1. A 10-year follow-up study of drug users in treatment Grethe Lauritzen, SIRUS

2. A prospective co-hort study 10-year observation period (1998-2009) 481 clients interviewed in 20 treatment facilities in and around Oslo – purposely selected 13 residential units 7 out-patient units, 3 Psychiatric Youth Teams specialized for drug treatment (PUT) and 4 Opioid Substitution Teams (OST)

3. 4 groups of treatment facilities 11 residential units for adults (n=276) 2 residential units for youth (n= 31) 3 PUT teams (n=100) 4 OST teams (n= 74)

4. Material – follow-up interviews PeriodNumberResponse percentages After 1 year42891 « 2 years41089 « 7 years34884 « 10 years29577

5. Instruments All the clients were interviewed in person within the first 2 weeks after entering treatment with the –European Addiction Severity Index (EuropASI) –Alcohol and drug use, physical and psychological health, family and social problems, education/work and income situation, criminal behaviour. Life time and last 30 days Self-administered instruments for assessing anxiety, depression and personality disorders: –Hopkins Symptom Checklist 25 (HSCL-25) –Millon Clinical Multiaxial Inventory II (MCMI II) Childrens Trauma Questionaire Data from The Cause of Death Registry (1998-2009)

6. The clients at treatment entry (baseline) All Youth in residential PUT Adults in residential OST Women %3255353028 Age, average3116273140 Born in Norway %9490939497 Have one or more children %440215070 Have daily responsibility for one or more children % 805114 Lived alone in a stable residence % (past 6 months) 293332741 Lived with partner/spouse with or without children % (past 6 months) 173211625 Leisure time spent mainly with friends/acquaintances with drug/alcohol problems 4887315624

7. Education, employment and sources of income All Youth in residential PUT Adults in residential OST Learning and/or behavioural problems in primary school 648761 69 Completed high school %2804226 Student/pupil %13612270 Income from own employment/ sick leave pay the past 30 days % 17337147 Disability benefit past 30 days %1105738 Social welfare benefits past 30 days %5811407061 Income from selling drugs past 30 days %4058254345 Income from other criminal activites past 30 days % 2752113615 Income from prostitution past 30 days %63575

8. Background burdens All Youth in residential PUT Adults in residential OST Alcohol problems mother and/or father % 5271445157 Drug/medication problems mother and/ or father % 21501620 Psychiatric problems mother and/or father % 4471483854 CTQ Emotional neglect/abuse, moderate/serious – serious/extreme 61 CTQ Physical neglect/abuse, moderate/serious – serious/extreme 45 CTQ – Sexual abuse – moderate/serious – serious/extreme 27 Time spent mostly with friends/acquaintances who have drug and alcohol problems % 4887315624

9. Drug and alcohol use AllYouth in residential PUTAdults in residential OST Heroin no. Years high frequency 603614 Amphetamine51266 Cannabis10281115 Sedativa /hypnotica 51359 Alcohol for intoxication 41345 Needle use (share) 82525391100 Overdosed (share)5913476573 NOK used on drugs last month 16 6004 4005 50021 10020 200

10. Physical health All Youth in residential PUT Adults in residential OST Chronic physical injuries/diseases % 3519343251 HCV infected %65 4297594 HIV tested %88427396100 HIV positive % 3 0 1 210 Considerably/severely afflicted or concerned about physical problems in the last 30 days 16 3 13 14 31

11. Mental/psychological health All %Youth in residential % PUT %Adults in Residential % OST % Seriously depressed6158715668 Serious anxiety5833655766 Suicide attempts4238324064 Cognitive difficulties (in understanding, memorizing, consentration) 5263395457 Medications for mental problems past 30 days 17329177

12. Basic personality disorders (>84 MCMI-II) (%) ScaleAllMen Women (n=481) (n=324) (n=157) Basic personality disorders Schizoid 12.915.7 7.0* Evasive 25.925.5 26.8 Dependent13.913.2 15.3 Histrionic23.413.8 43.3*** Narcissistic25.930.2 17.2** Antisocial52.152.6 51.0 Aggressive sadistic27.231.7 17.8* Compulsive 1.7 1.2 2.5 Passive aggressive44.844.9 44.6 Self-deprecating18.915.7 25.5*

13. Severe personality disorders: Schizotype 7.7 8.0 7.0 Borderline26.8 24.631.2 Paranoid 2.5 2.5 2.5 Scale All Men Women (n=481) (n=324) (n=157) Basic personality disorders (>84 MCMI-II) cont.

14. Prevalence of personality disorders (PD) 75% has one or more PD (same share as in ROP study, Oppland/Hedmark) The most serious and frequent personality disorders were antisocial PD and borderline PD Not surprising that a group with such large mental burdens during childhood, and major psycho-social burdens for many years as substance abusers, develop relationship problems/PD End of description

15. Completion of treatment Completion percent Number of days/consultations (average) Youth Residential41339 days PUT3814 consultations Adult Residential55582 days OST 66 (cont.)

16. Prediction for completion of treatment PD was a negative predictor for completion/continuation in all modalities 3 or more previous residential treatments is a negative predictor for completion among clients in residential modalities Use of heroin for 3 or more years is a negative predictor for completion among PUT clients Changes

17. Income status Last 30 days Admission1 year2 years7 years10 years*P-verdi Income from work 1918232832<0.001 Social security 5844423025<0.001 Disability pension 1112153036<0.001 Selling drugs 4091299<0.001 Other criminal activity 278633<0.001 Prostitution 63210<0.001

18. Change in use of substances/medications ( p-value = admittance to ten years) Last 30 days (%) Admittance (n=481) 1 year (n=428) 2 years ((n=410) 7 years (n=348) 10 years (n=296) *p-value Heroin62302816 <0.001 Methadon/Bupren- orphin 419254147+<0.001 Other opiates2214111810<0.001 Amphetamine3417162219<0.001 Sedativa/hypnotica51303437 <0.001 Cannabis5936404345<0.001 Cocaine55555ns Alcohol for intoxication 1815 2725+<0.05

19. Changes in substance use

20. Change in use of syringes Admit. (n=481) 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) *p value Use of syringes past 30 days (%) 6932 1721p<0.001 Daily use of syringes (%) 4181266p<0.001

21. Change in non-fatal overdoses 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) All (%)201774 Youth in residential0480 PUT181550 Adults in residential272187 OST 5872

22. Change in mental problems (EuropASI) The year prior to follow-up (%) 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Seriously depressed42394543 Serious anxiety66625154 Problems concentrating / understanding/ remembering 36375460 Prescribed medications for mental problems 19263540 Suicidal thoughts27252825 Suicide attempts7796

23. Change in mental health SCL- 25 and Europ-ASI (composite score)

24. Change in criminal behaviour Charged of - types of crime: (%) last year prior to follow- up 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Possession/sale of drugs 16 102 Crime of gain other than drug sale 171194 Crime of violence 3332

25. Change in criminal behaviour Admittance (n=481) 1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) P. value Illegal activities to earn money 49141362<0.001

26. Mortality rate 74 persons died in the course of 10 years (10 women) Average age at death was 32 years Mortality rate 1.5 per 100 person/years –2.0 for men –0.6 for women

27. Causes of death (n=74) %Number Overdoses6850 Violent deaths (traffic accident, drowning, fires, suicide, homicide, etc) 2015 Hepatitus C11 HIV/AIDS32 Unknown cause86 Total10074

28. Differences in client characteristics dead and surviving clients Dead (n=74) Not dead (n=407) P- value Age 3230ns Alcohol abuse years (before entering treatment, b.e.t) 7.85.3p<0.05 Overdoses (numbers) (b.e.t) 5.93.6p<0.05 Years using syringes (b.e.t.) 11.39.5ns Months in prison (b.e.t.) 19.211.8p<0.05 Days in index treatment 369468p<0.05

29. Thank you for listening to me! What can we learn from this study?

30. Strength and weaknesses with a longitudinal co-hort study like this? Strategies for prevention on behalf of this study? Comments on treatment systems/organisation of treatment? New research questions?

31. Clients in OST last year prior to follow-up interviews (from the different recruitment groups) %1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Youth in residential 00414 PUT5727 Adults in residential 71440 53 OST83 7365

32. Clients in out-patient treatment prior to follow-up interviews (from the different recruitment groups) %1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Youth in residential 8155448 PUT71355733 Adults in residential 26414833 OST27252621

33. Clients in residential treatment prior to the follow-up interviews (from the different recruitment groups) %1 year (n=428) 2 years (n=410) 7 years (n=348) 10 years (n=296) Youth in residential 777800 PUT1117125 Adults in residential 88601516 OST26223015

34. Gender differences Generally few large gender differences Women reported to have been more emotionally, physically and sexually abused than men Women reported more mental problems than men upon admittance to treatment, the differences were gone after 10 years Women equally violent as men

35. Gender differences The women were less likely to use heroin, amphetamines and cannabis throughout the entire observation period Women less antisocial than men A smaller share of the women reported criminal behaviour A smaller share of the women died A smaller share of the women died of (90% vs. 59%)

36. Gender differences The share of women involved in education was characteristically higher than the men in the entire observation period Women more satisfied with civil status after 10 years Many of the women lived with partners that had substance use problems throughout the entire observation period Women more involved in social networks

37. Strength and weaknesses with such a longitudinal co-hort design? Strategies for prevention on behalf of this study? Comments on treatment systems/organisation of treatment? New research questions?