Dr Karla Rix-Trott Senior Medical Officer

Dr Karla Rix-Trott Senior Medical Officer

Change in treatment approach since advent of HIV/AIDS Retention in treatment and harm reduction Many clients growing old while in treatment Change in mortality statistics

International mortality studies Previous New Zealand study Current study Discussion and some recommendations

Analysed mortality data for newly notified addicts for 2 periods 1967-76 and 1984-93 5,310 deaths in 92,802 addicts General decline in death rates and excess deaths over this period with significantly lower rates in 2 nd time period Males decrease: 13x to 7x; Females 16x to 10x Drug-related deaths 65% due to opiates most <45

Analysed studies done 1966 to 1999 Prior to HIV, deaths in discharged patients more than 2x higher than those who continued in treatment Post discharge heroin related deaths 51x the rate in active patients Alcohol related conditions leading cause in treatment in patients over 30

With onset of HIV in 1980s AIDS related conditions became major cause of death in treatment Past 2 years deaths related to HCV risen to 9% - expected to eclipse AIDS related deaths in next decade

10,454 heroin users entering treatment in 1998-2001 followed in treatment and out of treatment 41 OD deaths 10 during treatment -standardised mortality ratio (SMR) 3.9, and 31 out of treatment - SMR 21.4 Risk fatal OD 2.3% in the month immediately after treatment hazard ratio (HR) 26.6, and 0.77% thereafter HR 7.3 Need to further investigate the potential benefits and harms of short-term therapies for opiate use

Only previous NZ study Studied deaths in Wellington opioid substitution program 1972 1989 Pre HIV/AIDS Total 997 treated over this time 67 deaths (6.72%) 46M (68.66%), 21F (31.34%)

Cause of death 6 trauma 9% 28 accidental causes (23 drug overdoses 24x normal population rate) 42% 8 suicide 12% (7.1x normal population rate) 4 myocarditis & 21 other natural causes 37%

Age at death 13 in 15 to 24 age group (15.9% of total clients) 19.4% 39 in 25 to 34 age group (69.3% of total clients) 58.2% 4 in 35 to 44 age group (8.5% of total clients) 6% 11 in 45 plus age group (5.8% of total clients) 16.4%.

Observed mortality rate adjusted for age and sex cf expected rate for NZ population 15 to 24 yrs 11.5 x expected rate 25 to 34 yrs 5.8 x expected rate 35 to 44 yrs 2.6 x expected rate 45+ yrs -<1 x expected rate Overall rate 2.44 x expected rate

Information from CADS Clinical Review Committee database Coronial autopsy report obtained where uncertainty about cause of death (15 cases)

Total client numbers varied between 1066 and 1131 average 1095 51 deaths over the 5 year period (approx 4.7%) 11 in 2005, 6 in 2006, 9 in 2007, 7 in 2008 and 18 in 2009. 14 F (27.45%) F = 38% of total client deaths 37 M (72.55%) M = 62% of total clients deaths

Year 2005 2006 2007 2008 2009 Total% Age range 15 24 0 0 0 0 0 0 25 34 2 (1F, 1M) 35 44 4 (2F, 2M) 45 54 years 0 0 0 0 2 (1F, 1M) 3.92% 3 (1F, 2M) 3 (1F, 2M) 1 (1M) 3 (2F, 1M) 14 (6F, 8M) 27.45% 4 (4M) 3 (1F, 2M) 6 (1F, 5M) 3 (2F, 1M) 9 (1F, 8M) 25 (5F, 20M) 49.02% 55+ 1 (1M) 0 0 3 (1F, 2M) 6 (1F, 5M) 10 (2F, 8M) 19.61% Total 11 6 9 7 18 51 (14F, 7M)

Cause of death 2005 2006 2007 2008 2009 Total (%) Natural cause/ disease Trauma/ accident 7 (2 Liver Disease, 5 Other) 5 (3 LD, 2 Other) 5 (1 LD, 4 Other) 6 (1 LD, 5 Other) 13 (5 LD, 8 Other) 36 (70.59%) 12 LD (33.33%) 24 Other (66.67%) 0 1 1 0 1 3 (5.88%) Overdose 1 0 3 1 4 9 (17.65%) Suicide 3 0 0 0 0 3 (5.88%) Total 11 6 9 7 18 51

12 deaths from liver disease 11 chronic Hep C (21.6%), 1 chronic Hep B, at least 4 with associated alcohol abuse 24 other disease 5 Ca, 5 CV event, 6 infection (2 24 other disease 5 Ca, 5 CV event, 6 infection (2 endocarditis, 2 pneumonia, 1 H1N1 virus, 1 septicaemia), 2 complications of IDDM, 2 renal disease & 1 each pulmonary thromboembolism, CORD, acute GI bleed, uncertain

2 deaths in 15 to 34 age group 1 suicide & 1 liver disease + alcohol abuse 9 overdoses none in 15 34 age group, 3 aged 35 44 (1 methadone only, 1 methadone and methamphetamine, 1 morphine) 6 males aged 48 to 56 years (3 methadone alone, 2 alcohol & methadone, 1 alcohol, methanol & methadone)

Distinct shift in cause of death in OST in NZ in past 30 to 40 years Dukes et al 36% related to disease/natural causes and alcohol related liver disease a factor in only 2 of the deaths This study -70% due to disease/natural causes of which 1/3 due to liver disease Dukes et al 34.33% due to overdose This study 17.65% due to overdose

But 5.8% of Dukes et al clients were aged 45+ compared with 53% of AOTS clients

This study all overdose deaths in 35+ age group, 2/3 in men 48 and over & alcohol involved in half of these. Possibility of unrecognised suicide. No HIV related deaths in this post-hiv study

Prevention of Hepatitis B & C related deaths not as successful with 23% of subjects in this study dying of chronic hepatitis-related liver disease. Trend towards deaths in older patients and increased deaths from disease (particularly the effects of longterm hepatic viral infection) probably the result of increased retention in treatment and longer term treatment.

This highlights the need to encourage our clients (especially males) to become engaged in primary health care and the monitoring, management and treatment of chronic health issues. Other substance use related problems that impact on health also need addressing as well as injecting related problems, smoking reduction/cessation (both cigarettes and cannabis) and safer alcohol use.

We seem to have done well in terms of reducing overdose deaths in our younger clients but need to increase our focus on encouraging our older clients to take long-term health care issues more seriously. Further analysis of the AMS data collected, especially standardised mortality ratios, would be useful for comparing this study with other studies.

A study of the coronial autopsy reports indicated that in nearly all cases it seemed that the pathologist did not have information on whether the person was on methadone treatment nor of the person s usual dose. This appeared to create difficulties in drawing conclusions about the contribution of methadone to the death, particularly in the cases of overdose deaths.