Mortality among older adults with opioid use disorders in the Veteran's Health Administration, 2000–2011☆
Introduction
Opioid use disorders (OUD) are associated with significant mortality. Regular and dependent opioid users die at nearly 15 times the rate of their age- and sex-matched peers, with a crude mortality rate of 2% per year (Degenhardt et al., 2011). Common causes of death include drug overdose, suicide, trauma, and AIDS-related illnesses. The relative contribution of specific causes of death to overall mortality varies with factors such as geography, background HIV prevalence and access to opioid substitution treatment (Degenhardt et al., 2011).
One factor plausibly affecting mortality in OUD that has received little research attention is aging. Observational cohort studies of people with OUD have demonstrated that, among those who survive into their fifties and sixties, ongoing opioid use (whether regular or occasional) is more common than long-term abstinence (Hser et al., 2007, Hser et al., 2001). In recent years, concomitant with the aging of the general population, there have been substantial increases in the numbers of older drug users. In the United States, an increasing proportion of first-time entrants to drug treatment programs are aged over 55, and the proportion of these reporting heroin as a problem drug is also increasing (Arndt et al., 2011). Projected continued increases in the number of older people with substance use disorders (Han et al., 2009) suggest a need to better understand the health of this group, including mortality rates and causes of death as indicators of areas for intervention.
Although a small number of studies have reported that all-cause mortality rates increase with age (Degenhardt et al., 2009, Ødegård et al., 2007), there has been little analysis of how cause-specific mortality in older people with OUD may differ from that seen in younger cohorts. Deaths not directly related to drug use are more common among older people with OUD than their younger counterparts (Beynon et al., 2010, Ødegård et al., 2007); however, no studies on this issue have used a large enough sample to allow for further disaggregation of non-drug-related causes of death. As such, it is unclear what non-drug causes of death are most important as people with OUD age. It is also unclear if drug-related mortality among people with OUD decreases with age, and is replaced by non-drug deaths, or if non-drug deaths comprise an additional burden on people with OUD (Beynon et al., 2010, Ødegård et al., 2007).
A related question is how mortality in older people with OUD may be similar to, or differ from, mortality in same-age peers without OUD. It may be that aging-related increases in certain causes of death affect people with and without OUD similarly, and for these causes, mortality rates in older people with OUD may simply be as they are in older people generally. In one opioid-dependent cohort, cancer mortality was elevated compared to the general population in those aged 35–54, but at age 55 and over, there was no significant difference between opioid dependent persons and the general population (Randall et al., 2011). This may not be the case, however, for causes of death that are directly drug-related, such as overdose, or indirectly drug-related, such as HIV or liver disease subsequent to hepatitis C infection.
There are few data sources that permit direct comparisons of mortality between people with and without OUD, or that contain detailed information about comorbidities that may affect mortality. One possible avenue for examining these relationships with sufficient sample size are electronic health records (EHR) linked to cause-specific mortality record. One such source of data is the Veterans Health Administration (VHA). The VHA is the largest integrated health system in the United States and has long used EHR nationally to record demographic and diagnostic information for all treatment contacts of patients seen anywhere in the national WHA system. Recent efforts have led to the linkage of VHA EHR data with cause-specific mortality data from the Centers for Disease Control and Prevention's National Death Index. Veterans who receive care from the VHA are a particular population of interest for the study of OUD and mortality among older adults. Although many Veterans who receive care from VHA are from recent conflicts, the majority of VHA patients are older adults. Opioid prescribing is common in VHA (Bohnert et al., 2014), and VHA patients have a high rate of drug-related mortality (Bohnert et al., 2011a).
In light of the aging of the OUD population and the lack of knowledge of how aging may impact cause-specific mortality in this group, this paper aimed to (a) describe mortality in a cohort of older (≥50 years) adults with a history of OUD; (b) compare mortality in this cohort to that in younger (<50 years) adults with a history of OUD, and older (≥50 years) adults with no record of OUD and (c) determine risk factors for cause-specific mortality in older adults with a history of OUD.
Section snippets
Methods
This study was approved by the Institutional Review Boards of the Ann Arbor Veterans Health Administration (VA) and University of Michigan.
Results
The older OUD cohort comprised 36.608 patients (97.3% male) with a median age of 55 years at cohort entry (Table 1). Compared to younger OUD, older OUD were more likely to be male and less likely to be Caucasian or ‘other’ race. By design, the older non-OUD patients were of the same age and sex as the older OUD patients; however, older OUD were more likely than older non-OUD to be African American.
Older OUD patients were significantly more likely than younger OUD patients to have a Charlson
Discussion
In this study we found that, in contrast to younger people with an OUD, older people with an OUD are more likely to die from chronic illness than drug-related causes. This is consistent with studies in other settings (Beynon et al., 2010, Ødegård et al., 2007). Unlike some studies (Beynon et al., 2010), we did not observe a decrease in drug-related deaths with age. Our findings suggest that mortality risks traditionally associated with OUD – overdose, suicide and other unnatural deaths – may
Role of the funding source
No funders had any role in the design of this study, the data analysis or interpretation, the writing of the manuscript, or the decision to submit for publication.
Contributors
SL and ASBB defined the research questions. DG conducted the statistical analyses. SL drafted the manuscript. ASMM, MAI, MH, FCB and LD reviewed and commented on manuscript drafts.
Conflict of interest
LD has received untied educational grants from Reckitt Benckiser for the post-marketing surveillance of opioid substitution therapy medications in Australia, the development of an opioid-related behavior scale, and a study of opioid substitution therapy uptake among chronic non-cancer pain patients. LD has also received untied educational grants from Mundipharma to conduct surveillance of the use of Oxycontin in Australia. All such studies’ design, conduct and interpretation of findings are the
Acknowledgements
SL and LD are supported by Australian National Health and Medical Research Council Research Fellowships (APP1035149 and APP1041742, respectively). ASSB and DG were supported by National Institute of Aging grant R03 AG042899. The National Drug and Alcohol Research Center at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grants Fund.
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Supplementary material can be found by accessing the online version of this paper. Please see Appendix A for more information.