Half the picture – beyond drug overdose as a cause of death in opioid using people

The big rise in heroin and other opioid drug poisonings that the ONS reported last year has been real focus of concern amongst service providers, policy makers and anyone who cares about the lives of vulnerable people.

But new research from the University of Manchester suggests that while overdoses in opioid users remains the largest cause of death (43%) there are other causes which providers, commissioners and policy makers need to be conscious of particularly amongst older drug users.

Dr Tim Millar who led the research says,

“It is apparent that older users of opioids are one of the most vulnerable groups in society.”

Looking at the paper it’s easy to see why.

The researchers have examined data on 198,247 individuals over 541,891 person years between April, 2005 and March, 2009 and find that there were more than five and a half times the number of deaths amongst opioid users than would be expected in the general population.

Their research suggests that older users are much more vulnerable to both overdose and a number of other diseases than both the general population and their younger peers.

This research makes clear that 15% of the deaths not categorised as drug-related poisonings were caused by liver disease. The majority were alcoholic liver disease (72%) where the opioid users were 7 times more likely to be affected by the disease than the general population.

Fibrosis and cirrhosis of the liver was also a significant factor in the deaths observed in the study (19% of liver disease deaths amongst the cohort).  The researchers found that the chances of being affected by this increased dramatically amongst older opioid users.  Younger users (18-34 years) were just under three times more likely to die of fibrosis and cirrhosis of the liver as the general population, but this rose to 6 times for the 35 to 44 year olds, and then to 14 times for the 45-64 year old opioid users captured in the data sets examined by the researchers.

• 2 in 5 injecting drug users are living with Hepatitis C

There is increasing focus on smoking related diseases by substance use services – for example Turning Point worked with Public Health England on smoking cessation pilots in six of their services last year.  The data from the Manchester University research suggests that there are higher rates of death amongst opioid users as a result of circulatory system diseases (3.1 times higher), respiratory system problems (8.9 times higher), and cancer (1.8 times higher), which makes this focus an imperative.

Worryingly the research found that rates of homicide were 12 times higher in opioid users than in the general population, and that was markedly higher amongst older opioid users.

The rate of homicides in the United Kingdom during the period of the study was 1 per 100,000 of population.  Younger users (18-34 years) were more than 8 times as likely to be murdered; those between 35 and 44 more than 15 times; and for those between 45 and 64, they were a staggering 27 times more likely to be murdered than the general population.

Suicide rates were also much higher than might be expected with rates of between three and four and a half times higher than the general population.

DrugScope’s policy work on older drug users makes the following recommendations:

• A range of interventions are needed for older people with substance use problems, from age-appropriate, non-time limited treatment and support for those who are drug and/or alcohol dependent, to brief interventions for those who are drinking at risk. Support for those with problems with prescription and/or over-the-counter medications also needs to be available.
• Many of the services we visited during the research process for the briefing were delivering positive outcomes but faced a discontinuation of their funding. Independent and statutory funders and commissioners need to recognise the importance of services and interventions for older people and to consider options for sustainable funding going forward, particularly as research indicates increased prevalence and need.
• Substance misuse services can implement a range of measures to help ensure the accessibility and relevance of services for older people, including specific groups or times for older people, satellite services operating out of community provision aimed specifically at older people – for instance, local support groups – and home visits.
• Older people with substance misuse problems may come into contact with a number of health and social care professionals, including those working in primary care settings, older people’s mental health services, residential services, and for social care providers. With particular reference to alcohol, these professionals should be trained to deliver brief interventions (IBA) and ‘sensible drinking’ advice to those who are not dependent, but are drinking at risk. Links with specialist support should be developed for referral of those with serious substance misuse problems.

Read our report It’s about time: Tackling substance misuse in older people