Chronic non-cancer pain and the epidemic prescription of opioids in the Danish population: trends from 2000 to 2013.

BACKGROUND: Chronic pain has serious consequences for individuals and society. In addition, opioid prescription for chronic non-cancer pain (CNCP) has become more frequent. This study aims to examine the trends regarding the prevalence of CNCP, dispensed opioids, and concurrent use of benzodiazepine (BZD)/BZD-related drugs in the Danish population. METHODS: Data from the cross-sectional national representative Danish Health and Morbidity Surveys (2000, 2005, 2010, and 2013) were combined with The Danish National Prescription Registry at an individual level. The study populations varied between 5000 and 13,000 individuals ≥16 years (response rates: 51-63%). Respondents completed a self-administered questionnaire, which included the analyzed items on identification of chronic pain (≥6 months). RESULTS: From 2000 to 2013, the prevalence of CNCP increased and subsequently the annual prevalence of opioid use from 4.1% to 5.7% among CNCP individuals. Higher CNCP prevalence was related to female gender, no cohabitation partner, short education, non-Western origin, and overweight/obesity. In addition, women with CNCP, especially >65 years, became more frequent users of opioids and used higher doses than men. Concurrent use of BZD/BZD-related drugs decreased (13%) from 2010 to 2013, still one-third of long-term opioid user were co-medicated with these drugs. CONCLUSIONS: The use of opioids has increased in Denmark, especially among elderly women. The concurrent use of BZD/BZD-related drugs has decreased from 2010 to 2013, but still one-third of long-term opioid users were co-medicated.

Association between passive smoking in adulthood and phalangeal bone mineral density: results from the KRAM study--the Danish Health Examination Survey 2007-2008.

UNLABELLED: The study investigates an association between phalangeal bone mineral density (BMD) and self-reported passive smoking using data on 15,038 persons (aged 18-95 years), who underwent a BMD scan in the Danish KRAM study. BMD was significantly lower in persons exposed to long-term passive smoking in their home during adulthood. INTRODUCTION: Smoking is associated with decreased bone mineral density (BMD) and increased risk of osteoporotic fractures. This study aimed to investigate a possible association between BMD at the phalangeal bones and self-reported passive smoking. METHODS: The study included a cohort of 15,544 men and women aged 18-95 years, who underwent a BMD scan in the Danish KRAM study. BMD scans of the middle phalanges of the second, third and fourth digits of the non-dominant hand were performed with a compact radiographic absorptiometry system (Alara MetriScan®). Also, height, weight and body fat percentage were measured and 96.7% (n = 15,038) of the participants answered a self-reported questionnaire with information on passive smoking, other lifestyle factors, education, etc. The association between passive smoking and BMD was examined using multiple linear regression analysis. RESULTS: A total of 39.1% (n = 5,829) of the participants had been exposed to passive smoking in adulthood at home. BMD was significantly lower in subjects exposed to passive smoking, 0.343 vs. 0.331 g/cm(2); p < 0.01 (unadjusted) and 0.339 vs. 0.337 g/cm(2); p < 0.05 (adjusted for age, gender, height and weight, and smoking). Multiple linear regression analysis showed that exposure to passive smoking for more than 20 years in adulthood at home was significantly related to BMD when adjusted for potential confounders (men, ß = -4.4 × 10(-3); r = -0.05; p < 0.01 and women, ß = -2.3 × 10 (-3); r = -0.03; p < 0.05). This relationship was also seen in the group of never smokers (ß = -3.3 × 10(-3); r = -0.03; p = 0.01). CONCLUSION: Our study supports a potential negative effect of long-term passive smoking in adulthood at home on phalangeal BMD.

Drug-use pattern, comorbid psychosis and mortality in people with a history of opioid addiction.

OBJECTIVE: To compare the 15-year mortality of people with a history of opioid dependence that had achieved stable abstinence, with the mortality associated with continued drug use. Another objective was to study the influence of hospitalization with comorbid psychosis on the 15-year mortality. METHOD: In 1984, 188 persons (122 men and 66 women) with a history of intravenous narcotics addiction were interviewed about their drug-use pattern. A registry-based follow-up continued through 1999 and mortality was assessed. Three 1984-drug-use categories were formed. In category 1, cohort members had achieved stable abstinence from drug use by 1984. Using Cox multiple regression analysis, we (i) estimated reduced mortality of category 1 drug users, and (ii) studied the influence of hospitalization with comorbid psychosis on mortality. RESULTS: About 32% had died during the 15-year follow-up. The 15-year mortality associated with stable abstinence was reduced by 56% when compared with the perceived worst drug-use pattern. Hospitalization for comorbid psychosis was not independently associated with mortality in this sample. When drug-use categories were compared with mortality expectations for the general population, the standard mortality rates (SMRs) were clearly elevated. Even in the stably abstinent drug-use category (category 1), SMR was significantly elevated by at least seven-fold in both genders. CONCLUSION: People who had achieved stable abstinence from injecting narcotics use were at lower risk of premature death than people with continued drug use. A residual observed excess mortality in people who had apparently achieved stable abstinence from drug use is consistent with the view of drug addiction as a chronic disease.

Mortality among anesthesiologists in Denmark, 1973-95.

BACKGROUND: Preliminary data from Sweden indicating that anesthesiologists have a high mortality risk has caused a lot of concern in Denmark. The aim of this study therefore was to compare mortality between consultant anesthesiologists and other consultants in Denmark. METHODS: A historical prospective cohort study based on the membership register of the Danish Medical Association from 1973 to 1992. The study population consisted of 6854 consultants who were members of the Association of Medical Specialists, 406 of whom were anesthesiologists. The all-cause mortality between the two groups was compared during the period 1972-95 using Cox's proportional hazard regression model. RESULTS: The study covered approximately 86000 person-years. A total of 1205 deaths occurred within the period studied, 41 of whom were anesthesiologists. The relative risk for all-cause mortality among the anesthesiologists compared with all the other consultants was 1.0 (95% confidence limit: 0.7-1.4). CONCLUSION: In Denmark there is no evidence of a high mortality risk in consultant anesthesiologists compared with other consultants.

[Morbidity among patients with clinically localized prostatic cancer. A registry-based case-control study]. / Sygelighed blandt patienter med klinisk lokaliseret prostatacancer. Et registerbaseret case-control-studie.

INTRODUCTION: Until recently, expectant management of localised prostate cancer was the routine strategy in Denmark. MATERIAL AND METHODS: In a historical, prospective, case-control study, morbidity in 4744 patients, aged 74 years or younger, with newly diagnosed clinically localised prostate cancer, was compared to that in an age-matched background population. RESULTS: Patients with clinically localised prostate cancer were found to have significant excess morbidity compared to the background population. Patients were admitted 6.7 times more often than the controls in the year prostate cancer was diagnosed and 2.7 times more often in the nine years following the diagnosis. When adjusted for prostate cancer-related admissions, morbidity approximates unity. Costs associated with the hospital care of patients with prostate cancer significantly exceeded the costs in the control group. DISCUSSION: The study demonstrates that patients with newly diagnosed, clinically localised prostate cancer have a significant morbidity associated to their primary malignancy. Further, these patients were found to have a significant excess morbidity compared to age-matched controls. The possibility of reducing morbidity and associated costs is discussed.

Abstention from smoking extends life and compresses morbidity: a population based study of health expectancy among smokers and never smokers in Denmark.

OBJECTIVE: To estimate health expectancy--that is, the average lifetime in good health--among never smokers, ex-smokers, and smokers in Denmark. DESIGN: A method suggested by Peto and colleagues in 1992 for estimating smoking attributable mortality rates was used to construct a life table for never smokers. This life table and relative risks for death for ex-smokers and smokers versus never smokers were used to estimate life tables for ex-smokers and smokers. Life tables and prevalence rates of health status were combined and health expectancy was calculated by Sullivan's method. SETTING: The Danish adult population. MAIN OUTCOME MEASURES: The expected lifetime in self rated good health or without longstanding illness for never smokers and smokers. RESULTS: The expected lifetime of a 20 year old man who will never begin to smoke is 56.7 years, 48.7 (95% confidence interval (CI), 46.8 to 50.7) years of which are expected to be in self rated good health. The corresponding figures for a man who smokes heavily are 49.5 years, 36.5 (95% CI 35.0 to 38.1 ) years of which are in self rated good health. A 20 year old woman who will never begin to smoke can expect to live a further 60.9 years, with 46.4 (95% CI 44.9 to 47.8) years in self rated good health; if she is a lifelong heavy smoker, her expected lifetime is reduced to 53.8 years, 33.8 (95% CI 31.7 to 35.9) years of which are in self rated good health. Health expectancy based on long standing illness is reduced for smokers when compared with never smokers. CONCLUSIONS: Smoking reduces the expected lifetime in good health and increases the expected lifetime in poor health.

[Impact of tobacco, alcohol overconsumption and drug abuse on mortality in Denmark. Trends over 25 years, 1973-1997]. / Betydning af tobak, stort alkoholforbrug og stofmisbrug på dødeligheden i Danmark. Udviklingen gennem 25 år, 1973-1997.

INTRODUCTION: The aim of the study was to estimate the national impact of smoking, alcohol, and drugs on mortality. MATERIAL AND METHODS: The analysis was based on the cause of death register. Deaths attributable to smoking were calculated by an indirect method. Deaths related to alcohol and drugs (illegal drugs and prescription drugs) were defined by the underlying and contributory causes of death. RESULTS: In the period, 1993-1997, 30% of all deaths in men and 20% in women were related to tobacco, alcohol, or drugs. The percentages of all deaths for tobacco, alcohol, and drugs were respectively 22.8%, 6.3%, and 1.2% for men and 16.5%, 2.5%, and 0.7% for women. Every year 12,000 Danes die 11-13 years prematurely, because of tobacco, more than 2500 die more than 20 years prematurely, because of alcohol, and about 600 die almost 30 years prematurely, because of drugs. The standardised lifetime risk of death from one of these three causes was about 30% for men, highest in the middle five-year period. For women--because of substantially increased mortality attributable to smoking--there was a large increase from 8% to 20%. In the municipality of Copenhagen, the lifetime risk for men was about 50%, for women it increased from 15% in the middle of the 1970s to more than 30% in the middle of the 1990s. For both men and women, mortality in the age group 35-74 declined sharply, when mortality related to the three causes was excluded. However, the heavy increase in smoking-related deaths in women means that the total mortality over the entire period has been almost constant. DISCUSSION: It is a tremendous challenge to change the impact of tobacco, alcohol, and drugs on mortality in Denmark.

[Acute myocardial infarction in Denmark. Incidence development and prognosis during a 20-year period]. / Akut myokardieinfarkt i Danmark. Udvikling i incidens og prognose gennem 20 år.

INTRODUCTION: The paper describes the epidemiology of acute myocardial infarction in Denmark. The study provides statistics on mortality, incidence and case-fatality for 1996 and the time trend since 1978. The results are compared to the results from the international MONICA study. METHOD: The analyses are based on national population-based registers on causes of death and hospital admissions. RESULTS: The mortality from ischaemic heart disease has declined considerably. The study confirms that the decline in mortality can be ascribed to a decrease in incidence as well as a decrease in case fatality. In the period 1985-1996 the incidence decreased by 3.5% per year for men and 2.5% for women. Mortality rates within 28 days after admission to hospital with MI was almost constant until 1988 following which there was a significant drop. Despite the improved prognosis for MI patients, one quarter die before admission to hospital, and one quarter die within one year after an MI. DISCUSSION: The incidence rates of MI based on the national population-based registers are consistent with the results from the Danish MONICA study. The reduction in incidence rates is a little smaller than the results in the Danish part of the MONICA study, whereas the marked reduction in case-fatality found in this study is not in agreement with the results from MONICA. This discrepancy is not yet understood. The declining trend in case fatality started in 1988 and may be related to the introduction of thrombolysis and acetylsalcylic acid treatment.

Sex differences in mortality in Denmark during half a century, 1943-92.

OBJECTIVE: The emphasis of this study is on the relative mortality of 45-74-year-old men and women in Denmark in 1943-92, following economic and political changes that have affected the social meaning of gender over the last 50 years, and which have diminished former sex differences in health behaviour. METHODS: Sex ratios of total mortality and mortality from major non-sex-specific causes of death were calculated on computerized mortality data from the Danish National Cause of Death Register that covers all deaths in Denmark since 1943. RESULTS: In the early 1940s the sex ratio of all-cause mortality was low, 1.0-1.1, it increased to a peak level in the late 1970s and early 1980s, but has since decreased due to an increase in female mortality and a more favourable trend in male mortality. CONCLUSION: Gender equality, employment, and economic autonomy may have beneficial health effects on both men and women, but the effects are inconsistent. The trend in smoking is the major explanatory factor for the more recent trends in gender differentials in mortality in Denmark.

Asthma mortality in Danish children and young adults, 1973-1994: epidemiology and validity of death certificates.

Several reports indicate that asthma mortality has increased during the last few decades. International comparisons reveal some striking differences in the pattern of asthma mortality. The authors investigated the asthma mortality rate in the Danish child and youth population 1973-1994 and studied the validity of death certificates. The authors reviewed all death certificates coded as asthma death in the International Classification of Diseases (ICD 8-ICD 10 (1994)) and adjacent respiratory code numbers for the age group 1-19 yrs. Hospital records and autopsy reports were assessed to validate the cause of death. Age-standardized and age-specific mortality rates were calculated. From 1973 to 1987 there was a significant upward trend in the mortality. On subdivision, this trend was limited to the age group 15-19 yrs. Generally the mortality rate decreased from 1988 to 1994. Four per cent coded as asthma were false positive. Twelve per cent were false negative asthma deaths, wrongly coded as due to other causes. Only 62% of all true positive death caused by asthma were appropriately coded. The number of false negative certifications increased with increasing autopsy frequency. Asthma mortality rates in Denmark increased in adolescents during 1973-1987 and decreased from 1988 to 1994. A possible explanation may be an increased awareness of asthma symptoms combined with a steadily improved treatment of asthma. Even in children and young adults under the age of 20 yrs, validity problems still make comparisons between countries difficult; even interpretation of national trends requires caution.

Estimating mortality due to cigarette smoking: two methods, same result.

We estimated the mortality from various diseases caused by cigarette smoking using two methods and compared the results. In one method, the "Prevent" model is used to simulate the effect on mortality of the prevalence of cigarette smoking derived retrospectively. The other method, suggested by R. Peto et al (Lancet 1992;339:1268-1278), requires data on mortality from lung cancer among people who have never smoked and among smokers, but it does not require data on the prevalence of smoking. In the Prevent model, 33% of deaths among men and 23% of those among women in 1993 from lung cancer, chronic bronchitis, emphysema, ischemic heart disease, and stroke were caused by cigarette smoking. In the method proposed by Peto et al, 35% of deaths among men and 25% of deaths among women from these causes were estimated to be attributable to cigarette smoking. The differences between the two methods are small and appear to be explicable. The Prevent model can be used for more general scenarios of effective health promotion, but it requires more data than the Peto et al method, which can be used only to estimate mortality related to smoking.

The need for hospital care of patients with clinically localized prostate cancer managed by noncurative intent: a population based registry study.

PURPOSE: We studied the need for hospital care of patients 74 years old or younger with clinically localized prostate cancer managed by deferred endocrine therapy. MATERIALS AND METHODS: Our series included all cases of newly diagnosed, clinically localized prostate cancer reported to the Danish Cancer Registry from 1977 to 1992. Information on the number of hospitalizations and operations performed from 1977 to 1994 was obtained from the Danish Hospital Discharge Registry. RESULTS: Our study included 4,790 men 37 to 74 years old with clinically localized prostate cancer. During the year of diagnosis and once a year of the following 9 years patients were hospitalized an average of 2.2 and 1 times and remained hospitalized an average of 22 and 10 days, and prostate cancer accounted for approximately 80% and 67% of hospitalizations the year of diagnosis and once a year subsequently. Nearly 90% of patients underwent transurethral prostatic resection within the year of diagnosis and in 30% repeat resection was necessary. A third of the patients underwent orchiectomy during the study period. Median time from the diagnosis to orchiectomy was 23 months. The estimated probability of surviving 5 and 10 years without orchiectomy was 39% and 17%, respectively. CONCLUSIONS: Patients diagnosed with clinically localized prostate cancer managed expectantly had a substantial need for hospital care in the years after the diagnosis. When evaluating outcome and quality of life after treatment of localized prostate cancer, the cost and impact of associated morbidity must be considered as well as patient survival.

The Danish registers of causes of death.

In 1875 registration of causes of death in Denmark was established by the National Board of Health, and annual statistics of death have since been published. Until 1970 the national statistics were based upon punched cards with data collected from the death certificates. Since then the register has been fully computerized and includes individual based data of all deaths occurring among all residents in Denmark dying in Denmark. Furthermore, a microfilm of all death certificates from 1943 and onward is kept in the National Board of Health. The Danish Institute for Clinical Epidemiology (DICE) has established a computerized register of individual records of deaths in Denmark from 1943 and onwards. No other country covers computerized individual based data of death registration for such a long period, now 54 years. This paper describes the history of the registers, the data sources and access to data, and the research based upon the registers, presenting some examples of research activities.

Causes of death in familial adenomatous polyposis.

BACKGROUND: The prognosis in familial adenomatous polyposis (FAP) has improved over the past decades owing to a reduction in the prevalence of colorectal cancer, resulting from effective early screening. During the same period several polyposis registers have recorded an increasing number of deaths due to duodenal/periampullary cancer and desmoid tumours. The aim of this study was to examine the causes of death with special emphasis on duodenal/periampullary cancer. METHODS: The material consisted of 328 patients (144 females and 184 males) registered from I January 1943 to 31 December 1992 in the Danish Polyposis Register. The standard mortality rate (SMR) was calculated for known major causes of death, using the entire Danish population as background population. The attributable risk was also calculated for selected death causes. RESULTS: One hundred and thirty-three patients had died, SMR being 4.98 (95% confidence limits, 4.17-5.90). There were significantly lower SMRs in the call-up group than in the proband group. The late cohort (1943-1992) had lower SMRs than the early group (1889-1942). SMR was significantly increased for death due to colorectal cancer (145), duodenal cancer (214), and ovarian cancer (30). No deaths due to desmoids were observed in the examination period. The attributable risk for colorectal cancer was 29% and for duodenal cancer only 0.6%. CONCLUSION: Colorectal cancer is the most frequent cause of death in polyposis patients, followed by duodenal/periampullary cancer, but the latter is still a rare cause of death in FAP.

Mortality and causes of death among Danish medical doctors 1973-1992.

BACKGROUND: To examine the mortality pattern of Danish doctors for the period 1973-1992. METHODS: A historical prospective cohort study based on the membership register of the Danish Medical Association. The study population consisted of 21,943 medical doctors, 6012 of whom were women. The doctors' cause-specific mortality was compared with that of the general population. RESULTS: The study covered about 277,000 person-years. A total of 2387 deaths occurred from 1 January 1973 to 31 December 1992. The doctors' mortality was lower than that of the general population. Both sexes showed a standardized mortality ratio (SMR) below one for cancer, circulatory diseases and other natural causes. Mortality due to lung cancer was particularly low. The SMR for suicide was significantly increased, 1.6 for males (95% CI: 1.4-1.9) and 1.7 for females (95% CI: 1.1-2.5). The suicide rate was increased, in particular because of an increased number of suicides by poisoning. In addition female doctors displayed a relatively high mortality due to accidents and other types of violent death. CONCLUSIONS: Compared with the general population the doctors' mortality was low, but the mortality from external causes was increased, mainly due to an excess number of suicides.

Mortality of patients with clinically localized prostate cancer treated with observation for 10 years or longer: a population based registry study.

PURPOSE: We studied the outcome in patients with early and probably organ confined prostate cancer who were considered candidates for curative therapy and treated expectantly. MATERIALS AND METHODS: The study included 2,570 patients with newly diagnosed prostate cancer reported to the Danish Cancer Registry from 1943 to 1986 and surviving for 10 years or longer. Mortality and causes of death were analyzed and stratified by stage, age and time of diagnosis. Excess mortality was calculated from life expectancy tables for the general population. RESULTS: An overall excess mortality (standard mortality ratio 1.58, 95% confidence interval [95% CI] 1.51 to 1.65) was found. Young age and advanced clinical stage at diagnosis entailed a higher risk of death from prostate cancer. Overall 42.7 and 19.1% of the patients who died had prostate cancer as the direct or contributing cause of death, respectively. Of the annual deaths 13% were attributable to prostate cancer. In 1,326 patients 55 to 64 and 65 to 74 years old with clinically localized prostate cancer at diagnosis the excess mortality was still significant (standard mortality ratio 1.72, 95% CI 1.54 to 1.93 and 1.50, 95% CI 1.39 to 1.62, respectively). Prostate cancer was the primary or contributing cause of death in 42.9% of the younger group and 21.5% of the older group. In these patients 15% of the annual deaths were related to prostate cancer. CONCLUSIONS: Patients with clinically localized prostate cancer for 10 years or longer, who were likely candidates for curative therapy when diagnosed, had significant excess mortality when treated expectantly.

Drug-related mortality in Denmark 1970-93.

We analysed drug-related mortality in Denmark with respect to secular trends, gender, and regional variations, for the period 1970-93, for all deaths from poisoning and among drug addicts. The study was based on the Register of Causes of Death in Denmark and included 6,229 drug-related deaths, defined by specific combinations of manner of death, underlying cause of death, and contributory cause of death. The main outcome measure is age-specific mortality rate. A total of 63% of the drug-related deaths were registered as unnatural deaths. During the period studied, mortality increased for men in the 25 49 year age group and for women in all age groups over 25 years of age. For both men and women, the youngest birth cohorts from the mid-1950s and 1960s suffered much higher mortality than those born before 1950; however, the three youngest birth cohorts had almost the same mortality. During the entire period, mortality in the capital, Copenhagen, was much higher than in the provinces, but in the last years, a more favourable trend has been seen in Copenhagen.

Morbidity in patients with clinically localized prostate cancer managed with non-curative intent. A population-based case-control study.

To compare the morbidity in patients with newly diagnosed clinically localized prostate cancer managed conservatively with the morbidity in a randomly selected age-matched background population with no history of prostate cancer. Patients younger than 75 y at diagnosis with newly diagnosed clinically localized prostate cancer reported to the Danish Cancer Registry in the period 1977-1992. Morbidity in patients and age-matched controls was extracted from The Danish Hospital Discharge Registry. Admissions were stratified by discharge diagnosis. Overall 4744 patients were hospitalized for 251,695 days within the first 10 y following diagnosis compared with 74,563 days in 4774 age-matched controls. The patients were admitted 6.7 (6.4-7.1) times more often than controls in the year following diagnosis, and 2.7 (2.6-2.8) times more often in the following 9 y. Excess morbidity declined over time. When prostate cancer-related admissions were excluded, the relative risk of admission was reduced to 1.35 (1.3-1.4) and 0.86 (0.83-0.89), respectively. The estimated costs associated with deferred therapy in patients with clinically localized prostate cancer exceeded the estimated cost in age-matched controls by approximately US$88 million, equivalent to an average extra cost per patient of approximately US$18,500. Patients with clinically localized prostate cancer managed conservatively had a significantly higher morbidity than age-matched controls due to admissions associated with prostate cancer. In future comparisons of treatment strategies, morbidity following treatment and impact on quality of life have to be included when evaluating the outcome.