Surviving Drug Addiction

The Effect of Treatment and Abstinence on Mortality

Christy K. Scott, PhD; Michael L. Dennis, PhD; Alexandre Laudet, PhD; Rodney R. Funk, BS; Ronald S. Simeone, PhD

Disclosures

Am J Public Health. 2011;101(4):737-744. 

In This Article

Discussion

We set out to estimate the overall mortality rate in a longitudinal cohort of people with substance use disorders seeking treatment and to examine the risk associated with several baseline factors, as well as the complex interaction between baseline characteristics, treatment, and abstinence (the proximal outcome of treatment) in predicting mortality. The overall mortality rate in this sample was 11 per 1000 person-years, which is consistent with the prior treatment literature but more than twice the expected rate (4.4 per 1000 person-years) for a community sample in Cook County, Illinois (where this study was conducted), matched according to age, race, and gender with the Centers for Disease Control and Prevention Wonder tables.[53]

The individual baseline factors associated with enhanced mortality risk in our multivariate analyses (Table 2) were older age, preexisting chronic illness, and greater engagement in illegal activity for money in the 6 months before intake. Abstinence from drugs and alcohol (even intermittent abstinence) was associated with a lower risk of mortality.

The relationship of long-term treatment with mortality revealed both direct and indirect effects via the duration of sustained abstinence achieved. Participating in more treatment episodes (particularly in one's early years of drug use) is beneficial, but participating in treatment episodes in one's later years and spending a greater percentage of one's lifetime in treatment is not. This finding provides further evidence that the nature of the effects of substance abuse treatment on abstinence and mortality does not support an acute care or simple dosage model; rather, it supports a chronic disease model. In the case of cancer, for instance, early treatment and reintervention (when necessary) are generally associated with a reduced risk of mortality. However, the more instances in which patients relapse and require additional treatment and the more time they spend being treated, the lower their likelihood of achieving sustained remission and the higher their risk of mortality.

Strengths and Limitations

Although this study involved numerous strengths, including a large sample, long duration, repeated observations, high follow-up rates, detailed measurement, and multiple data sources, its limitations are important to note. Data were not readily available on causes of mortality. In addition, although we incorporated urine test data, these data were primarily relevant to past-week use and may have missed unreported use in the preceding year. The sample presenting to treatment was made up predominantly of African American inner-city residents with high rates of criminal justice system involvement. Consequently, the predictors of mortality for this largely African American sample are probably not generalizable to other sociodemographic groups in treatment.

Another limitation was the lack of available mortality data in the specific communities from which the sample was drawn. Although we compared our rates with those of Cook County, our rates were probably underestimated. However, the clinical case mix of the sample was similar to that of the US public treatment system as a whole[54] in terms of median age at first use (16 vs 17 years), frequency of weekly or greater use (64% vs 66%), and prior treatment history (58% vs 54%). The patterns of primary substance use (alcohol, cocaine, opioids, marijuana, methamphetamines) were also consistent with those of the US treatment system. In the future, it would be useful to replicate our work with less severe clinical samples and in other locations.

Conclusions

Combined with previous studies involving highly marginalized samples that show that ongoing monitoring and early intervention over the life course of addiction[37] are associated with fewer years of use, our results further indicate the need for the addiction field to shift to a more chronic disease management paradigm. Contrary to many current managed care practices, our findings indicate the need for more aggressive screening, early intervention, adequate initial treatment, ongoing monitoring, disease management skills, and better linkage to recovery support services and mutual aid groups that help sustain recovery.

To facilitate this paradigm shift in the private and public sectors, it is particularly important for the US Preventive Services Task Force, as well as accreditation groups and insurance groups, to recommend that drug use be added to the list of conditions for which regular screening and monitoring is expected. Such action is warranted given that drug use is one of the 10 leading causes of mortality and that treatment and subsequent abstinence are associated with a reduced risk of mortality.

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