Gregorio Barrio

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies

Objective To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment. Design Systematic review and meta-analysis. Data sources Medline, Embase, PsycINFO, and LILACS to September 2016. Study selection Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine. Data extraction and synthesis Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis. Results There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment. Conclusions Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.

Has health in Spain been declining since the economic crisis

Background The economic recession starting in 2008 may be having negative effects on health. Purpose We aimed to identify and characterise changes in trends in 15 health indicators in Spain during the recession. Methods Joinpoint regression and average annual percent change (AAPC) were used to compare trends. Results Premature mortality rates from several causes of death, except from cancer, showed statistically significant downward trends during the recession, as did poor self-reported health. HIV incidence was stable. No indicator declined significantly more slowly during the recession than in the preceding 4-year period, and two declined significantly faster. Conclusion Health in Spain has continued to improve during the first four years of the economic recession at a rate equal to or higher than in previous years.

Use of supervised injection facilities and injection risk behaviours among young drug injectors

AIMS To study the use of supervised injection facilities (SIFs) as a predictor of safer injecting practices. DESIGN Cross-sectional study conducted with face-to-face interview using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were collected for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) antibody testing. SETTING All participants were street-recruited by chain referral methods in Madrid and Barcelona. PARTICIPANTS A total of 249 young heroin drug injectors recruited by the ITINERE cohort study in two Spanish cities with SIFs. MEASUREMENTS The main outcome measures were self-reported injecting behaviours and SIFs attendance. RESULTS SIF users were more marginalized socially than non-users. They were also more often regular injectors (weekly or more versus sporadic) [odds ratio (OR) = 4.9, 95% confidence interval (CI): 2.7-8.8], speedball users (OR = 2.5, 95% CI: 1.5-4.3) and anti-HCV-positive (OR = 3.1, 95% CI: 1.4-7.1). In the logistic regression analysis, using SIFs was associated independently with not borrowing used syringes (OR = 3.3, 95% CI: 1.4-7.7). However, no significant association was found between SIF use and not sharing injection equipment indirectly (OR = 1.1, 95% CI: 0.5-2.2). CONCLUSIONS SIFs attract highly disadvantaged drug injectors who engage none the less in less borrowing of used syringes than non-users of these facilities. The risks of indirect sharing should be emphasized when counselling SIF attendees.

Severity of Dependence Scale as a Diagnostic Tool for Heroin and Cocaine Dependence

Aims: Our aim was to further assess the Severity of Dependence Scale (SDS) validity and to identify the cut-off score for a DSM-IV diagnosis of heroin and cocaine dependence through a cross-sectional survey in Barcelona, Spain. Methods: The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was used as the gold standard. 146 young (18–30 years old) heroin users were recruited from outside the healthcare context, 135 of whom were also current cocaine users. SDS scores were correlated to quantity, frequency and length of drug use. Results: The SDS cut-off point at which there was optimal discrimination of a DSM-IV diagnosis presence was found to be 3 (i.e., a score of 3 or more) for heroin dependence and 4 for cocaine dependence. Conclusions: The study gives further support to SDS dimensional properties and to its validity for rapid assessment of current heroin and cocaine dependence.

Cocaine use and risk of stroke: A systematic review

BACKGROUND Both cocaine use and strokes impact public health. Cocaine is a putative cause of strokes, but no systematic review of the scientific evidence has been published. METHODS All relevant bibliographic-databases were searched until January 2014 for articles on the epidemiological association between cocaine use and strokes. Search strings were supervised by expert librarians. Three researchers independently reviewed studies for inclusion and data extraction following STROBE recommendations. Quality appraisal included study validity and bias. Both ischemic and hemorrhagic strokes were considered. RESULTS Of 996 articles, 9 were selected: 7 case-control studies (CCS) and 2 cross-sectional (CSS) studies. One CCS (aOR=6.1; 95% CI: 3.3-11.8) and one CSS (aOR=2.33; 95% CI: 1.74-3.11) showed an association between cocaine and hemorrhagic strokes. The latter study also found a positive relationship with ischemic stroke (aOR=2.03; 95% CI: 1.48-2.79). Another CCS found the exposure to be associated with stroke without distinguishing between types (aOR=13.9; 95% CI: 2.8-69.4). One forensic CCS found that deaths with cocaine-positive toxicology presented a 14.3-fold (95% CI: 5.6-37) and 4.6-fold (95% CI: 2.5-8.5) increased risk of atherosclerosis compared to opioid-related deaths and hanging-deaths respectively. One CCS did not provide an aOR but found a statistically significant association between cocaine and hemorrhagic stroke. Three CCS and one CSS did not find any relationship between cocaine and strokes. Inadequate control for confounding was not uncommon. CONCLUSIONS Epidemiological evidence suggests that cocaine use increases the risk of stroke. Larger, more rigorous observational studies, including cohort approaches, are needed to better quantify this risk, and should consider stroke type, hypertension variation, frequency/length of cocaine use, amphetamines co-use, and other factors.

Are Participants in a Street-Based HIV Testing Program Able to Perform Their Own Rapid Test and Interpret the Results?

Objective Availability of over-the-counter rapid HIV tests could improve access to testing those reluctant or unable to use current services. We aimed to evaluate the feasibility of HIV self-testing using a finger-stick whole-blood rapid test (Determine™ HIV Combo) to detect both antigen and antibody. Methods Before being tested, 313 participants in a street-based testing program were given adapted instructions and a test kit, and performed the self-test without supervision. These participants, together with another 207 who performed supervised self-testing, received additional instructions on how to interpret the test results shown in six colour photos and filled out a questionnaire. Logistic regression and generalized estimating equations (GEE) were used in the statistical analysis. Results About 8.0% (95%CI:4.8%–11.2%) obtained an invalid self-test. An invalid result was inversely associated with male participants who had sex with men (OR = 0.3;95%CI:0.1–1.0). Of the 3111 photos interpreted,4.9% (95%CI:4.1–5.7) were incorrect. Only 1.1% (95%CI:0.3–1.8) of the positive results were interpreted as negative. Age 30 or older (OR = 2.1; 95%CI:1.2–3.7), having been born in Latin America (OR = 1.6; 95%CI:1.1–2.2),and not having university education (OR = 2.1;95%CI:1.2–3.7) were associated with misinterpreting test results in the GEE. Participants perceptions of both their proficiency when conducting the test and interpretation were related with actual outcomes. Most participants (83.9%) were more motivated than before to use the self-test in the future, and 51.7% would pay >10 Euros for the test if it was sold in pharmacies. Conclusions This is the first study showing that blood-based self-testing with current technology is feasible in HIV-negative participants demanding the test and without prior training or supervision. Bearing in mind that it was conducted under difficult weather conditions and using a complex kit, over-the-counter tests could be a feasible option to complement current diagnostic strategies. More studies are needed to accommodate technology, minimise interpretation mistakes and provide on-line support.

Mortality decrease according to socioeconomic groups during the economic crisis in Spain: a cohort study of 36 million people

BACKGROUND Studies of the effect of macroeconomic fluctuations on mortality in different socioeconomic groups are scarce and have yielded mixed findings. We analyse mortality trends in Spain before and during the Great Recession in different socioeconomic groups, quantifying the change within each group. METHODS We did a nationwide prospective study, in which we took data from the 2001 Census. All people living in Spain on Nov 1, 2001, were followed up until Dec 31, 2011. We included 35 951 354 people alive in 2001 who were aged between 10 and 74 years in each one of the four calendar years before the economic crisis (from 2004 to 2007) and in each one of the first four calendar years of the crisis (from 2008 to 2011), and analysed all-cause and cause-specific mortality in those people. We classified individuals by socioeconomic status (low, medium, or high) using two indicators of household wealth: household floor space (<72 m2, 72-104 m2, and >104 m2) and number of cars owned by the residents of the household (none, one, and two or more). We used Poisson regression to calculate the annual percentage reduction (APR) in mortality rates during 2004-07 (pre-crisis) and 2008-11 (crisis) in each socioeconomic group, as well as the effect size, measured by the APR difference between the pre-crisis and crisis period. FINDINGS The annual decline in all-cause mortality in the three socioeconomic groups was 1·7% (95% CI 1·2 to 2·1) for the low group, 1·7% (1·3 to 2·1) for the medium group, and 2·0% (1·4 to 2·5) for the high group in 2004-07, and 3·0% (2·5 to 3·5) for the low group, 2·8% (2·5 to 3·2) for the medium group, and 2·1% (1·6 to 2·7) for the high group in 2008-11 when individuals were classified by household floor space. The annual decline in all-cause mortality when people were classified by number of cars owned by the household was 0·3% (-0·1 to 0·8) for the low group, 1·6% (1·2 to 2·0) for the medium group, and 2·2% (1·6 to 2·8) for the high group in 2004-07, and 2·3% (1·8 to 2·8) for the low group, 2·4% (2·0 to 2·7) for the medium group and 2·5% (1·9 to 3·0) for the high group in 2008-11. The low socioeconomic group showed the largest effect size for both wealth indicators. INTERPRETATION In Spain, probably due to the decrease in exposure to risk factors, all-cause mortality decreased more during the economic crisis than before the economic crisis, especially in low socioeconomic groups. FUNDING None.

Harm reduction interventions for drug injectors or heroin users in Spain: expanding coverage as the storm abates

AIMS To show the utility of analysing time trends of need and coverage of needle-exchange programmes (NEPs) and opioid substitution treatment (OST) to assess harm reduction policies targeting drug injectors or heroin users. DESIGN Multiple methods applied to secondary data. SETTING Spain. PARTICIPANTS Thousands of drug injectors or heroin users included in administrative registers, surveys and published studies during 1987-2010. MEASUREMENTS Coverage for the general population was calculated as the ratio between interventions provided (obtained directly from the sources) and interventions needed (estimated by multiple methods), and as the difference between the two. Timeliness was estimated by time elapsed between year of highest need and year in which coverage reached a reference level. FINDINGS In 2010 NEPs provided 138 syringes per drug injector [95% confidence interval (CI) 100-223], covering 25.7% (95% CI 18.3-43.3) of their need. OST coverage was 60.3% (95% CI 44.3-94.2). Syringe and OST provision increased between 1991 and 2001 and then declined. Syringe and OST coverage also increased substantially during this period and then stabilized, due mainly to decreases in drug injection or heroin use. Medium-level coverage for both syringes and OST was not achieved until 2000, 8 years after the peak in need (1992). CONCLUSIONS In Spain, the expansion of harm reduction interventions was greatly delayed, although the concomitant decrease in heroin and injecting drug use led to reasonable coverage after 2000. A longitudinal measurement of need and coverage provides insight into the timeliness and potential population impact of interventions, enabling better assessment of their adequacy.

Depression among regular heroin users: the influence of gender.

The aim of this study was to determine the prevalence of recent (last 12 months) depression in regular young heroin users and to ascertain factors associated with depression in this population, broken down by gender. A sample of 561 participants completed a cross-sectional survey. Eligibility criteria were: age 30 years or younger, and having used heroin for at least 12 days in the last 12 months and at least one day in the last 3 months. Participants were recruited outside of health-care facilities in the cities of Barcelona, Madrid and Seville by targeted sampling and chain referral methods. Depression was assessed using the World Mental Health Composite International Diagnostic Interview. The prevalence of recent depression was 22.3% (35.2% among women and 17.3% among men, p<0.001). In the multivariate analysis, the factors positively associated with recent depression in the whole sample were female gender, age 25 or less, inability to work due to health problems and high risk consumption of alcohol. Among woman, the related variables were age 25 or less, cocaine dependence in the last 12 months, and alcohol consumption in that period. Among men, employment status was the only related variable. Analysis of an overall sample without the gender breakdown may hide important differences in the factors associated with depression in men and women. Both prevention and treatment of depression should rely on specific gender analysis.

Gender differences in health related quality of life of young heroin users

BackgroundHealth Related Quality of Life (HRQL) of opiate users has been studied in treatment settings, where assistance for drug use was sought. In this study we ascertain factors related to HRQL of young opiate users recruited outside treatment facilities, considering both genders separately.MethodsCurrent opiate users (18-30 y) were recruited in outdoor settings in three Spanish cities (Barcelona, Madrid, Sevilla). Standardised laptop interviews included socio-demographic data, drug use patterns, health related issues, the Severity of Dependence Scale (SDS) and the Nottingham Health Profile (NHP).ResultsA total of 991 subjects (73% males), mean age = 25.7 years were interviewed. The mean global NHP score differed by gender (women: 41.2 (sd:23.8); men:34.1(sd:23.6);p < 0.05). Multivariate analysis was implemented separately by gender, variables independently related with global NHP score, both for males and females, were heroin and cocaine SDS scores. For women, only other drug related variables (alcohol intake and length of cocaine use) were independently associated with their HRQL. HIV+ males who suffered an opiate overdose or had psychiatric care in the last 12 months perceived their health as poorer, while those who had ever been in methadone treatment in the last 12 months perceived it as better. The model with both genders showed all factors for males plus quantity of alcohol and an interaction between gender and HIV status.ConclusionsHeroin users were found to be at a considerable risk of impaired HRQL, even in these young ages. A score approaching severity of dependence was the factor with the strongest relation with it.