Health improvements needed in persons with mental disorders and substance use disorders. / Helsa til folk med psykiske lidelser og rusmiddellidelser må bedres.

People with severe mental disorders and substance use disorders have poorer health and a shorter life expectancy than the general population. We can change this.

Mortality, Causes of Death, and Predictors of Death among Patients On and Off Opioid Agonist Treatment: Results from a 19-Year Cohort Study.

BACKGROUND: Mortality is increased among people with opioid use disorder but reduced while on opioid agonist treatment (OAT). However, the impact of patient and treatment characteristics on mortality and causes of death is insufficiently studied. OBJECTIVES: The objective of this study was to explore mortality and causes of death and examine the impact of patient and treatment characteristics on mortality in an OAT cohort with high retention in treatment. METHODS: Design: longitudinal cohort study. SETTING: Norway. Observation period: time from OAT start as of 1998 until death or end of 2016, 2,508 person-years (PY) in total. SAMPLE: 200 persons starting OAT 1998-2007. DATA SOURCES: hospital records, interviews, the Norwegian Cause of Death Registry, Statistics Norway. RESULTS: Retention: 86.4% of the observation period was on OAT, 9.0% off, 4.6% unknown OAT status. All-cause crude mortality rate per 100 PY during the whole observation period was 1.64 (95% CI: 1.19-2.20), for deaths of somatic cause 0.88 (0.56-1.31), for drug-induced deaths 0.44 (0.23-0.76), and traumatic deaths 0.24 (0.10-0.50). Off-versus-on-OAT all-cause mortality ratio was 2.31 (1.00-4.85). On OAT, 58% of the deaths were of somatic cause and 21% drug-induced; off OAT, 38% of somatic cause and 50% drug-induced. Increasing baseline age and rate of somatic hospital treatment episodes were independently associated with increased all-cause mortality risk, while increasing rate of in-patient psychiatric treatment episodes was associated with reduced risk. Increasing duration of nicotine and cannabis use and alcohol dependence as well as increasing severity of polydrug use were associated with increased all-cause and somatic mortality adjusted for age and sex. CONCLUSION: The long observation period made it possible to demonstrate the importance of long-term retention in OAT to reduce mortality. Further, the preponderance of somatic and reduction of drug-induced causes of death during OAT underlines the need for follow-up of chronic diseases and health-promoting lifestyle changes. These findings add to the knowledge about long-term OAT effects, not least in ageing OAT populations.

Organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder: a nation-wide 2-year cross-sectional study.

AIMS: To document organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder and estimate the extent to which individual characteristics are associated with pulmonary, cardiovascular, hepatic or renal pathologies. DESIGN: Two-year cross-sectional nation-wide study. SETTING: Norway. PARTICIPANTS: Among all 200 patients who died during opioid agonist treatment between 1 January 2014 and 31 December 2015, 125 patients (63%) were autopsied. Among these, 122 patients (75% men) had available autopsy reports and were included. The mean age at the time of death was 48 years. MEASUREMENTS: Information on pulmonary, cardiovascular, hepatic and renal pathologies were retrieved from forensic or medical autopsy reports, with no (0) and yes (1) as outcome variables and age, sex and body mass index as covariates in logistic regression analyses. FINDINGS: Pathologies in several organs were common. Two-thirds (65%) of the decedents had more than two organ system diseases. The most common organ pathologies were chronic liver disease (84%), cardiovascular disease (68%) and pulmonary emphysema (41%). In bivariate analyses, only older age was associated with any pulmonary pathology [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.01-1.10], cardiovascular pathology (OR = 1.11; 95% CI = 1.05-1.17) and renal pathology (OR = 1.05; 95% CI = 1.00-1.11). Older age remained independently associated with cardiovascular pathology (OR = 1.10; 95% CI = 1.04-1.16) and renal pathology (OR = 1.06; 95% CI = 1.01-1.12) adjusted for body mass index and sex. CONCLUSIONS: Among autopsied Norwegians who died during opioid agonist treatment in 2014 and 2015, two-thirds had more than two organ system diseases, despite their mean age of 48 years at the time of death. Older age was independently associated with at least one cardiovascular or renal pathology after adjusting for sex and body mass index.

Post-mortem toxicological analyses of blood samples from 107 patients receiving opioid agonist treatment: substances detected and pooled opioid and benzodiazepine concentrations.

AIMS: To present the substances and their concentrations detected post-mortem in patients receiving opioid agonist treatment (OAT) stratified by cause of death, estimate the pooled opioid and benzodiazepine concentrations using established conversion factors for blood concentrations from the Norwegian Road Traffic Act, and explore the association between drug-induced cause of death and the pooled opioid and benzodiazepine concentrations. DESIGN: Cross-sectional nationwide study. SETTING: Norway. PARTICIPANTS: One hundred and seven patients who died during OAT (i.e. within 5 days after the last intake of OAT medication) between 1 January 2014 and 31 December 2015, with post-mortem femoral blood available for toxicology. Data were collected from hospital records, the Norwegian Cause of Death Registry and autopsy reports. MEASUREMENTS: Presence of alcohol and non-alcohol substances in the bloodstream at time of death, determined through records of toxicology of post-mortem femoral blood. FINDINGS: A median of four substances was detected across the causes of death. At least one benzodiazepine was detected in 81 (76%) patients. The median pooled opioid concentration was significantly higher in drug-induced deaths compared with other causes of death (362 ng/mL versus 182 ng/mL, P < 0.001), in contrast to the pooled benzodiazepine concentration (5466 versus 5701 ng/mL, P = 0.353). The multivariate regression analysis showed that only increasing pooled opioid concentration (ng/ML) was associated with increased odds of a drug-induced cause of death (odds ratio, 1.003; 95% confidence interval: 1.001-1.006). CONCLUSIONS: In Norway, overall opioid concentration seems to play an important role in drug-induced deaths during opioid agonist treatment in patients prescribed methadone or buprenorphine. Patients prescribed buprenorphine tend to replace their agonist with full agonists, while patients prescribed methadone tend to have high opioid concentrations from methadone as the only opioid.

Levels of mental distress over 18 years after entering treatment for substance use disorders: A longitudinal cohort study.

Aims: The aims were to investigate whether baseline characteristics and problematic substance use were related to change in mental distress over time in patients with substance use disorders during an 18-year period. Method: This was a prospective, longitudinal study of patients followed for 18 years after entering specialised treatment for substance use disorders. A sample of 291 patients was recruited in 1997 and 1998. Mental distress was measured using the Hopkins Symptom Checklist 25 at baseline, and at six and 18 years. Lifetime psychiatric disorders and substance use disorders at baseline were measured using the Composite International Diagnostic Interview, while personality disorders were measured using the Millon Clinical Multiaxial Inventory II. At the six- and 18-year follow-ups, substance use was measured using the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test. Linear mixed model was estimated to assess the overall level of mental distress over 18 years for participants with complete data at baseline (n = 232). Results: In an adjusted model, problematic substance use assessed simultaneously with mental distress, having lifetime affective, anxiety and personality disorder at baseline were associated with greater levels of mental distress over the 18-year period. The change in mental distress from baseline to the six-year, but not to the 18-year, follow-up was significantly larger among females than among males. Conclusion: The results suggests a reciprocal relationship over time between substance use and mental health problems. Also, there seems to be an additive effect between ongoing problematic substance use and lifetime mental disorders on greater levels of mental distress. This addresses the importance of integrated treatment for both substance use disorders and mental disorders to improve the long-term course for patients with these comorbid disorders.

Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study.

BACKGROUND: Mortality rates and causes of death among individuals in opioid agonist treatment (OAT) vary according to several factors such as geographical region, age, gender, subpopulations, drug culture and OAT status. Patients in OAT are ageing due to effective OAT as well as demographic changes, which has implications for morbidity and mortality. Norway has one of the oldest OAT populations in Europe. Because of the varying mortality rates and causes of death in different subgroups and countries, research gaps still exist. The aims of this study were to describe the causes of death among OAT patients in Norway, to estimate all-cause and cause-specific crude mortality rates (CMRs) during OAT and to explore characteristics associated with drug-induced cause of death compared with other causes of death during OAT. METHODS: This was a national, observational register study. Data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry were combined with data from medical records. We included all patients in the Norwegian OAT programme who died not more than 5 days after the last intake of OAT medication, between 1 January 2014 and 31 December 2015. RESULTS: In the 2-year observation period, 200 (1.4%) of the OAT patients died. A forensic or medical autopsy was performed in 63% of the cases. The mean age at the time of death was 48.9 years (standard deviation 8.4), and 74% were men. Somatic disease was the most common cause of death (45%), followed by drug-induced death (42%), and violent death (12%). In general, CMRs increased with age, and they were higher in men and in patients taking methadone compared with buprenorphine. Increasing somatic comorbidity, measured by the Charlson comorbidity index, reduced the odds of dying of a drug-induced cause of death compared with other causes of death. CONCLUSIONS: Both somatic and drug-induced causes of death were common during OAT. Improved treatment and follow-up of chronic diseases, especially in patients aged > 40 years, and continuous measures to reduce drug-induced deaths appear to be essential to reduce future morbidity and mortality burdens in this population.

Helpful Ingredients in the Treatment of Long-Term Substance Use Disorders: A Collaborative Narrative Study.

Relatively few individuals with a substance use disorder (SUD) seek or receive treatment, and knowledge about the effective ingredients in SUD treatment, from the perspective of those who receive it, is scarce. Our study purpose was to explore the experiences of those with long-term SUDs and the aspects they found helpful during treatment and long-term recovery. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a long-term SUD, and who had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to study planning, preparation, and initial analyses. Participants preferred individualized, long-term treatment, and support from both therapists and other clients. They further acknowledged the importance of their own sense of responsibility for their treatment and recovery success. Greater focus should be placed on viewing long-term SUD as a long-term condition, similar to somatic diseases, and SUD treatment services should place greater emphasis on developing partnership care models, long-term monitoring and support, and actively engaging recovered clients in the care of others in SUD treatment.

Compliance to antibiotic guidelines leads to more appropriate use of antibiotics in skin and soft tissue infections in injecting drug users.

Background: Knowledge about the treatment of skin and soft tissue infections in injecting drug users in countries with a low prevalence of antibiotic resistance is limited. We investigated bacterial antibiotic resistance and treatment of skin and soft tissue infections in Norwegian drug users. Methods: We performed a two year clinical cross-sectional observational study in a Norwegian hospital. Data were collected retrospectively from hospital records. We examined bacteriological findings and antibiotic resistance, and evaluated compliance to treatment guidelines and appropriateness of empirical antibiotic therapy relative to results of cultures and susceptibility testing. Descriptive and univariate analyses were performed. Results: Hundred and thirty-five injecting drug users were admitted with skin and soft tissue infection in the study period. Cultures were obtained from 103 (77%) abscesses and eight (24%) erysipelas and cellulitis, with bacterial growth in 80 (78%) and five (63%), respectively. Streptococci and staphylococci were the most prevalent bacteria, but methicillin-resistant Staphylococcus aureus was found in only one patient. Compliance to hospital antibiotic guidelines was 70%. Ninety-one per cent of patients in the compliant and 79% in the non-compliant group were given effective empirical antibiotics (p = .334). In the non-compliant group, significantly more patients received broad-spectrum empirical antibiotics (p < .001). In 30 cases where adjustment of antibiotic therapy was possible according to susceptibility testing, this was performed in only 14 cases. Conclusions: Bacteria and resistance patterns did not differ significantly from the skin and soft tissue infections in the general population in Norway. Compliance to antibiotic guidelines led to significantly less use of broad-spectrum antibiotics and to good bacterial coverage. General guidelines for treatment should be applied to injecting drug users with skin and soft tissue infections.

How Social Relationships Influence Substance Use Disorder Recovery: A Collaborative Narrative Study.

Individuals with a substance use disorder (SUD) often have fewer social support network resources than those without SUDs. This qualitative study examined the role of social relationships in achieving and maintaining stable recovery after many years of SUD. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a SUD and each of whom had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to the study planning, preparation, and initial analyses. The relationship that most participants described as helpful for initiating abstinence was recognition by a peer or a caring relationship with a service provider or sibling. These findings suggest that, to reach and maintain abstinence, it is important to maintain positive relationships and to engage self-agency to protect oneself from the influences of negative relationships. Substance use disorder service providers should increase the extent to which they involve the social networks of clients when designing new treatment approaches. Service providers should also focus more on individualizing services to meet their clients on a personal level, without neglecting professionalism or treatment strategies.

Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders: a 19-year prospective cohort study.

BACKGROUND: This study investigated cause of death, mortality rates and explored if baseline characteristics were associated with risk of death in patients with alcohol use disorder alone or poly-substance use disorders. METHODS: This was a prospective, longitudinal study of patients followed for 19 years after entering specialized treatment for substance use disorders. At baseline 291 patients (mean age 38.3 years, standard deviation 11.4 years, 72% male) with high psychiatric co-morbidity were recruited; 130 (45%) had lifetime alcohol use disorder alone, while 161 (55%) had poly-substance use disorders. Time and causes of death were gathered from the Norwegian Cause of Death Registry. Lifetime psychiatric symptom disorders and substance use disorders at baseline were measured with The Composite International Diagnostic Interview and personality disorders at baseline were measured with The Millon Clinical Multiaxial Inventory II. RESULTS: Patients with alcohol use disorder alone more often died from somatic diseases (58% versus 28%, p = 0.004) and more seldom from overdoses (9% versus 33%, p = 0.002) compared with patients with poly-substance use disorders. The crude mortality rate per 100 person year was 2.2 (95% confidence interval: 1.8-2.7), and the standardized mortality rate was 3.8 (95% confidence interval: 3.2-4.6) in the entire cohort during 19 years after entering treatment. Having lifetime affective disorder at baseline was associated with lower risk of death (Hazard Ratio 0.58, 95% confidence interval: 0.37-0.91). Older age was associated to increased risk of death among men (p < 0.001) and non-significantly among patients with poly-substance use (p = 0.057). The difference in association between age and risk of death was significantly different between men and women (p = 0.011) and patients with alcohol use disorder alone and poly-substance use disorders (p = 0.041). CONCLUSIONS: Patients with alcohol use disorder alone died more often from somatic disease than patients with poly-substance use disorders, and all subgroups of patients had an increased risk of death compared with the general population. Men with long-lasting substance use disorders are a priority group to approach with directed preventive measures for somatic health before they reach 50 years of age.

Why Do Those With Long-Term Substance Use Disorders Stop Abusing Substances? A Qualitative Study.

Although a significant proportion of adults recover from substance use disorders (SUDs), little is known about how they reach this turning point or why they stop using. The purpose of the study was to explore the factors that influence reasoning and decision making about quitting substance use after a long-term SUD. Semistructured interviews were conducted with 18 participants, each of whom had been diagnosed with a SUD and had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to the study's planning, preparation, and initial analyses. Participants recalled harmful consequences and significant events during their years of substance use. Pressure and concern from close family members were important in their initial efforts to abstain from substance use. Being able to imagine a different life, and the awareness of existing treatment options, promoted hope and further reinforced their motivation to quit. Greater focus on why those with SUDs want to quit may help direct treatment matching; treatment completion may be more likely if the person's reasons for seeking help are addressed.

General practitioners' views on drug-assisted rehabilitation.

BACKGROUND: The Norwegian model for opioid maintenance treatment (OMT) "Drug-assisted rehabilitation" (DAR) is a cross-disciplinary tripartite model for the treatment of opioid dependence. The model requires collaboration among GPs, the social services and the specialist health services. To some degree it restricts the doctor's professional autonomy. The investigation aims to examine GPs' attitudes to the model and in particular the experiences of those who have actively participated. MATERIAL AND METHOD: An electronic questionnaire (Questback) was sent to Norwegian GPs listed on the members' register of the Norwegian Medical Association. The respondents were questioned about their general opinions of drug-assisted rehabilitation. Those who had had relevant patients were asked about their experiences and evaluations based on 22 statements. RESULTS: 1,165 doctors (34 % of all registered GPs) responded to the survey. 155 (13 %) were negative, 395 (34 %) neutral, and 604 (53 %) were positive towards drug-assisted rehabilitation. 683 (59 %) were doctors with DAR experience. These were treating approximately 50 % of the country's DAR patients. The tripartite model received significant support. Very few want greater autonomy. The majority also support the strong emphasis on monitoring, although some, particularly older doctors with DAR experience, believe that urine tests could be replaced by personal contact. INTERPRETATION: Drug-assisted rehabilitation was mainly viewed positively by Norwegian GPs in this sample. There was little opposition to the doctor's role in the model, even though it restricts the autonomy of the individual doctor to some degree.

Changes in somatic disease incidents during opioid maintenance treatment: results from a Norwegian cohort study.

Objectives To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design Retrospective cohort study. Setting OMT programme in two Norwegian counties. Participants 200 OMT patients, participation rate 71.2%. Main outcome measures Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out.

[Quality of life among patients in drug-assisted rehabilitation programmes]. / Livskvalitet hos pasienter i legemiddelassistert rehabilitering.

BACKGROUND: Drug-assisted rehabilitation programmes reduce mortality and improve somatic and mental health among opioid abusers. We have explored changes in patients' perception of their QoL (quality of life) after enrollment in such a programme, and their explanations for these changes. MATERIAL AND METHODS: 26 patients, enrolled a drug-assisted rehabilitation programme, were interviewed according to a semi-structured guide. Changes in QoL were recorded on a five-point scale; from much worse to much better. Answers to the question "What are your two main explanations for improved/reduced QoL?" were recorded literally and analysed by systematic text condensation. RESULTS: The informants made 42 statements on reasons for improved QoL and six for reduced QoL. Important explanations for improved QoL were that life is no longer ruled by addiction, fewer social problems, and improved relationships to family and friends. Improved physical and psychological health was rarely mentioned. Loneliness and isolation, as well as the control imposed on them by the programme were explanations for reduced QoL. INTERPRETATION: A large majority of patients experienced improved QoL, and having regained control of their life was the most important explanation. Some felt the treatment dominated their life too much, and therefore expressed a poorer QoL.

Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study.

BACKGROUND: The long-term impact of opioid maintenance treatment (OMT) on morbidity and health care utilization among heroin addicts has been insufficiently studied. The objective of this study was to investigate whether health care utilization due to somatic disease decreased during OMT, and if so, whether the reduction included all kinds of diseases and whether a reduction was related to abstinence from drug use. METHODS: Cohort study with retrospective registration of somatic disease incidents (health problems, acute or sub-acute, or acute problems related to chronic disease, resulting in a health care contact). Medical record data were collected from hospitals, Outpatients' Departments, emergency wards and from general practitioners (GPs) and prospective data on substance use during OMT were available from 2001 onwards. The observation period was five years before and up to five years during OMT. The cohort consisted of 35 out of 40 patients who received OMT between April 1999 and January 2005 in a Norwegian district town. Statistical significance concerning changes in number of incidents and inpatient and outpatient days during OMT compared with the pre OMT period was calculated according to Wilcoxon signed rank test. Significance concerning pre/during OMT changes in disease incidents by relation to the type of health service contacts, as well as the impact of ongoing substance use during OMT on the volume of contacts, was calculated according to Pearson chi-square and Fisher's exact tests. RESULTS: 278 disease incidents were registered. There was a reduction in all incidents by 35% (p = 0.004), in substance-related incidents by 62% (p < 0.001) and in injection-related incidents by 70% (p < 0.001). There was an insignificant reduction in non-fatal overdose incidents by 44% (p = 0.127) and an insignificant increase in non-substance-related incidents by 13% (p = 0.741). Inpatient and outpatient days were reduced by 76% (p = 0.003) and 46% (p = 0.060), respectively. The disease incidents were less often drug-related during OMT (p < 0.001). Patients experienced a reduction in substance-related disease incidents regardless of ongoing substance use, however there was a trend towards greater reductions in those without ongoing abuse. CONCLUSION: Although as few as 35 patients were included, this study demonstrates a significant reduction in health care utilization due to somatic disease incidents during OMT. The reduction was most pronounced for incidents related to substance use and injection. Inpatient and outpatient days were reduced. Most probably these findings reflect somatic health improvement among heroin addicts during OMT.

[General practitioners can take responsibility for medication-based rehabilitation]. / Allmennleger kan ta ansvar for legemiddelassistert rehabilitering.

BACKGROUND: In Gjoevik, a Norwegian town with 28,000 inhabitants, general practitioners (GPs) have taken more responsibility for Methadone Maintenance Treatment (MMT) of heroin addicts than usual in Norway. We have assessed the treatment results in Gjoevik by comparing the fraction of patients who continue with treatment (retention in treatment, from 1999 to 2003), frequency of patient contact with professionals and the treatment outcome with the results for the rest of Norway. MATERIAL AND METHODS: In Norway, annual treatment results are reported for every MMT patient and the results are entered into a national register. This study is based on data in the national register from 2003. RESULTS: Retention is significantly higher in Gjoevik (93% vs. 77%) than in the rest of Norway. Patients have more contact with their GP in Gjoevik, while contact with local social service and so-called "responsibility groups" (organised cooperation between patient and professionals) are on the same level as for the country as a whole. The patients have less contact with specialized substance abuse and MMT centres than the average Norwegian patient. Treatment outcome regarding social rehabilitation (housing, source of income, occupation) and control of addictive behaviour (injecting drugs, opiate and illegal benzodiazepines in urine tests and overall assessment of drug behaviour) is close to the national average. INTERPRETATION: This may indicate that MMT programs with considerable delegation of treatment responsibility to GPs and local social service, can function as well as programs that rely more on specialised MMT-centres.