Determinants of hospitalizations for pneumonia among Finnish drug users.

OBJECTIVE: The study examined the determinants of being hospitalized for pneumonia in a large cohort of drug users. METHODS: Information of 4817 clients seeking treatment for illicit drug use was linked with the Finnish hospital discharge register to identify those who were hospitalized with main/primary diagnoses of pneumonia during 1997-2013. Cox regression models were used to examine the association between age, gender, homelessness, and route of drug administration of the primary drug at initial clinical consultation and pneumonia hospitalization. Findings were presented as adjusted hazard ratios and 95% confidence intervals. RESULTS: There were 354 persons diagnosed with pneumonia, with a total of 522 hospitalizations at the end of 2013. The univariate Cox models revealed that being over 44 years of age, male gender, homelessness, and intravenous drug use at initial clinical consultation increased the risk of being hospitalized for pneumonia. In the fully adjusted multivariate model, being over 44 years was the strongest factor independently associated with pneumonia hospitalization (adjusted hazard ratio: 2.67, 95% confidence interval: 1.56-4.57, p < 0.001), followed by homelessness (adjusted hazard ratio: 1.75, 95% confidence interval: 1.38-2.22, p < 0.001) and intravenous drug use (adjusted hazard ratio: 1.27, 95% confidence interval: 1.01-1.59, p = 0.041). Of the 354 clients hospitalized for pneumonia, 31.9% (n = 113) were rehospitalized within 30 days of being discharged. One-third of the reasons for the 30-day rehospitalization were pneumonia-related. CONCLUSION: Vaccination, measures addressing housing instability, safe injecting and good hygienic practices, and treating underlying drug use problems could help to reduce morbidity for pneumonia in this cohort.

Diabetes hospitalizations and deaths in a cohort of treatment-seeking illicit drug users.

BACKGROUND: Studies on diabetes among illicit drug users are scarce in Finland. This study aimed to describe hospitalization and death due to diabetes among treatment-seeking illicit drug users. METHODS: Information of 4817 treatment-seeking drug users (3365 men and 1452 women) aged 11-65 years (mean 24.5 years) was linked to the Finnish national hospital discharge register and the national death registry to identify those clients who were hospitalized or died from diabetes mellitus during 1997-2013. RESULTS: Fifty-three persons (42 men and 11 women) had primary diagnoses of diabetes, with a total of 146 hospitalizations (121 among men and 25 among women). The total length of stay among men (1183 days) far exceeded those of women (138 days). Overall, type 1 diabetes was the main contributor to hospitalizations (67%, n = 98/146). The proportion of Type 1 diabetes with complications was 31% in men (n = 37/121) and 44% in women (n = 11/25). All cases of deaths due to diabetes (n = 7) occurred in men. CONCLUSION: Diabetes hospitalizations were mainly due to Type 1 diabetes. Longer length of hospital stay was observed in men, and all diabetes deaths occurred among men. Male drug users and drug users in general would require more support to reduce morbidity and mortality due to diabetes.

Association between route of illicit drug administration and hospitalizations for infective endocarditis.

OBJECTIVE: This study examined the association between the route of drug administration and being hospitalized for infective endocarditis among 4817 treatment-seeking illicit drug users in Finland. METHODS: Cox regression models were used to examine the association between the route of drug administration and infective endocarditis hospitalization, adjusted for age, gender, and homelessness. Cases of infective endocarditis as a primary/main diagnosis were tracked using the 10th version of the International Classification of Disease code I33. RESULTS: In all, 47 persons had a primary diagnosis of infective endocarditis. These 47 persons contributed a total of 95 hospitalizations and their total length of hospital stay was 1393 days. There was a statistically significant difference in hospitalizations between injectors and non-injectors (Log-Rank test p = 0.018). Univariate Cox model showed that injectors had higher hazard or risk for infective endocarditis hospitalization compared to non-injectors (hazard ratio: 2.04, 95% confidence interval: 1.12-3.73, p = 0.020). After adjusting for age, gender, and homelessness in the multivariate model, the elevated hazard among injectors compared to non-injectors remained statistically significant with adjusted hazard ratio of 2.12 (95% confidence interval: 1.11-4.07, p = 0.024). CONCLUSION: The study findings suggested a need to boost harm reduction measures targeting high-risk injecting and other health behaviors among injecting drug users in order to reduce their hospitalizations for infective endocarditis.

Potential Years of Life Lost Due to Premature Mortality Among Treatment-Seeking Illicit Drug Users in Finland.

Premature death is a serious public health concern. The primary objective of this study was to examine premature deaths in terms of potential years of life lost (PYLL) in a cohort of 4817 treatment-seeking illicit drug users. Clients' data were linked to the Finnish national cause-of-death register and the follow-up period ranged from 31 January 1997 to 31 December 2010. PYLL before 70 years was calculated for all deaths and cause-specific deaths by gender. We observed 496 deaths (417 males and 79 females) at the end of 2010. The mean age at death was 33.8 years, 34.3 years for males (range 18-68) and 31.4 years for females (range 16-53). Overall, 17,951 life years were lost; 14,898 among males and 3053 among females. The overall PYLL rate for males was more than twice that of females (513.0/1000 vs. 243.7/1000 person-years) but the mean PYLL was higher in females than males (38.6 vs. 35.7 years). Of the total PYLL, 34.8 % was due to accidental overdose, and 24.0 % to suicide. In both genders, accidental overdose and suicide were the two top-ranking causes of PYLL. Premature deaths among drug users are a potential loss to the society. Our findings suggest that measures targeting accidental overdose and suicide are top priorities for reducing preventable loss of life.

Factors associated with hospitalization for blood-borne viral infections among treatment-seeking illicit drug users.

Blood-borne viral infections (BBVIs) are important health consequences of illicit drug use. This study assessed predictors of inpatient hospital admissions for BBVIs in a cohort of 4817 clients seeking treatment for drug use in Finland. We examined clients' data on hospital admissions registered in the Finnish National Hospital Discharge Register from 1997 to 2010 with diagnoses of BBVIs. Cox proportional hazards regression analyses were separately conducted for each of the three BBVI groups to test for association between baseline variables and hospitalizations. Findings were reported as adjusted hazard ratios (aHRs). Based upon primary discharge diagnoses, 81 clients were hospitalized for HIV, 116 for hepatitis C, and 45 for other types of hepatitis. Compared to those admitted for hepatitis C and other hepatitis, drug users with HIV had higher total number of hospital admissions (294 versus 141 and 50 respectively), higher crude hospitalization rate (7.1 versus 3.4.and 1.2 per 1000 person-years respectively), and higher total length of hospital stay (2857 days versus 279 and 308 respectively). Trends in hospitalization for all BBVI groups declined at the end of follow-up. HIV positive status at baseline (aHR: 6.58) and longer duration of drug use (aHR: 1.11) were independently associated with increased risk for HIV hospitalization. Female gender (aHR: 3.05) and intravenous use of primary drug (aHR: 2.78) were significantly associated with HCV hospitalization. Having hepatitis B negative status at baseline (aHR: 0.25) reduced the risk of other hepatitis hospitalizations. Illicit drug use coexists with blood-borne viral infections. To address this problem, clinicians treating infectious diseases need to also identify drug use in their patients and provide drug treatment information and/or referral.

Hospitalization in a cohort seeking treatment for illicit drug use in Finland.

Illicit drug use is associated with various health problems that result in inpatient hospital admissions. The primary objective of this study was to examine all-cause and cause-specific hospitalizations by gender. The cohort comprised 4817 drug users (3365 males and 1452 females) who sought treatment in Helsinki between 1997 and 2008. Data on hospitalizations that occurred among these clients were extracted from the National Hospital Discharge Register. Crude hospitalization rates (CHRs) and standardized hospitalization ratios (SHRs) with 95% confidence intervals (CIs) were calculated, and Kaplan-Meier analysis with Log-Rank test was used to compare survival in terms of time to hospitalization between males and females. At the end of the follow-up period, 84.5% of females and 73.3% of male clients were hospitalized at least once. Female clients had higher CHR (607.6/1000 person-years, 95%CI: 594.1-621.4) than males (511.0/1000, 95% CI: 502.9-519.3), and had significantly poorer survival than males (Log-Rank test, P<0.001). However, male clients stayed longer on admission than females (mean length of stay 70.2days versus 60.7days respectively, P<0.001). Compared to the national rates, excess hospitalizations were noted in both males (SHR=6.3, 95% CI: 6.2-6.4) and female clients (SHR=4.3, 95% CI: 4.2-4.4). Based upon primary discharge diagnosis, the leading causes of hospitalizations included psychosis (n=622), schizophrenia (n=604), depression (n=497), cardiovascular diseases (n=223), hepatitis C (n=116), HIV (n=81), and other types of hepatitis (n=45). Female clients were more likely than males to be admitted for hepatitis C infection (P<0.001) and depression (P<0.001). Male clients were more likely than females to be diagnosed with other types of hepatitis infections (P=0.032) and psychosis (P=0.035). Excess hospitalizations signify excessive utilization of health resources. Effective drug abuse treatment, gender-sensitive approaches, and regular health checks can help to reduce morbidity. Appropriate measures are needed to address psychiatric problems in this population.

Characteristics of drug-abusing females with and without children seeking treatment in Helsinki, Finland.

AIMS: This study characterizes treatment-seeking female users of illicit drugs in Finland, and examines possible differences among women with or without children under 18. METHODS: The subjects were 2526 drug-using clients from the Helsinki metropolitan area, who sought treatment at Helsinki Deaconess Institute between 2001 and 2008. A total of 775 (30.6%) were females with complete information regarding their parental status. Of these, 225 (29%) had children under 18. The proportion of women with children varied between 20% and 30% annually, except in 2006, when it peaked at 40.5%. RESULTS: Women with children were more likely to be somewhat older (p<0.001), married or cohabiting (p<0.001), homeless (p=0.007), unemployed (p<0.001), and living with other illicit drug users (p=0.014), compared with those without children. Self-referral and referral to treatment by child healthcare services were more common among those who had children (p<0.001). A higher proportion of women with children reported use of opiates as the primary drug (p<0.001), and used them more often intravenously (p=0.001), and daily (p=0.007), during the previous month. However, polydrug use (p=0.607) and sharing of needles/syringes (p=0.945) were similar in both groups. Prevalence of hepatitis B and C (p=0.041 and p<0.001, respectively) were more common in females with children. Among women who had children, 34.2% had children living within the same household, 37.3% in foster care, and 22.7% elsewhere. CONCLUSIONS: Women with children had more risky drug consumption patterns, and were more likely to live with other drug users; this creates an unhealthy environment for child rearing.

Patterns and 14-year trends in mortality among illicit drug users in Finland: the HUUTI study.

BACKGROUND: Although mortality is a known complication of illicit drug use, robust epidemiological studies on drug-related mortality in Finland are scarce. We examined all deaths, specific causes of death, and trends in mortality among a large number of illicit drug users in Finland during a 14-year period. METHODS: Details of 4817 clients who sought treatment for drug use at Helsinki Deaconess Institute between 1997 and 2008 were linked to national cause of death register to identify all deaths and causes of death. Standardised mortality ratios (SMRs) were calculated to compare all-cause deaths in our study cohort with those in the general population. Trends in mortality rates were assessed using Poisson (log-linear) regression. RESULTS: A total of 496 deaths occurred during 41,567.5 person-years with crude mortality rate of 1193.2 per 100,000 person-years. Mean follow-up was 8.6 years and the mean age at death was 33.8 years. Most deaths (84.1%) occurred among male clients, 189 deaths occurred in the 25-34 age-group and all-cause SMR was 8.9 [95% confidence interval (CI)=8.1-9.7]. Two-thirds (64.9%) were deaths from external causes and 35.1% from disease-related causes. The four leading causes of death were accidental poisoning/overdose (n=165), suicide (n=108), mental and behavioural disorders (n=49) and circulatory system diseases (n=45). Younger clients died from acute effects of drug use while older clients died more from chronic health conditions. A decline in annual rates was noted for all-cause mortality (P=0.01), deaths from mental and behavioural disorders (P<0.001) and suicides (P<0.001). CONCLUSION: The four leading causes of death among illicit drug users are preventable. Overdose management training, drug education and other preventive measures could help reduce mortality.

Factors associated with buprenorphine compared to amphetamine abuse among clients seeking treatment in Finland.

Abuse of prescription opioids is becoming increasingly widespread. This study compared the social, health and treatment-related factors associated with buprenorphine and amphetamine abuse in Finland. Structured clinical interviews were conducted with clients seeking treatment for buprenorphine (n=670) or amphetamine (n=557) abuse in Helsinki from January 2001 to August 2008. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were computed for factors associated with buprenorphine compared to amphetamine abuse. In multivariate analyses, buprenorphine abuse was associated with male gender (OR 1.57, 95% CI 1.17-2.09), daily abuse (OR 5.45, 95% CI 4.14-7.18), no drug free months during the last year (OR 1.68, 95%CI 1.23-2.29), and inversely associated with increasing age (OR 0.95, 95% CI 0.93-0.97 per year) and psychotic symptoms (OR 0.33, 95% CI 0.24-0.45). Despite more intense abuse patterns, clients seeking treatment for buprenorphine abuse shared similar characteristics to amphetamine clients. These characteristics were different to characteristics of those who abuse prescription opioids in North America. This is important for developing and targeting intervention programs.

Mortality among clients seeking treatment for buprenorphine abuse in Finland.

BACKGROUND: It is unclear whether buprenorphine abuse is associated with a similar risk of death to other substance abuse. This study examined all-cause mortality rates and causes of deaths among clients seeking treatment for buprenorphine abuse. METHODS: Structured clinical interviews were conducted with 4685 clients between January 1998 and August 2008. Records of deaths that occurred among these clients were extracted from the Official Causes of Death Register in Finland. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were computed using national mortality rates over a 13-year follow-up to examine excess mortality. Kaplan-Meier survival analysis was used to compare survival between buprenorphine and other clients. RESULTS: Sixty-one of 780 (7.8%) clients who sought treatment for buprenorphine abuse and 408 of 3905 (10.4%) other clients died during the 13-year follow-up period. The most common cause of death was drug-related in buprenorphine (n=25, 41.0%) and other clients (n=142, 34.8%). Survival rates were similar among buprenorphine and other clients (log-rank χ[df=1](2)=0.215, p=0.643). The SMR was 3.0 (95% CI 2.3-3.8) and 3.1 (95% CI 2.8-3.4) for buprenorphine and other clients, respectively. Excess mortality was highest among women aged 20-29 years, and more pronounced in buprenorphine clients (SMR 27.9 [95% CI 12.6-49.0]) compared to other clients (SMR 14.0 [95% CI 9.3-19.6]). CONCLUSIONS: Clients seeking treatment for buprenorphine abuse had a three times higher mortality rate than the national average, with the excess risk highest among female clients. Overall mortality rates were similar among clients seeking treatment for buprenorphine and other substance abuse.

Extended-release methylphenidate for treatment of amphetamine/methamphetamine dependence: a randomized, double-blind, placebo-controlled trial.

AIMS: To assess the efficacy of methylphenidate as a substitution therapy for amphetamine/methamphetamine dependence in Finland and New Zealand. DESIGN: Parallel-group, double-blind, randomized placebo-controlled trial. SETTING: Out-patient care. PARTICIPANTS: Amphetamine-/methamphetamine-dependent, aged 16-65 years. MEASUREMENTS: The primary outcome measure was presence/absence of amphetamine/methamphetamine in urine samples collected twice weekly. Secondary measures included treatment adherence, alterations in craving scores and self-reported use. Primary analysis was by intention-to-treat (ITT). The study drug, methylphenidate (as Concerta(®) ), was up-titrated over 2 weeks to a maximum dose of 54 mg daily and continued for a further 20 weeks. Doses were given under daily supervision at the clinics. FINDINGS: Seventy-nine participants were randomized (40 methylphenidate; 39 placebo); 76 received allocated treatment and 27 completed the trial. ITT analysis (n = 78) showed no statistically significant difference in the percentage of positive urines between the methylphenidate and placebo arms (odds ratio: 0.95, 95% confidence interval: 0.83-1.08). However, there was a significant difference (P < 0.05) between the active and placebo arms in retention, the placebo arm displaying a significantly lower retention from 6 weeks that persisted until the end of the trial. CONCLUSIONS: The trial failed to replicate earlier findings suggesting that methylphenidate was superior to placebo. The low retention rate confounded the ability to draw firm conclusions about efficacy. The higher retention rate was observed in the methylphenidate arm. Any replication of this work would need to consider alternatives to the rigid clinic attendance criteria, and consider an increased dose.

Twelve-year trend in treatment seeking for buprenorphine abuse in Finland.

BACKGROUND: Buprenorphine abuse is becoming increasingly common worldwide. However, large-scale long-term studies of buprenorphine abuse are lacking. The objective of this study was to examine the trend in characteristics of clients seeking treatment for buprenorphine abuse and compare them to those seeking treatment for heroin and amphetamine abuse. METHODS: A 12-year descriptive study was conducted at the Helsinki Deaconess Institute (HDI), a public utility foundation responsible for providing treatment for substance abuse in the greater Helsinki area. All clients seeking treatment between 31 January 1997 and 31 August 2008 received a structured clinical interview concerning demographic characteristics and abuse patterns. Characteristics of clients who reported that their primary drug of abuse was buprenorphine (n=780) were compared to those whose primary drug of abuse was either heroin (n=598) or amphetamine (n=1249). RESULTS: The annual proportion of buprenorphine clients increased from 3.0% in 1998 to 38.4% in 2008. Daily abuse (73.8%) and intravenous administration (80.6%) were common among buprenorphine clients. Concurrent abuse of prescription medications (p<0.001), stimulants (p=0.001) and alcohol (p<0.001) increased from 1997 to 2008. Treatment seeking for heroin abuse declined to approximately 1% of clients annually after 2002. Buprenorphine clients were more likely to be daily users of their primary drug (p<0.001), abuse prescription medications (p<0.001) and administer drugs intravenously (p=0.001 from 1997 to 2001) compared to heroin and amphetamine clients. CONCLUSIONS: Our results highlight the increasing abuse of buprenorphine in Finland. Buprenorphine clients had risky abuse patterns in terms of daily use and intravenous administration. Concurrent substance abuse increased during the study period.

Sociodemographic characteristics and drug abuse patterns of treatment-seeking illicit drug abusers in Finland, 1997-2008: the Huuti study.

The epidemiological part of the Huume tietokanta (HUUTI) consortium research project is the first large-scale longitudinal study of treatment-seeking illicit drug abusers in Finland. The objective of this report was to describe the sociodemographic characteristics and drug abuse patterns of treatment-seeking clients at their first visit. This study analysed baseline data of 4817 clients (3365 men and 1452 women) aged 11-65 years who sought treatment for drug abuse between 1997 and 2008 at Helsinki Deaconess Institute. Data were collected using a structured questionnaire. The majority (56%) of clients were between 15 and 24 years, educated at elementary school level (75%), and unemployed (57%). Opiates (30%) were the primary drugs of abuse. The primary drugs were mostly injected (45%) and were abused daily during the past month (44%). Cannabis was the most common secondary drug of abuse (34%). The secondary drugs were predominantly smoked (39%) or taken orally (38%) and were abused once per week or less frequently during the past month (33%). Age at initiation of illicit drug abuse ranged from 5 to 49 years. Polydrug abuse was common, with a mean consumption of 3.5 concurrent polydrug use, which were combined from 3 or more drug classes. The prevalence of lifetime/ever intravenous drug abuse was 64% and past month intravenous drug abuse was 64%, respectively, and 13% reported sharing injecting equipment during the past month. Early initiation, polydrug abuse, and risky consumption of illicit drugs were major areas of concern among the study population. Injecting drug use could place considerable burden on health services in view of complications and transmission of infectious diseases.

Naltrexone implant for the treatment of polydrug dependence: a randomized controlled trial.

OBJECTIVE: The majority of drug addicts are polydrug dependent, and no effective pharmacological treatment is currently available for them. The authors studied the overall real-world effectiveness of naltrexone implant in this patient population. METHOD: The authors assessed the effectiveness of a naltrexone implant in the treatment of coexisting heroin and amphetamine polydrug dependence in 100 heroin- and amphetamine-dependent outpatients in a 10-week randomized, double-blind, placebo-controlled trial. The main outcome measures were retention in the study, proportion of drug-free urine samples, and improvement score on the Clinical Global Impressions Scale (CGI). Analyses were conducted in an intent-to-treat model. RESULTS: At week 10, the retention rate was 52% for patients who received a naltrexone implant and 28% for those who received a placebo implant; the proportions of drug-free urine samples were 38% and 16%, respectively, for the two groups. On the CGI improvement item, 56% of the patients in the naltrexone group showed much or very much improvement, compared with 14% of those in the placebo group (number needed to treat=3). CONCLUSIONS: Naltrexone implants resulted in higher retention in the study, decreased heroin and amphetamine use, and improved clinical condition for patients, thus providing the first evidence of an effective pharmacological treatment for this type of polydrug dependence.

A comparison of aripiprazole, methylphenidate, and placebo for amphetamine dependence.

OBJECTIVE: Problems related to illegal amphetamine use have become a major public health issue in many developed countries. To date, evidence on the effectiveness of psychosocial treatments has remained modest, and no pharmacotherapy has proven effective for amphetamine dependence. METHOD: Individuals meeting DSM-IV criteria for intravenous amphetamine dependence (N=53) were randomly assigned to receive aripiprazole (15 mg/day), slow-release methylphenidate (54 mg/day), or placebo for 20 weeks. The study was terminated prematurely due to unexpected results of interim analysis. An intention-to-treat analysis was used. The primary outcome measure was the proportion of amphetamine-positive urine samples. RESULTS: Patients allocated to aripiprazole had significantly more amphetamine-positive urine samples than patients in the placebo group (odds ratio=3.77, 95% CI=1.55-9.18), whereas patients who received methylphenidate had significantly fewer amphetamine-positive urine samples than patients who had received placebo (odds ratio=0.46, 95% CI=0.26-0.81). CONCLUSIONS: Methylphenidate is an effective treatment for reducing intravenous drug use in patients with severe amphetamine dependence.