A 10-year prospective study of mortality among Norwegian drug abusers after seeking treatment
Summary (2 min read)
Introduction
- There is a high mortality rate among drug abusers, and death by overdose is the most common cause of death [1-4].
- Those who die of an overdose have often had previous nonfatal overdoses [2,8,9], and the majority of these deaths occur at a residential address [4,10,11].
- Such studies are difficult to implement and costly in terms of finances and other resources required.
- Given the high death rate among drug abusers in Norway the authors expected that the death rate would be higher in this treatment cohort than in similar J Addict Res Ther ISSN:2155-6105 JART, an open access journal Volume 6 Issue 1 216 populations internationally.
- During a 10-year period, some would also finish serving their sentences, leave prison and be in great danger of overdose death [14,19,20].
Design and study setting
- The study is a prospective, naturalistic study of 481 substance abusers who consecutively entered 13 inpatient (n=307) and 7 outpatient (n=174) programs in Oslo and surrounding counties between January 1998 and August 2000.
- The programs were purposely chosen to provide a sample of the most widely used treatment programs in Norway at the time.
- Additionally, the programs were chosen for practical reasons, thus excluding similar treatment programs situated in regions far away from Oslo.
- The majority of these programs worked for the intention for patients to stay for extended periods of time.
- In 1998 the first national treatment program for Opiate Maintenance Treatment (OMT) started and also this program was included in the study.
Participants, recruitment and procedures
- All follow-up interviews were performed by ER and GL and by specially trained interviewers (social workers and master students).
- Clients with mean score of 1.0 and above are considered “cases”.
- In the analyses the depression and anxiety scores were used as well as the GSI index.
- The MCMI II is a self-report instrument with 175 true/false items measuring 13 personality profiles and nine clinical syndromes according to the DSM-III-R system [24].
National death register
- Information on deaths and causes of death (ICD coded) was obtained from the National Death Register kept by Statistics Norway (SSB, 2013).
- Inclusion of deaths in the “overdose” category is based on ICD codes F11 and X42 with opioid use as the main cause of death.
Statistical analyses
- Mortality rate was calculated by the number of deaths divided by the number of 100 person years at risk.
- Highly skewed continuous data were analysed using the Mann-Whitney U statistic, a non-parametric analogue of the t-test.
- First differences in background variables before index treatment were tested between the deceased and non-deceased group of clients.
- Then Cox regression analysis was used to analyse factors hypothesized to be associated with the risk of death.
- Statistics were performed by SPSS version 19.0.
Deceased patients
- A total of 74 deaths (15%) were registered among the 481 study participants during the ten-year observation period.
- Ten of these were females and 64 were men.
Main causes of death
- Overdose-related mortality was the most common specific cause of death for 68% of the sample.
- During the last 30 days before intake to treatment, 62% had used heroin, 34% amphetamines (69% had injected), 51% benzodiazepines, and 18% reported alcohol abuse (According to EuropASI alcohol abuse is defined as use of alcohol at least 3 days per week, with five or more alcoholic units a day, or twodays binge drinking, making daily functioning difficult).
- The correlation between number of nonfatal overdoses and number of years injecting was 0.44, while the correlation between nonfatal overdoses and suicide attempts was 0.28.
- In addition, patients who dropped out of index treatment had more chances of dying during the observation period than patients who completed (p<0.05) the period.
Discussion
- Fifteen percent of the drug users in the study died during the 10 years after admission to index treatment.
- Having had one or more nonfatal overdoses before index treatment was also associated with death.
- Preventive strategies should therefore be specially tailored towards patients who leave treatment prematurely as well as towards patients at treatment completion.
- Whereas most Norwegian heroin injectors also use benzodiazepines, less than half reported combined use with alcohol [29].
Limitations and strengths
- Factors leading to overdoses and death are complex.
- Knowing that other factors may be associated with premature deaths.the authors.
- Also, all reports were self-reports and some bias in data is possible.
- The strength of the study lies in the prospective design and the length of the study period.
- Few studies of mortality among drug abusers have been able to follow a cohort of patients over a period of ten years.
Conclusions
- The annual mortality rate in this study was 1.5, which is in line with similar studies from Europe.
- The mortality rate was by far the highest among the men, and the main cause of death was overdoses.
- The deceased females were on average four years younger than the males at time of death, they used less heroin than the males all through the observation period, fewer entered OMT, and all died from overdoses.
- Male gender, lengthy time in prison prior to index treatment, having had several overdoses prior to index treatment and dropout from index treatment were all independent and significant predictors of premature death.
- Outreach strategies should be implemented to minimize destructive life-style patterns by crisis interventions and the use of low-threshold measures.
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Citations
38 citations
Cites background from "A 10-year prospective study of mort..."
...fatal [42,43] and fatal events, including fatal overdose [21,22]....
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...Non-fatal overdose has been proved to be a predictor of overdose deaths [21,22]....
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...A follow-up study on mortality among Norwegian drug misusers after seeking treatment revealed that reported alcohol misuse before intake to treatment in the sample was a significant predictor of death (Ravndal et al., 2015)....
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References
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176 citations
"A 10-year prospective study of mort..." refers background in this paper
...Drug users also represent an overlooked potential workforce; they can be interested in and willing to attend preventive training courses and to apply such knowledge when necessary [37-39]....
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...Preliminary results indicate lifesaving events through peer administration of naloxone [37,43]....
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...Programs to prevent fatal overdoses may be established and evaluated in the community, using resuscitation techniques as well as opioid antagonist medication such as naloxone [37,40-42]....
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156 citations
Additional excerpts
...Programs to prevent fatal overdoses may be established and evaluated in the community, using resuscitation techniques as well as opioid antagonist medication such as naloxone [37,40-42]....
[...]
147 citations
"A 10-year prospective study of mort..." refers background in this paper
...Those who die of an overdose have often had previous nonfatal overdoses [2,8,9], and the majority of these deaths occur at a residential address [4,10,11]....
[...]
134 citations
Additional excerpts
...Programs to prevent fatal overdoses may be established and evaluated in the community, using resuscitation techniques as well as opioid antagonist medication such as naloxone [37,40-42]....
[...]