Opium Use and Mortality: A Prospective Cohort of 50,000 Adults in Iran Farin Kamangar 1

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 2

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 3

Opium and Opioid Use Recreational and medicinal use Recreational and medicinal use Long history Long history 13 – 22 million used opium or its derivatives in – 22 million used opium or its derivatives in 2008 Many areas of the world Many areas of the world 4

Opium: Recreational Use (19 th Century) 5

Opium: Medicinal Use 6

Opium: Distributed and Used Worldwide 7

Long History: Goddess of Opium 8

Tintin and Opium Use 9

Epidemiologic Studies of Opium and Health Very few epidemiologic studies of chronic opium use, despite such widespread use and long history Very few epidemiologic studies of chronic opium use, despite such widespread use and long history Only a few case-control studies Only a few case-control studies 10

Studies of Opium and Health Increases the risk of esophageal cancer (Ghadirian 1985, Nasrollahzadeh 2008) Increases the risk of esophageal cancer (Ghadirian 1985, Nasrollahzadeh 2008) Increases the risk of bladder cancer (Behmard 1981, Aliasgari 2004, Shakhssalim 2010, Hosseini 2010) Increases the risk of bladder cancer (Behmard 1981, Aliasgari 2004, Shakhssalim 2010, Hosseini 2010) Increases the risk of laryngeal cancer (Mousavi, 2003) Increases the risk of laryngeal cancer (Mousavi, 2003) Increases the risk of two other cancers (unpublished) Increases the risk of two other cancers (unpublished) 11

Studies of Opium and Health Increases the risk of cardiovascular disease (Sadeghian 2007, Sadeghian 2010, Masoomi 2010, Masoumi 2010) Increases the risk of cardiovascular disease (Sadeghian 2007, Sadeghian 2010, Masoomi 2010, Masoumi 2010) Increases the risk of deep vein thrombosis (Safaii 2010) Increases the risk of deep vein thrombosis (Safaii 2010) Increases the risk of lung disease with chronic obstruction (Da Costa 1971) Increases the risk of lung disease with chronic obstruction (Da Costa 1971) 12

Research Gap No large-scale or long-term prospective cohort studies of opium and health No large-scale or long-term prospective cohort studies of opium and health 13

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 14

Objectives Use data from Golestan Cohort Study To determine the effect of opium use on overall and cause-specific mortality To determine the effect of opium use on overall and cause-specific mortality To determine this effect by type of opium use To determine this effect by type of opium use Teriak Teriak Shireh Shireh Sukhteh Sukhteh Heroin Heroin 15

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 16

Golestan Cohort In Golestan Province, northeast of Iran In Golestan Province, northeast of Iran 50,045 adults, 40 to 75 years of age 50,045 adults, 40 to 75 years of age Detailed questionnaire data Detailed questionnaire data General Questionnaire General Questionnaire Food Frequency Questionnaire Food Frequency Questionnaire Biologic samples Biologic samples Blood Blood Urine Urine Hair Hair Nail Nail 17

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Very High Rates of Esophageal Cancer Anecdotal reports Anecdotal reports Reports from central institutions (Habibi 1965, Haghighi 1971) Reports from central institutions (Habibi 1965, Haghighi 1971) Exploratory observations (Kmet 1966) Exploratory observations (Kmet 1966) Cancer registry (1968 to 1971, Iran-IARC collaborations) Cancer registry (1968 to 1971, Iran-IARC collaborations) 20

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Registry Results The highest rates ever reported in the world The highest rates ever reported in the world Rates also very high in women Rates also very high in women Large differences in rates in 500 kilometers Large differences in rates in 500 kilometers 22

Ecologic Studies in the 1970s Differences in fauna and flora Differences in fauna and flora Differences in foods consumed (sheep’s milk, fruit and vegetables, sesame oil, etc) Differences in foods consumed (sheep’s milk, fruit and vegetables, sesame oil, etc) Hot tea consumption in high quantities Hot tea consumption in high quantities Chewing of nass (a mixture of ash, lime, and tobacco) Chewing of nass (a mixture of ash, lime, and tobacco) Opium use (up to 50% of both sexes over 35 years) Opium use (up to 50% of both sexes over 35 years) 23

Case-Control Study (350 cases and 700 controls) Not associated: sheep’s milk, sesame oil, chewing of nass, use of pregnancy diets, salting and sun- drying Not associated: sheep’s milk, sesame oil, chewing of nass, use of pregnancy diets, salting and sun- drying Moderately associated: cigarette smoking, drinking hot tea, low intake of fresh fruits and vegetables, low socio-economic status Moderately associated: cigarette smoking, drinking hot tea, low intake of fresh fruits and vegetables, low socio-economic status Not assessed: opium use Not assessed: opium use Cook-Mozaffari, BJC 1979 Cook-Mozaffari, BJC

Opium: Further Studies Types: Types: Crude opium Crude opium Sukhteh (opium pipe residues): mutagen in Ames test Sukhteh (opium pipe residues): mutagen in Ames test Shireh (refined opium extract) Shireh (refined opium extract) Hewer, Lancet 1978 Case-control study of families Case-control study of families A half-completed case-control study showed a non-significant two-fold risk associated with EC risk A half-completed case-control study showed a non-significant two-fold risk associated with EC risk Ghadirian, IJC 1985 Ghadirian, IJC

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Summary Results from the 1970s Northeastern Iran: a very high-risk area for EC Northeastern Iran: a very high-risk area for EC Risk similar in men and women Risk similar in men and women Smoking a weak risk factor, and alcohol consumption very uncommon Smoking a weak risk factor, and alcohol consumption very uncommon Some risk factors suggested (low SES, low intake of fresh fruit and vegetables, hot tea intake, but none striking) Some risk factors suggested (low SES, low intake of fresh fruit and vegetables, hot tea intake, but none striking) Opium: some suggestions, but studies incomplete Opium: some suggestions, but studies incomplete 27

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Case-Control Study: Basic idea To re-evaluate the previous hypotheses for the very high incidence of esophageal cancer (e.g., opium use, hot tea intake, low socioeconomic status, low intake of fresh fruits and vegetables) To re-evaluate the previous hypotheses for the very high incidence of esophageal cancer (e.g., opium use, hot tea intake, low socioeconomic status, low intake of fresh fruits and vegetables) To test new hypotheses (e.g., animal contact, oral hygiene, genetic studies) To test new hypotheses (e.g., animal contact, oral hygiene, genetic studies) Use new technology (e.g., new genotyping capabilities, proteomics) Use new technology (e.g., new genotyping capabilities, proteomics) 31

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Cases and controls 300 esophageal cancer cases (all squamous cell) 300 esophageal cancer cases (all squamous cell) 600 neighborhood controls, matched for age, sex, and neighborhood of residence 600 neighborhood controls, matched for age, sex, and neighborhood of residence 33

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Data and samples General questionnaire General questionnaire Food Frequency Questionnaire (validated against 24- hour recalls) Food Frequency Questionnaire (validated against 24- hour recalls) Blood Blood Hair and Nail Hair and Nail Biopsy samples Biopsy samples 35

General Questionnaire Demographic characteristics Demographic characteristics Residential history Residential history Occupational history Occupational history Family and SES Family and SES Personal history of disease Personal history of disease Upper GI signs and symptoms Upper GI signs and symptoms Personal and family history of cancer Personal and family history of cancer Tobacco and opium use Tobacco and opium use Alcohol consumption Alcohol consumption Medication history Medication history Oral health Oral health Anthropometric indices Anthropometric indices Animal contact Animal contact Tea consumption Tea consumption Physical activity Physical activity Methods of cooking and food preservation and water source Methods of cooking and food preservation and water source 36

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Esophageal Cancer Lecture for Turkmen Doctors 41

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Case-Control Study Recruitment started in 2003 and was completed in Recruitment started in 2003 and was completed in A total of 300 cases and 571 matched controls were recruited. A total of 300 cases and 571 matched controls were recruited. Several papers have been published. Several papers have been published. 44

Opium and Tobacco Use in Relation to Esophageal Cancer Tobacco and/or opium Tobacco and/or opium Neither1.00 Neither1.00 Tobacco only1.70 (1.05 – 2.73) Tobacco only1.70 (1.05 – 2.73) Opium only2.12 (1.21 – 3.74) Opium only2.12 (1.21 – 3.74) Both 2.35 (1.50 – 3.67) Both 2.35 (1.50 – 3.67) Some 30% of all cases can be attributed to these two factors. Some 30% of all cases can be attributed to these two factors. Nasrollahzadeh et al. BJC 45

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Cohort Study 47

Cohort Study This cohort study was designed to enroll 50,000 subjects from the eastern part of Golestan Province, with objectives similar to the case-control study. This cohort study was designed to enroll 50,000 subjects from the eastern part of Golestan Province, with objectives similar to the case-control study. Design was very similar to the case-control study. Design was very similar to the case-control study. General questionnaire General questionnaire Dietary questionnaire Dietary questionnaire Blood Blood Hair and nail Hair and nail Urine Urine 48

Cohort Study Plasma (x8), RBC (x2), and buffy coat (x4) are stored in bar-coded straws and kept in – 80 freezers or nitrogen tanks. Plasma (x8), RBC (x2), and buffy coat (x4) are stored in bar-coded straws and kept in – 80 freezers or nitrogen tanks. Urine samples (used for PAH and opium assays) are also stored in -20 freezers or nitrogen tanks. Urine samples (used for PAH and opium assays) are also stored in -20 freezers or nitrogen tanks. Half the samples in Iran and half in IARC. Half the samples in Iran and half in IARC. 49

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Cohort Study Outcomes: Outcomes: Death (from any cause) Death (from any cause) Incident cancer (any site) Incident cancer (any site) Esophageal and gastric cancers (emphasis) Esophageal and gastric cancers (emphasis) Outcome assessment: Outcome assessment: All relevant data are collected from hospitals and clinics All relevant data are collected from hospitals and clinics Two internists assign codes; may be a third one Two internists assign codes; may be a third one For EC and GC: an international panel of experts For EC and GC: an international panel of experts 51

Cohort Study Recruitment started in 2004 and was completed in May Recruitment started in 2004 and was completed in May Follow-up continues to date Follow-up continues to date 52

Cohort Study Follow-Up Annual follow-up: Annual follow-up: Private phone (available to 98% of the participants) Private phone (available to 98% of the participants) Phone numbers from relatives and friends Phone numbers from relatives and friends Home visits Home visits In rural areas: the Behvarz (local health person) In rural areas: the Behvarz (local health person) Follow-up through May 2011: Follow-up through May 2011: 234,928 person-years 234,928 person-years > 99% success rate > 99% success rate 2,145 deaths (130 due to esophageal cancer) 2,145 deaths (130 due to esophageal cancer) 53

Case-control GEMINI Cohort 54

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 55

Regression model Cox proportional hazards models to estimate the hazard ratios and 95% confidence intervals Cox proportional hazards models to estimate the hazard ratios and 95% confidence intervals Adjustment for potential confounders Adjustment for potential confounders Assessment of interactions Assessment of interactions Sensitivity analyses Sensitivity analyses 56

Exposure and Outcome Variables Exposure: Opium use Exposure: Opium use Type (teriak, shireh, sukhteh, heroin) Type (teriak, shireh, sukhteh, heroin) Typical amount of use in nokhod (~ 0.2 g) Typical amount of use in nokhod (~ 0.2 g) Duration of use Duration of use Frequency of use Frequency of use Outcome: Death Outcome: Death Overall Overall Cause-specific Cause-specific 57

Other Variables Potential confounders and effect modifiers Potential confounders and effect modifiers Age Age Sex Sex Place of residence Place of residence Ethnicity Ethnicity Marital Status Marital Status Highest educational level Highest educational level Cigarette smoking Cigarette smoking Body mass index Body mass index Height Height Consumption of fruit and vegetables Consumption of fruit and vegetables Socioeconomic status indicators Socioeconomic status indicators 58

Pilot Studies Reliability and validity of opiate use self-report in a population at high risk for esophageal cancer in Golestan, Iran. (Cancer Epidemiol Biomarkers Prev. 2004) Reliability and validity of opiate use self-report in a population at high risk for esophageal cancer in Golestan, Iran. (Cancer Epidemiol Biomarkers Prev. 2004) Golestan cohort study of oesophageal cancer: feasibility and first results. (Br J Cancer. 2005) Golestan cohort study of oesophageal cancer: feasibility and first results. (Br J Cancer. 2005) Validity and reliability of a new food frequency questionnaire compared to 24 h recalls and biochemical measurements: pilot phase of Golestan cohort study of esophageal cancer. (Eur J Clin Nutr. 2006) Validity and reliability of a new food frequency questionnaire compared to 24 h recalls and biochemical measurements: pilot phase of Golestan cohort study of esophageal cancer. (Eur J Clin Nutr. 2006) 59

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 60

Study Population 50,045 participants 50,045 participants 234,928 person-years of follow-up 234,928 person-years of follow-up Median follow-up = 4.7 years Median follow-up = 4.7 years Mean age at enrollment = 52 years Mean age at enrollment = 52 years 58% women 58% women 74% of Turkmen ethnicity 74% of Turkmen ethnicity 70% no formal education 70% no formal education 17% smokers 17% smokers 17% opium users 17% opium users 61

Opium Distribution Routes 62

Global Opium Consumption 63

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All-Cause Mortality HR (95% CI) HR (95% CI) Unadjusted = 2.26 (2.06 – 2.47) Unadjusted = 2.26 (2.06 – 2.47) Adjusted = 1.86 (1.68 – 2.06) Adjusted = 1.86 (1.68 – 2.06) Almost doubling the risk Almost doubling the risk Much stronger than cigarette smoking Much stronger than cigarette smoking (Khademi, BMJ 2012) (Khademi, BMJ 2012) 65

Opium and Mortality Adjusted HR (95% CI) All Causes (n = 2145) 1.86 (1.68 – 2.06) All Causes (n = 2145) 1.86 (1.68 – 2.06) Circulatory (n = 1073)1.81 (1.56 – 2.09) Circulatory (n = 1073)1.81 (1.56 – 2.09) Cancer(n = 449)1.61 (1.28 – 2.03) Cancer(n = 449)1.61 (1.28 – 2.03) Respiratory (n = 95)3.78 (2.36 – 6.04) Respiratory (n = 95)3.78 (2.36 – 6.04) Digestive (n = 69)3.12 (1.82 – 5.37) Digestive (n = 69)3.12 (1.82 – 5.37) Infectious (n = 51)5.47 (2.87 – 10.4) Infectious (n = 51)5.47 (2.87 – 10.4) External (n = 135)0.86 (0.54 – 0.35) External (n = 135)0.86 (0.54 – 0.35) Other (n = 150)1.66 (1.11 – 2.48) Other (n = 150)1.66 (1.11 – 2.48) Unknown (n = 123)2.42 (1.59 – 3.67) Unknown (n = 123)2.42 (1.59 – 3.67) 66

By Duration of Use (only in those who used it before diagnosis of major diseases) Never users1.00 Never users1.00 Former users1.27 Former users1.27 Current users1.70 Current users1.70 ≤ 3 years1.62 ≤ 3 years to 7 years to 7 years to 12 years to 12 years to 20 years to 20 years1.79 ≥ 21 years1.90 ≥ 21 years1.90 p for trend < p for trend <

By time since last used 68

Subtype Analyses & Sensitivity Analyses Teriak, shireh, and heroin all increased risk Teriak, shireh, and heroin all increased risk Both smoking and ingesting opium increased risk Both smoking and ingesting opium increased risk Excluding deaths that occurred in the first 6, 12, 18, and 24 months of follow-up had little effect on the results Excluding deaths that occurred in the first 6, 12, 18, and 24 months of follow-up had little effect on the results Further adjustment didn’t change the results Further adjustment didn’t change the results Results remained unchanged in a “healthy” subcohort analysis Results remained unchanged in a “healthy” subcohort analysis 69

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 70

Evidence for Causality (1) Consistent with results of case-control studies of cancer and cardiovascular diseases Consistent with results of case-control studies of cancer and cardiovascular diseases Relatively strong association (hazard ratio of ~ 2), stronger than tobacco use in this population Relatively strong association (hazard ratio of ~ 2), stronger than tobacco use in this population Dose-response association with duration of use Dose-response association with duration of use Risk reduction after cessation of exposure Risk reduction after cessation of exposure 71

Evidence for Causality (2) Adjusting for multiple confounders (age, sex, ethnic group, place of residence, tobacco smoking, education, intake of fruit and vegetables, …) Adjusting for multiple confounders (age, sex, ethnic group, place of residence, tobacco smoking, education, intake of fruit and vegetables, …) Measures taken to study reverse causality Measures taken to study reverse causality Excluding those who started opium use after diagnosis of major diseases Excluding those who started opium use after diagnosis of major diseases Excluding outcomes within 24 months from the initiation of the cohort Excluding outcomes within 24 months from the initiation of the cohort 72

Evidence for Causality (3) Biologic plausibility: Much to be learned, but alkaloid and non-alkaloid components have a number of systemic effects. Examples: Biologic plausibility: Much to be learned, but alkaloid and non-alkaloid components have a number of systemic effects. Examples: Lung and Bronchi Lung and Bronchi Activation of opioid receptors in medulla, resulting in reduced breathing frequency and tidal volume Activation of opioid receptors in medulla, resulting in reduced breathing frequency and tidal volume Upper airway constriction Upper airway constriction Cancers Cancers Activating angiogenesis and neovascularization Activating angiogenesis and neovascularization PAHs due to smoking PAHs due to smoking Liver Liver Perivenular and focal hepatocelluar necrosis Perivenular and focal hepatocelluar necrosis 73

Evidence for Causality (4) Opium users in this cohort use very low amounts of opium (average of 0.6 g/day), are at very low risk of overdose, and are NOT very different from other study participants for most other studied variables. Opium users in this cohort use very low amounts of opium (average of 0.6 g/day), are at very low risk of overdose, and are NOT very different from other study participants for most other studied variables. Results mostly reflect long-term effects of low amounts of use Results mostly reflect long-term effects of low amounts of use 74

Implications Opium and opioids are widely used. Death due to opium use is not limited to overdose. Opium and opioids are widely used. Death due to opium use is not limited to overdose. This study may (and only may) have implications for long-term use of opioids in medicine. This study may (and only may) have implications for long-term use of opioids in medicine. 75

Outline Significance of the Study Significance of the Study Objectives Objectives Golestan Cohort Study Golestan Cohort Study Statistical methods Statistical methods Results Results Discussion Discussion Lessons learned and suggestions for further research Lessons learned and suggestions for further research 76

Further Research Case-control studies of various outcomes in relation to opium use (keep in mind reverse causality) Case-control studies of various outcomes in relation to opium use (keep in mind reverse causality) Studies of the biologic effects of opium and opioid use Studies of the biologic effects of opium and opioid use Investigating long-term effects of opioid analgesics Investigating long-term effects of opioid analgesics 77

Lessons Learned Just do it! Just do it! There is a story and a rationale behind every study but things take you where you don’t necessarily expect. There is a story and a rationale behind every study but things take you where you don’t necessarily expect. For more cohorts, try to find a few unique things. For more cohorts, try to find a few unique things. Leadership, collaborations, and patience: All very important. Leadership, collaborations, and patience: All very important. 78

Further Reading Khademi et al. Opium use and mortality in Golestan Cohort Study. BMJ, 2012 Khademi et al. Opium use and mortality in Golestan Cohort Study. BMJ, 2012 Pourshams et al. Cohort Profile: The Golestan Cohort Study. Int J Epidemiol, Pourshams et al. Cohort Profile: The Golestan Cohort Study. Int J Epidemiol, Kamangar et al. Esophageal cancer in Iran. Arch Iran Med, Kamangar et al. Esophageal cancer in Iran. Arch Iran Med,

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