Elsevier

Drug and Alcohol Dependence

Volume 156, 1 November 2015, Pages 104-111
Drug and Alcohol Dependence

Mortality among heroin users and users of other internationally regulated drugs: A 27-year follow-up of users in the Epidemiologic Catchment Area Program household samples

https://doi.org/10.1016/j.drugalcdep.2015.08.030Get rights and content

Highlights

  • Heroin users were 3–4 times more likely to die prematurely as compared to non-using individuals.

  • Heroin-predicted excess risk of dying is seen even with relatively low intensity heroin use.

  • Traumatic injury, infections (e.g., HIV/AIDS) and poisonings were prominent causes of death among heroin users.

Abstract

Background

In contrast to research on more restricted samples of drug users, epidemiological studies open up a view of death rates and survivorship of those who have tried heroin a few times, with no acceleration toward sustained use patterns often seen in treatment and criminal justice samples. At their best, epidemiological estimates of heroin effects on risk of dying are not subject to serious selection biases faced with more restricted samples.

Methods

Data are from 7207 adult participants aged 18–48 years in United States Epidemiologic Catchment Area Program field surveys, launched in 1980–1984. US National Death Index (NDI) records through 2007 disclosed 723 deaths. NDI enabled estimation of heroin-associated risk of dying as well as survivorship.

Results

Estimated cumulative mortality for all 18–48 year old participants is 3.9 deaths per 1000 person-years (95% confidence interval, CI = 3.7, 4.2), relative to 12.4 deaths per 1000 person-years for heroin users (95% CI = 8.7, 17.9). Heroin use, even when non-sustained, predicted a 3–4 fold excess of risk of dying prematurely. Post-estimation record review showed trauma and infections as top-ranked causes of these deaths.

Conclusions

Drawing strengths from epidemiological sampling, standardized baseline heroin history assessments, and very long-term NDI follow-up, this study of community-dwelling heroin users may help clinicians and public health officials who need facts about heroin when they seek to prevent and control heroin outbreaks. Heroin use, even when sporadic or non-sustained, is predictive of premature death in the US, with expected causes of death such as trauma and infections.

Introduction

Heroin user deaths are in the news for good reason, and this study's main aim is to understand whether heroin users might be at an increased risk of premature death, even when the use is limited and without the complexity of progression into sustained near-daily heroin use. Epidemiological evidence on this topic is needed in order to clarify premature death risks faced by young people who intend to try heroin no more than a few times, with no expectation of becoming regular users. The expectation of these young people might be that trying heroin on multiple occasions, without sustained use, has little or nothing to do with risk of dying prematurely.

Newsworthy epidemiologic estimates now show an increased prevalence of heroin use in the United States (US), with more than 650 thousand active heroin users in recent years versus an estimated 350–400 thousand in 2007 (SAMHSA, 2013). Concurrently, exponentially increasing numbers of heroin user deaths are being seen, sometimes when heroin use has displaced use of prescription pain relievers (Cicero et al., 2014, Rudd et al., 2014, Volkow, 2014a).

The observed pattern of heroin displacement of prescription pain relievers (PPR) might lead one to believe that heroin deaths and PPR deaths are exchangeable. Nonetheless, when studying the epidemiology of PPR deaths versus epidemiological profiles for heroin deaths, Cerdá and colleagues (2013) discovered marked differences. It is for this reason that the current research report is focused on estimation of risks of dying and survivorship, as experienced by heroin users in the community versus area-matched non-users, with differentiation of sustained near-daily heroin users versus non-sustained users. That is, the evaluation addresses whether excess risk is seen only for sustained near-daily heroin users, versus an alternative possibility – namely a history of sporadic or non-sustained heroin use also predict and account for an excess risk of dying prematurely.

Epidemiological estimates of the type reported here can be important in prevention and risk communication initiatives. A potential under-statement of risk is faced when the count of heroin deaths in a risk estimate's numerator is based solely on death certificates that mention heroin explicitly. Potential over-statement of risk may be present when mortality estimates are based on heroin users found via treatment and criminal justice facility records or via injecting drug user outreach or network sampling, for a variety of reasons suggested elsewhere. For example, Robins et al. (1975) and Mowbray et al. (2010) noted that restricted samples of heroin users might be considered a non-random subset of all heroin users in the community – i.e., those with more extreme pre-heroin life circumstances, severe impairment, or maladaptation. It follows that the experiences of this non-random subset of heroin users, in living and in dying, might be not at all representative of heroin users in the community at large. To the extent that epidemiological samples provide a more complete representation of the full spectrum of heroin involvement, mortality studies based on epidemiology's field survey samples should promote a more balanced perspective on how limited heroin use might eventually translate into a premature risk of dying.

Prior studies on this topic generally have produced heroin death rates for populations as a whole (e.g., see Cerdá et al., 2013), with no estimates of risk of dying for heroin users per se because this estimation task requires pre-mortem ascertainment of a positive heroin history in pre-selected individuals observed prior to death. Past estimates with pre-mortem heroin ascertainment generally involved identification of heroin users after entry to a treatment or criminal justice facility, more rarely via ‘outreach’ to injecting drug use communities, and even more rarely from samples of military veterans.

On one side of the coin, all of these prior estimates can be regarded as important, irrespective of ascertainment or sampling approaches, because they help quantify what heroin overdose death certificates do not disclose. Namely, heroin use can affect risk of dying via mediational mechanisms such as development of heroin dependence syndromes, HIV/AIDS complications or other infections caused by unsanitary injecting drug use or unsafe sex, via exposure to other noxious agents or trauma, suicide, and homicide, or via treatment-related complications (Ball et al., 1983, Degenhardt et al., 2010, Evans et al., 2012, Goldstein and Herrera, 1995, Hser et al., 2001, Price et al., 2001, Vlahov et al., 2005, Vlahov et al., 2008).

On the other side of the coin, substantial numbers of community residents in the US have used heroin without injecting, without becoming heroin dependent, and without treatment for heroin problems, if we are to believe estimates from many prior epidemiological studies in the US (Anthony et al., 1994, Brittingham et al., 1998, SAMHSA, 2005, SAMHSA, 2013, Wu et al., 2011). To the extent that restricted sample subsets of heroin users in the US are skewed toward more serious heroin involvement, the estimates of risk of dying based on these studies might be dismissed as irrelevant by young people in the general population who might start using heroin with an intention to try it no more than a few times.

For these reasons, we sought an opportunity to derive epidemiological field survey estimates on the issue of whether using heroin, per se, might be followed by an excess risk of premature death, even when sustained heroin use is absent, and to investigate possible heroin-caused excess risk of dying and reduced survivorship. The study estimates are based on four large US community cohorts sampled and recruited in the early-mid 1980s for the Epidemiologic Catchment Area Program (ECA).

By linking ECA heroin data with the National Death Index registry of all US deaths (NDI), we estimate the degree to which a heroin use history might predict and account for increased risk of dying prematurely. Focused on heroin, this work extends prior ECA mortality research on alcohol and other drug dependence syndromes (Eaton et al., 2013, Neumark et al., 2000).

A note about ‘premature death’ may be in order. This concept is grounded in relation to expected death ages for the sample as observed at baseline. For US adults age 45–49 years old 25–30 years ago, dying prematurely means dying somewhat before age 80, given survivorship statistics (National Center for Health Statistics, 2010). All deaths described in this report occurred before age 80.

Section snippets

Study design, study population and sample

As previously described in detail by the ECA team (Eaton et al., 1984), this prospective cohort study was launched in 1980–83 with multi-stage area probability sampling and IRB-approved recruitment of adult household residents from five US communities (mean participation, 76%). This study of deaths is based on 7207 18–48 year old participants from ECA sites in New Haven, CT (1980–1981); Baltimore, MD (1981); Saint Louis, MO (1981–1982); Durham, NC (1982–1983). A total of 78 decedents had

Results

Table 1 shows noteworthy sample facts. In aggregate, during 24–27 years of follow-up, the 7207 18–48 year olds lived through 183,654 person-years (p-y) (Table 1, Column 1, Row 1). For 101 adults with a positive history of heroin use at baseline, the cumulative person-year count is 2331 p-y (Table 1, Col 1).

Table 1 also presents estimates from two useful approaches for answering questions about the absolute risk or rate of dying during follow-up. A ‘rate’ approach involves forming ratios by

Discussion

The first novel finding of note is that self-identified heroin users in these US community field survey samples from the early 1980s were an estimated 3–4 times more likely to die prematurely as compared to their non-using neighbors in the same areas. Second, heroin-predicted excess risk of dying is seen even when the measured intensity of heroin use was less than sustained near-daily use. The excess risk remained statistically robust when holding constant age differences and other known and

Financial disclosures

The authors are not aware of conflicts of interest. The financial support for the research is from the US National Institutes of Health National Institute on Drug Abuse [K05 award K05DA015799 (JCA); T32 award DA021129 (CLQ); R01 award DA026652 (WWE). Contents are the sole responsibility of the authors and do not necessarily represent official views of our university or the National Institute on Drug Abuse.

Contributors

Anthony JC designed the study; Roth K prepared the dataset, Lopez-Quintero C managed the literature searches, wrote the first draft of the manuscript and conducted the statistical analyses. All authors contributed to and have approved the final manuscript.

Conflict of interest

No conflict declared.

References (33)

  • T.J. Cicero et al.

    The changing face of heroin use in the United States: a retrospective analysis of the past 50 years

    JAMA Psychiatry

    (2014)
  • L. Copeland et al.

    Changing patterns in causes of death in a cohort of injecting drug users, 1980–2001

    Arch. Intern. Med.

    (2004)
  • L. Degenhardt et al.

    Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

    Addiction

    (2010)
  • DHHS NIMH, 1992. Department of Health and Human Services, National Institute of Mental Health. Epidemiologic Catchment...
  • W.W. Eaton et al.

    The design of the Epidemiologic Catchment Area surveys: the control and measurement of error

    Arch. Gen. Psychiatry

    (1984)
  • W.W. Eaton et al.

    The relationship of mental and behavioral disorders to all-cause mortality in a 27-year follow-up of 4 Epidemiologic Catchment Area samples

    Am. J. Epidemiol.

    (2013)
  • Cited by (28)

    • Drug toxicity and forensic pharmacokinetics

      2022, Pharmacokinetics and Toxicokinetic Considerations - Vol II
    • Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users

      2020, Drug and Alcohol Dependence
      Citation Excerpt :

      As many as 11.8 million Americans over the age of 12 misuse any form of opiates, with the majority misusing prescription opiates (N = 10.9 million; (Bose et al., 2018). Heroin (Lopez-Quintero et al., 2015), other intravenous drug use (Artenie et al., 2015), and polysubstance misuse and dependence (Artenie et al., 2015) have consistently been identified as risk factors for accidental and suicidal overdose. Recent research indicates that prescription opioid use is also associated with premature mortality due to accidental overdose (Calcaterra et al., 2013) and suicide (Austin et al., 2017).

    • The impact of drug court participation on mortality: 15-year outcomes from a randomized controlled trial

      2019, Journal of Substance Abuse Treatment
      Citation Excerpt :

      Death has been directly related to complications from substance use, including septicemia, cancer, suicide, hepatitis, injury and HIV/AIDS (Cook et al., 2008; Hingson, Zha, & Weitzman, 2009; Lopez-Quintero et al., 2015; Rehm & Shield, 2013; Ridolfo & Stevenson, 2001). Unsurprisingly, people with substance use disorders (SUD) are more likely to die prematurely (Neumark, Van Etten, & Anthony, 2000); one study finding that heroin users were 3–4 times more likely to die prematurely, at an average age of 45 (Lopez-Quintero et al., 2015). For those with criminal justice involvement in addition to a SUD, the statistics are even bleaker.

    • Approaching Retention within the ABCD Study

      2018, Developmental Cognitive Neuroscience
    View all citing articles on Scopus
    View full text