1. Mortality during Opioid Maintenance Treatment in Norway in the years 2014 and Anne Bech1, Thomas Clausen2, Helge Waal2,3, Ivar Skeie4,2
Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust
Norwegian Centre for Addiction Research, University of Oslo
Norwegian National Advisory Unit on Substanse Use Disorder Treatment, Oslo University Hospital
District Psychiatric Centre Gjoevik, Innlandet Hospital Trust
I am a research fellow at the Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders at Innlandet Hospital Trust in Norway.
We are doing a study about mortality in Opioid Maintenance Treatment in Norway. This study is done in cooperation with the Norwegian Centre for Addiction Research, University of Oslo and Norwegian National Advisory Unit on Substance use disorder Treatment, Oslo University Hospital

2. There are no conflicts of interest

3. Background
Country-level differences in mortality rates and causes of death among opioid-dependent persons
Overdoses the most common cause of death
OMT reduces mortality, but still high
Few (older) studies from the Norwegian OMT-setting
There are country-level differences in mortality rates and causes of death among opioid dependent persons
Overdose is one of the most common cause of death among opioid users
It is well established that Mortality is reduced during OMT, but mortality is still high compared to the general population.
There are few (older) studies from the Norwegian OMT setting

4. Mortality among regular or dependent users of heroin and other opioids Meta-analysis 2011
Cause of death
Mortality- rate/100PY
% of the deaths
Overdose
0.65
47.4
Suicide
0.12
8.8
Traumatic deaths
0.25
18.2
Liver-related
0.16
11.7
CVD
0.09
6.6
Cancer
0.07
5.1
Resp. disease
0.03
2.2
(Other/unknown
0.72) -
Total
2.09
100.0
A systematic review by Degenhardt and collegues from 2011 shows that overdoses cause almost 50 % of the deaths among regular or dependent users of opioids.
Traumatic incidents, such as accidents, homicides and suicides are also quite common, and the cause of death in 27 % of the cases.
Liver related diseases are the cause of death in almost 12 % of the cases, and this is not unexpected considering the prevalence of hepatitis C among injecting drug users.
Degenhardt and collegues reported a mortality rate of 2 per 100/PY.
Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, et al. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction 2011 Jan;106(1):32-51
From: Knut Boe Kielland, 2015

5. Aims
To examine the distribution between different causes of death among OMT-patients in Norway
-overdoses
-traumatic deaths and suicides
-deaths caused by diseases
To estimate all-cause and cause-specific mortality rates
To examine differences according to age and gender
This is part of a larger study investigating mortality during OMT in Norway
The aims of this study was to
examine the distribution between different causes of death among OMT-patients in Norway
We also wanted to estimate all-cause and cause-specific mortality rates, and to examine differences according to age and gender
This is part of a larger study investigating mortality during OMT in Norway

6. Setting National treatment programme since 1998 50 % coverage
7554 patients, mean age 44.3 years
30 % women
OMT drugs:
Methadone 38 %, mean dose 93 mg
Buprenorphine 39 %, mean dose 15 mg
Buprenorphine/naloxone (Suboxone®) 20 %, mean dose 13 mg
Other 3 %
OMT has existed as a national treatment programme since 1998.
It is estimated that around 50 % of opioid dependent persons are in OMT.
The treatment is based on a collaboration between hospitals, General Practitioners GPs and the health and social services in til municipalities. The treatment is publicly funded, and free of charge for the patients.
The retention in OMT treatment is high, around 90 %.
In 2016, we have 7500 patients in OMT, and the mean age is 44 years. 30 % of the patients are women.
In 2016 almost 40 % of the patients used methadone, while 60 % used buprenorphine either alone or in combination with naloksone

7. Annual status report OMT 2016
The mortality rate in the Norwegian OMT programme has been between 0.8 and 1.7, except 2006.
Annual status report OMT 2016

8. Methods Cross-sectional study:
Electronic patient journals from the public hospitals
Norwegian Cause of Death Registry
Norwegian National Patient Registry
Forensic autopsy reports, incl. toxicology
This is a cross-sectional study, where we collect data from different data sources.
Here we present preliminary results based on data from electronic patient journals from the public hospitals
We are also waiting for data from
Norwegian Cause of Death Registry, data from the National Patient Registry on treatment episodes and forensic autopsy reports, incl. toxicology

9. Preliminary results

10. Mortality rate OMT 2014 – 2015 Reported deaths from the hospitals 255
Excluded:
Died >5 days after last intake
OMT-status not known at time of death
ID not found 42 11 6
Died during OMT-treatment <5 days
196
Personyears (PY) OMT and 2015
14633
All-cause mortality rate during OMT
1.3/100 PY
The hospitals have reported that 255 patients died in these two years.
We have excluded 42 patients who died more than five days after the last intake of OMT-medication. The reason for this is that according to the national clinical guideline for OMT, patients who skip the dose for more than five consecutive days have to be reassessed by a doctor before treatment is to be continued.
We have also excluded 11 patients where the hospitals did not know the OMT status at time of death. We excluded 6 patients where the hospitals could not find their ID number.
196 patients died less than five days after the last intake of OMT-medication and were included in the study.
We found an all-cause mortality rate of 1.3/100 personyears in the Norwegian OMT-programme in 2014 and 2015

11. Study population n (%) Mean (SD)* Range
Men 144 (74) 48.6 (8.2) 22 – 71
Women 52 (26) 47.4 (8.2) 23 – 68
Total 196 (100) 48.2 (8.2) 22 – 71
*12 missing age
n=184, 12 missing age
If we look at the study population,
The average age of those who died during treatment was 48 years. There seemed to be surprisingly small differences in age between men and women.
we found that 26 % of those who died during OMT were women.
Life expectancy in Norway is more than 80 years for both men and women, and with a mean age of 48 years, the patients in OMT die more than 30 years earlier than the general population.

12. Causes of death 2014-2015 (of those with known cause of death)
Causes of death n (%) MR/100PY Mean age* (SD) Somatic disease 96 (64) (7.0) Overdose deaths 29 (20) (9.9) Traumatic deaths 25 (15) (7.4) Total 150 (100) Unknown cause of death 46 Total 196
If we take a look at the distribution of different causes of death, we found that 64 % of the OMT-patients in Norway died from a somatic disease.
20 % died from overdose, while 15 % died from accidents, suicides and a few from homicides. Those who died from somatic disease are older than those who died from overdose and traumatic deaths.
There are almost 50 patients where the hospitals had no or very little information about the fatalities, and we hope to get more information about these patients when we get data from the death cause registry. Therefore, the mortality rates are preliminary and should be interpreted with caution.
* 6 patients age is missing

13. Somatic cause of death 2014-2015 (% of all with known cause of death, n=150)
N (%) MR/ Mean age (SD)*
100PY
Cardiovascular disease (17) (7.3)
Cancer (not liver) (12) (7.9)
Bacterial infections (10) (5.5)
Liver disease, incl. liver cancer (9) (4.5)
Kidney disease (4) (6.7)
Other somatic disease (14) (8.0)
Total somatic causes (64) (7.0)
Among those who died from somatic causes, cardio vascular diseases such as heart failure, heart attack and stroke were the most common cause of death with 17 %. Cancer was the second most common cause of death, with 12%.
Bacterial infections, such as endocarditis or pnemonia caused the death of 10 %.
The prevalence of hepatitis C among OMT patients in Norway is probably more than 50 %, so it is not unexpected that 9 % died from liver related diseases, including liver cancer.
*1-6 patients age missing

14. Age distribution mortality rates Per 100 /PY
If we look at the age distribution, we found that overdoses and traumatic deaths are quite evenly distributed across all age groups (red and green bars), while somatic causes of death have a steap increase from 40 years an older (the dark blue bar).
We found no patients under 30 years who died from somatic diseases. 500 patients under 30 years.

15. Comparison (% of all with known cause of death)
Systematic review Norway
(Degenhardt 2011)
Overdose
Traumatic deaths
Somatic diseases
If we compare the Norwegian findings with the results form the systematic review by Degenhardt and collegues, we find that more than twice as many patients in the Norwgian OMTprogramme died from somatic disease, 64 % compared to 26 %.
When it comes to overdose, only 20 % died from overdoses in the Norwegian OMT compared to 47 % in the systematic review.
Explanations for the differences could be the age profile in the Norwegian OMT programme and that OMT reduces overdoses
Fra: Ivar Skeie, 2016

16. Summing up
The most common cause of death among OMT-patients in Norway is somatic disease, especially from 40 years upwards
20 % of the deaths during OMT were caused by overdose
Both primary and specialist health care services should reinforce prevention and treatment of somatic comorbidity among OMT-patients
Thank you!
In contrast to other studies, the most common cause of death among OMT-patients in Norway is somatic disease, especially after 40.
Only 20 % died from overdose.
Some of the older OMT patiens suffer from accumulated physical and mental health effects of a long drug career,
As OMT patients get older, it is important to focus on prevention and treatment of somatic comorbidity.
they face health problems many years earlier than the general population.