Years of Potential Life Lost amongst Heroin Users in the Australian Treatment Outcome Study Cohort, 2001-2015

BACKGROUND:

Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL).

METHODS:

The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy.

RESULTS:

The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65yr 63.0%, average life expectancy 63.7%) and suicide (<65yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known.

CONCLUSIONS:

YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable.

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By:  Darke S1, Marel C2, Mills KL2, Ross J2, Slade T2, Tessson M2.

• 1National Drug and Alcohol Research Centre, University of New South Wales, Australia. Electronic address: s.darke@unsw.edu.au.
• 2National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia 
• Drug Alcohol Depend. 2016 Mar 18. pii: S0376-8716(16)00152-6. doi: 10.1016/j.drugalcdep.2016.03.010. 

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Excess Mortality among Opioid-Using Patients Treated with Oral Naltrexone in Australia

To estimate the number of deaths that would have occurred among patients receiving oral naltrexone for opioid use under the Special Access Scheme if these patients had received methadone.

We analysed mortality in cohorts treated with oral naltrexone and methadone. Data were from 1097 patients of in WA providing oral naltrexone for opioid use under the SAS,1998-2000, and all participants in WA (n = 2520) and New South Wales (NSW) (n = 11,174) methadone programs over the same period. We calculated mortality rates among patients receiving naltrexone and methadone, and excess mortality among patients receiving naltrexone.

Oral naltrexone patients had higher mortality than those treated with methadone, even when favourable assumptions were made about the effects of naltrexone on mortality. Total oral naltrexone mortality was significantly greater than for methadone in WA (rate ratio 3.5; 95% confidence interval 2.2-5.8) and NSW (rate ratio 3.5; 95% confidence interval 2.4-5.0). Among 1097 oral naltrexone patients we estimate that there were 25-29 deaths over two years that would probably not have occurred if these patients had received methadone. The major reason was higher mortality rate post-treatment cessation.

Large-scale use of oral naltrexone to treat opioid users may not have, as intended, saved lives. Implant naltrexone continues to be prescribed under the SAS in the absence of reliable efficacy and safety data. There is a need to review widespread use of unregistered medications under the SAS, particularly with vulnerable patient groups.

Full article at:  http://goo.gl/URGh5z

By:  Degenhardt L1, Larney S, Kimber J, Farrell M, Hall W.

• 1National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; School of Population and Global Health, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Department of Global Health, School of Public Health, University of Washington, Seattle, USA. 

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A Cost-Effectiveness Analysis of Opioid Substitution Therapy Upon Prison Release in Reducing Mortality among People with a History of Opioid Dependence

Although opioid substitution therapy (OST) immediately after prison release reduces mortality, the cost-effectiveness of treatment has not been examined. Therefore, we undertook a cost-effectiveness analysis of OST treatment upon prison release and the prevention of death in the first 6 months post-release.

Design: Population-based, retrospective data linkage study using records of OST entrants (1985-2010), charges and court appearances (1993-2011), prison episodes (2000-11) and death notifications (1985-2011).

Participants: A cohort of 16 073 people with a history of opioid dependence released from prison for the first time between 1 January 2000 and 30 June 2011.

Intervention: OST treatment compared to no OST treatment at prison release.

Measurements: Mortality and costs (treatment, criminal justice system-court, penalties, prison-and the social costs of crime) were evaluated at 6 months post-release. Analyses included propensity score matching, bootstrapping and regression.

A total of 13 468 individuals were matched (6734 in each group). Twenty (0.3%) people released onto OST died, compared with 46 people (0.7%) not released onto OST. The final average costs were lower for the group that received OST post-release ($7206 versus $14 356). The incremental cost-effectiveness ratio showed that OST post-release was dominant, incurring lower costs and saving more lives. The probability that OST post-release is cost-effective per life-year saved is 96.7% at a willingness to pay of $500.

Opioid substitution treatment (compared with no such treatment), given on release from prison to people with a history of opioid dependence, is cost-effective in reducing mortality in the first 6 months of release.

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By:  Gisev N1, Shanahan M1, Weatherburn DJ2, Mattick RP1, Larney S1,3, Burns L1, Degenhardt L1,4.

• 1National Drug and Alcohol Research Centre, UNSW Australia, Sydney, New South Wales, Australia.
• 2New South Wales Bureau of Crime Statistics and Research (BOCSAR), Sydney, New South Wales, Australia.
• 3Alpert Medical School, Brown University, Providence, Rhode Island, USA.
• 4School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia. 

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All-Cause, Drug-Related & HIV-Related Mortality Risk by Trajectories of Jail Incarceration & Homelessness among Adults in New York City

We studied a cohort of 15,620 adults who had experienced at least 1 jail incarceration and 1 homeless shelter stay in 2001-2003 in New York City to identify trajectories of these events and tested whether a particular trajectory was associated with all-cause, drug-related, or human immunodeficiency virus (HIV)-related mortality risk in 2004-2005. 

Using matched data on jail time, homeless shelter stays, and vital statistics, we performed sequence analysis and assessed mortality risk using standardized mortality ratios (SMRs) and marginal structural modeling. We identified 6 trajectories. Sixty percent of the cohort members had a temporary pattern, which was characterized by sporadic experiences of brief incarceration and homelessness, whereas the rest had the other 5 patterns, which reflected experiences of increasing, decreasing, or persistent jail or shelter stays. Mortality risk among individuals with a temporary pattern was significantly higher than those of adults who had not been incarcerated or stayed in a homeless shelter during the study period; all-cause and HIV-related SMRs in other patterns were not statistically significantly different. 

When we compared all 6 trajectories, the temporary pattern was more strongly associated with higher mortality risk than was the continuously homelessness pattern. Institutional interventions to reduce recurrent cycles of incarceration and homelessness are needed to augment behavioral interventions to reduce mortality risk.

Full article at: http://goo.gl/WyuLRa

By: Lim S, Harris TG, Nash D, Lennon MC, Thorpe LE.

  

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