Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs

BACKGROUND: There exists substantial evidence that individuals with alcohol and drug disorders have heightened comorbidities and health care costs. However, little is known about the larger population of "hazardous" drinkers (those whose consumption increases their "risk of physical and psychological harm") and drug users. METHODS: A sample of 1,419 patients from HMO primary care clinics was screened for hazardous drinking and drug use. Health plan databases were used to examine medical conditions and health care costs of hazardous drinkers and drug users in the year prior to screening, in comparison to 13,347 patients from the same clinics, excluding those screened. RESULTS: We found a prevalence of 7.5% for hazardous drinking and 3.2% for drug use in primary care (10% had at least one of the two problems). Hazardous drinkers and drug users had heightened prevalences for eight medical conditions, including costly conditions such as injury and hypertension, and psychiatric conditions. Medical costs for the year examined were not higher, except for those who also had psychiatric conditions. CONCLUSIONS: The prevalence of hazardous drinking and drug use was similar to hypertension and diabetes. Hazardous drinkers and drug users' heightened medical conditions, especially those related to alcohol and drug abuse, indicate that screening and brief intervention at this lower threshold of hazardous drinking and drug use will detect individuals with health risks sooner. Optimal treatment and prevention of some medical disorders may require identification and intervention of underlying hazardous alcohol or drug use.     

Malaysian schistosomiasis: description of a population at risk

A stable population at risk of Malaysian schistosomiasis was studied. Census results indicated that approximately one-fourth of the inhabitants used a stream where Schistosoma malayensis-infected snails were present as their principal source of water for bathing, drinking, and household tasks. The general population also contacted this stream when fording it or while fishing. Serological surveys using enzyme-linked immunosorbent assay (ELISA) and the circumoval precipitin (COP) test revealed six (9%) and three (4%) positives, respectively, among 67 persons examined. No schistosome ova were found in a general survey of 56 persons which included five ELISA positive and two COP test positive patients. ELISA and COP test prevalences among those dependent on the foci of transmission for water, 13 and 7% respectively, were only slightly higher than prevalences among the remainder of the population, 8 and 4% respectively. These results indicate that even among a stable population at risk of Malaysian schistosomiasis the prevalence is low. Our findings support the hypothesis that S. malayensis is a zoonotic infection in man and that it is unlikely to become a significant public health problem.     

Estimating the prevalence of problem drug use in inner London: a discussion of three capture-recapture studies

Aims. To provide an evidence base of estimates of the prevalence of problem drug use in inner London. Design. Re-analysis of three capture-recapture studies using subjects aged 15-49 years, that aim to estimate the hidden population from analysing the overlaps between three data sources. Setting. Newham (1995) Camden and Islington (C&I) (1993/4) and Lambeth, Southwark and Lewisham (LSL) (1992). Participants. Each study collected data from three sources of problem drug users including: the Regional Drug Misuse Database, specialist drug agencies, HIV tests, social services, police arrests and court records. In LSL opiate users were analysed separately. The studies identified 1832 individuals in LSL, 543 in Newham, and 1321 in C&I. Measurements. Poisson models were fitted to the data testing different interactions between the data sources representing potential dependencies. The simplest model was selected on the basis of its AIC score and log-likelihood ratio tests. Findings. The number of hidden problem drug users were estimated to be 12 500 (95% CI 9600-16100) in LSL with 4400 (3200-6100) opiate users; 7000 (5000-10000) in C&I and 3800 (2000-7200) in Newham. The prevalence of problem drug use in those aged 15-49 was estimated to be 3.1% (2.5-3.9%) in LSL with 1.3% (1.0-1.6%) opiate users; and 3.6% (2.7-4.9%) and 3.3% (1.9-5.7%) in C&I and Newham, respectively. Conclusions. Despite the inherent problems with capture-recapture methods, our three studies establish an evidence base for estimates of problem drug use in London. It is important that a larger study is carried out in London.     

A comparison of different methods for estimating the prevalence of problematic drug misuse in Great Britain

Aims . The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has produced methodological guidelines for national drug prevalence estimation. This paper pilots the methods to estimate prevalence for Great Britain and provides a commentary on the methods and resulting estimates.
Design . Three types of methodology were used to estimate prevalence: (a) the multiple indicator (MI) method, (b) multipliers applied to (i) drug-treatment records (ii) HIV estimates and (iii) mortality statistics and (c) the British/Scottish Crime Surveys.
Setting . England, Scotland and Wales.
Participants . Aggregated data on people recorded on databases and respondents in household surveys.
Measurements . Prevalence estimates of different forms of problematic drug use.
Findings . The estimates are 161 133 (range: 120 850-241 700) for people at risk of mortality due to drug overdose; 161 000-169 000 for people who have ever injected drugs; 202 000 (range: 162 000-244 000) problem opiate users and 268 000 problem drug users (all types).
Conclusions . The multiple indicator method offers a comprehensive approach to estimating the prevalence of problematic drug use in the United Kingdom. Simple multiplier methods and household surveys also provide a range of estimates corresponding to different types of drug use in the United Kingdom. The current study suggests that previous national estimates of 100 000-200 000 were conservative. The new estimate of 161 000-266 000 should enable a more focused response. For further development of this method, reliable and timely estimates of anchor points are required for specific geographical areas such as cities or Drug Action Teams (DAT), as well as routine aggregation of drug indicators for these areas.     

Perceptions of Community HIV Prevalence,Own HIV Infection,and Condom Use among Teachers in KwaZulu-Natal,South Africa

A total of 120 teachers from KwaZulu-Natal, South Africa, underwent HIV/AIDS training. As part of the study, the teachers were surveyed, before and after the training, about their perceptions of HIV prevalences among pupils, other teachers, and community members, and about their perceptions of their own HIV status. Before the training, the teachers estimated average HIV prevalences among pupils, other teachers, and other community members to be 36%, 48%, and 61%, respectively. One-third of the teachers believed that they had a 50% or greater chance of currently being infected with HIV. Male teachers and teachers with a university degree gave lower HIV prevalence estimates for other people but not for themselves. Frequency of condom use was positively related to teachers’ HIV prevalence estimates for other people. Teachers’ estimates of HIV prevalence and perceived risk of own HIV infection increased significantly after the HIV/AIDS training.     

Discrepancies in estimates of prevalence and correlates of substance use and disorders between two national surveys

AIM: To assess the degree to which methodological differences might influence estimates of prevalence and correlates of substance use and disorders by comparing results from two recent surveys administered to nationally representative US samples. METHODS: Post-hoc comparison of data from the 2002 National Survey on Drug Use and Health (NSDUH) with data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) administered in 2001-02. RESULTS: Prevalence estimates for all substance use outcomes were higher in the NSDUH than in the NESARC; ratios of NSDUH to NESARC prevalences ranged from 2.1 to 5.7 for illegal drug use outcomes. In the NSDUH, past-year substance use disorder (SUD) prevalence estimates were higher for cocaine and heroin, but were similar to NESARC estimates for alcohol, marijuana and hallucinogens. However, prevalence estimates for past-year SUD conditional on past-year use were substantially lower in the NSDUH for marijuana, hallucinogens and cocaine. Associations among drug and SUD outcomes were substantially higher in the NESARC. Total SUD prevalence did not differ between surveys, but estimates for blacks and Hispanics were higher in the NSDUH. CONCLUSION: A number of methodological variables might have contributed to such discrepancies; among plausible candidates are factors related to privacy and anonymity, which may have resulted in higher use estimates in the NSDUH, and differences in SUD diagnostic instrumentation, which may have resulted in higher SUD prevalence among past-year substance users in the NESARC.     

Changes in substance use associated with emergency room and primary care services utilization in the United States general population: 1995-2000

OBJECTIVE: The purpose of this study was to compare changes in the prevalence of heavy problem drinking and drug use among those obtaining emergency room (ER), primary care, and other health care services between 1995 and 2000 in the U.S. general population. METHOD: Data analyzed are from the Alcohol Research Group's 1995 (n = 4925) and 2000 (n = 7612) National Alcohol Surveys. Data for the 1995 survey was based on face-to-face interviews in respondents' homes in the 48 contiguous states, while the 2000 interview was a random-digit dialing computer-assisted telephone interview of the household population in all 50 states. RESULTS: Those reporting any health services utilization were less likely to report heavy drinking, two or more alcohol problems, and symptoms of alcohol dependence during the previous year in 2000 compared with 1995, but heavy or problem drinking was not predictive of health services utilization at either time. Controlling for demographic characteristics and health insurance coverage, illicit drug users were almost twice as likely [odds ratio (OR) = 1.85] compared with nonusers, to report ER utilization, and one and a half times more likely (OR = 1.55) to report primary care utilization during the past year in the 2000 survey, but drug use was not significantly predictive of health services utilization in 1995. CONCLUSIONS: These data suggest that while those alcohol-involved individuals were no more likely than others to use ER and primary care services in either 1995 or 2000, those drug-involved individuals were more likely to do so in 2000, perhaps related to the fact that these individuals may be incurring more health problems associated with their drug use that require medical attention. While identification and intervention with problem drinkers in clinical settings has received a great deal of attention, drug users may be overrepresented in health service settings, and such settings also may provide a window of opportunity for screening and intervention for a reduction in drug-related problems.     

Longitudinal surveys of prevalence rates and use patterns of illicit drugs at selected high-prevalence areas in China from 1993 to 2000

AIMS: To identify the prevalence, patterns and trends of illicit drug use in the general population of selected high-prevalence areas in China between 1993 and 2000. DESIGN, SETTING AND PARTICIPANTS: Cluster sampling was employed and the Epidemiological Inventory for Illicit Drug Use (EIIDU) used as survey instrument. In 1993, 1996 and 2000, 56 792, 67 319 and 53 747 individuals aged 15 or above in community were interviewed, respectively, at the three time-points. MEASUREMENTS: Demographics and drug-related data were collected and the prevalence patterns of illicit drug are described. FINDINGS: The life-time prevalences of illicit drug use in the three consecutive surveys in 1993, 1996 and 2000 were 1.08, 1.60 and 1.52%, respectively, and the 1-year prevalence rates were 0.91, 1.17 and 1.17%, respectively. Heroin was the first choice for drug use (51.8% in 1993, 83.4% in 1993 and 95.9% in 2000). The two most frequent routes of drug administration were inhalation (89.2% in 1993, 60.1% in 1996 and 93.5% in 2000) and intravenous injection (27.2% in 1993, 31.0% in 1996 and 25.7% in 2000). CONCLUSION: At least for the time being, illicit drug use may have plateaued in these selected high-prevalence areas.     

Capturing crack cocaine use: estimating the prevalence of crack cocaine use in London using capture-recapture with covariates

AIM: To estimate the prevalence of crack cocaine use in 12 London Boroughs (and London as a whole). SETTING: Twelve London Boroughs, 2000-01. METHODS: (1) Covariate capture-recapture techniques applied to three data sources of subjects reporting crack cocaine use: specialist drug treatment (2905), arrest referral (1188) and accident and emergency and community survey (531); and (2) ratio-estimation multiplier, using an estimate of number of injecting drug users and proportion that use crack cocaine. FINDINGS: After matching, 4117 individuals aged 15-44 were identified. The best-fitting model estimated 16 855 unobserved crack cocaine users, giving an overall estimate of approximately 21 000 [95% confidence interval (CI) 13 000-43,000] and a prevalence of 1.5% (95% CI 1.0-3.2%). Prevalence of crack cocaine use was 2.4% (95% CI 1.5-5.0%) among men and 0.7% (95% CI 0.5-1.0%) among women, and similar by age groups 15-29 and 30-44 years. Overall, approximately 11 900 (57%) of the estimated number of crack cocaine users were also opiate users. In London as a whole there may be 46,000 (1.3%) crack cocaine users aged 15-44 years, with 28 000 (1.9%) in inner London-four times higher than estimates from population surveys. Some corroboration was provided by the ratio-estimation method, which estimated 23 000 users in the 12 Boroughs. CONCLUSIONS: Capture-recapture can be applied to crack cocaine and obtain better estimates than population surveys. The size of the crack cocaine-using population in London is large, although currently the majority are also opiate users. Given that half of current users are under 30 the problems associated with crack cocaine use are likely to increase in the future.     

Changes in Substance Use Associated with Emergency Room and Primary Care Services Utilization in the United States General Population: 1995–2000

Objective: The purpose of this study was to compare changes in the prevalence of heavy problem drinking and drug use among those obtaining emergency room (ER), primary care, and other health care services between 1995 and 2000 in the U.S. general population. Method: Data analyzed are from the Alcohol Research Group's 1995 (n = 4925) and 2000 (n = 7612) National Alcohol Surveys. Data for the 1995 survey was based on face‐to‐face interviews in respondents' homes in the 48 contiguous states, while the 2000 interview was a random‐digit dialing computer‐assisted telephone interview of the household population in all 50 states. Results: Those reporting any health services utilization were less likely to report heavy drinking, two or more alcohol problems, and symptoms of alcohol dependence during the previous year in 2000 compared with 1995, but heavy or problem drinking was not predictive of health services utilization at either time. Controlling for demographic characteristics and health insurance coverage, illicit drug users were almost twice as likely [odds ratio (OR) = 1.85] compared with nonusers, to report ER utilization, and one and a half times more likely (OR = 1.55) to report primary care utilization during the past year in the 2000 survey, but drug use was not significantly predictive of health services utilization in 1995. Conclusions: These data suggest that while those alcohol‐involved individuals were no more likely than others to use ER and primary care services in either 1995 or 2000, those drug‐involved individuals were more likely to do so in 2000, perhaps related to the fact that these individuals may be incurring more health problems associated with their drug use that require medical attention. While identification and intervention with problem drinkers in clinical settings has received a great deal of attention, drug users may be overrepresented in health service settings, and such settings also may provide a window of opportunity for screening and intervention for a reduction in drug‐related problems.     

Changes in prevalence of problem opiate use in Germany between 1990 and 2000

OBJECTIVES: Estimates of opiate use are calculated for the years 1990/1991, 1995 and 2000 in order to explore the development of problem opiate use in Germany in the preceding decade. METHODS: The estimates stem from multiplier methods which extrapolate from a sample (benchmark) of known drug users to the total population by multiplying the benchmark by an appropriate factor that accounts for the unknown population. Data came from the German treatment monitoring system, police and mortality statistics. RESULTS: The population estimates for 2000 resulted in 166,300-197,500 problem opiate users based on treatment data, 153,000-190,000 heroin users from police data, and 126,900-169,200 (current) injectors from mortality data. Recalculated estimates for 1990/1991 and 1995 derived from the same data sources were found to be somewhat lower. DISCUSSION: The reported estimates between 1990 and 2000 point at a moderate increase of problem opiate users in the 1990s. The population estimates based on the multiplier method using three different data sources may be considered consistent for the highly overlapping target groups of (current) injectors, problem heroin and problem opiate users. Nevertheless, some of the applied multipliers are based on small-scale studies, raising the question of representativeness. National prevalence estimates may be improved by using other techniques such as multivariate indicator, capture-recapture, or dynamic models.     

Drug use patterns and infection with sexually transmissible agents among young adults in a high-risk neighbourhood in New York City

Aims To determine relationships between drug use ‘hardness’ (defined in increasing order of hardness as no drug use, marijuana use, non‐injected heroin or cocaine use, crack smoking and injection drug use) and prevalences of several sexually transmissible infections among young adults in a high‐risk neighbourhood. Drug users, particularly injection drug users and crack smokers, may be a core group for some sexually transmitted infections. Design Cross‐sectional survey and assays of young adults from (a) a household probability sample and (b) a targeted sample of youth who have used injected drugs, crack, other cocaine or heroin. Setting Bushwick, an impoverished New York City minority neighbourhood with major drug markets. Participants A total of 363 18–24‐year‐olds from a household probability sample; 165 Bushwick 18–24‐year‐olds who have used injected drugs, crack, other cocaine or heroin. Measurements Drug use by self‐report; serum‐ and urine‐based assays for HIV, hepatitis B and C, syphilis, gonorrhoea, chlamydia and herpes simplex (type 2). Findings Household‐sample prevalences: HIV, hepatitis C and syphilis, 1%; gonorrhoea 3%; chlamydia 5%; past or present hepatitis B infection 8%; herpes simplex (type 2) 18%. In combined household and targeted samples, hepatitis C and HIV were concentrated among drug injectors. Herpes simplex (type 2), syphilis and hepatitis B increased among women with ‘hardest drug ever used’. Conclusions Using ‘harder’ drugs is associated with some but not all of these infections. Prevention efforts should help youth avoid unsafe sex and higher‐risk drugs.     

Burden of infection among heads and non-head of rural households in Rakai, Uganda

The objective was to determine HIV prevalence, symptomatology and mortality among adult heads and non-heads of households, in order to assess the burden of HIV on households. It was a community study of 11,536 adults aged 15-59, residing in 4,962 households in 56 villages, Rakai district, Uganda. First, 4,962 heads and 6,574 non-heads of households were identified from censuses. Interviews were then used to determine socio-demographic/behavioural characteristics. HIV seroprevalence was diagnosed by two EIAs with Western blot confirmation. The adjusted odds ratio (OR) and 95% confidence intervals (CI) of HIV infection in household heads and non-heads were estimated by multivariate logistic regression. Age-adjusted mortality was also assessed. HIV prevalence was 16.9% in the population, and 21.5% of households had at least one HIV-infected person (<0.0001). HIV prevalence was higher among heads than non-heads of households (21.5 and 13.3%, respectively, OR=1.79; CI 1.62-1.97). Most household heads were males (70.5%), and HIV prevalence was 17.8% among male heads compared with 6.6% in male non-heads of households (OR=2.31; CI 1.65-2.52). Women heading households were predominantly widowed, separated or divorced (64.4%). HIV prevalence was 30.5% among female heads, compared with 15.6% in female non-household heads (OR=1.42; CI 1.15-1.63). Age-adjusted mortality was significantly lower among male household heads than non-heads, both for the HIV-positive (RR=0.68) and HIV-negative men (RR=0.63). Among women, HIV-negative female household heads had significantly higher mortality than HIV-uninfected female non-heads (RR=1.72). HIV disproportionately affects heads of households, particularly males. Mortality due to AIDS is likely to increase the proportion of female-headed households, and adversely affect the welfare of domestic units.     

The Investigation of HIV and HCV Infection and Risk Factors among Opiate Drug Users in Beijing,China

Objective: To explore the prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and the risk factors among opiate drug users in Beijing. Methods: The opiate drug users enrolled in methadone maintenance treatment clinics of Beijing from 30 November 2004 to 31 March 2008 were investigated. The blood samples were collected and tested for HIV and HCV infection and questionnaires were used for all subjects admitted. Results: Among 1211 eligible subjects, 12 HIV and 713 HCV-positive subjects were observed; the HIV and HCV prevalences were .99% and 58.88%, respectively. Young age, unemployment, injection drug use, and more frequent and longer drug use were the independent risk factors for HCV infection using the multiple logistic regression analysis. The younger drug users are more likely to be infected than the older ones, and the adjusted odds ratios (OR) of 18–30 and 30–40 versus 40–54 years were 1.81 (95% confidence interval (95% CI): 1.13–1.92) and 1.51 (95% CI: 1.08–2.10). The drug users who were unemployed (OR = 1.70, 95% CI: 1.23–2.37), with injection drug use (OR = 10.99, 95% CI: 7.26–16.65), with more frequent drug use (OR = 2.42, 95% CI: 1.31–2.46), and with longer heroin abuse history (OR = 8.06, 95% CI: 1.19–57.54) were more likely to be infected with HCV. Conclusions: The HCV infection was popular among opiate drug users in Beijing. The findings indicated the need for educating the users taking into account their low literacy levels and the necessity for job training and decreasing the injection drug use and the frequency of drug use administrated as the prevention and intervention methods for controlling the HIV/HCV infection in this population.     

Intimate Partner Violence,Dependence Symptoms and Social Consequences from Drinking among White,Black and Hispanic Couples in the United States

This study estimates the association of intimate partner violence (IPV) and alcohol‐dependence symptoms, social consequences from drinking, and drug use among white, black, and Hispanic couples. A probability sample of 555 white, 358 black, and 527 Hispanic couples in the U.S. household population was interviewed in 1995. The response rate was 85%. Bivariate analysis indicates that most problem status variables are associated with increased rates of male‐to‐female (MFPV) and female‐to‐male (FMPV) partner violence. Logistic regression analyses showed that predictors of MFPV and FMPV vary by ethnicity.     

Study of bias in antenatal clinic HIV-1 surveillance data in a high contraceptive prevalence population in sub-Saharan Africa

OBJECTIVE: To describe patterns, sources and consequences of bias in antenatal clinic (ANC) HIV prevalence estimates in a high contraceptive prevalence population. BACKGROUND: HIV surveillance in Africa relies on data from pregnant women attending ANCs. HIV estimates from pregnant women understate female infection levels in low income, high fertility populations. Bias in high contraceptive use, delayed sexual debut populations remains undescribed. DESIGN AND METHOD: Comparison of parallel cross-sectional population and antenatal survey data from rural Zimbabwe, where 60% of women are recent contraceptive users. RESULTS: HIV prevalence in recently pregnant women (25.7%; n = 576) and all women (25.5%; n = 5138) is similar over the age-range 15-44 years. As in high fertility populations, HIV prevalence is higher in pregnant women at young ages and lower at older ages but the crossover point occurs later due to delayed sexual activity. HIV understatement at older ages due to HIV-associated infertility is mitigated by less HIV infection and less frequent ANC attendance in contraceptive users. The local ANC HIV prevalence estimate is lower [21.2%; n = 1215; risk ratio versus pregnant women in the general population, 0.8; 95% confidence interval (CI), 0.7-1.0], possibly because women from more remote areas are included. ANC estimates overstate the relative risk of HIV in more educated women (age-adjusted odds ratio, 1.1; 95% CI, 0.8-1.4 versus 0.7; 95% CI, 0.6-0.9). CONCLUSIONS: ANC estimates understate female HIV prevalence in this low fertility population but, here, the primary cause is not selection of pregnant women. ANC estimate adjustment procedures that control for contraceptive use and age at first sex are needed.     

Psychoactive substance use in three sites in China: gender differences and related factors

One year prevalence rates far psychoactive substance use are reported based on a community survey in Hunan, Helongjiang and Jiangsu. Data were gathered on more than 14 000 respondents (15–65 years old). The drinking rates ranged from 58.3% to 82.6% for men and from 16.3% to 31.4% for women. Smoking rates ranged from 64.9% to 68.1% for men and from 0.1% to 20.5% for women. Most drinkers were light users and most smokers were heavy users, Illicit drug use was found in the Hunan site. For both frequency and quantity of psychoactive substance use, women are lighter consumers than males (except for the use of minor tranquilizers and analgesics). Psychosocial factors related to drinking and smoking are also investigated in this study.     

新疆喀什地区2004年艾滋病综合调查分析

目的摸清各类人群艾滋病病毒（HIV）感染率和行为学指标,弥补监测数据不足,掌握喀什地区艾滋病（AIDS）流行现状,为制定可行的防治策略提供科学依据.方法随机抽取吸毒者、暗娼、性病门诊就诊者、孕产妇和调查时医院就诊者等5类人群,进行行为危险因素问卷调查和HIV抗体、梅毒和吸毒人群的丙型肝炎病毒（HCV）抗体检测.结果调查的400名吸毒者中,注射吸毒者占36.75%,近1个月内的共用针具率为15%.吸毒者最近一次与其配偶或性伴有性行为时安全套的使用率仅为10.78%,其HIV、HCV和梅毒感染率分别为24.25%、42.00%和42.25%,共用注射器吸毒者的HIV、HCV感染率均高于非共用者.暗娼、性病患者、孕产妇和调查时医院就诊者的HIV和梅毒感染率分别为0.67%和8.00%、0和5.75%、0.12%和4.61%、0.19%和1.45%.被调查人群艾滋病知识水平较低,普遍存在高风险行为.结论当地吸毒人群艾滋病的流行处于较高水平,流行的危险因素广泛存在,扩大流行的可行性极大.     

Suicide among heroin users: rates,risk factors and methods

ABSTRACT The current paper examines critically the literature on suicide rates, suicide risk factors and methods employed for suicide among heroin users, and compares these to those of the general population. Heroin users have a death rate 13 times that of their peers, and deaths among heroin users attributed to suicide range from 3–35%. Overall, heroin users are 14 times more likely than peers to die from suicide. The prevalence of attempted suicide is also many orders of magnitude greater than that of community samples. The major general population risk factors for suicide also apply to heroin users (gender, psychopathology, family dysfunction and social isolation). Heroin users, however, have extremely wide exposure to these factors. They also carry additional risks specifically associated with heroin and other drug use. Drugs as a method of suicide play a larger role in suicide among heroin users than in the general population. Heroin, however, appears to play a relatively small role in suicide among this group. Overall, suicide is a major clinical issue among heroin users. It is concluded that suicide is a major problem that treatment agencies face, and which requires targeted intervention if the rates of suicide among this group are to decline.