Dr Karla Rix-Trott

Senior Medical Officer

� Change in treatment approach since advent of

HIV/AIDS

Retention in treatment and harm reduction� Retention in treatment and harm reduction

� Many clients growing old while in treatment

� Change in mortality statistics

� International mortality studies

� Previous New Zealand study

� Current study

� Discussion and some recommendations

� Analysed mortality data for newly notified addicts for 2

periods 1967-76 and 1984-93

� 5,310 deaths in 92,802 addicts

General decline in death rates and excess deaths over � General decline in death rates and excess deaths over

this period with significantly lower rates in 2nd time

period

� Males decrease: 13x to 7x; Females 16x to 10x

� Drug-related deaths – 65% due to opiates – most <45

� Analysed studies done 1966 to 1999

� Prior to HIV, deaths in discharged patients more than � Prior to HIV, deaths in discharged patients more than 2x higher than those who continued in treatment

� Post discharge heroin related deaths 51x the rate in active patients

� Alcohol related conditions leading cause in treatment in patients over 30

� With onset of HIV in 1980s AIDS related conditions became major cause of death in treatment

� Past 2 years deaths related to HCV risen to 9% -expected to eclipse AIDS related deaths in next decade

� 10,454 heroin users entering treatment in 1998-2001 followed in treatment and out of treatment

� 41 OD deaths – 10 during treatment - standardised mortality ratio (SMR) 3.9, and 31 out of treatment -mortality ratio (SMR) 3.9, and 31 out of treatment -SMR 21.4

� Risk fatal OD 2.3% in the month immediately after treatment hazard ratio (HR) 26.6, and 0.77% thereafter HR 7.3

� Need to further investigate the potential benefits and harms of short-term therapies for opiate use

� Only previous NZ study

� Studied deaths in Wellington opioid substitution program 1972 – 1989

� Pre HIV/AIDS

� Total 997 treated over this time

� 67 deaths (6.72%) – 46M (68.66%), 21F (31.34%)

Cause of death

� 6 trauma – 9%

� 28 accidental causes (23 drug overdoses – 24x

normal population rate) – 42% normal population rate) – 42%

� 8 suicide – 12% (7.1x normal population rate)

� 4 myocarditis & 21 other natural causes – 37%

Age at death

� 13 in 15 to 24 age group (15.9% of total clients) –

19.4%

� 39 in 25 to 34 age group (69.3% of total clients) –

58.2% 58.2%

� 4 in 35 to 44 age group (8.5% of total clients) – 6%

� 11 in 45 plus age group (5.8% of total clients) – 16.4%.

Observed mortality rate adjusted for age and sex cf

expected rate for NZ population

� 15 to 24 yrs – 11.5 x expected rate

25 to 34 yrs – 5.8 x expected rate� 25 to 34 yrs – 5.8 x expected rate

� 35 to 44 yrs – 2.6 x expected rate

� 45+ yrs - <1 x expected rate

Overall rate 2.44 x expected rate

� Information from CADS Clinical Review Committee

database

� Coronial autopsy report obtained where uncertainty

about cause of death (15 cases)

� Total client numbers varied between 1066 and 1131

average 1095

� 51 deaths over the 5 year period (approx 4.7%)

11 in 2005, 6 in 2006, 9 in 2007, 7 in 2008 and 18 in � 11 in 2005, 6 in 2006, 9 in 2007, 7 in 2008 and 18 in

2009.

� 14 F (27.45%) – F = 38% of total client deaths

� 37 M (72.55%) – M = 62% of total clients deaths

Year 2005 2006 2007 2008 2009 Total%

Age range

15 – 24 0 0 0 0 0 0

25 – 34 2 (1F, 1M)

0 0 0 0 2

(1F, 1M)

3.92%3.92%

35 – 44 4 (2F, 2M)

3 (1F, 2M) 3 (1F, 2M) 1 (1M) 3 (2F, 1M) 14

(6F, 8M)

27.45%

45 – 54

years

4 (4M) 3 (1F, 2M) 6 (1F, 5M) 3 (2F, 1M) 9 (1F, 8M) 25

(5F, 20M)

49.02%

55+ 1 (1M) 0 0 3 (1F, 2M) 6 (1F, 5M) 10

(2F, 8M)

19.61%

Total 11 6 9 7 18 51

(14F, 7M)

Cause of

death2005 2006 2007 2008 2009 Total (%)

Natural

cause/

disease

7 (2 Liver Disease, 5 Other)

5 (3 LD, 2 Other)

5 (1 LD, 4 Other)

6 (1 LD, 5 Other)

13 (5 LD, 8 Other)

36

(70.59%)

12 LD

(33.33%)5 Other) (33.33%)

24 Other

(66.67%)

Trauma/

accident

0 1 1 0 1 3

(5.88%)

Overdose 1 0 3 1 4 9

(17.65%)

Suicide 3 0 0 0 0 3

(5.88%)

Total 11 6 9 7 18 51

� 12 deaths from liver disease – 11 chronic Hep C

(21.6%), 1 chronic Hep B, at least 4 with associated

alcohol abuse

� 24 other disease – 5 Ca, 5 CV event, 6 infection (2 � 24 other disease – 5 Ca, 5 CV event, 6 infection (2

endocarditis, 2 pneumonia, 1 H1N1 virus, 1

septicaemia), 2 complications of IDDM, 2 renal disease

& 1 each pulmonary thromboembolism, CORD, acute

GI bleed, uncertain

2 deaths in 15 to 34 age group – 1 suicide & 1 liver

disease + alcohol abuse

9 overdoses – none in 15 – 34 age group,

3 aged 35 – 44 (1 methadone only, 1 methadone and 3 aged 35 – 44 (1 methadone only, 1 methadone and

methamphetamine, 1 morphine)

6 males aged 48 to 56 years (3 methadone alone, 2

alcohol & methadone, 1 alcohol, methanol &

methadone)

� Distinct shift in cause of death in OST in NZ in past 30 to 40

years

� Dukes et al – 36% related to disease/natural causes and

alcohol related liver disease a factor in only 2 of the deathsalcohol related liver disease a factor in only 2 of the deaths

� This study - 70% due to disease/natural causes of which 1/3

due to liver disease

� Dukes et al 34.33% due to overdose

� This study 17.65% due to overdose

But 5.8% of Dukes et al clients were aged 45+

compared with 53% of AOTS clients

� This study – all overdose deaths in 35+ age group, 2/3

in men 48 and over & alcohol involved in half of these.

Possibility of unrecognised suicide.

� No HIV related deaths in this ‘post-HIV’ study

� Prevention of Hepatitis B & C related deaths not as

successful with 23% of subjects in this study dying of

chronic hepatitis-related liver disease.

� Trend towards deaths in older patients and increased

deaths from disease (particularly the effects of long-

term hepatic viral infection) probably the result of

increased retention in treatment and longer term

treatment.

� This highlights the need to encourage our clients

(especially males) to become engaged in primary

health care and the monitoring, management and

treatment of chronic health issues.

� Other substance use related problems that impact on

health also need addressing – as well as injecting

related problems, smoking reduction/cessation (both

cigarettes and cannabis) and safer alcohol use.

� We seem to have done well in terms of reducing

overdose deaths in our younger clients but need to

increase our focus on encouraging our older clients to

take long-term health care issues more seriously.

� Further analysis of the AMS data collected, especially

standardised mortality ratios, would be useful for

comparing this study with other studies.

� A study of the coronial autopsy reports indicated that

in nearly all cases it seemed that the pathologist did

not have information on whether the person was on

methadone treatment nor of the person’s usual dose.

This appeared to create difficulties in drawing This appeared to create difficulties in drawing

conclusions about the contribution of methadone to

the death, particularly in the cases of overdose deaths.