The Quantification Of Mortality Resulting From Illicit Substance Abuse In Iran

Objectives: The present study aimed to evaluate the epidemiology of mortality due to substance abuse to provide useful information for local, national and international administrators.

Methods: This cross-sectional study was carried out in 12 months leading to Feb 2017. The study population was a random sample of people who died from substance abuse. Data were collected by checklists which were designed according to the objectives of the study. Data were then analyzed in Stata software.

Results: Our findings show that the mortality rate for illicit opiate users was 40. 90 per 1,000,000 population. Most deaths occurred among people aged 30-39 years (32. 20%), male (89. 25%), single (46. 75%) and low education levels. Kermanshah, Lorestan, and Alborz provinces had the highest mortality rate respectively. History of overdose, suicide, hospitalization in psychiatric in hospital and incarceration observed in some people who died from substance abuse. Conclusions: A large number of death from drug abuse occur in unmarried young male 30-39 years with low education levels also in self-employed peoples. We suggest training programs and harm reduction approaches should be focused in this groups.

Keywords: Opium; Opioids; Addiction; Mortality: Epidemiology; Iran.

Introduction: Addiction is one of the most important health, social, behavioral and political problems in the globe (1) that refer to excessive use of a psychoactive or a non-medically prescribed substance (2). This issue is associated with a number of negative health outcomes, including morbidity, disability and premature mortality (3-5). Usually, morbidity and mortality rates for drug users are much greater than those observed in the general population (6). Iran is one of the main opium trade routes from Afghanistan (Afghanistan is the largest producer of opium in the world that located in the proximity of the Islamic Republic of Iran). So, Iran has a long history in opiate drug use and combating drug abuse. In spite of all that, information about the epidemiology of substance abuse, addiction and their complications in Iran is limited (7-8). Few researches have directly considered epidemiology of substance abuse in national level (7). So this study aimed to evaluate the epidemiology of mortality due to substance abuse to provide useful information for local, national and international administrators.

Material and Methods: Study design: This cross-sectional study was carried out from March 21, 2016, through February 20, 2017. The research protocol approved by the ethics committee at the Legal Medicine Organization (LMO), Tehran, Iran. Verbal consent was obtained from all deceased families.

Study setting and population: This study was conducted in all provinces of Iran by LMO data. In Iran, all deaths including the suspicious deaths should be referred to LMO centers and death certificate can just be issued after evaluation and confirmation by this organization. Therefore, LMO centers were chosen to do this research. Mortality from substance abuse is one of the definitions of suspicious causes of death which also include mortality due to road traffic accident, substance abuse, burning, toxin related death, drug intoxication, falling, suicide and work-related death. Totally, 3269 deaths due to illicit drug abuse were registered during the study period by LMO.

In this study, a random sample of 2750 substance abusing deceased records were evaluated. All the mortality rates are presented according to the total number of 3269 deaths, but the frequency tables and all other details are estimated in the sample size of 2750 persons.

Study protocol: This study was done using two data collection checklists which was designed according to the objectives of the study by the researchers and reviewed and confirmed by several external and internal experts in LMO center. The first section of the checklists included questions about demographic characteristics such as age, sex, education and marital status. The second section had substance abuse questions including, type of substance used, smoking and alcohol consumption, history of substance abuse in family and friends and history of overdose and suicide. Demographic variables were collected by interviews with friends and relatives of deceased. Also information about the type of substance use was obtained through conversation or interviews with a person or persons familiar with the deceased (verbal autopsy). The classification of mortality from substance abuse was carried out using the 10th edition of the international classification of disease (ICD-10: T40, F10, X42, X62 & Y12). Eventually, physicians that were responsible for autopsy room in each province collected the data and send them monthly to the capital legal medicine center in Tehran, Iran. Measures: Key measures in this study were mortality rate per 1,000,000 populations and proportionate mortality ratio. Substance abuse mortality rates were estimated by dividing the number of deaths in each province of Iran or in the whole country by the mid-year population of the province and once for all the country. In proportionate mortality ratio, the numerator was the number of deaths due to substance abuse and the denominator was the total number of deaths in 12 months leading to February 2017 in Iran.

Data analysis: Data were entered into Stata-MP version 14. Results were presented using descriptive statistics as mean value, standard deviation (SD), percentage, tables, and charts.

Results: The result indicates that among 2750 died cases, who were qualified for this study, 296 subjects (10. 75%) were female and 2454 cases (89. 25%) were male. High school education level was highest percentage of education level observed among the deceased (856; 31. 30%). People with university education had the lowest frequency. Of all study subjects, 46. 75% were single, 40. 55% were married, 11. 49% were divorced and in 1. 22% the spouse had died. The mean age of victims in our study was 36. 78 ± 13. 12 years and the median age was 35 years. The most affected age group was those aged 30-39. Table 1 shows the characteristic of the study sample by demographic variables. The overall mortality rate of substance abuse for the entire period was 40. 90 per 1,000,000 populations (60. 59 among men and 7. 51 among women per one million population). Kermanshah, Lorestan and Alborz provinces with 94. 24, 67. 02 and 59. 72 death per 1,000,000 populations had the highest mortality rate, respectively. The mortality from substance abuse in different provinces of Iran is shown in figure1.

The majority of cases have Iranian nationality (2686; 97. 66%) with recognizable identity (2625; 95. 45%). The mean age of first drug use was 25. 66 ± 8. 1 years, the median and modes of drug usage were 25 and 20 years, respectively. The minimum and maximum age in starting drug use were 9 and 70 years. The average time between beginning of substance use and death was 13. 18 ± 9. 28 years. In terms of employment status, self-employed and drug dealer had the highest and the lowest frequency, respectively (table 2). Based on the interview with family of deceased, opium and shire were the most prevalent substances (32. 14%). The frequency of heroin consumption was 16. 60 percent, crack 5. 5 percent, crystal 18. 00 and methadone 12. 32 percent. Alcohol consumption had the lowest frequency among study samples. Regarding the simultaneous consumption of alcohol and different illicit drugs in the last month before death, in 1023 (37. 56%) of cases, this history could not be obtained. In the remainder, in 40. 84% cases, they used just one substance/alcohol in 18. 58% of them had concurrent usage of two or three substance/alcohol and in 3. 02 had contemporaneous usage of four or more. In this research, almost 15. 64 percent of cases use the drug with injecting form. About 635 (23. 08%) of the cases had a history of incarceration. Based on the interview with family and friends of deceased, history of overdose, suicide, and hospitalization in psychiatric hospitals was observed in 21. 40%, 5. 15%, and 8. 52%, respectively. About, 15. 24% of deceased had a history of substance abuse in their family.

The past medical history was recorded according to their family’s report. It was revealed that 4. 40% of cases suffered from coronary heart disease, and 0. 76% of deceased were affected by chronic illness. More information about the history of medical conditions, war injury, employment status and place of residence in the month before death is expressed in table 2. Entirely, 13. 78% (n=379) of all people died from drug abuse, while they were under treatment for quitting addiction. The treatment situation was not clear among 31. 27% (n=860) of subjects. Among people who were under medication at the time of death, 51. 45% received methadone, 5. 80% opium tincture, 1. 32% received buprenorphine and 3% were treated with detoxification. In terms of location for drug treatment, about 26% of addicts were under medical care in drop in center (DIC) and 8. 71% were treated traditionally at home. About, 32. 98% of drug users were under care for drug rehabilitation in legal and authorized centers and 2. 37% in unauthorized centers. Also, 0. 79% of addicts were receiving drug addiction treatment by command of the judicial official, the place of drug treatment of others was also unclear (29. 15%). Figure 2 shows the mortality rate from drug abuse in 12 months leading to February 2017 disaggregated by the month of the year. About, half of deaths from drug abuse occurred at home or in another private location (1267; 46. 07%).

The hospital and public places with frequencies of 671 (24. 40%) and 296 (10. 76%) were located in the second and third ranks, respectively. About, one-fifth of the victims were alone at the time of death (562; 20. 45%) while the rest of them were not alone (2188; 79. 55%). The places of their residence in one month before death are presented in table 2. Based on the result of this research, proportionate substance abuse among unnatural causes of death was 8. 97% in all over the country. This ratio was higher in Alborz province (proportionate mortality ratio = 16. 58) and Mazandaran province had the lowest ratio (proportionate mortality ratio = 2. 30). The value of this index in Tehran province indicates that 14. 36% of all unnatural death occurred in Tehran province is due to substance abuse (figure 3). Figure 4 shows the proportionate mortality ratio from drug and psychotropic abuse in each provinces ordered by their rates. The value of this index in Kermanshah indicates, 1. 71% of all deaths occurred in Kermanshah province is due to substance abuse. Discussion: In this study, the mortality risk factors for substance abuse were investigated. The results showed that the mortality rate of substance abuse was higher in men than women. Furthermore, the highest frequency of drug-related death was observed in the 30-39 years age group. This findings is concordant with prior research that investigated epidemiological characteristics of people who died from sunstance abuse in Iran (7 & 8).

According to the world health organization (WHO) report, Iranian drug abuser are generally young (mean age = 33 years) and male (11). In the most of societies, men have more liberty in the familial and social communication and they work in the society more than women. Thus, they have more access to drugs. In the other words, in Iranian society, women's relationships are more restricted by their family members than men which results fewer opportunities for illicit drug use. Another point is that, there is limited information about addiction and drug abuse among Iranian women and it is obscure whether the absence of information about female drug user in Iran is due to a very low prevalence of drug abuse among female in Iran or that they are a hidden population and are reluctant to attend for drug rehabilitation. Studies in western countries have shown that drug abuse has been associated with more social stigmatization in women than men. Therefore, women's access to drug treatment is reduced. Nerveless, the importance of substance abuse in women should be not underestimated and it is necessary and substantial to establish a particular clinic for addicted women with women personnel to encourage them to seek treatment (8, 12). Most deaths from drug abuse occur in young people (30-39 years). This age group is active in social and economic programs in society; so reducing their death has a beneficial economic and social impact (7). This study highlights that opioid-related fatalities occur at home or in another private residence (46. 07%). This matter suggests that family members or friends of addicts are the key groups for targeting intervention programs (for example, training such individuals about overdose identification, basic life support measures, and emergency medical service activation may prove effective at reducing the death toll from this problem).

Of course, important obstacles in providing immediate care and the low rates of emergency medical service activation are fear from police involvement and concerning about homicide charges. These behaviors lead to delays in reaching medical assistance (13). In this study, some people used several addictive substances at the same time. These results would suggest that polysubstance use maximize mortality from substance abuse, although longitudinal data are required to support this inference (13-14). One clearing finding that has emerged from this study is that death from substance abuse were more frequent in individuals with lower education level, Perhaps is due to the understanding and awareness of people regarding social, familial, psychological, sanitarian and economic adverse effects of substance abuse. Higher education level was a protective factor against drug abuse (7, 15). The results showed that 18. 04% cases were unemployed. Being employed was a protective factor against substance abuse and being employed was strongly and significantly associated with substance abuse and was proposed as a risk factor. However, further studies are needed to determine the effects of drug abuse on occupation and whether can increase the rate of unemployment (8, 16). According to this study, most of the death that is caused by substance use occur in unmarried people. This matter represents the importance of family support in addiction rehabilitation programs (7, 8). Based on the findings, 23. 08% of deceased has the history of staying in prison. It can be a serious warning for directors and authorities. In fact, drug use can be an underlying cause for crime from one hand, while drug use imprison can create numerous health problem such as viral infection on the other hand (17).

According to this study, family history of drug abuse increase chance of addiction in other family members. Kardia et al. in their study demonstrated that parental substance abuse is a factor for the tendency and dependence on the drug (17). There are several limitations in this study that warrant discussion. First, we included all individuals that were found to have positive screens at the time of death. It is impossible to know how many individuals died from substance abuse yet did not receive a toxicology assessment. Thus an underestimation of the magnitude of substance abuse mortality might have occurred in this study. Second, the cross-sectional nature of research limits the ability to draw any causal inference. Conclusion: In summary, the large numbers of death from illicit substance abuse occur in unmarried young male aged 30-39 years with low education levels also in self-employed. These findings highlighted that training programs and harm reduction approaches for drug rehabilitation should be focused in this groups.

Acknowledgment: We are grateful to legal medicine organization and also legal medicine research center for providing the data of this research. Conflict of interest: All authors declare that they have no conflict of interest.