The past 20 years, the USA is facing a serious opioid crisis initiated by an increase in prescription opioid use. Europe has also seen an increase in prescription opioid use, but the extent of related harm is still largely unknown. Given the impact of the US opioid epidemic, it is important to closely monitor signs of emerging opioid-related problems to guarantee early warnings and timely actions. Shared and meaningful definitions for opioid use and related harms, and relevant information about specific drivers for opioid use and related problems are needed for an adequate policy response. In this commentary, we discuss these definitions, the need to know more about the specific drivers for increased opioid use, its related harm, and proposals for strategies to move forward. Policy recommendations include making a distinction between licit and illicit opioids when monitoring and reporting on opioid-related harm, and using oral morphine equivalents to quantify prescription opioid use in a clinically relevant and comparable manner. A major topic of further research is exploring unique and universal drivers of prescription opioid (mis)use across Europe, in particular the role of opioid diversion.

The identification of artefacts in reporting of drug-induced deaths using structural breaks analysis of time series statistics

INTRODUCTION

Drug-related mortality is a key epidemiological indicator that is collected nationally and internationally. Significant efforts were made in 2006-2007 to improve the quality of data concerning drug-related mortality in the Czech Republic. The aim of this article is to identify the effect of a quality improvement project on the drug-induced mortality data reported in the General Mortality Registry (GMR), and to demonstrate how to identify, quantify and interpret changes in drug-induced mortality based on the example of the Czech Republic.

METHODS

We extracted data on illicit drug-induced deaths from the Czech Republic GMR and Special Mortality registry (SMR) for the years between 2004 and 2012, and aggregated monthly and quarterly time series. We applied a new procedure to identify structural breakpoints in time series based on dating structural changes in standard linear regression models.

RESULTS

In the GMR, breakpoints were identified in three time series: (i) opioid-related deaths; (ii) other stimulant-related deaths; and (iii) total drug-induced deaths. In the SMR, the structural breaks were identified for opioids, volatile substances and selection D time series. In each of these time series, the analysis identified a decrease in the intercepts in the different segments.

DISCUSSION AND CONCLUSIONS

The structural breaks identified and quantified in the GMR time series were plausibly caused by the quality improvement efforts that started in 2006. These results demonstrate that it is critical for the analysis and use of drug mortality data collected in the registries to identify practice changes in the relevant registries, to quantify their influence and to adjust mortality estimates accordingly.

Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up

BACKGROUND

We need to better understand how the use of different substances and psychiatric comorbidity influence premature death generally and cause-specific death by overdose, intoxication and somatic disorders in people with substance use disorders.

METHOD

A cohort of 1405 patients consecutively admitted to a Swedish detoxification unit for substance use disorders in 1970-1995 was followed-up for 42 years. Substances were identified by toxicological analyses. Mortality figures were obtained from a national registry. Causes of death were diagnosed by forensic autopsy in 594 patients deceased by 2012. Predictions were calculated by competing risks analysis.

RESULTS

Forty-two per cent of the cohort died during follow-up; more men than women (46.3% vs 30.4%). The standardised mortality ratio (SMR) was calculated as the ratio of observed deaths in males and females in specific age groups in the cohort versus expected deaths in corresponding groups in the general population. SMR was 5.68 for men (CI 95%; 5.04-6.11) and 4.98 (CI 95%; 4.08-5.88) for women. The crude mortality rate (number of deaths divided by number of person observation years) was 2.28% for men and 1.87% for women. Opiates predicted increased risk of premature death while amphetamine and cannabis predicted lower risk. Comorbid psychiatric disorders were identified in 378 cases and personality disorders in 763 cases. Primary psychoses or mood/depression and anxiety disorders predicted a higher risk of premature mortality. Death by overdose was predicted by male gender, younger age at admission to substance treatment, opiate use, and comorbid depression and anxiety syndromes. Cannabis and amphetamine use predicted a lower risk of overdose. Death by intoxication was predicted by male gender, use of sedatives/hypnotics or alcohol/mixed substances, primary psychoses and depression/anxiety syndromes. Premature death by somatic disorder was predicted by male gender and alcohol/mixed abuse.

CONCLUSION

Psychiatric comorbid disorders were important risk factors for premature drug-related death. Early identification of these factors may be life-saving in the treatment of patients with substance use disorders.

Likegyldighetens tvetydighet: Overdosedødsfall etter rusmiddelbehandling

Ambiguous indifference – fatal overdoses among marginalized drug users after discharge from inpatient treatment

Background

In the European context, Norway is one of the countries with the highest overdose-related mortality rate. Research proves that the risk of overdose mortality among marginalized drug users is particularly high during the first weeks after discharge from inpatient treatment.

Aim

It is therefore interesting to investigate whether there might be a connection between marginalization and treatment culture to understand fatale overdoses after discharge from inpatient treatment.

Design & Methods

The case study is based on a previous field study connected to the death register. The study focuses on a single individual, Sam, and his treatment process. Data is analyzed in the light of a cultural analytical perspective.

Results

The results shows how the treatment system can be a social arena for institutional exclusion and marginalization that aggravate the person's self-esteem and life situation. One central aspect of the process of treatment was that it generated indifference. Sam's treatment motivation developed into treatment indifference. In the last part of the article, the author discusses indifference as a risk aspect of overdose mortality after discharged from treatment. It is not possible to conclude if Sam's overdose death was an accident or suicide. However, in the light of action theory the case shows that indifference can be a central aspect of both an unintentional and intentional overdose. Sam's death can be understood in the light of the concept ambiguous indifference.

Conclusion

The case shows that there may be a relationship between marginality, treatment culture and overdose mortality. Cultural and structural aspects of the treatment system put Sam in an empty and risky situation that probably contributed to his death. In a comparison of risk situations in this case-history with recent research on treatment system, we can see several worrisome resemblances considering overdose mortality after discharge from inpatient treatment.

Lack of overlap and large discrepancies in the characteristics of the deceased in two sources of drug death. A linkage study of the Cause of Death and the Police Registries in Norway 2007-2009

BACKGROUND

Registries for drug deaths may include different persons and provide different characteristics of the deceased. The aim of this study was to establish whether a database of drug-induced deaths (Cause of Death Registry (CDR) using the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) definition and the Police registry of drug deaths) included the same persons and provided the same characteristics of the deceased and thus yielded the same information for establishing targeted prevention measures.

METHODS

Notifications from 2007 to 2009 were drawn from the CDR and the police registry of drug deaths and the unique Norwegian personal identification number was used to match the registrations.

RESULTS

The two sources of drug deaths yielded 1384 registrations, encompassing 929 individuals of whom only 49% were included in both registries. A large proportion of the deceased (40%) were not listed in the police registry. This group was older (mean age 43 years vs. 35 years); dependence and suicide were listed more often as cause of death (33% vs. 8%); and heroin was listed less often as the type of drug causing death (24% vs. 67%) than those included in both registries. In particular, among women not included in the police registry, the cause of death was identified with much greater frequency as pharmaceuticals with morphine or codeine (47% vs. 16%).

CONCLUSION

The large discrepancies in size, overlap, and characteristics of the deceased included in two sources of drug death imply that prevention measures based on the two sources will differ.

Drug-related causes of death: Socioeconomic and demographic characteristics of the deceased

AIM

The aim of this study was to describe subgroups of those who died from a drug-related cause of death employing demographic and socioeconomic data.

METHODS

A total of 1,628 persons with registered drug-related deaths in the Norwegian Cause of Death Registry between 2003 and 2009 were matched with research registers of data on demographic and socioeconomic factors during the five years prior to their deaths.

RESULTS

Three equal-sized clusters were identified: persons with very low socioeconomic status, disability pensioners and people on the edge of the workforce.

CONCLUSIONS

Socioeconomic situation prior to drug-related deaths was more heterogeneous than expected. Greater knowledge about the members of the disability pensioner and the edge of the workforce clusters must be established in order to make prevention efforts towards these groups more precise and goal oriented.

Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users

BACKGROUND

The aim of the study was to estimate the lethality of opioid overdose among young heroin users.

METHODS

A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.

RESULTS

The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).

CONCLUSIONS

Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.