Abstract
AimsTo compare the change in illicit opioid users’ risk of fatal drug‐related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion.DesignNational data linkage cohort study of the English National Drug Treatment Monitoring System and the Office for National Statistics national mortality database. Data were analysed using survival methods.SettingAll services in England that provide publicly funded, structured treatment for illicit opioid users.ParticipantsAdults treated for opioid dependence during April 2005 to March 2009: 151 983 individuals; 69% male; median age 32.6 with 442 950 person‐years of observation.MeasurementsThe outcome was fatal DRP occurring during periods in or out of treatment, with adjustment for age, gender, substances used, injecting status and CJS referral.FindingsThere were 1499 DRP deaths [3.4 per 1000 person‐years, 95% confidence interval (CI) = 3.2–3.6]. DRP risk increased while patients were not enrolled in any treatment [adjusted hazard ratio (aHR) = 1.73, 95% CI = 1.55–1.92]. Risk when enrolled only in a psychological intervention was double that during OAP (aHR = 2.07, 95% CI = 1.75–2.46). The increased risk when out of treatment was greater for men (aHR = 1.88, 95% CI = 1.67–2.12), illicit drug injectors (aHR = 2.27, 95% CI = 1.97–2.62) and those reporting problematic alcohol use (aHR = 2.37, 95% CI = 1.90–2.98).ConclusionsPatients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.
Highlights
Non-medical use of opioid drugs is associated with a significant global burden of disease [1]
During treatment there was a greater reduction in this risk for men, for illicit drug injectors and those who reported problematic alcohol use and, consistent with meta-analysis [6,7,8], Opioid agonist pharmacotherapy (OAP) was associated with a strong reduction in drug-related poisoning (DRP) risk
The DRP risk increased during the month following discharge from OAP or residential treatment and elevated risk persisted beyond the month following discharge
Summary
Non-medical use of opioid drugs is associated with a significant global burden of disease [1]. Opioid agonist pharmacotherapy (OAP) is a community treatment for opioid dependence which aims to reduce heroin and other non-medical opioid use and associated harm. Using oral methadone or buprenorphine, well-delivered OAP manages the patient’s physiological dependence, attenuates drug use cravings and facilitates access to health-care and recovery supports. Meta-analyses of randomized controlled trials show that OAP is effective at retaining patients in treatment and reducing heroin use [6,7,8]. The World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE) recommend OAP as the front-line maintenance treatment for opioid dependence [9,10]. Oral methadone and buprenorphine are used for medically supervised withdrawal in community and hospital settings
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