Quality of life in a community sample of young cocaine and/or heroin users: the role of mental disorders.

PURPOSE: Drug addiction and psychiatric disorders are frequently concomitant; however, few studies have investigated the impact of psychiatric disorders other than substance use disorder (SUD) on health-related quality of life (HRQoL) in drug users not in treatment. We studied the association of psychiatric disorders other than SUD with HRQoL in a street-recruited sample of cocaine and/or heroin users. METHODS: It is a cross-sectional study involving 287 young users of cocaine and/or heroin in Barcelona, Spain. HRQoL was assessed with the Nottingham health profile (NHP). Patterns of drug use and mental disorders were assessed using the Spanish version of the psychiatric research interview for substance and mental disorders IV, and degree of dependence through the severity of dependence scale (SDS). The association of mental disorders with HRQoL was assessed through a Tobit regression analysis. RESULTS: The overall NHP score was 23.9 (SD = 20.5, range 0-91.7). Sixty-one percent of the sample had two or more SUDs; 22 % had at least one non-SUD Axis I disorder (anxiety, mood, psychotic, or eating disorder); and 27.2 % had a borderline personality disorder (BPD) and/or antisocial personality disorder. Variables negatively associated with the global NHP score were psychosis [transformed beta coefficient: 15.23; 95 % confidence interval [CI] 4.48-25.97], BPD (9.55; 95 % CI 2.95-16.15), severity of dependence (8.12; 95 % CI 3.37-12.87), having two or more SUDs (for two or three SUDs: 6.83; 95 % CI 2.08-11.59) (>3 SUDs: 7.70; 95 % CI 1.72-13.68) and the intravenous use of some substance (10.20; 95 % CI 6.00-14.40). CONCLUSION: HRQoL among street-recruited illegal substance users was impaired, particularly among those with psychiatric comorbidity, psychosis, and BPD being especially relevant.

Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain.

AIMS: To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city. DESIGN: All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models. FINDINGS: The study recruited 5049 patients, which provided 23,048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record. CONCLUSIONS: The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.

Mortality trends in a cohort of opiate addicts, Catalonia, Spain.

BACKGROUND: Opiate addiction affects young adults whose life expectancy is reduced as a consequence of their habit. In the midst of the AIDS epidemic, the present study objective was to analyse recent overall and cause-specific mortality trends among opiate addicts in Catalonia (Spain). METHODS: Mortality was assessed retrospectively in an opiate addict cohort assembled from admissions to hospital emergency wards and drug treatment centres during the period 1985-1991. The cohort included 12 711 opiate addicts (12 045 men and 3666 women) aged 15-44 years. Overall and cause-specific mortality trends were analysed using age as the time scale and Cox regression with staggered entry determined by the age at entry in the study. Annual trends were adjusted by sex and source of entry, and were stratified by length of opiate use. RESULTS: Mortality rates increased throughout the entire period from 13.8 to 34.8 deaths per 1000 person-years, with a statistically significant increase in 1987-1988 and 1988-1989. In a model including age, gender, source of entry and length of drug use, risk increased significantly in men and for longer length of use, but not with age and for source of entry into the study cohort. The causes of death associated with high mortality rates were AIDS and the causes directly related to addiction. CONCLUSIONS: A threefold increase in mortality rates was observed during the period, mainly accounted for by AIDS and direct addiction-related causes. Length of opiate use was an important determinant of mortality.

Opiate and cocaine consumers attending Barcelona emergency rooms: a one year survey (1989).

Due to the limitations of standard epidemiological methods, indirect indicators have often been used to describe the characteristics of drug abusing populations and to assess prevalence trends in illegal drug use. In Barcelona (Spain), a study of emergency room (ER) attendance was carried out to describe the population of opiate/cocaine consumers across the whole city who use this service. Three thousand four hundred and five consumers of opiates and/or cocaine, aged 15-44 years, who attended ERs during 1989, were identified. They accounted for 6807 episodes in the hospitals surveyed. Their mean age was 26 years, men (73%) being 1 year older than women (25.2 years). The drug of abuse was specified in the clinical records of 60% of individuals, heroin being the most frequently specified (56%). The main reason for attendance was 'other medical condition' (OMC) (55% of episodes), followed by withdrawal (34%) and overdoses (6%). Seventy-one percent of individuals were residents of Barcelona city, yielding a rate of 3.2 opiate/cocaine consumers attending ERs per thousand Barcelona residents aged 15-44. The geographical distribution of the rates in the city showed a very large difference between districts, the most deprived ones having a higher rate of consumers attending ERs. ER data can provide valuable insights into the nature and dimensions of drug abuse problems.

Use of the Nottingham Health Profile for measuring health status of patients in methadone maintenance treatment.

This study was conducted to assess changes in health-related quality of life over a 3-year follow-up period in a cohort of 135 opioid dependent patients using the Nottingham Health Profile (NHP) questionnaires. Data obtained at 12 months from 80 patients retained in the programme are presented. In summary, opioid addicts in a methadone maintenance programme for a 12-month period experienced an early and substantial improvement in health-related quality of life. The use of the NHP questionnaire to monitor changes in the subjective health of opioid-dependent patients over time provides new insights in the assessment of treatment effectiveness of methadone maintenance programmes.

A small area analysis estimating the prevalence of addiction to opioids in Barcelona, 1993.

STUDY OBJECTIVE: To determine the distribution of opioid use prevalence in small areas and its relation with socioeconomic indicators. DESIGN: Capture-recapture was applied using data from the Barcelona Drug Information System for 1993 (treatment demands, hospital emergency room visits, deaths from heroin acute adverse reaction and pre-trial prison admissions). To avoid dependence between sources, a log-linear regression model with interactions was fitted. For small neighbourhoods, where capture-recapture estimates were not obtainable, the Heroin Problem Index (HPI) was used to predict prevalence rates from a regression model. The correlation between estimated opioid use prevalence by neighbourhoods and their socioeconomic level was computed. MAIN RESULTS: The city's estimated prevalence was 12.9 opioid addicts per 1000 inhabitants aged 15 to 44 years (95% CI: 10.1, 17.2), which represents 9176 persons. The highest rate was found in the inner city neighbourhood. Comparing rates obtained for each neighbourhood with their unemployment rates, a high correlation coefficient was obtained (r = 0.80, p < 0.001). CONCLUSION: The main contribution of this study is that of combining capture-recapture with the HPI to produce small area prevalence estimates, which would not have been possible using only one method. Areas with higher socioeconomic status showed proportionally low addiction prevalences, but in depressed areas, prevalences varied widely.

Methadone treatment in Spain, 1994.

The objective of this study was to describe the methadone treatment (MT) network in Spain, and to evaluate compliance with criteria known to influence the spread of human immunodeficiency virus (HIV). During the last 3 months of 1994, a mailed questionnaire was sent to the coordinators of all methadone treatment centers in Spain. A total of 224 centers completed the questionnaire (90% response rate). The total number of patients receiving MT in the studied centers was 13,402. Their mean age was 29 years, 79% were male, and approximately 60% were HIV positive. The rate of patients in MT varied by Region (mean: 6.7 patients in MT per 10,000 inhabitants). Although the global mean of reported daily dose of methadone was 60 mg, in 44% of the centers it was lower than that. Despite the high number of centers involved with MT in Spain, the coverage by regions is unequal. Studied centers revealed only a moderate adherence to procedures considered to be effective in HIV prevention. Given the magnitude of HIV infection in Spain, there is a clear need for improvement.

Differences in mortality between patients attending the emergency room services for asthma and chronic obstructive pulmonary disease.

Asthma has a more favourable prognosis than chronic obstructive pulmonary disease (COPD), based on studies including few asthmatics and few women with COPD. We assessed differences in mortality between people attending the emergency room for asthma and for COPD in a population-based cohort. We recruited all the men and women, who were residents of Barcelona (Spain) over 14 years of age, who attended emergency room services for an obstructive lung disease during the period 1985-1989. Vital status was followed up to the end of 1995. A total of 15,517 individuals (including 4555 asthmatics and 2194 females with COPD) were studied. Mortality was ascertained using a record linkage with the regional Mortality Registry. Overall, 43.6% people died during the follow-up period. Mortality was higher among individuals with COPD than with asthma, in males and females, for all causes of death, as well as for cancer, cardiovascular and respiratory causes. After adjusting for age, the relative risk (RR) of dying of a male attending for COPD and discharged home was 1.50 (1.29-1.74) in comparison with a male attending for asthma, and 3.06 (2.66-3.51) for a male attending for COPD and admitted into the hospital. Similar figures were found for females. The increased risk for patients with COPD was significantly higher than for asthma in all age groups. Both males and females with asthma have a more favourable prognosis than patients with COPD, for all age groups.

Psychosocial considerations for the prevention of HIV infection in injecting drug users.

In this article, the authors discuss a study that investigated the meaning that injecting drug users attribute to risk behaviors linked to HIV transmission, especially through the use of nonsterile syringes or the failure to use condoms. To do this, social discourses with respect to the prevention of HIV infection are evaluated. The discussion focuses on how these discourses affect the daily practices of heroin users, practices that in turn influence discourses. Ethnography was used to observe 78 heroin users and 35 people following a methadone treatment program. Observation was carried out in a central district of Barcelona, Spain, with a low socioeconomic level. The results are a useful starting point for generating strategies aimed at preventing HIV transmission among this population on personal, community, and sociostructural levels.

[Information on opiate and cocaine consumption in the emergency room clinical records: validity and reliability]. / Información sobre el consumo de opioides y cocaína en la anamnesis de urgencias: validez y fiabilidad.

BACKGROUND: Data on drug consumption obtained from emergency room clinical records have been used for various epidemiological purposes. However the validity and reliability of these data remain unknown. This paper assesses the reliability and validity of an Emergency Room Toxicological Register (HMR) which has collected information on drug misuse from emergency room clinical records since 1979, and examines the implications for epidemiological applications. SUBJECTS AND METHODS: An Emergency Room Survey (ERS) was carried out in a Barcelona Hospital including opiate or cocaine users identified by the physician and a systematic sample of other patients age 15 to 49 years old. Data on clinical records of interviewed patients were also reviewed. Episodes from identified drug users (686) and HMR (676) for the same study period were linked and validity and reliability were analyzed. RESULTS: Sensitivity ranged between 63 and 86%, and specificity was 98%, Kappa index higher than 0.72 and intraclass correlation coefficient was 0.99. CONCLUSIONS: Information about drug users included in emergency room clinical records proved to be valid as an information system for drug use surveillance. However data about patterns of less heavy users, as cocaine use, are underreported.

[Prevalence of human immunodeficiency virus and risk behaviours among opioid users seen in an emergency room]. / Prevalencia de la infección por el virus de la inmunodeficiencia humana y conductas de riesgo en consumidores de opioides visitados en un servicio de urgencias.

INTRODUCTION: As prevalence of HIV-1 among drug users in Spain is high and it is difficult to contact them because of their hidden behaviors, emergency rooms are one of the health facilities where they can be located. A cross-sectional interview study was planned. The aims of the study were to estimate prevalence of HIV-1 and to describe risk behaviors. METHODS: The sample included all patients that in spring 1992 were detected and referred by the doctor as being current opiate users, defined as any use in the 30 days prior the interview. Drug users who did not know their HIV status or were negative for more than six months were asked to provide a urine sample to test HIV serology. A descriptive analysis with simple stratification was carried out. Row and adjusted odds ratio were used to analyse association between different variables and HIV status. Logistic regression was used to examine variables associated with HIV infection and risk behaviors (injecting drug use, sharing needles, and no use of condom). RESULTS: Three hundred and eighty three opiate users were interviewed. It was possible to know HIV status of 94% of the subjects. Of them, 61% were positive (219). The best adjusted logistic model to predict associated variables with HIV included being female, primary school level, sickness absence, to attend because of organic pathology, and more years of parenteral use. Seventy five percent of the sample injected drugs during the past 30 days, and among them 30% shared syringes. The variables associated with a higher probability of having injected heroin or cocaine in the last 30 days were to have completed at least primary education, to be unemployed or reliant on illegal activities, not to be in drug treatment, and a larger number of drugs used in the last 30 days. A higher probability of sharing syringes was associated with a lower educational level, not to be in drug treatment, to live alone and a higher number of drugs used during last 30 days. Twenty one percent of the subjects who were sexually active always or nearly always used condom with regular partners and 56% with casual partners. Women were more likely to use condom than men with casual partners. Subjects who shared syringes during last 30 days were nearly three times more likely not to use condom with casual partners. CONCLUSIONS: Although a high prevalence of HIV-1 was estimated among opioid users seen in an emergency room, it is not higher than estimates for intravenous drug users recruited from treatment centres, prison or needles exchange programs. A high frequency of risk behavior was also observed indicating a need to develop specific prevention programs for drug users.

[The characteristics of opiate users seen in an emergency service]. / Características de los consumidores de opioides visitados en un servicio de urgencias.

INTRODUCTION: Despite of the fact that it was reported for years that emergency rooms are the first health services where drug users attend, there are very few direct studies of this population. In most emergency room studies, the information was obtained from data available in the clinical records, and in very few drug users were interviewed. With the aim of having a deeper knowledge of opiate users who attend the emergency room it was planned to carry out a cross-sectional study interviewing them. The aims of this paper are to describe demographic characteristics, patterns of drug use and to know whether they contact first to an emergency room or to a treatment centre. METHODS: The sample included all patients detected and referred by the doctor as being current opiate users, defined as any use in the 30 days prior the interview. A descriptive bivariate analysis with simple stratification was carried out. RESULTS: Of the subjects referred by the doctor 383 opiate users were interviewed and 76 were not interviewed. The male/female ratio for the 383 interviewed opiates users was 2. Women were younger than men (25.8 vs 28.3, p (3/4) 0.001). Heroin or cocaine ever injected was reported by 93% and 76% reported injecting in the last 30 days. The mean age at the first use of heroin was higher for those who started use during 1989 or after (21.6) than those who started before 1989 (17.9) (p (3/4) 0.0001). Patients attending the emergency room for organic pathology were older (28.5) than those who attended for withdrawal (26.2) and those who attended for overdose (27.3) (p (3/4) 0.05). Thirty eight percent reported to attend first an emergency room for a drug related problem since they started drug use, and 47% to contact first with a treatment centre for drug dependence. CONCLUSION: Drug users interviewed seem to be more heavy users than those who started drug treatment in the public centres of Barcelona in 1992. Also, the hypothesis that emergency rooms are for this population the first contact point with health services is not supported by this study.

[Methadone maintenance programs with supplementary services: a cost-effectiveness study]. / Programas de mantenimiento de metadona con servicios auxiliares: un estudio de coste-efectividad.

OBJECTIVE: Methadone maintenance programs (MMP) currently offer the best treatment for opioid-addicted patients. The aim of this study was to examine the cost-effectiveness of three MMPs that offered varying levels of supplementary services. Health-related quality of life was used as a measure of effectiveness. METHODS: A 12-month follow-up study of 586 patients beginning methadone treatment in Drug Care Centers in Barcelona was performed. The Nottingham Health Profile was used to measure quality of life. Standard unit costs and total cost per patient were calculated from activity registries. Sociodemographic, health-related and toxicological data were collected through a semi-structured interview. A cost-effectiveness analysis was performed through two multiple linear regressions with the same adjusting variables. RESULTS: The greater the number of supplementary services involved, the higher the costs. The adjusted models revealed a significant increase in health-related quality of life (an increase of 8% in the Nottingham Health Profile) and in costs (17%) between low- and medium-intensity programs. CONCLUSION: The medium-intensity program showed the best cost-effectiveness ratio. However, the study's limitations preclude categoric generalization of the data.

[Proposal of an indicator of "social class" based on the occupation]. / Propuesta de un indicador de la "clase social" basado en la ocupación.

Socioeconomic level is a variable related with health. In order to obtain an indicator of this variable which is suitable for epidemiological and public health studies, we propose to assign the "social class" on the basis of occupation. Having as a reference the British Classification of Social Class we have used the National Classification of Occupations (CNO) for social classification. Once elaborated, we have used the classification in two population-based studies. More than 96% of individuals studied could be classified. We evaluate the usefulness of this indicator and its limitations. Also, we have indicate the need of validating the proposed classification in the future.

[Formation of a cohort of opiate addicts through linkage of confidential records]. / Obtención de una cohorte de adictos a opiáceos a partir de la conexión de registros confidenciales.

The need to combine several files in order to create a cohort of opiate addicts, sufficiently large for the analysis of its mortality, requires use of the probabilistic method of record linkage. This study is a preliminary phase in which two sub-files of the Hospital del Mar (Barcelona) Register of toxicological emergencies are linked. This phase served to adapt probabilistic record linkage to our files, develop computer programs, define agreement criteria, and evaluate the validity and performance of the method. In order to safeguard confidentiality, identification variables were limited to sex, birth date and three initial letters from each surname. The automated probabilistic linkage was seen to be feasible, valid and efficient; in contrast to deterministic approaches, sensitivities and specificities above 95% were obtained with visual reviewing of under 5% of the records. Difficulties encountered during the process are discussed.

Depression among regular heroin users: the influence of gender.

The aim of this study was to determine the prevalence of recent (last 12 months) depression in regular young heroin users and to ascertain factors associated with depression in this population, broken down by gender. A sample of 561 participants completed a cross-sectional survey. Eligibility criteria were: age 30 years or younger, and having used heroin for at least 12 days in the last 12 months and at least one day in the last 3 months. Participants were recruited outside of health-care facilities in the cities of Barcelona, Madrid and Seville by targeted sampling and chain referral methods. Depression was assessed using the World Mental Health Composite International Diagnostic Interview. The prevalence of recent depression was 22.3% (35.2% among women and 17.3% among men, p<0.001). In the multivariate analysis, the factors positively associated with recent depression in the whole sample were female gender, age 25 or less, inability to work due to health problems and high risk consumption of alcohol. Among woman, the related variables were age 25 or less, cocaine dependence in the last 12 months, and alcohol consumption in that period. Among men, employment status was the only related variable. Analysis of an overall sample without the gender breakdown may hide important differences in the factors associated with depression in men and women. Both prevention and treatment of depression should rely on specific gender analysis.

Glossary of terms relating to capture-recapture methods.

This glossary provides basic definitions for terms that have a specific meaning in the application of the capture-recapture methodology, particularly with respect to standard techniques for the application of log linear models to multiple lists. In epidemiology, capture-recapture is used for prevalence estimation. It is intended that, as well as being a central point of reference for terms used in the capture-recapture methodology, this glossary should provide a resource for those new to this methodology. It aims to provide a simple introduction using terms that should be understood by an uninitiated audience.

Health-related quality of life in young cocaine users and associated factors.

AIM: To analyse drug consumption patterns and demographic and medical factors associated with health-related quality of life (HRQL) in a nonclinical sample of regular cocaine consumers. METHODS: Face-to-face interviews with 687 young regular cocaine users (aged 18-30 years) in three Spanish cities: Barcelona, Madrid and Seville. HRQL was measured using the Nottingham Health Profile (NHP), and degree of dependence through the Severity of Dependence Scale (SDS). Bivariate analyses were conducted using nonparametric techniques, and a Tobit regression analysis was carried out to determine which variables best explained HRQL. RESULTS: Most participants showed a good HRQL, but differences in HRQL were found for sociodemographic (gender), medical (days stayed in bed during the previous 12 months) and consumption-pattern related variables (length of drug use, intravenous drug use, crack use, SDS). In multivariate analyses cocaine dependence measured by SDS explained the greatest amount of HRQL variation. Although women declared worse HRQL (13.6 versus 9.7, P < 0.01), in the final model with interactions no gender differences were observed, except that HRQL for women worsened with the number of days they had stayed in bed in the previous 12 months. CONCLUSIONS: Even in early phases of dependence, deterioration in HRQL is observed, mainly related to drug-use history and patterns.