Association of Methadone Treatment With Substance-Related Hospital Admissions Among a Population in Canada With a History of Criminal Convictions

Importance  People with criminal histories experience high rates of opioid dependence and are frequent users of acute health care services. It is unclear whether methadone adherence prevents hospitalizations. Objective  To compare hospital admissions during medicated and nonmedicated methadone periods. Design, Setting, and Participants  A retrospective cohort study involving linked population-level administrative data among individuals in British Columbia, Canada, with provincial justice contacts (n= 250 884) and who filled a methadone prescription between April 1, 2001, and March 31, 2015. Participants were followed from the date of first dispensed methadone prescription until censoring (date of death, or March 31, 2015). Data analysis was conducted from May 1 to August 31, 2018. Exposures  Methadone treatment was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Main Outcome and Measures  Adjusted hazard ratios (aHRs) of acute hospitalizations for any cause and cause-specific (substance use disorder [SUD], non–substance-related mental disorders [NSMDs], and medical diagnoses [MEDs]) were estimated using multivariable Cox proportional hazards regression. Results  A total of 11 401 people (mean [SD] age, 34.9 [9.4] years; 8230 [72.2%] men) met inclusion criteria and were followed up for a total of 69 279.3 person-years. During a median follow-up time of 5.5 years (interquartile range, 2.8-9.1 years), there were 19 160 acute hospital admissions. Dispensed methadone was associated with a 50% lower rate of hospitalization for any cause (aHR, 0.50; 95% CI, 0.46-0.53) during the first 2 years (≤2.0 years) following methadone initiation, demonstrating significantly lower rates of admission for SUD (aHR, 0.32; 95% CI, 0.27-0.38), NSMD (aHR, 0.41; 95% CI, 0.34-0.50), and MED (aHR, 0.57; 95% CI, 0.52-0.62). As duration of time increased (2.1 to ≤5.0 years; 5.1 to ≤10.0 years), methadone was associated with a significant but smaller magnitude of effect: SUD (aHR, 0.43; 95% CI, 0.36-0.52; aHR, 0.47; 95% CI, 0.37-0.61), NSMD (aHR, 0.51; 95% CI, 0.41-0.64; aHR, 0.60; 95% CI, 0.47-0.78), and MED (aHR, 0.71; 95% CI, 0.65-0.77; aHR, 0.85; 95% CI, 0.76-0.95). Conclusions and Relevance  In this study, methadone was associated with a lower rate of hospitalization among a large cohort of Canadian individuals with histories of convictions and prevalent concurrent health and social needs. Practices to improve methadone adherence are warranted. &nbsp

Methadone Maintenance Treatment and Mortality in People with Criminal Convictions: A Population-Based Retrospective Cohort Study from Canada

Background Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. Methods and findings We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23–0.33]) and external (AHR 0.41 [95% CI 0.33–0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13–0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30–0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. Conclusions Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Epidemiological evaluations of methadone adherence in opioid dependent offenders: Implications for public health and public safety

Background: Opioid use is associated with elevated rates of morbidity and mortality and has a significant impact on public health and public order. Justice involved individuals are disproportionately affected by opioid related harms but effective interventions are underutilized. Methadone maintenance treatment is the best researched and mostly widely implemented pharmacotherapy option for the treatment of opioid dependence. Despite its demonstrated efficacy in general populations, few studies have examined its effectiveness among patients with criminal justice histories and complex health and social challenges. This thesis aims to address the deficits in existing extant literature through three unique research studies described herein. Methods: All studies were conducted using a retrospective cohort design involving linked population-level administrative data. Participants comprised a cohort of individuals from British Columbia, Canada with histories of convictions and who filled a methadone prescription. Three independent analyses estimated the effect of methadone on crime, mortality and hospitalization. Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Cox regression was used in all three analyses and hazard ratios with 95% confidence intervals were reported as an effect size. In all instances additional subgroup and sensitivity analyses were performed. Results: Over a mean follow-up time of eight years, findings from the sample (n=14, 530) revealed a significant association between dispensed methadone and lower rates of violent and non-violent crime; all-cause and cause-specific mortality; and any-cause hospitalization (n=11, 401) even after controlling for a number of covariates. Findings for crime and hospitalization analyses demonstrated the magnitude of protective effect for methadone was greatest during the initial years following methadone treatment initiation but decayed in periods exceeding a decade. Subgroup and sensitivity analyses demonstrated a similar pattern of results. Conclusions: Adherence to methadone is associated with lower rates of opioid related harms among justice involved patients with opioid dependence. Results consistently point to the need for increased access to methadone and higher rates of adherence for offenders and similarly marginalized groups. Implementation of evidence-based policies and programs are required to improve adherence and promote recovery in this vulnerable population

Emergency department utilization among formerly homeless adults with mental disorders after 1-year of housing first: a randomized controlled trial

Homeless individuals represent a disadvantaged and marginalized group who experience increased rates of physical illness, mental and substance use disorders. Compared to housed individuals, homeless adults use emergency departments (ED) and other acute healthcare services at a higher frequency. Housing First (HF) has been identified as an effective means of facilitating acute health service reductions among homeless populations. The present analysis is based on (n=297) participants enrolled in the Vancouver At Home Study (VAH) randomized to one of three intervention arms: HF in a congregate setting (CONG), HF in scattered site apartments (SS), or to treatment as usual (TAU), and incorporates linked data from a regional database representing six urban ED’s. Compared to TAU, significantly lower ED utilization was observed during the post-randomization period in the SS arm. Our results suggest that HF, particularly the SS model, produces significantly lower ED visits among homeless adults with a mental disorder

Association of homelessness and psychiatric hospital readmission—a retrospective cohort study 2016–2020

Abstract Background A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital. Methods A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression. Results The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period. Conclusions Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed. Question Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission? Findings In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission. Meaning Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission

HR estimates of dispensed methadone on mortality among 14,530 convicted offenders from BC, 1998–2015.

<p>HR estimates of dispensed methadone on mortality among 14,530 convicted offenders from BC, 1998–2015.</p

Flow chart of offenders included in the study.

<p>^αThe cohort included participants (offenders) who had convictions (found or plead guilty and sentenced) as well as those (nonoffenders) who did not have any convictions but were under supervision of the Ministry of Justice due to remand or bail and later found not guilty. ^βThis time period included the study/exposure period (January 1, 1998 to March 31, 2015) for methadone as well as time prior to enrolment (from the time when justice databases became available, January 1997). BC, British Columbia; PY, person-year.</p

Kaplan-Meier curve for all-cause mortality among 14,530 convicted offenders from BC, 1998–2015.

<p>BC, British Columbia.</p