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
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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