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
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.
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