Mats Fridell

Abstract: In 2014 this review was withdrawn from publication because it is out of date and the authors are currently not available for updating it.

Abstract: Mixed findings have been made with regard to the long-term predictive validity of antisocial personality disorder (ASPD) on criminal behaviour in samples of substance abusers. A longitudinal record-linkage study of a cohort of 1052 drug abusers admitted 1977-1995 was undertaken. Subjects were recruited from a detoxification and short-term rehabilitation unit in Lund, Sweden, and followed through criminal justice registers from their first treatment episode to death or to the year 2004. In a ML multinomial random effects regression, subjects diagnosed with antisocial personality disorders were 2.16 times more likely to be charged with theft only (p<0.001), and 2.44 times more likely to be charged committing multiple types of crime during an observation year (p<0.001). The findings of the current study support the predictive validity of the DSM-III-R diagnosis of ASPD. ASPD should be taken seriously in drug abusers, and be targeted in treatment to prevent crime in society.

Abstract: A group of 125 drug abusers admitted consecutively for detoxification and short-term rehabilitation were followed up 5 years after discharge They were asked about possible suicide attempts in a semi-structured face-to-face interview Nearly half of the group (45%) reported having attempted suicide at some point in their life The most common reasons given were the loss of a person whom they loved, and feelings of loneliness Only three respondents reported using their drug of choice in the attempt(s) The suicide attempters were more often found to have been in child psychiatric treatment earlier, and to have experienced loss of significant others in childhood, than those who did not report attempting suicide At follow-up the suicide attempters indicated that they experienced more depressive moods and more severe psychological problems than those who had never made a suicide attempt The importance of assessing the risk of suicide attempts among drug addicts in order to be able to take measures to prevent future suicidal behaviour is emphasized

Abstract: Aim To investigate whether socio-economic status (SES) in childhood and school failure at 15 years of age predict illicit drug abuse in youth and young adulthood. Design setting and participantsReg ...

Abstract: Few longitudinal cohort studies have focused on the impact of substances abused and psychiatric disorders on premature mortality. The aim of the present study was to identify predictors of increased risk of drug related death and non drug related death in substance abusers of opiates, stimulants, cannabis, sedatives/hypnotics, hallucinogens and alcohol over several decades. Follow-up study of a consecutive cohort of 561 substance abusers, admitted to a detoxification unit January 1970 to February 1978 in southern Sweden, and followed up in 2006. Demographic and clinical data, substance diagnoses and three groups of psychiatric diagnoses were identified at first admission. Causes of death were coded according to ICD-10 and classified as drug related deaths or non drug related deaths. To identify the incidence of some probable risk factors of drug related premature death, the data were subjected to a competing risks Cox regression analysis. Of 561 patients in the cohort, 11 individuals had either emigrated or could not be located, and 204/561 patients (36.4%) were deceased by 2006. The cumulative risk of drug related death increased more in the first 15 years and leveled out later on when non drug related causes of death had a similar incidence. In the final model, male gender, regular use of opiates or barbiturates at first admission, and neurosis were associated with an increased risk of drug related premature death, while cannabis use and psychosis were associated with a decreased risk. Neurosis, mainly depression and/or anxiety disorders, predicted drug related premature death while chronic psychosis and personality disorders did not. Chronic alcohol addiction was associated with increased risk of non drug related death. The cohort of drug abusers had an increased risk of premature death to the age of 69. Drug related premature death was predicted by male gender, the use of opiates or barbiturates and depression and anxiety disorders at first admission. The predicted cumulative incidence of drug related death was significantly higher in opiate and barbiturate abusers over the observed period of 37 years, while stimulant abuse did not have any impact. Alcohol contributed to non drug related death.

Abstract: Aims To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables. Methods Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta‐analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random‐effects meta‐analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta‐regressions examined potentially important sources of heterogeneity across studies. Results Fifty‐eight prospective studies reported mortality rates from opioid‐dependent samples. Very high heterogeneity across studies was observed; pooled all‐cause CMR was 2.09 per 100 person‐years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out‐of‐treatment periods had higher mortality risk than in‐treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication. Conclusions Mortality among opioid‐dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non‐randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.

Abstract: OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals. DATA SOURCES Major electronic databases were searched from inception to August 2005. Industry submissions to the National Institute for Health and Clinical Excellence were accessed. REVIEW METHODS The assessment of clinical effectiveness was based on a review of existing reviews plus an updated search for randomised controlled trials (RCTs). A decision tree with Monte Carlo simulation model was developed to assess the cost-effectiveness of BMT and MMT. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible MMT with flexible dose BMT. Utilities were derived from a panel representing a societal perspective. RESULTS Most of the included systematic reviews and RCTs were of moderate to good quality, and focused on short-term (up to 1-year follow-up) outcomes of retention in treatment and the level of opiate use (self-report or urinalysis). Most studies employed a trial design that compared a fixed-dose strategy (i.e. all individuals received a standard dose) of MMT or BMT and were conducted in predominantly young men who fulfilled criteria as opiate-dependent or heroin-dependent users, without significant co-morbidities. RCT meta-analyses have shown that a fixed dose of MMT or BMT has superior levels of retention in treatment and opiate use than placebo or no treatment, with higher fixed doses being more effective than lower fixed doses. There was evidence, primarily from non-randomised observational studies, that fixed-dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy and one small RCT has shown the level of mortality with fixed-dose BMT to be significantly less than with placebo. Flexible dosing (i.e. individualised doses) of MMT and BMT is more reflective of real-world practice. Retention in treatment was superior for flexible MMT than flexible BMT dosing but there was no significant difference in opiate use. Indirect comparison of data from population cross-sectional studies suggests that mortality with BMT may be lower than that with MMT. A pooled RCT analysis showed no significant difference in serious adverse events with MMT compared with BMT. Although treatment modifier evidence was limited, adjunct psychosocial and contingency interventions (e.g. financial incentives for opiate-free urine samples) appeared to enhance the effects of both MMT and BMT. Also, MMT and BMT appear to be similarly effective whether delivered in a primary care or outpatient clinic setting. Although most of the included economic evaluations were considered to be of high quality, none used all of the appropriate parameters, effectiveness data, perspective and comparators required to make their results generalisable to the NHS context. One company (Schering-Plough) submitted cost-effectiveness evidence based on an economic model that had a 1-year time horizon and sourced data from a single RCT of flexible-dose MMT compared with flexible-dose BMT and utility values obtained from the literature; the results showed that for MMT vs no drug therapy, the incremental cost-effectiveness ratio (ICER) was pound 12,584/quality-adjusted life-year (QALY), for BMT versus no drug therapy, the ICER was pound 30,048/QALY and in a direct comparison, MMT was found to be slightly more effective and less costly than BMT. The assessment group model found for MMT versus no drug therapy that the ICER was pound 13,697/QALY, for BMT versus no drug therapy that the ICER was pound 26,429/QALY and, as with the industry model, in direct comparison, MMT was slightly more effective and less costly than BMT. When considering social costs, both MMT and BMT gave more health gain and were less costly than no drug treatment. These findings were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS Both flexible-dose MMT and BMT are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with MMT was found be somewhat more effective in maintaining individuals in treatment than flexible-dose BMT and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the more recent experience of clinicians in the use of buprenorphine, the possible risk of higher mortality of MMT and individual opiate-dependent users' preferences. Future research should be directed towards the safety and effectiveness of MMT and BMT; potential safety concerns regarding methadone and buprenorphine, specifically mortality and key drug interactions; efficacy of substitution medications (in particular patient subgroups, such as within the criminal justice system, or within young people); and uncertainties in cost-effectiveness identified by current economic models.

Abstract: Suicide is a leading cause of death, but it is not well understood or well researched. Our purpose in this review is to summarize extant knowledge on neurobiological and psychological factors involved in suicide, with specific goals of identifying areas particularly in need of future research and of articulating an initial agenda that may guide future research. We conclude that from both neurobiological and psychological perspectives, extant research findings converge on the view that two general categories of risk for suicide can be identified: (a) dysregulated impulse control; and (b) propensity to intense psychological pain (e.g., social isolation, hopelessness), often in the context of mental disorders, especially mood disorders. Each of these categories of risk is underlain at least to some degree by specific genetic and neurobiological factors; these factors in general are not well characterized, though there is emerging consensus that most if not all reside in or affect the serotonergic system. We encourage future theorizing that is conceptually precise, as well as epistemically broad, about the specific preconditions of serious suicidal behavior, explaining the daunting array of suicide-related facts from the molecular to the cultural level.

Abstract: Completion of addiction treatment is one of the most consistent factors associated with a favorable treatment outcome. Unfortunately, it is more common for a patient to drop-out of addiction treatment than to complete the treatment. To prevent drop-out, risk factors must be identified. This box-score review focuses on studies investigating the risk factors associated with drop-out from addiction treatment published in peer-reviewed journals from 1992 to 2013. A total of 122 studies involving 199,331 participants met the inclusion criteria. Contrary to recommendations from previous reviews, 91% of the included studies focused primarily on enduring patient factors, mainly demographics. The most consistent risk factors across the different study designs, samples, and measurement methods were cognitive deficits, low treatment alliance, personality disorder, and younger age. With the exception of younger age, none of the demographic factors emerged as consistent risk factors. Further research on the relationship between simple demographic factors and drop-out risk is of limited value. However, little is known about the potential risk factors related to treatment programs and to the treatment processes. Based on the review, clinical recommendations include assessing cognitive functioning and personality disorders at baseline and continuous monitoring of treatment alliance.

Abstract: OBJECTIVE: To systematically review cohort studies of mortality among people who inject drugs, examine mortality rates and causes of death in this group, and identify participant- and study-level variables associated with a higher risk of death. METHODS: Tailored search strings were used to search EMBASE, Medline and PsycINFO. The grey literature was identified through online grey literature databases. Experts were consulted to obtain additional studies and data. Random effects meta-analyses were performed to estimate pooled crude mortality rates (CMRs) and standardized mortality ratios (SMRs). FINDINGS: Sixty-seven cohorts of people who inject drugs were identified, 14 of them from low- and middle-income countries. The pooled CMR was 2.35 deaths per 100 person-years (95% confidence interval, CI: 2.12-2.58). SMRs were reported for 32 cohorts; the pooled SMR was 14.68 (95% CI: 13.01-16.35). Comparison of CMRs and the calculation of CMR ratios revealed mortality to be higher in low- and middle-income country cohorts, males and people who injected drugs that were positive for human immunodeficiency virus (HIV). It was also higher during off-treatment periods. Drug overdose and acquired immunodeficiency syndrome (AIDS) were the primary causes of death across cohorts. CONCLUSION: Compared with the general population, people who inject drugs have an elevated risk of death, although mortality rates vary across different settings. Any comprehensive approach to improving health outcomes in this group must include efforts to reduce HIV infection as well as other causes of death, particularly drug overdose.