A 10-year follow-up study of drug users in treatment Grethe Lauritzen, SIRUS
A prospective co-hort study 10-year observation period (1998-2009) 481 clients interviewed in 20 treatment facilities in and around Oslo purposely selected 13 residential units 7 out-patient units, 3 Psychiatric Youth Teams specialized for drug treatment (PUT) and 4 Opioid Substitution Teams (OST)
4 groups of treatment facilities 11 residential units for adults (n=276) 2 residential units for youth (n= 31) 3 PUT teams (n=100) 4 OST teams (n= 74)
Material follow-up interviews Period Number Response percentages After 1 year 428 91 «2 years 410 89 «7 years 348 84 «10 years 295 77
Instruments All the clients were interviewed in person within the first 2 weeks after entering treatment with the European Addiction Severity Index (EuropASI) Alcohol and drug use, physical and psychological health, family and social problems, education/work and income situation, criminal behaviour. Life time and last 30 days Self-administered instruments for assessing anxiety, depression and personality disorders: Hopkins Symptom Checklist 25 (HSCL-25) Millon Clinical Multiaxial Inventory II (MCMI II) Childrens Trauma Questionaire Data from The Cause of Death Registry (1998-2009)
The clients at treatment entry (baseline) All Youth in residential PUT Adults in residential OST Women% 32 55 35 30 28 Age, average 31 16 27 31 40 Born in Norway % 94 90 93 94 97 Have one or more children % 44 0 21 50 70 Have daily responsibility for one or more children % Lived alone in a stable residence % (past 6 months) Lived with partner/spouse with or without children % (past 6 months) Leisure time spent mainly with friends/acquaintances with drug/alcohol problems 8 0 5 11 4 29 3 33 27 41 17 3 21 16 25 48 87 31 56 24
Education, employment and sources of income All Youth in residential PUT Adults in residential OST Learning and/or behavioural problems in primary school 64 87 61 61 69 Completed high school % 28 0 42 26 26 Student/pupil % 13 61 22 7 0 Income from own employment/ sick leave pay the past 30 days % 17 3 37 14 7 Disability benefit past 30 days % 11 0 5 7 38 Social welfare benefits past 30 days % 58 11 40 70 61 Income from selling drugs past 30 days % 40 58 25 43 45 Income from other criminal activites past 30 days % 27 52 11 36 15 Income from prostitution past 30 days % 6 3 5 7 5
Background burdens All Youth in residential PUT Adults in residential OST Alcohol problems mother and/or father % Drug/medication problems mother and/ or father % Psychiatric problems mother and/or father% CTQ Emotional neglect/abuse, moderate/serious serious/extreme CTQ Physical neglect/abuse, moderate/serious serious/extreme CTQ Sexual abuse moderate/serious serious/extreme Time spent mostly with friends/acquaintances who have drug and alcohol problems % 52 71 44 51 57 21 50 16 20 20 44 71 48 38 54 61 45 27 48 87 31 56 24
Drug and alcohol use Heroin no. Years high frequency All Youth in residential PUT Adults in residential 6 0 3 6 14 Amphetamine 5 1 2 6 6 Cannabis 10 2 8 11 15 Sedativa /hypnotica Alcohol for intoxication Needle use (share) 5 1 3 5 9 4 1 3 4 5 OST 82 52 53 91 100 Overdosed (share) 59 13 47 65 73 NOK used on drugs last month 16 600 4 400 5 500 21 100 20 200
Physical health All Youth in residential PUT Adults in residential OST Chronic physical injuries/diseases % 35 19 34 32 51 HCV infected % 65 4 29 75 94 HIV tested % 88 42 73 96 100 HIV positive % 3 0 1 2 10 Considerably/severely afflicted or concerned about physical problems in the last 30 days 16 3 13 14 31
Mental/psychological health All % Youth in residential % PUT % Adults in Residential % Seriously depressed 61 58 71 56 68 Serious anxiety 58 33 65 57 66 Suicide attempts 42 38 32 40 64 Cognitive difficulties (in understanding, memorizing, consentration) Medications for mental problems past 30 days 52 63 39 54 57 17 3 29 17 7 OST%
Basic personality disorders (>84 MCMI-II) (%) Scale All Men Women (n=481) (n=324) (n=157) Basic personality disorders Schizoid 12.9 15.7 7.0* Evasive 25.9 25.5 26.8 Dependent 13.9 13.2 15.3 Histrionic 23.4 13.8 43.3*** Narcissistic 25.9 30.2 17.2** Antisocial 52.1 52.6 51.0 Aggressive sadistic 27.2 31.7 17.8* Compulsive 1.7 1.2 2.5 Passive aggressive 44.8 44.9 44.6 Self-deprecating 18.9 15.7 25.5*
Basic personality disorders (>84 MCMI-II) cont. Scale All Men Women (n=481) (n=324) (n=157) Severe personality disorders: Schizotype 7.7 8.0 7.0 Borderline 26.8 24.6 31.2 Paranoid 2.5 2.5 2.5
Prevalence of personality disorders (PD) 75% has one or more PD (same share as in ROP study, Oppland/Hedmark) The most serious and frequent personality disorders were antisocial PD and borderline PD Not surprising that a group with such large mental burdens during childhood, and major psycho-social burdens for many years as substance abusers, develop relationship problems/pd End of description
Completion of treatment Completion percent Number of days/consultations (average) Youth Residential 41 339 days PUT 38 14 consultations Adult Residential 55 582 days OST 66 (cont.)
Prediction for completion of treatment PD was a negative predictor for completion/continuation in all modalities 3 or more previous residential treatments is a negative predictor for completion among clients in residential modalities Use of heroin for 3 or more years is a negative predictor for completion among PUT clients Changes
Income status Last 30 days Income from work Social security Disability pension Selling drugs Other criminal activity Admission 1 year 2 years 7 years 10 years *P-verdi 19 18 23 28 32 <0.001 58 44 42 30 25 <0.001 11 12 15 30 36 <0.001 40 9 12 9 9 <0.001 27 8 6 3 3 <0.001 Prostitution 6 3 2 1 0 <0.001
Change in use of substances/medications (p-value = admittance to ten years) Last 30 days (%) Admittance 1 year 2 years 7 years 10 years *p-value (n=481) (n=428) ((n=410) (n=348) (n=296) Heroin 62 30 28 16 16 <0.001 Methadon/Buprenorphin 4 19 25 41 47 +<0.001 Other opiates 22 14 11 18 10 <0.001 Amphetamine 34 17 16 22 19 <0.001 Sedativa/hypnotica 51 30 34 37 37 <0.001 Cannabis 59 36 40 43 45 <0.001 Cocaine 5 5 5 5 5 ns Alcohol for intoxication 18 15 15 27 25 +<0.05
Changes in substance use
Change in use of syringes Admit. 1 year 2 years 7 years 10 years *p value (n=481) (n=428) (n=410) (n=348) (n=296) Use of syringes past 30 days (%) Daily use of syringes (%) 69 32 32 17 21 p<0.001 41 8 12 6 6 p<0.001
Change in non-fatal overdoses 1 year (n=428) 2 years (n=410) 7 years (n=348) All (%) 20 17 7 4 Youth in residential 0 4 8 0 PUT 18 15 5 0 Adults in residential 27 21 8 7 OST 5 8 7 2 10 years (n=296)
Change in mental problems (EuropASI) The year prior to follow-up (%) 1 year 2 years 7 years 10 years (n=428) (n=410) (n=348) (n=296) Seriously depressed 42 39 45 43 Serious anxiety 66 62 51 54 Problems concentrating / understanding/ remembering Prescribed medications for mental problems 36 37 54 60 19 26 35 40 Suicidal thoughts 27 25 28 25 Suicide attempts 7 7 9 6
Change in mental health SCL- 25 and Europ-ASI (composite score)
Change in criminal behaviour Chargedoftypes of crime: (%) last year prior to followup Possession/sale of drugs Crime of gain other than drug sale 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) 16 16 10 2 17 11 9 4 Crime of violence 3 3 3 2
Change in criminal behaviour Illegal activities to earn money Admittance (n=481) 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) P. value 49 14 13 6 2 <0.001
Mortality rate 74 persons died in the course of 10 years (10 women) Average age at death was 32 years Mortality rate 1.5 per 100 person/years 2.0 for men 0.6 for women
Causes of death (n=74) % Number Overdoses 68 50 Violent deaths (traffic accident, drowning, fires, suicide, homicide, etc) 20 15 Hepatitus C 1 1 HIV/AIDS 3 2 Unknown cause 8 6 Total 100 74
Differences in client characteristics dead and surviving clients Dead (n=74) Not dead (n=407) P- value Age 32 30 ns Alcohol abuse years (before entering treatment, b.e.t) 7.8 5.3 p<0.05 Overdoses (numbers) (b.e.t) 5.9 3.6 p<0.05 Years using syringes (b.e.t.) 11.3 9.5 ns Months in prison (b.e.t.) 19.2 11.8 p<0.05 Days in index treatment 369 468 p<0.05
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Strength and weaknesses with a longitudinal co-hort study like this? Strategies for prevention on behalf of this study? Comments on treatment systems/organisation of treatment? New research questions?
Clients in OST last year prior to follow-up interviews (from the different recruitment groups) % 1 year (n=428) Youth in residential 2 years (n=410) 7 years (n=348) 10 years (n=296) 0 0 4 14 PUT 5 7 27 27 Adults in residential 7 14 40 53 OST 83 83 73 65
Clients in out-patient treatment prior to follow-up interviews (from the different recruitment groups) % 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Youth in residential 8 15 54 48 PUT 71 35 57 33 Adults in residential 26 41 48 33 OST 27 25 26 21
Clients in residential treatment prior to the follow-up interviews (from the different recruitment groups) % 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Youth in residential 77 78 0 0 PUT 11 17 12 5 Adults in residential 88 60 15 16 OST 26 22 30 15
Gender differences Generally few large gender differences Women reported to have been more emotionally, physically and sexually abused than men Women reported more mental problems than men upon admittance to treatment, the differences were gone after 10 years Women equally violent as men
Gender differences The women were less likely to use heroin, amphetamines and cannabis throughout the entire observation period Women less antisocial than men A smaller share of the women reported criminal behaviour A smaller share of the women died A smaller share of the women died of (90% vs. 59%)
Gender differences The share of women involved in education was characteristically higher than the men in the entire observation period Women more satisfied with civil status after 10 years Many of the women lived with partners that had substance use problems throughout the entire observation period Women more involved in social networks
Strength and weaknesses with such a longitudinal co-hort design? Strategies for prevention on behalf of this study? Comments on treatment systems/organisation of treatment? New research questions?