Elsevier

Preventive Medicine

Volume 44, Issue 4, April 2007, Pages 369-374
Preventive Medicine

Years of potential life lost among heroin addicts 33 years after treatment

https://doi.org/10.1016/j.ypmed.2006.10.003Get rights and content

Abstract

Objective.

To examine premature mortality in terms of years of potential life lost (YPLL) among a cohort of long-term heroin addicts.

Method.

This longitudinal, prospective study followed a cohort of 581 male heroin addicts in California for more than 33 years. In the latest follow-up conducted in 1996/97, 282 subjects (48.5%) were confirmed as deceased by death certificates. YPLL before age 65 years was calculated by causes of death. Ethnic differences in YPLL were assessed among Whites, Hispanics, and African Americans.

Results.

On average, addicts in this cohort lost 18.3 years (SD = 10.7) of potential life before age 65. Of the total YPLL for the cohort, 22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents. The total YPLL and YPLL by death cause in addict cohort were significantly higher than that of US population. The YPLL among African Americans was significantly lower than that among Whites or Hispanics.

Conclusion.

The YPLL among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.

Introduction

Heroin abuse remains a major public health problem in the United States, with the burden of heroin-induced problems reaching a staggering height (Substance Abuse and Mental Health Services Administration, 2004). Many studies have examined the consequences associated with heroin abuse, mostly in terms of criminal involvement, morbidity, and mortality (Booth et al., 1991, Hser et al., 1993, Hser et al., 1994, Hser et al., 2001, McGlothlin et al., 1977). Mortality statistics are one of the most commonly used and important measures of the health status of populations. However, it ignores that death at a young age is generally considered to be a greater loss to the individual and society compared with death at an older age. This paper, therefore, considers premature death, weighing death at a young age more heavily than death at an older age, and compares that to traditional mortality statistics in a cohort of long-term heroin addicts.

Various formulas for measuring premature mortality have been proposed (Wise et al., 1988). The Centers for Disease Control and Prevention (CDC) has customarily assessed premature mortality with a simple definition of “years of potential life lost” (YPLL) before age 65 (Centers for Disease Control, 1986). The United States General Accounting Office (General Accounting Office, 1996) also accepts the concept of YPLL and reports that premature mortality, measured as YPLL, is the best single indicator for reflecting differences in the health status of populations and recommends that it be used to assist the distribution of federal funding for core public health functions.

The advantage of examining premature death using YPLL is that age at death and cause of death are taken into consideration. Causes of death generally may be classified as degenerative diseases, communicable diseases, or causes due to social pathologies (Rogers, 1995). Pathologies such as drug abuse, homicide, and cirrhosis of the liver are much more prevalent among younger persons, while degenerative diseases such as cancer, heart disease, or cerebrovascular disease have a much greater impact among the elderly (Rogers, 1995). From a public health perspective, deaths at younger ages warrant increased attention because they result in lost productivity, reduce the support young persons generally provide to dependent elderly persons and children, and are more likely to be preventable. YPLL is being utilized currently to assess the social and economic burdens of smoking, alcohol use, suicide, and HIV/AIDS (Centers for Disease Control and Prevention (CDC), 2004, Selik and Chu, 1997, Rivara et al., 2004, John and Hanke, 2003, Obiri et al., 1998). Like substance abuse, HIV/AIDS is predominantly found in the 20- to 40-year-old group, a subset of the community that is generally economically and socially productive (Lai et al., 2006, Stewart, 1997, Obiri et al., 1998).

The number of longitudinal prospective studies of heroin addiction has grown steadily in recent years. In general, the death rates in these studies range from 1.24% to 3.3% per year for the period of the individual studies (Brugal et al., 2005, Rathod et al., 2005, Sorensen et al., 2005, Termorshuizen et al., 2005, De Angelis et al., 2004, Vlahov et al., 2004, Oppenheimer et al., 1994, Barr et al., 1984, Haastrup and Jepsen, 1988, Joe et al., 1982, Joe and Simpson, 1987). Many such studies reported traditional mortality data, however, few of them provided information on premature mortality because of small sample sizes, short observational periods, or failure to report adequate findings for deceased addicts. Based on a 33-year follow-up study, the present paper focuses on premature death among long-term heroin addicts with varied ethnic backgrounds. With such a long period of follow-up data on a sample in which half of the participants have died, our study is unique in amassing unparalleled data regarding mortality and YPLL among a cohort of heroin addicts.

Section snippets

Subjects

The sample was selected from men admitted to the California Civil Addict Program (CAP) during 1962–1964. CAP was a compulsory drug treatment program under the California Department of Corrections for heroin-dependent criminal offenders committed under court order. It was enacted in 1961 and was the only major publicly funded treatment available to California addicts in the 1960s. CAP consisted of an inpatient period followed by supervised community aftercare. From 1962–1964, 581 eligible

Heroin addicts

At time of admission (1962–64), the original cohort had a mean age of 25.4 and consisted of 323 Hispanic (55.6%), 212 White (36.5%), and 46 African American (7.9%) heroin abusers. More than 60% of the sample started using heroin before age 20 years. Before age 18 years, more than 80% of them had been arrested and 80% had tried marijuana.

At the first follow-up interview (1974–75), 80 subjects were deceased. The number of death was 81 at 1984–85 and 121 at 1996–97. At the 33-year follow-up, the

Discussion

The present study focused on premature mortality among a cohort of heroin addicts in California that have been followed for 33 years since their admission to the California Civil Addict Program. The major findings are that on average, the addicts lost 18.3 years of potential life before age 65 and that the leading causes of premature death by YPLL measurement in this cohort were heroin overdose, chronic liver disease, and accidents. To our knowledge, while there are many studies investigating

Acknowledgments

This research was supported by the National Institute on Drug Abuse Grants DA09169, K02DA00139, and DA016383-01A1 to Dr. Hser and DA07272 to Dr. Smyth. The authors thank Dr. Richard Selik at CDC for his valuable advice, and staff at the UCLA Integrated Substance Abuse Programs for their support in manuscript preparation.

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