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Evidence-Based Mental Health Online First, published on April 17, 2013 as 10.1136/eb-2013-101305 Prognosis

People registered with drug treatment services have increased risk of drug-related death following discharge from hospital
doi:10.1136/eb-2013-101305

QUESTION Question: Are drug users at increased risk of drug-related death and non-drug-related suicide following discharge from hospital? Population: In total 69 457 individuals (69% men) were registered on the Scottish Drug Misuse Database (SDMD) over a 10-year period (April 1996March 2006). Deaths and hospital admissions were identied through linkage to national registers held by Scotlands Information Services Division, the General Register Ofce for Scotland and Health Protection Scotland. Setting: Scotland drug services; April 1996March 2006. Prognostic factors: Drug use as indicated by SDMD and hospital admission. Time-at-risk was calculated as date of rst attendance at drug treatment services to death or end of study (whichever came rst), and categorised according to time since most recent hospitalisation: during hospitalisation; within 28 days; 2990 days; 91 days to 1 year; and >1 year since discharge. The reference category was never admitted. Outcomes: Drug-related death (DRD), dened as main cause of death recorded with an ICD code indicating mental and behavioural disorders due to psychoactive substance misuse; accidental poisoning; intentional self-poisoning or assault by drugs, medicaments and biological substances; and poisoning events of undetermined intent. Non-DRD suicide, dened as any suicide excluding those with any ICD code corresponding to DRD. METHODS Design: Cohort study. Follow-up period: 10 years.

MAIN RESULTS There were 1383 DRDs during the study period, with a rate for the full cohort of 3.9/1000 person-years of follow-up (95% CI 3.7 to 4.2). Thirty-nine per cent of the cohort experienced at least one hospital stay. Those who never admitted had a DRD rate of 1.9/1000 person-years (95% CI 1.7 to 2.1). Those who admitted had higher DRD rates, with rates highest in the periods during and shortly following hospitalisation. The rate of DRD per 1000 person-years during hospitalisation was 87 (95% CI 72 to 103); within 28 days of hospitalisation it was 21 (95% CI 18 to 25); within 2990 days it was 12 (95% CI 10 to 15); within 91 days to 1 year it was 8.5 (95% CI 7.5 to 9.5); and >1 year since discharge it was 4.2 (95% CI 3.7 to 4.7). Following adjustment for demographic and behavioural factors (including age, sex, injecting history, substances used), compared to those who never admitted, people who admitted had an increased risk of DRD: hazard ratios 9.6 (95% CI 8 to 12) within 28 days of discharge; 5.6 (95% CI 4.6 to 6.8) within 2990 days; 4.0 (95% CI 3.5 to 4.7) within 91 days to 1 year; and 2.3 (95% CI 2.0 to 2.7) at >1 year since discharge. There were 269 non-DRD suicides during the study period. Non-DRD suicides showed a similar pattern to DRDs, with highest rate during hospitalisation (18/1000 person-years). The year following hospitalisation accounted for 38% of all non-DRD suicides. CONCLUSIONS People who are registered with drug treatment services have an increased rate of DRD and non-DRD suicide in the period following discharge from hospital. ABSTRACTED FROM
Merrall EL, Bird SM, Hutchinson SJ. A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 19962006. Addiction. 2013;108:37784. Correspondence to: Elizabeth LC Merrall, MRC Biostatistics Unit, Robinson Way, Cambridge, CB2 OSR, UK; Elizabeth.merrall@mrc-bsu.cam.ac.uk Sources of funding: Medical Research Council and a grant from the Chief Scientist Ofce of the Scottish Executive. Additional reference is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/eb-2013-101305).

COMMENTARY

errall and colleagues report the ndings of a notably signicant, meaningful and relevant study of postdischarge death or suicide among drug treatment clients in Scotland. While people experiencing substance and/or alcohol misuse seldom evoke the same or similar societal response than those with heart disease, diabetes or oncology do, for many occidental countries, alcohol and substance misuse are signicant public health problems. According to the data provided by the WHO, drug and alcohol-related problems account for as much as 5.4% of the global burden of disease.1 Yet it can be argued that the corresponding body of research activity (and funding) dedicated to this area does not correspond to the associated burden of disease; as a result, Merrall and colleagues study can be considered to be timely.

The use of electronic administrative records as the primary source of data is a most welcome development, the limitations of epidemiological research notwithstanding. For instance, in this case, the validity of ndings is determined, at least in part, by the methodological rigour of the original classication, and the problems of determining when a suicide is a suicide as a matter of public record. Accordingly, perhaps a brief acknowledgment here of such limitations may have been useful. The authors ndings are in keeping with the limited, related extant body of literature, wherein evidence indicates the period of time immediately following discharge has been found to be a particularly high-risk time for suicide. Accordingly, the recommendation for an additional support at the time of discharge echoes the exhortations of related studies. However, the

authors could have extended this argument to illustrate how the need to provide care for substance and/or alcohol users merely changes (rather than stops) after discharge. Perhaps some specic postdischarge follow-up interventions or strategies could have been identied. While the authors should be commended for including some suggestions for further statistically focused studies, a deeper insight into the particular lived experiences that contribute to these elevated postdischarge death rates would better inform the service responses to these needs.
John R Cutcliffe Adjunct Professor: University of Ottawa, Canada; School of Nursing, University of Coimbra, Portugal; and University of Malta, Malta Competing interests None.

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People registered with drug treatment services have increased risk of drug-related death following discharge from hospital
Evid Based Mental Health published online April 17, 2013

doi: 10.1136/eb-2013-101305

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Topic Collections

Articles on similar topics can be found in the following collections Suicide (psychiatry) (191 articles) Alcohol dependence (105 articles) Substance dependence (380 articles) Epidemiologic studies (521 articles) Epidemiology (1371 articles)

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