Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study

BACKGROUND: Specialist drug treatment is critical to overdose prevention; methadone maintenance is effective, but we lack evidence for other modalities. We evaluate the impact of a range of treatments for opiate dependence on overdose mortality. METHODS: Prospective cohort study of 10,454 heroin users entering treatment 1998-2001 in Italy followed-up for 10,208 person-years in treatment and 2,914 person-years out of treatment. Standardized overall mortality ratios (SMR) estimate excess mortality risk for heroin users in and out of treatment compared to the general population. Cox models compare the hazard ratio (HR) of overdose between heroin users in treatment and out of treatment. RESULTS: There were 41 overdose deaths, 10 during treatment and 31 out of treatment, generating annual mortality rates of 0.1% and 1.1% and SMRs of 3.9 [95% confidence interval (CI) 2.8-5.4] and 21.4 (16.7-27.4), respectively. Retention in any treatment was protective against overdose mortality (HR 0.09 95% CI 0.04-0.19) compared to the risk of mortality out of treatment, independent of treatment type and potential confounders. The risk of a fatal overdose was 2.3% in the month immediately after treatment and 0.77% in the subsequent period; compared to the risk of overdose during treatment the HR was 26.6 (95% CI 11.6-61.1) in the month immediately following treatment and 7.3 (3.3-16.2) in the subsequent period. CONCLUSIONS: We demonstrate that a range of treatments for heroin dependence reduces overdose mortality risk. However, the considerable excess mortality risk in the month following treatment indicates the need for greater health education of drug users and implementation of relapse and overdose death prevention programmes. Further investigation is needed to measure and weigh the potential benefits and harms of short-term therapies for opiate use.     

The shifting pattern of cause-specific mortality in a cohort of human immunodeficiency virus-infected and non-infected injecting drug users

AIMS: To monitor changes in cause-specific mortality before and after 1997 according to human immunodeficiency virus (HIV) serological status in a cohort of injecting drug users (IDUs) observed for a 17-year period (1987--2004). DESIGN: Community-based prospective cohort study of IDUs recruited in three acquired immunodeficiency virus (AIDS) prevention centres (1987--96) and followed-up until to 2004. METHODS: We obtained annual overall mortality rates and mortality rates by specific causes according to HIV status. Poisson regression models were adjusted to compare mortality rates between calendar periods. Significant changes in slope trends were evaluated by join-point regression. Disease-specific mortality rates were estimated using competing risk models. FINDINGS: From 7186 IDUs recruited (80677.218 person-years), 1589 deaths were observed with an overall mortality rate of 19.7 per 1000 person-years (95% CI, 18.8-20.7). This rate decreased from 22.9 per 1000 (95% CI, 21.4-24.7) before 1997 to 17.4 per 1000 (95% CI, 16.3-18.6) after 1997 [relative risk (RR) 0.83; 95% confidence interval (CI), 0.75-0.92]. Risk of death for HIV-positive was four times higher than for HIV-negative (RR 4.08; 95% CI, 3.63-4.58). Among HIV-positive individuals a significantly decreased change point in trend was found in 1997 for both total and AIDS mortality. HIV-negative individuals showed a similar pattern for drug overdose, suicide and accident mortality. Both groups showed an increase in proportional mortality by liver-related causes, cardiovascular diseases and cancer. Furthermore, a progressively increasing trend was observed for the three causes. However, there were no significant differences according to serological groups. CONCLUSIONS: Cardiovascular and cancer mortality are increasing among IDUs, but the increases are not related to HIV infection. We have not found a link between highly active antiretroviral therapy (HAART) introduction and increases in mortality for specific causes.     

Progression of HIV infection in the post-HAART era among a cohort of HIV+ Greek haemophilia patients

AIM: The study aims to describe the course of HIV-1 infection in the pre- and post-HAART period in a cohort of HIV+ haemophilia patients followed up for up to 21 years. METHODS: The cohort includes 158 haemophilic men with known seroconversion dates followed up prospectively for a median time of 12 and 5.7 years in the pre- (1980-96) and post-HAART period (1997-2003), respectively. RESULTS: The risk of developing AIDS was lowered by 56% in the post- as compared to the pre-HAART period. Of the 158 patients 69 developed AIDS in the pre-HAART period while of the 59 subjects still alive and AIDS free on 1/1/1997 six developed AIDS. The rate of PCP (12.0 cases per 1000 person-years) and NHL (5.4 cases per 1000 person-years), the most common causes of AIDS diagnosis in the pre-HAART era, were remarkably reduced in the post-HAART era (both rates: 2.8 cases per 1000 person-years). On the contrary, the corresponding risk for non-AIDS deaths was fourfold increased in the post-HAART period. Of the 38 non-AIDS related deaths in both periods, 13 occurred post-HAART. The predominant cause of non-AIDS mortality in both periods was end-stage liver disease (ESLD) (7 pre- and 4 post-HAART). The rate of non-AIDS related cancers was also increased during the post-HAART period. CONCLUSION: In this haemophilia cohort the risk of AIDS has substantially reduced in the post-HAART period, but the rate of non-AIDS mortality tended to increase. Among haemophilia subjects, due to the high rates of HCV/HIV coinfection, ESLD, the predominant cause of non-AIDS mortality, will become an increasingly important clinical problem.     

Ten-year survival analysis of a cohort of heroin addicts in Catalonia: the EMETYST project

Aims. To determine mortality rates and immediate causes of death in a cohort of heroin addicts, and to compare them with other European samples. Design. Longitudinal follow-up study of a cohort for 10.5 years (March/July 1985–December 1995). Setting. Catalonia, Spain. Participants. One hundred and thirtyfive heroin addicts. Measurements. (a) Number of total and annual events; (b) annual mortality rate; (c) average annual mortality rate; and (d) standardized mortality ratio (SMR). Kaplan–Meier (log rank test) was used to assess the predictive factors. Findings. During this period, 41 heroin addicts died (30%), the average annual mortality rate was 3.4% and the SMR was 28.5. The most frequent causes of death fell in ICD-9 chapter III (which includes AIDS) (51%) and in chapter XVII (which includes overdose) (30%). Neither the socio-demographic characteristics nor the history of heroin consumption were predictors of survival or cause of death. Conclusions. Compared to other European studies, the cohort in the EMETYST project has the highest SMR and members have a higher chance of dying due to AIDS. The predictors of survival in the long term must be interpreted with caution, with the exceptions of being HIV positive or being diagnosed with AIDS.     

The increasing mortality burden of liver disease among opioid-dependent people: cohort study

Aims Hepatitis C (HCV) infection is highly prevalent among injection drug users (IDUs) and likely to cause significant mortality over time, but little research attention has focused upon the magnitude of this risk, particularly among ageing users. This study examined trends over time in mortality attributed to liver disease, and in particular contrasting this with other more commonly studied causes of death [acquired immune deficiency syndrome (AIDS), suicide and overdose] among an ageing cohort of heroin‐dependent people in Australia. Design Data linkage study of methadone treatment entrants with the National Deaths Index. Setting A cohort entering methadone treatment for heroin dependence in New South Wales, Australia, 1980–85. Participants A total of 2489 people entering methadone treatment for heroin dependence and 54 847 person‐years (PY) of follow‐up. Measurements Linkage of data on all methadone entrants between 1980 and 1985 with data from the Australian National Deaths Index, linked using probabilistic record linkage software. Findings There were 8.2 deaths per 1000 PY [95% confidence interval (CI) 7.5–9.0], with standardized mortality ratios (SMRs) of 4.6 (95% CI 4.2–5.0). Almost one in five (17%) of deaths were from underlying liver‐related causes, most commonly viral hepatitis. The overall mortality rate for any liver cause was 1.4 deaths per 1000 PY (95% CI 1.1–1.7), 17 times higher than to the general population (95% CI 13.4–21.3), with relative elevations more marked for females (SMR 27.9; 95% CI 17.7–41.9) than males (SMR 14.5; 95% CI 10.8–19.0). Liver mortality increased over time, becoming the most common cause of death by the end of follow‐up. Conclusions Liver disease has become the most common cause of mortality among ageing opioid‐dependent people in an ageing Australian cohort. There is an imperative to reduce the long‐term risks of HCV and other risks to the liver, including alcohol consumption, which are typically not the major clinical focus for this group.     

Predictors of mortality among injecting and non-injecting HIV-negative drug users in northern Thailand

AIMS: To estimate mortality rates among HIV-negative injecting drug users (IDUs) and non-injecting drug users (non-IDUs), and to assess predictors for mortality among the IDUs. DESIGN: Prospective cohort study in northern Thailand with 2-year follow-up. SETTING: IDUs and non-IDUs who were admitted for detoxification treatment for opiate or amphetamine dependence in a regional drug treatment center were screened. After discharge, HIV-negative individuals were followed-up in the community. PARTICIPANTS: A total of 821 HIV-negative drug users [346 IDUs (42%) and 475 non-IDUs, median age = 32; 51% were ethnic minorities]. MEASUREMENTS: All-cause mortality. FINDINGS: There were 33 deaths over 1360 person-years of follow-up. The all-cause mortality rate was 39 per 1000 person-years among IDUs [standardized mortality ratio (SMR) = 13.9], and was 14 per 1000 person-years among non-IDUs (SMR = 4.4). Among male IDUs, the hazards for all-cause deaths were ethnic minority status [adjusted hazard ratio (HR) = 2.9, 95% CI = 1.2-7.2], incident HIV infection (HR = 2.8, 95% CI = 1.1-7.7) and longer duration of drug injection (HR = 1.07, 95% CI = 1.01-1.14). CONCLUSIONS: The mortality among IDUs is high. Being from an ethnic minority, recent HIV acquisition, and a greater number of years of drug injection are predictors of mortality among the IDUs in this region.     

Progression of HIV infection and mortality by hepatitis C infection in patients with haemophilia over 20 years.

Hepatitis C virus (HCV) infection is an important cause of mortality in human immune deficiency virus (HIV)-positive haemophiliacs. This study describes progression to AIDS, death from HCV end-stage liver disease (ESLD) and all-cause mortality over 20 years. All HIV-positive haemophiliacs in La Paz University Hospital were included in this cohort. HIV seroconversion was estimated using mathematical techniques for interval-censored data from 1979 to 1985. Poisson regression was used to estimate rates of AIDS, death from ESLD and all causes in different periods: before 1988, 1988-89, 1990-91, 1992-93, 1994-95, 1996-97 and 1998-2001 using competing risk models. Among 383 cohort members, global AIDS incidence was 9.7 per 100 person-years, peaking in 1992-93 and dropping by 87% in 1998-2001 compared with before 1988 [incidence rate ratio (IRR) 0.13; 95% CI: 0.03-0.53]. Overall mortality was 7.5 per 100 person-years, was highest from 1992 to 1997, and fell by 66% in 1998-2001 compared with before 1988 (IRR 0.34; 95% CI: 0.14-0.81). Eighteen (5%) persons died of ESLD which represented 19% of deaths before 1988, 4% during 1988-89, 1990-91 and 1992-93, 2% in 1994-95, 10% in 1996-97 and 33% in 1998-2001. Overall death rate from ESLD was 0.5 cases per 100 person-years with no statistically significant trend observed over time. Important reductions in HIV disease progression to AIDS and death have been observed from 1998 to 2001, and can be attributed to highly active antiretroviral therapy. Although no increase in the rate of HCV-related deaths can be demonstrated, HCV accounts for an increasing proportion of deaths in the recent years.     

Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection

AIMS: To examine the long-term impact of methadone maintenance treatment (MMT) on mortality, re-incarceration and hepatitis C seroconversion in imprisoned male heroin users. DESIGN, SETTING AND PARTICIPANTS: The study cohort comprised 382 imprisoned male heroin users who had participated in a randomized controlled trial of prison-based MMT in 1997/98. Subjects were followed-up between 1998 and 2002 either in the general community or in prison. MEASUREMENTS: All-cause mortality, re-incarceration, hepatitis C and HIV serostatus and MMT retention. FINDINGS: There were no deaths recorded while subjects were enrolled in MMT. Seventeen subjects died while out of MMT, representing an untreated mortality rate of 2.0 per 100 person-years (95% CI, 1.2-3.2). Re-incarceration risk was lowest during MMT episodes of 8 months or longer (adjusted hazard ratio 0.3 (95% CI, 0.2-0.5; P < 0.001), although MMT periods 2 months or less were associated with greatest risk of re-incarceration (P < 0.001). Increased risk of hepatitis C seroconversion was significantly associated with prison sentences of less than 2 months [adjusted hazard ratio 20 (95% CI, 5-76; < P = 0.001)] and MMT episodes less than 5 months [adjusted hazard ratio 4.2 (95% CI, 1.4-12.6; P = 0.01)]. Subjects were at greatest risk of MMT dropout during short prison sentences of 1 month or less (adjusted hazard ratio 10.4 (95% CI, 7.0-15.7; P < 0.001). HIV incidence was 0.3 per 100 person-years (95% CI, 0.03-0.99). CONCLUSIONS: Retention in MMT was associated with reduced mortality, re-incarceration rates and hepatitis C infection. Prison-based MMT programmes are integral to the continuity of treatment needed to ensure optimal outcomes for individual and public health.     

The effect of HIV infection on overdose mortality

OBJECTIVES: To quantify the association of HIV infection with overdose mortality and explore the potential mechanisms. DESIGN: A prospective cohort study. METHODS: A total of 1927 actively injecting drug users who were HIV seronegative at baseline, of whom 308 later HIV seroconverted, were followed semi-annually for death from 1988 to 2001. Survival analyses using marginal structural and standard Cox models were used to evaluate the effect of HIV infection on the risk of overdose mortality. RESULTS: Overdose death rates were higher in HIV-seropositive than HIV-seronegative drug users: 13.9 and 5.6 per 1000 person-years, respectively (P < 0.01). The hazard ratio (HR) was 2.54 [95% confidence interval (CI) 1.47, 4.38] for the marginal structural model and 2.06 (95% CI 1.25, 3.38) for the standard Cox model, both adjusted for demographics, drug injection characteristics, alcohol abuse, substance abuse treatment, and sexual orientation. Adjusting for possible time-varying mediators (i.e. drug use, medical conditions and healthcare access) in extended marginal structural models reduced the effect of HIV on overdose mortality by 30% (HR 1.82, 95% CI 1.01, 3.30). Abnormal liver function was associated with a higher risk of overdose mortality (HR 2.00, 95% CI 1.05, 3.84); adjustment for this further reduced the effect of HIV on overdose mortality. CONCLUSION: HIV infection was associated with a higher risk of overdose mortality. Drug use behavior, systematic disease and liver damage associated with HIV infection appeared to account for a substantial portion of this association. The data suggest a group to target with interventions to reduce overdose mortality rates.     

An update on the impact of HIV/AIDS on life expectancy in the United States

We used the potential gains in life expectancy to quantify the impact of eliminating HIV/AIDS,heart disease and malignant neoplasms on the life expectancy of the population of the USA from 1987 to 1999 by race and sex groups. We previously reported the results from 1987 to 1992,with a focus on the year 1992. This report gives an update to 1999, showing the impact of improvements in the care and treatment of HIV/AIDS in recent years.     

Mortality among problem drug users in Rome: an 18-year follow-up study, 1980-97

Aim . To analyse overall and cause-specific mortality among problem drug users (PDUs) attending treatment centres in Rome and to evaluate differences in mortality between genders.
Methods . A cohort of 11 432 PDUs entering treatment in Rome between 1980 and 1995 was enrolled and followed-up as of May 31, 1997. Directly standardized mortality rates and standardized mortality ratios (SMRs) and their 95% confidence intervals (95% CI) were calculated. Results. The study population included mainly males (82%), heroin users (92%) and had a mean age of 26.6 (SD 5.9) at enrolment. At the end of the study period 1734 deaths were observed. Overall mortality rates began to increase in 1985-86 and decreased slightly afterwards. AIDS mortality peaked in 1991-92 (13.2/1000) and fell in the following years. A slight decrease in overdose mortality also occurred after 1989-90. Mortality for causes other than AIDS and overdose remained high and relatively steady for the whole study period. Women showed higher mortality rates for AIDS but lower mortality rates for overdose than males. Overall mortality risk among drug addicts was about 15 times higher compared to the general population of the same age among men, and 38 times higher among women.
Conclusions . AIDS mortality among drug addicts began to decrease earlier than expected; the decrease was particularly significant in the period 1993-94 for both sexes. Afterwards a continuous but slight decrease was observed among males only. Even though overdose mortality has also decreased slightly in recent years, we still observe high mortality levels for both overdose and all other causes. These findings suggest that interventions directed specifically towards the reduction of baseline mortality are still needed.     

An increase in overdose mortality during the first 2 weeks after entering or re-entering methadone treatment in Amsterdam

Aims It has been suggested that starting and temporarily discontinuing methadone treatment is related to an increased risk in overdose mortality. This study describes the incidence of overdose mortality in relation to time after (re)entering or leaving treatment. Design A dynamic cohort of 5200 Amsterdam methadone clients was observed during treatment and (a maximum of 1 year) after treatment. Findings Between 1986 and 1998, 29 729 person‐years (py) and 68 overdose deaths were recorded, leading to an overdose mortality rate of 2.3/1000 py (2.2 during and 2.4 after treatment). A modest increase was observed during the first 2 weeks after (re)entering treatment; 6.0/1000 py (rate ratio: 2.9; 95% confidence interval 1.4; 5.8). Directly after leaving treatment no increase was observed. Conclusions Inhaling heroin, common among Amsterdam heroin users, is thought to account for low OD mortality rates both during and after treatment. Accumulation of methadone, inadequate assessment of tolerance of known clients re‐entering treatment and concurrent periods of stress or extreme heroin use when entering treatment are mentioned as possible explanations of the increased risk within the first 2 weeks. An Australian study reported a much higher increase. The modest increase in Amsterdam is explained by low background risk of overdose mortality, low starting dosage and the low threshold to treatment.     

Impact of hepatitis C infection on long-term mortality of injecting drug users from 1990 to 2002: differences before and after HAART

OBJECTIVE: To assess the impact of HIV and hepatitis C virus (HCV) infection on long-term mortality in injecting drug users (IDU). DESIGN: Community-based prospective cohort study. METHODS: Mortality data from follow-up in clinical sites and the Mortality Registry by December 2002 were collected for 3247 IDU who attended three centres for voluntary counselling and testing for HIV/AIDS, HCV and hepatitis B virus (HBV) in 1990-1996. Mortality rates by Poisson regression were adjusting for age, sex, duration of drug use, education, HBV and calendar period (1990-1997 and 1998-2002). RESULTS: Overall, 11.2% were HIV/HCV negative, 43.7% positive only for HCV and 45.1% positive for both. During 26 772 person-years of follow-up, 585 deaths were detected (2.19/100 person-years). Before 1997, HIV/HCV-positive subjects had a five-fold increase in risk of death [relative risk (RR), 5.4; 95% confidence interval (CI), 2.5-11.4] compared with those negative for both; after 1997, a three-fold increase was observed (RR, 2.7; 95% CI, 1.7-4.2). Being HCV positive/HIV negative was not associated with an increase in the risk of death either before (RR, 1.3; 95% CI, 0.6-2.9) or after (RR, 1.2; 95% CI, 0.8-1.9) 1997 compared with HCV/HIV negative. While increases in mortality were seen in those HCV/HIV negative (RR, 1.6; 95% CI, 0.7-3.7) and those only positive for HCV (RR, 1.5; 95% CI, 1.0-2.1), a 20% reduction among coinfected IDUs was observed after 1997 (interaction P = 0.033). CONCLUSIONS: HCV/HIV coinfection has had a large impact on mortality in IDU. After 1997, mortality increased in HIV negative/HCV positive subjects and decreased in HIV positive/HCV positive.     

Rates and causes of child mortality in an area of high HIV prevalence in rural South Africa

OBJECTIVE: To determine child mortality rates in a rural area of South Africa with high HIV prevalence. METHODS: A community-based survey was conducted between 1 January 2000 and 31 December 2002 on deaths in children under the age of 15 years. Children were followed up through four monthly home visits. Cause of death was ascertained by verbal autopsy. Rates were calculated using Poisson regression. RESULTS: Mortality ratios were 59.6 deaths per 1000 live births for infants and 97.1 for children under 5 years of age. Infant and under-5 mortality rates were, respectively, 67.5 and 21.1 deaths per 1000 person-years. HIV/AIDS was attributed to 41% of deaths in the under-5 age group, with a mortality rate of 8.6 per 1000 person-years. Lower respiratory infections caused an estimated 24.9 deaths per 1000 person-years in children under 1 year of age. CONCLUSIONS: In rural South Africa, infant and child mortality levels are high, with HIV/AIDS estimated as the single largest cause of death. Interventions to reduce child mortality are required urgently.     

Changes and predictors of change in the physical health status of heroin users over 24 months

Aims   (i) To describe the course of physical health among the ATOS cohort over 24 months; and (ii) to examine the effects of treatment, drug use patterns and social and psychological factors on health status over 24 months.
Design   Longitudinal cohort.
Setting   Sydney, Australia.
Participants   A total of 615 heroin users recruited for the Australian Treatment Outcome Study (ATOS).
Findings   The general health of the cohort improved significantly over 24 months. Significant predictors of poor health over 24 months were: being older, being female, past month heroin, other opiate and tobacco use, past month unemployment and current major depression. Spending a greater proportion of time in residential rehabilitation (RR) was associated with better health over 24 months. No other treatment factors demonstrated a significant, independent relationship with health.
Conclusions   The physical health of dependent heroin users is affected by drug use and psychosocial problems. RR treatment appears to be particularly beneficial to the health of heroin users, suggesting the importance of a comprehensive approach to improving health among this group.     

Impact of HAART and injection drug use on life expectancy of two HIV-positive cohorts in British Columbia

BACKGROUND: The introduction of HAART has led to consistent improvements in survival among HIV-infected individuals. However, there is evidence that not all populations have benefited equally from HAART and that mortality rates are higher in HIV-infected injection drug users than in non-users. OBJECTIVE: To model life expectancies for HIV-positive individuals subdivided according to history of injection drug use and treatment with HAART. DESIGN: Population-based study of HIV-positive persons in British Columbia's HIV/AIDS treatment program. METHODS: The primary outcome measures in this study were life expectancy at exact age 20 and potential years of life lost. RESULTS: The highest life expectancy (38.9 years) and lowest potential years of life lost were measured for individuals taking HAART and without a history of injection drug use. The lowest life expectancy (19.1 years) and highest potential years of life lost were measured in HIV-positive injection drug users who were not taking HAART. CONCLUSIONS: There are substantial disparities in life expectancy for persons living with HIV in British Columbia. Members of the injection drug community, particularly those who are not taking HAART, experience elevated mortality in comparison with those without a history of drug use.     

Antiretroviral medication use among injection drug users: two potential futures

OBJECTIVE: To model the potential impact of HIV infection rates and the use of antiretroviral medication on life expectancy and mortality in the Downtown Eastside of Vancouver, British Columbia, Canada, from 1999 to 2006. DESIGN: Population projections were made to estimate the population of the Downtown Eastside in the year 2006. METHODS: Two scenarios were modelled to predict the impact of HIV infection and antiretroviral use on mortality and life expectancy. The use of antiretroviral therapy was estimated to be 80% in the first scenario and 20% in the second. The prevalence of HIV by age and sex, and by year infected was estimated using data from the Vancouver Injection Drug User Study. RESULTS: If the level of antiretroviral therapy use among HIV-positive individuals was 80% at baseline, then we estimate that the life expectancy at birth in the year 2006 will be 60.8 years for men and 72.8 years for women, and 172 AIDS deaths will occur between 1999 and 2006. In contrast, if the present level of antiretroviral medication use persists, the life expectancy at birth in the year 2006 will be 56.9 years for men and 68.6 years for women, and 503 AIDS deaths will occur between 1999 and 2006. CONCLUSION: Our analysis suggests that if the low levels of antiretroviral therapy use persist, life expectancy in Vancouver's Downtown Eastside will soon be on a par with many of the world's least developed countries. Our findings highlight the large health status decline that can be expected in many inner city neighbourhoods if low levels of antiretroviral use persist. Although reasonable coverage targets for injection drug users (IDU) have not been established, the expanded use of antiretroviral medication is urgently needed to avert a drastic decline in health status.     

The distribution of naloxone to heroin users

Overdose deaths are a major contributor to excess mortality among heroin users. It has been proposed that opioid overdose morbidity and mortality could be reduced substantially by distributing the opioid antagonist naloxone to heroin users. The ethical issues raised by this proposal are evaluated from a utilitarian perspective. The potential advantages of naloxone distribution include the increased chance of comatose opioid users being quickly resuscitated by others present at the time of an overdose, naloxone's safety and its lack of abuse potential. The main problems raised by the proposal are: the medico-legal complications of medical practitioners prescribing a drug that is most likely to be administered to and by people other than the one for whom it is prescribed; the economic costs of distributing naloxone sufficiently widely to have an impact on overdose morbidity and mortality; and the potentially greater cost-effectiveness of simpler educational interventions. Given the possible benefits of naloxone distribution, it may be worthwhile considering a controlled trial of naloxone distribution to high-risk heroin users.     

Youth mortality due to HIV/AIDS in South Africa, 2001–2009: An analysis of the levels of mortality using life table techniques

South Africa has one of the highest HIV/AIDS prevalence rates in the world. It is estimated that 5.38 million South Africans are living with HIV/AIDS. In addition, new infections among adults aged 15+ were reportedly 316 900 in 2011. New infections among children (0–14 years old) was also high in 2011 at 63 600. This paper examines South Africa's mortality due to HIV/AIDS among the youth (15–34 years old). This age group is of fundamental importance to the economic and social development of the country. However, the challenges of youth development remain vast and incomparable. One of these challenges is the impact of HIV/AIDS on mortality. Life table techniques are used to estimate among others, sex differentials in death rates for the youth population, probability of dying from HIV/AIDS before the age of 35 and life expectancy should HIV/AIDS be eradicated from the population. The study used data from the National Registry of Deaths, as collated by Statistics South Africa from 2001 to 2009. Results show that youth mortality due to HIV/AIDS has remained consistently higher among older youths than in younger ones. By sex, mortality due to this cause has also remained consistent over the period, with mortality due to HIV/AIDS being higher among females than males. Cause-specific mortality rates and proportional mortality ratios reflect the increased mortality of older youth (especially 30–34 years old) and females within the South African population. Probability of dying from HIV/AIDS shows that over the period, fluctuations in likelihood of mortality have occurred, but for both males and females (of all age groups) the chances of dying from this cause decreased in 2007–2009.