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Who dies while on methadone treatment? Who dies while on methadone treatment?

Who dies while on methadone treatment? - PowerPoint Presentation

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Who dies while on methadone treatment? - PPT Presentation

Casecontrol study of risks and causes of death among opioid dependent patients registered on methadone maintenance treatment Dr Edyta Truszkowska Dr Pavel Konovalov Dr Tahir ID: 264604

treatment mmt drug mortality mmt treatment mortality drug death cases methadone study controls factors risk deaths results hiv problem

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Slide1

Who dies while on methadone treatment? Case-control study of risks and causes of death among opioid dependent patients registered on methadone maintenance treatment.

Dr Edyta TruszkowskaDr Pavel Konovalov Dr Tahir GalanderDr Suzi Lyons Dr Eamon KeenanDr Bobby P Smyth Slide2

Introduction & backgroundMortality - higher among those with problem alcohol or drug use, especially amongst injecting drug users (IDU

) (Mathers 2013)Methadone Maintenance Treatment proved to reduce mortality among IDU, but it remains higher in comparison to general population (Degenhardt 2009, Cornish 2010)Slide3

A recent Irish study (O’Kelly 2012) confirmed the high mortality among IDU in Ireland.IDU were followed up for 25 years 63% had diedSlide4

MortalityRisk Factors

Predictors of survivalmethadone dose below 60mgmedical co-morbidityHIV infectionalcohol use history of psychiatric admissionsyounger age on admission to treatmentliving with a partner/spousenot abusing benzodiazepines (BZD) on admissionremaining in treatmentIn Scotland a history of psychiatric admissions together with co-prescription of BZD (not other psychotropic medications) was associated with drug-dependent deaths (McCowan 2009)Slide5

Problem Cocaine use(Camacho 1996; Williamson 2007)Increases prevalence of risk behaviours:

Frequency of injecting heroinInjecting unsafelyUsing more heroinGreater criminal activityImpacts negatively on retention in treatmentSlide6

The common causes of death among drug users Accidental overdoseMedical consequences of

blood-born viral infections such as HIV, HCV, HBVOther health complications (such as deep vein thrombosis, liver disease, cancer)Suicide and deaths due to traumaSudden unexplained deathIn Israel accidental ODs were most common in individuals who left MMT, while cancer was most common in those who remained in treatment (Peles 2010)Slide7

Risk of accidental overdoseElevated in those with reduced opiate tolerance (leaving MMT, post detoxification, after prison etc)

poly-drug use, BZD use, heavy alcohol use, while on MMTThe Health Research Board reported an increased number of poisoning deaths between 2005 and 2011 59% of those deaths in 2011 were due to polysubstance poisoningSlide8

Study questionsIs lower methadone dose and problem cocaine and/or BZD use associated with higher mortality?What other risk factors can be identified?Slide9

Method - settingsMMT in Ireland

This study has focused on the patients attending the NDTCCentral Treatment List (CTL)- records basic information on every individual in receipt of MMT & reason for leaving MMTSlide10

Study procedurecontrols matched for gender & age, attending NDTC at the same time

patients recorded as 'dead‘ in NDTC notes/CTLΔt: Feb 2005 –Feb 2012drug use, viral status, co-morbid illnesses, personal history Review of the notes

case-control

designSlide11

Cause of death It was recorded from clinical notes and confirmed (where available) with National Drug Related Death Index (NDRDI) The NDRDI records data from:

the Coroner Service the Hospital In-Patient Enquiry scheme the Central Treatment Listthe General Mortality Register via the Central Statistics OfficeSlide12

Analysis Examining differences between cases and controls in quantitative normally distributed variables |

Students t-testskewed variables | Mann-Whitney U test categorical variables | Chi Square test unless a cell count <5 | Fisher’s Exact testLogistic regression analysis Power calculationsthe conventional level of statistical significance (p<0.05) was usedSlide13

Results

80 deaths & 500 patients (on average) on MMT in NDTC during this period the mortality rate 23 per 1000 person-years of treatment Slide14

Results –methadone dose

No significant difference (p=0.6)Slide15

Results – use of illicit substances

n cases(%)n controls(%)P ValueOpiatesAbstinent

26

(32)

28

(35)

Occasional

32

(40)

30

(37)

Regular

22

(27)

22

(27)

0.93

Cocaine

A

bstinent

61

(76)

65

(81)

Occasional

12

(15)

10

(12)

Regular

7

(9)

5

(6)

0.72

Benzodiazepines

A

bstinent

8

(10)

8

(10)

Occasional

7

(9)

13

(16)

Regular

65

(81)

59

(74)

0.35Slide16

Results - risk factors impacting on mortality

Factorsn cases(%)n controls(%)P ValueHomelessness Ever (%)33(41)

24

(30)

0.14

Comorbid

Psychiatric Disorder

50

(62)

45

(56)

0.42

Problem

Alcohol Use

21

(27)

14

(17)

0.18

Prescribed Psychotropic medication %

Non-

Benzo

Hypnotic only

8

(10)

6

(7)

0.58

Other psychotropic

apart

from "Z" hypnotic

46

(57)

48

(60)

0.75

Prescribed Benzodiazepine

22

(27)

20

(25)

0.72

any

antidepressant

29

(36)

24

(30)

0.40

Prescribed Olanzapine

19

(24)

20

(25)

0.84

HCV antibody positive

50

(62)

53

(66)

0.62Slide17

Results

PredictorsAdjusted Odds Ratio (AOR)95% CI AORP valueHistory of Imprisonment4.6(2.0-10.1)

<0.001

Current

non-HIV/HCV

related medical illness

5.3

(2.2-12.6)

<0.001

DNAed

for

at least one week prior to death

19.2

(2.3-160)

0.006

HIV

status: positive

2.2

(0.8-5.7)

0.11

HIV status: not known

8.8

(0.9-90)

0.06

Logistic Regression analysis of factors associated with increased risk of death among patients on MMT

Factors

n

cases

(%)

n controls

(%)

P Value

History

of Imprisonment

57

(71)

28

(35)

<0.001

Other medical problems

38

(47)

13

(16)

<0.001

DNAed

for

at least one week

prior

to death

18

(23)

1

(1)

<0.001

HIV positive

23

(29)

10

(12)

0.01Slide18

Results – causes of death

Medical notes suggested 8 suicidesSlide19

DiscussionThe profile of deaths was similar to that observed in other MMT groupsIn this study:no relationship between methadone dose & mortality

no difference in problem drug use between cases and controlsthe prevalence of co-morbid psychiatric disorder was high but similar in both groupsthose who died were more likely to have a lifetime history of imprisonment compared to controlsSlide20

In this study:recent non-attendance for MMT was more prevalent among casesHIV was more prevalent amongst cases

medical problems other than HIV/HCV were higher among those who diedAlso in those who died by poisoning Slide21

ConclusionsSlide22

Thank you