Society of Analytical Psychology, London
Commission for Social Care Inspection, London, UK
Correspondence: Dr N. H. Rathod, Corsletts Farm, Broadbridge Heath, Horsham, West Sussex RH12 3LD, UK. E-mail: rajrathod{at}onetel.com
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ABSTRACT |
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Aims To investigate the outcome for patients treated for injected heroin addiction 33 years after they were first seen, and 26 years after they were first followed up, in terms of sustained abstinence, continuing maintenance on methadone and deaths.
Method Eighty-six people with heroin addiction first seen in in 19661967 in a small town in the south-east of England were located and their clinical state assessed using multiple sources, including personal interviews with a proportion of the cohort.
Results Forty-two per cent of the cohort had been abstinent for at least 10 years; 10% were taking methadone and were classified as addicted; and 22% had died. Eight percent of the cohort could not be located.
Conclusions Results proved favourable in the above three parameters compared with other long-term studies.
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INTRODUCTION |
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METHOD |
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Local sources
The following local sources were used:
National sources
National sources included the Home Office and the Office for National
Statistics.
Data collection
A questionnaire was used as a guideline when interviewing general
practitioners and making a record search; this was done in 28 cases (32%).
Another questionnaire was used as a guide to elicit information in personal
interviews with former patients, who we invited to come to the hospital. The
interviews, which lasted 90 min or more, were recorded, with the
patients consent; 17 patients (20%) were interviewed. Copies of death
certificates were obtained from the Office for National Statistics (17 cases)
and the local coroners office (2 cases) for the 19 cohort members (22%)
who had died.
Assessment of drug status
Drug status was ascertained by clinical judgement, founded upon information
from a range of sources as described above, for example medical records and
other official sources. The criterion of drug status adopted was that the
person had been abstinent or receiving methadone maintenance therapy for at
least 10 years prior to the collection of data. This cut-off point was chosen
because three of the group currently taking methadone had been abstinent from
opiates for up to 5 years and had then relapsed. Therefore, to be on the safe
side, we opted for a period of 10 years where we believed that relapse was
much less likely, as the results have proved.
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RESULTS |
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Drug status
Thirty-six people in the cohort (80% of those alive, 42% of the total
cohort) were not using opioids, and 9 (20% of those alive, 10% of the cohort)
were receiving methadone maintenance therapy. As mentioned above, this status
had been maintained for at least 10 years. There was no significant difference
in the proportion of those not using opioids and those using methadone among
those married or cohabiting (56 v. 66%), and there was no noticeable
difference between the two groups as far as employment was concerned
(Table 2). This could be due to
the fact that unemployment has always been low in this town.
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Use of other drugs
Seven of the abstinent group had at some time experienced problems from
excessive use of alcohol. Six of them also had been registered with clinics or
private practitioners outside our area and had received heroin or methadone
for a few years in the early 1970s. At least four of the people using
methadone had serious problems with alcohol and all of them used other
drugs.
Deaths
Nineteen people (22%) had died, 2 during the period of information
gathering (Table 3). One had
been interviewed (but has not been included in the category of the interviewed
listed above), and clinical information was obtained from the general
practitioner on the other. This amounts to 220 deaths per 1000, compared with
the crude national death rate of 11.8 per 1000 for the year 1966 and 10.6 per
1000 for the year 1997 (Office for
National Statistics, 1997). Of the 19 dead, 17 were men and 2 were
women. Twelve deaths occurred in people under the age of 40 years. The mean
age at time of death was 33 years, the youngest being 18 years, the oldest 49
years. Information on marital status was meagre. Seventeen of the death
certificates stated an occupation, but in only two cases was there information
on current employment. One person had been an invalid for many years.
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In 11 individuals (58% of deaths) overdose of drugs (excluding alcohol) was implicated, primarily in the under-40 age group. Only one such death occurred in the age group 4049 years. Overdose of opioids was the cause in eight cases, in all of which the individual was receiving methadone from a clinic outside our area. One death (case 44) was attributed to methadone poisoning in a non-dependent person. We were informed by the general practitioner that the person in case 3 was receiving methadone maintenance, even though the death certificate gave liver failure and cancer of the liver as the cause of death. In case 1, the diary entry near the time of death mentioned excessive use of methylphenidate, although the death certificate gave the cause of death as myocardial ischaemia. Of the remaining cases, two involved chronic misuse of alcohol, but the actual cause of death was multiple injuries during a fall in one case and aspiration pneumonia/liver failure in the other. Two other people died of multiple injuries in successful suicide attempts, and the remaining four died of natural causes. In none of these 8 cases was there any reason to suspect use of opioids. In the 4049 year age category, 4 out of 7 had some liver pathology. Unfortunately, we have no further details to suggest the cause of this.
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DISCUSSION |
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The study differs in three significant respects from most others. First, the sample is derived from a small town, and the patients were treated in a general psychiatric service, whereas all other longitudinal studies are based on city populations and their cohorts were treated in drug dependency clinics in the UK or special treatment facilities in the USA. Second, the mode of spread of injecting practices was through established social networks and this might have affected the outcome, in the sense that individuals are influenced by the behaviour of their friends. However, we have no proof of this and to our knowledge there is no other study on the relationship between mode of spread and outcome. Third, substitute opioids were not prescribed by our service for 23 years after recruitment of the cohort began, and as there was no other facility in the area patients were left with few options. They either had to accept treatment locally, forgo treatment or seek help elsewhere, an option that entailed a risk of exposing their addiction to family and friends and also of admitting a loss of control over their drug-using behaviour a major shift in attitude. This factor might have acted as an incentive towards abstinence in the early years of the service, but is no longer relevant because methadone prescribing started in 1989 and continues in the local service.
Attrition of the cohort and non-availability of data
We were unable to contact seven of the cohort members. This attrition rate
of 8% compares favourably with many other reports, for example 14% at 10-year
follow-up (Edwards & Goldie,
1987) and 17% at 67 year follow-up
(Willis & Osbourne, 1978). This may partly be due to the size of the town and the relative stability of
the population compared with metropolitan areas. It could also have been due
to the service emphasising the importance of keeping in touch with former
patients and the long-standing contact between N.H.R. and the local general
practitioners.
How to classify the drug status of the cohort members for whom there is no information poses a dilemma. In our study this applied to 17 individuals: for 10 we could not obtain any clinical information although we knew they were still alive, 5 could not be traced and 2 had emigrated. This inevitably affects the total results.
It is unfortunate that we were unable to interview more of the cohort members. This was partly due to the reluctance of two health centres in the town to allow us to contact these patients, in spite of our having the approval of the local ethics committee, and partly due to an understandable reluctance on the part of some of the people we contacted to be interviewed so long after their treatment. However, we can be fairly confident that as far as drug status is concerned, since the general practitioners whom we interviewed had up-to-date, detailed information about both the physical and mental health of the individuals and often also of their families in many cases, they would be unlikely to have missed evidence of long-term use of opioids.
Comparison of outcomes with the first follow-up of this cohort
The first follow-up period was up to 6 years
(Rathod, 1977). At that
assessment 13% (n=11) were judged to have stopped using any illegal
drugs, 51% (n=44) were still injecting, 6% (n=5) had died
and 12% (n=10) had experienced alcohol-related problems. Precise
comparisons between the outcomes of the 1977 study and this study are not
possible, the main reason being the large number of cases in this study for
which we have no information. However, the main trends are clear: 42% are not
using opioids and only 10% are still using them, but 22% have died.
Comparison with other long-term follow-up studies
Long-term follow-up studies resemble postmortem examinations: any
concordance among studies despite differences in the nature of the
cohorts, treatments and the methods of collecting and processing the data
will illustrate the natural history of a disorder. There are two types
of study: one-off and repeat studies. Repeat studies follow up
the same population some years later and thus the cohort acts as its own
control; they reveal trends in outcome over the years which may help future
planning of services.
We reviewed the existing three one-off British studies with a follow-up period of 10 years and a minimum cohort-size of 60 (Table 4). The death rates are comparable (1520%) but the rates of abstinence and methadone dependency differ. This may be due to the nature of the cohort, the service or other factors. Authors also differ in their definition of non-addicted patients (Cottrell et al, 1985).
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We found few repeat studies; these were of cohorts in England, California and New York (Table 5). The only common feature was the prescribing of substitute opioids (methadone).
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Outlook
It is encouraging that trend studies
(Table 5) show agreement on
certain aspects of the lives of people with narcotic addiction. The proportion
of those maintaining sustained abstinence rises with time, and simultaneously
the proportion of those still addicted declines, despite the pessimistic views
expressed by some, such as Hser et al
(2001) and Goldstein &
Herrera (1995). However, there
is no way of knowing whether the proportion of those dying because of the
effects of drug-taking reaches a peak after about 20 years. One worrying
feature is the proportion of premature deaths, mostly due to overdoses.
Except for Stimson & Oppenheimer (1982), few researchers in the UK have explored patients perceptions of their addiction or of their treatment. We address this aspect elsewhere (Addenbrooke, 2004). Interview-based studies are more frequent in the USA; for example, a 25-year longitudinal study interviewed 841 participants in order to examine trends in patterns of spontaneous remission and treatment use an impressive achievement (Price et al, 2001).
Deaths
We are not the only authors to highlight the high premature death rate and
the fact that overdose of drugs is the most common cause (see Tables
4 and
5). As overdose with opioids is
often mentioned as a cause of death, a closer monitoring of opioid use,
especially the prescribed ones, is called for. We also noticed the frequency
of liver pathology mentioned in the death certificates in our study. This is
not surprising in those who inject drugs, yet it is rarely highlighted
(Vaillant, 1973; Oppenheimer et al,
1994; Goldstein & Herrera,
1995; Hser et al,
2001). It is possible that regular screening for liver functions
may help early detection and treatment. The same could apply in the case of
alcohol misuse, which is not insignificant among drug users. Interestingly,
seven people in our abstinent group had experienced excessive use of alcohol
at some time.
A recent study advocates caution in the prescription of antidepressants to people with heroin addiction, as these therapeutic agents may be implicated in deaths due to overdoses (Cheeta et al, 2004).
Pharmacotherapy in perspective
The advantages of long-term substitute prescribing of methadone are obvious
in terms of increased social stability and the reduction of crime. However, we
were struck by the number of premature deaths in people taking methadone, and
also by the negative perceptions of life among those who are currently
prescribed this opioid. Our study findings suggest that equally satisfactory
results are possible without recourse to long-term prescribing of opioids.
This points to the necessity of comparing outcomes between people prescribed
substitute drugs for addictions and those who are not.
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication September 13, 2004. Revision received December 3, 2004. Accepted for publication January 28, 2005.
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