Department of Public Health Sciences
Narcotic misuse in Sweden:
Examining changes in age structure and gender
from 1997- 2017 through events of
hospitalizations and mortality
Master thesis in Public Health Sciences (30 ECTS)
Spring 2020
Name:
Supervisors:
Rachel Erin Elizabeth Wasson
Lena Eriksson
Abstract
Aim: The motivation of this explorative study is to analyze the changing age structure of individuals misusing narcotics presenting with events of hospitalization or mortality. Methods: The data is derived from three anonymous, aggregated data sets for the mortality (n=4,999), hospitalization (n=143,264), and general population data. Descriptives, independent T-Tests, and simple linear regression is used for the analysis of age among events of mortality and hospitalizations throughout time. Results: The structure of ages among individuals with mortality linked to narcotic misuse does not significantly change. The trends in ages among males and females present themselves differently in mortality related to narcotic misuse as the female median ages continue to increase in age, whereas male median ages remain relatively stable. The age structure of individuals with hospitalizations linked to narcotic misuse has changed over time, with the males and females presenting similar significant trends in declining age. Conclusion: The changes in age structure among individuals misusing narcotics differ when measuring mortality and hospitalizations. Significant changes indicate that hospitalizations have increased over time and are more prevalent in younger adults, suggesting that more individuals are misusing narcotics at younger ages and requiring more medical care as they age and live longer lives.
Key words
Table of contents
Introduction ... 1
Narcotic misuse and the Swedish context ……….. 1
Social risk factors ... 2
Shifting trends in narcotic misuse ……….. 3
Narcotic misuse and gender ……….……….. 4
Age and narcotic misuse ……….……….. 5
Aim and research questions ... 7
Methods ... 8
Data material ... 8
Ethical considerations ... 9
Defining the age structure ... 9
Defining the time periods ... 11
Variables ... 12
Statistical analysis ... 13
Results ... 15
Counts of mortality and age adjusted mortality rates ... 15
Counts of hospitalization occurrences and age adjusted mortality rates ... 16
Percentages of events by age category ... 18
Comparisons among males and females with a record of mortality associated with narcotic misuse………20
Comparisons among males and females with a record of hospitalization associated with narcotic misuse………22
Discussion ... 23
Age groups and narcotic misuse ... 23
Gender and narcotic misuse ... 27
Policy implications ... 29
Strengths and limitations of the study ... 31
Conclusions ... 33
Introduction
Narcotic misuse and the Swedish context
In 2010, Disability-adjusted life year (DALY) calculations identified illicit drug use
(inclusive of narcotics) as the 10th largest risk factor in Sweden for that year (Nilsson, 2017). Looking specifically at Stockholm, the capital and most populous region of the nation, DALY calculations listed narcotic misuse as the 8th largest risk factor in 2017 (Allebeck, et al., 2019). Disability-adjusted life years (DALY’s), a global measurement used to help navigate scientists and healthcare providers towards effective and equitable treatment,
(Murray & Acharya 1997), were established to track the number of years lost to disease or
early death (Nilsson, 2017). The use of DALYs has been criticized for its “irrelevance in a situation of deprivation” due to the measure's inability to capture “pain and suffering” or taking into consideration the individual coping abilities of persons affected by a particular illness or health risk (Barker & Green, 1996:181). However, the measurement has been, and continues to be used by the Swedish health agencies to enumerate the disease burden of narcotic misuse. Despite the problematic approach of this measure and its ability, or lack thereof, to offer equitable measurements (Anand & Hanson, 1997), the continued use of the measure allows for easy comparability over time when used within the same population. In the case of Sweden, the measurement draws attention to the growing concern surrounding the misuse of narcotic substances and the risks of premature mortality linked to narcotic misuse. In the 2015 report regarding drug use in Europe, the European Monitoring Center for Drugs and Drug Addiction (EMCDDA) found that Sweden had one of the highest rates (70 deaths per million) of drug related mortality in Europe in 2013, whereas the overall trend in Europe was decreasing in drug related mortality at that time. Further, the report stated that Sweden’s drug related mortality rates were “four times higher than the EU average” (EMCDDA, 2015;
Eriksson & Edman, 2017). Further, in a 2017 survey by the Central Association for Alcohol
and Drug Information (CAN), five percent of the adult population in Sweden reported that, within the last year, they had used prescription drugs differently than what their doctors had prescribed, with the drugs usually being classified as opioids (Nilsson, 2017). In a 2019 follow- up report CAN concluded that the availability of drugs had increased over the course of the previous 10 years as cocaine and prescription drug misuse became more common (CAN, 2019). The findings from these reports are indicative of the rising influence of drug
standing history of restrictive drug policies (Blomqvist, et al., 2009; Eriksson & Edman, 2017).
As policy developed over time, so did the definition and identification of the misuse of drugs; any use of narcotic substances that are used without prescription or used differently than as prescribed became, and still is, classified as misuse (Blomqvist, et al., 2009). The misuse of drugs and dependency on illicit substances first gained political interest in Sweden in the 1960’s and has since become a concern and cause relating to premature mortality (Engstrom, et al., 2009; Olsson, 1994). In the late 1970’s, as the use of illicit substances spread
throughout society, Sweden developed the ultimate goal of becoming a “drug free” society (Blomqvist, et al., 2009; Eriksson, & Edman, 2018). This goal is maintained in present day and is reflected in the current abstinence focused policies surrounding drug misuse. It is widely accepted that individuals who misuse narcotics and other illicit drugs have a much higher risk of dying prematurely (Gjersing & Bretteville-Jensen, 2014; Nyhlen, et al., 2011; Onyeka, et al., 2014). While the risk is not as high, the risk for premature mortality remains even after periods of continued abstinence from substance abuse (Ledberg, 2017;
Nyhlen, et al., 2011). The risk for premature death can result not only from the direct effect of fatal overdose and poisonings of the illicit substances, but also residual effects such as organ failure from repeated or long term use, and risky, self-destructive behavior (Engstrom, et al., 2009). Swedish studies focusing on the misuse of drugs commonly conclude that individuals misusing drugs have a shorter life expectancy, especially those residing in urban areas such as Stockholm (Engstrom, et al., 2009). Therefore, this study seeks to further examine the age of individuals misusing narcotics in Sweden and analyze if the age of
individuals, at time of mortality or hospitalization, has been changing over the course of time. Social risk factors
The “Social Stress Model of Substance Abuse” is a theoretical model created to help describe some of the factors that influence drug use. Per the social stress model of substance abuse, the chances of an individual displaying habits of drug misuse is observed as “a function of the stress level and the extent to which it is offset by stress modifiers” (Lindenberg, et al.,
protective measures, such as social networks and community resources (Lindenberg, et al., 1998). Several studies have shown that social aspects, or stressors, such as lower academic achievements and poorer living conditions, have played a large role in the lives of a majority of individuals who misuse illicit substances; further, individuals who misuse narcotics tend to have encountered these social challenges at a much greater frequency than those who have never used illicit substances (Nilsson, 2017; Eriksson, & Edman, 2017). Engstrom, et al. notes that there was an increased risk among children of immigrants living in Stockholm during the 1980’s (Engstrom, et al., 2009). In a Swedish study by Byqvist, it was found that 23% of the individuals who misused narcotics had an immigrant background either as an immigrant themselves or as a child of immigrants, 75% of the individuals misusing narcotics had poor or no employment, and 37% individuals had illegal forms of income that was used to support their continued misuse of narcotics; further, 18% of the individuals misusing narcotics lacked stable housing and living conditions (Byqvist, 2006). Allebeck, et al.,
affirms that lower education levels as well as lower socio economic position were risk factors for individuals struggling with dependency and misuse of narcotics in the 2019 Stockholm public health report. The 2019 Stockholm public health report also found that when compared to the highest socio-economic class, from 2005- 2015, the risk of dying prematurely between the ages of 30 and 60 years has increased for individuals in the lowest socio-economic class. Additionally, it is reported that between 2002 and 2007, the lowest socio-economic class has seen a decrease in median income with 1 in 5 Stockholm residents living in relative poverty (Allebeck, et al., 2019). Acknowledging the aforementioned findings, it would not be unsubstantiated to state that the increasing economic difficulties among the lowest socio-economic class are influential in the rise of narcotic misuse in Sweden. While the information regarding prevalence of social stressors is not available for the data used in this study, it could be expected that there are issues of intersectionality of nationality, socioeconomic status and social mobility, and addiction among the individuals represented in this study. This intersectionality, the combined impact of these social categories (Carbado, et al., 2013;
Carpenter, 2009), could ultimately affect the health and longevity of life of these individuals.
Shifting trends in narcotic misuse
these seizures have not had much impact on the illegal drug market (CAN, 2019).
Amphetamines have been identified as the preferred substance commonly misused in the Swedish context, however, the preference among illicit substances have, for various reasons, been shifting (Blomqvist, et al., 2009). There has not been a noticeable increase in the use of intravenous drugs, thus indicating that the increasing use of illicit substances are being driven by other forms of drugs such as those that are orally consumed which is inclusive of opiates and misused pharmaceutical drugs (Blomqvist, et al., 2009; Nilsson, 2017). In a 2019 report, it was found that opioids were the most common substances used, in combination with additional substances, in the cases that resulted in narcotic related mortality (CAN, 2019). Not only has the method of narcotic consumption shifted, but, through reporting of surveys, it was observed that there has also been an increase in polydrug use (Byqvist, 2006). Even with the recognized operational errors that can be derived from the aforementioned studies,
surveys and questionnaires are trusted to be reliable in revealing truthful developments and trends (Nilsson, 2017). Trusting the reliability of these studies, the developing trend of polydrug use could make the identification of substances and the tracking of trends among substance use more difficult. Further, and arguably the most concerning, polydrug use results in challenges regarding the complexity of care and treatment for the individuals misusing the drugs.
Narcotic misuse and gender
It is well known in the field of public health that life expectancy between males and females is not equal, and this is also notable when studying the misuse of narcotics. The difference in life expectancy between males and females in OECD countries has been found to differ by 7 years with males having a lower life expectancy. A contributing factor to this difference is
due to the tendency that males choose to live riskier lifestyles (Murray & Acharya 1997).
This riskier lifestyle choice is inclusive of an inclination to use and misuse narcotics.
However, various modeling methods have observed that in wealthier countries with lower
mortality this difference in life expectancy is much smaller (Murray & Acharya 1997). In the
case of Sweden, the difference in life expectancy between males and females is 3.4 years
(SCB, 2020). Nonetheless, the general increased occurrence of males misusing narcotics as
misuse illicit drugs as compared to females (Young, et al., 2002). The higher prevalence of narcotic related deaths among men has also been observed in the city of Stockholm, Sweden (Allebeck, et al., 2019).
In studies examining gender and the use of narcotics it is commonly revealed that there is no clear pattern between gender and preference of narcotic substance, however Byqvist states that a difference in the type of narcotics among the Swedish population has emerged. Byqvist goes on to note that age differences play a role in influencing the type of drugs that are misused; habits of polydrug use, which is more common among males in Sweden,
increases as the age of the individual misusing drugs increases, and as the individuals change substances or learn to combine illicit substances to reach the desired outcome (Byqvist, 2006). While additional research is being developed regarding gender and the trends of drug use, there has been little discussion surrounding age differences between genders and how it does or does not relate to narcotic misuse. This omission within the Swedish context has therefore become a driving force in this exploratory study.
Age and narcotic misuse
As more reports develop surrounding the issue of drug misuse in Sweden, an area that is not well reported concerns the representation of age and age structures in mortality related to narcotic misuse, and if or how the ages change over time. The age structures are studied to an even lesser extent in relation to hospitalization and treatment of health conditions due to narcotic abuse. Young, et al. states that dependency and misuse of substances are types of developmental disorders that often begin in adolescence (Young, et al., 2002), suggesting that, through the lens of life course theory, adolescence is a sensitive period in which an exposure of narcotic misuse would have a stronger impact on the emergence of, and
studies provide a plethora of information detailing the interaction of age and misuse of narcotics and serve as a guide when navigating the study of age structure in relation to narcotic misuse in Sweden.
A study completed in 2008 aimed to examine the predictors of prescription narcotic misuse by age groups in the U.S. from 1994 to 2003 and found that there was a 10% increase in usage among the 12th grade (final year) of high school students and college students from 2002-2003 (Arkes & Iguchi, 2008). When applying the social stress model of substance abuse to the following findings, it becomes visible that stress, either physical or
mental/emotional, surfaces as a plausible catalyst in the identified predictors of narcotic misuse. While the researchers identified the motivations for teenage narcotic misuse as simply seeking to “get high” and to follow the examples of their peers, indicative of social stressors, college students’ narcotic misuse was mostly in the form of stimulants to help with focus and alertness to aid in their studies, indicating the presence of mental and emotional stress to, arguably, meet the demands of social standards. However, the motivation for narcotic misuse found in adults was addiction, characterized as recurrent episodes of narcotic misuse, which often developed after receiving prescription narcotic for a medical purpose
(Arkes & Iguchi, 2008). The aforementioned reporting of differing motivations coincides
well with the findings of a Finnish study which found, through monitoring 14 years of mortality related to drug misuse, that younger users died from acute effects of narcotic misuse, such as poisonous overdoses, whereas older users died from chronic conditions brought about from multiple encounters of narcotic misuse (Onyeka, et al., 2014). Despite the previous observation that the majority of mortality related to narcotic misuse is prevalent in younger users (Onyeka, et al., 2014), these findings may suggest that the age structure of mortality and hospitalizations may be shifting towards older age groups as a result of potential medical complications stemming from long term, repetitive misuse of narcotic substances, such as the advancement of Hepatitis C and HIV.
with the age group of 35-39 years increasing in mortality (Harlow, 1990). A national U.S. study completed between 1999 and 2002 compared itself with previous studies from 1979-1995, 1992-1996, and also noted that the age of mortality narcotic abuse has gradually increased over time (Cone, et al., 2003). The shift in mortality age structure is not isolated to the United States. In a study conducted in Spain in 1995, it was found that the mean age of mortality caused by narcotic misuse increased from 25.1 years to 28 years of age (Sanchez, et al., 1995). The Spanish study also observed an increase in mortality between 1983-1991 with the largest increases occurring in the 30-34 years and 40-44 years age groups (Sanchez, et al., 1995). To better understand the reasons behind these changes in age structure researchers propose a number of various reasons, with the most common suggestion being that there is an overall increase in older users of narcotics in the population (Harlow, 1990; Cone, et al., 2003; Sanchez, et al., 1995). The increase in older users is likely indicative of the users of narcotics living longer, rather than an increased introduction and uptake in narcotic use among older individuals. However, there remains little reporting regarding the age structure of narcotic related mortality and hospitalizations, and even less reporting surrounding age and narcotic use has been done within the Swedish context. This omission is important to note as the lack of research reporting the ages of individuals misusing narcotics could prove itself to be an impediment for public health officials as they aim to develop effective treatment and rehabilitation programs for individuals wishing to enter into replacement therapy programs or regain sober living.
Aim and research questions
and mortality related to narcotic misuse present itself in the same way for both males and females?
Methods
Data material
This is an explorative nationwide study examining events of harm related to narcotic misuse in Sweden among the registered residents of the country from 1997 to 2017. The data utilized in this epidemiologic explorative study solely focused on the Swedish context and, therefore, was derived from multiple Swedish data registries. Mortality data was obtained from the Swedish National Board of Health and Welfare (Socialstyrelsen) and further extracted from the Swedish cause-of-death registry (Dödsorsaksregistret). The hospitalization data was extracted from the Swedish registry of inpatient care (Patientregistret). The population data was obtained through Statistics Sweden (Statistiska centralbyrån). These were anonymous, aggregated data sets, with each containing information regarding the year, number of reported occurrences, as well as the gender and age of individuals. The two data sets concerning hospitalizations and mortality were the main focus of the study, with the population data set being utilized for reference and relativity. The population data was inclusive of all registered residents living within Sweden between the years of 1997-2018. The mortality and hospitalization data were inclusive of all registered residents living within Sweden between the years of 1997-2017 and 1997-2016, respectively, with a record of mortality and/or hospitalization documented as having narcotics misuse as the primary cause or diagnosis of the event. The hospitalization data was count data of the number of inpatient treatment experiences, or rather, the number of times individuals were admitted into the hospital for a temporary stay due to the need of medical intervention. All events of hospitalization represented in the data were had by documented residents of Sweden with one of the following ICD-10 codes for narcotic related diagnosis:
• F11.- mental and behavioral disorders due to opioid use • F12.- mental and behavioral disorders due to cannabinoid use
• F13.- mental and behavioral disorders due to sedative or hypnotics use • F14.- mental and behavioral disorders due to cocaine use
• F15.- mental and behavioral disorders due to stimulant use (including caffeine use) • F16.- mental and behavioral disorders due to hallucinogen use
The mortality data, also count data, was comprised of individuals with a diagnosis of narcotic related death as defined by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), which states that “Drug-related deaths and mortality among drug users refers to those deaths that are caused directly by the consumption of drugs of abuse. These deaths occur generally shortly after the consumption of the substance(s)” (EMCDDA, 2012). Data utilized in this study included only registered persons within the data set between the ages of 10-80 years of age.
Ethical considerations
The data utilized in this study was derived from Swedish registry data and, therefore, was used in accordance with regulations on registry studies. Because the study utilized anonymous register data that extends beyond 20 years past, it was not possible to seek individual consent at the participant level. However, there was very little risk of harm or potential burden to the individuals represented in this study due to the high level of anonymity. No access to the personal data of the participants was available, as it was not necessary to the study being conducted. Nonetheless, if consent were possible to obtain, doing so could have undoubtedly skewed results. For example, some individuals or families of individuals may have declined participation, thus potentially distorting the efforts from researchers and healthcare professionals aiming to identify the most at-risk groups for narcotic misuse and develop target treatments for individuals struggling with narcotics misuse.
Defining the age structure
With the general aim of this study being to analyze the age of individuals misusing narcotics in Sweden and how the age changes in relation to hospitalization occurrences and events of mortality over the course of time, it is important to clarify that the concept of age structure in this report is demonstrated through age groups representing developmental stages throughout the life course. The individuals in this study were categorized into one of five developmental stages by the age in which the recorded mortality or hospitalization occurred. These
developmental stages were created through consideration of previous studies that share a focus on age.
knowledge that it was determined to limit the age of individuals in this study to the age of 80 years, as this elder population may possibly contain some trace of influence from the first introduction of drugs in Sweden or have lasting medical conditions that were onset through the effect of narcotic misuse. Based on the principle of agency (Alwin, 2012), the lower limit of the age range was limited at age 10, as it is believed that any case of hospitalization related to narcotic misuse in those under the age of 10 would have been influenced by an outside party, rather than the misuse resulting directly from the action of the individual.
In the 2015 report regarding drug use in Europe, the European Monitoring Center for Drugs and Drug Addiction (EMCDDA) identified the ages of 15- 34 years as young adults
(EMCDDA, 2015). However, it was thought to be important in this study to differentiate between adolescents (of the age 18 years and under) and adults above the age of 18, as the possibility of influential social factors such as education and sharing family residence would likely change once individuals turned 18 years of age and are recognized as legal adults. In this study, individuals ages 10-18 years are categorized as adolescents. Individuals ages 19-27 years were categorized as young adults. This developmental stage is a time period when new social stressors are introduced, and most individuals would be entering the work force or continuing secondary education. This categorization is particularly interesting as a study in Wales found that ages 20-24 were particularly prone to mortality linked to narcotic misuse (Oyefeso, et al., 1999). Additionally, a study conducted in Colorado, USA, found that narcotic misuse was the highest among the ages of 18 -29 years (Young, et al., 2002). The third developmental stage, adulthood, encapsulates individuals ages 28-39 as this has been found to be the age bracket in which the average Swede begins a family; Svensson, et al. reports that the mean parental age at first childbirth was 31 years in 2009 (Svensson, et al., 2011). Based on the results of a Spanish study where increased mortality was seen to be occurring most in the 30-34 years and 40-44 years age groups (Sanchez, et al., 1995), the fourth developmental stage captures individuals age 40-60 years. A Canadian study focusing on the outcomes of narcotic use in seniors focused on a sample population of 65 years of age or older (Ebly, et al., 1997); when examining the patterns of global ageing and morbidity, Chatterji et al. classifies the population of individuals 60 years and older as the “older
new social stressors at each developmental stage, such as moving out of a family home, beginning or ending full time employment, or having to provide care and stability for an increasing family contribute to an increased likelihood of becoming influenced by habits of narcotic misuse, further motivating the divisions of the developmental stages, as they are. It is with these developmental stages that the study hopes to examine any possible patterns or changes in the age structure through monitoring the developmental stages and the rates of hospitalizations and mortality occurring within each stage.
Defining the time periods
In an effort to best identify and monitor changes over time groups of years were categorized into time periods and are used as the variable YearGroups. The years being observed in this study, 1997-2016/2017 were divided and categorized into four different time periods, or year groups. The division of the four time periods, (1997-2000), (2001-2006), (2007-2012) and (2013- 2016/2017), were created through thoughtful consideration of previous studies, global trends in narcotic misuse, and changes in Swedish policy. The first time period, (1997-2000), was created to mark the beginning of the millennium and determine if there was any
noticeable difference in the measured events of harm due to narcotic misuse. These events of harm are measured through number of inpatient experiences, or hospitalizations, in the Swedish healthcare registries and the number of mortalities. The United Nations’ 2007 review of Swedish drug policies uses the year 2000 as a year of distinction, as well as other years that occur at the beginning of a decade, to express notable changes in trends in drug use (United Nations, 2007). The second time period, (2001-2006), was established with
harm, being the number of recorded hospitalizations and mortalities linked to narcotic misuse. The final time periods, (2013- 2016/2017), were established with consideration to global trends in narcotic misuse, specifically that of North America. Since 2010, Canada has recognized a growing problem with climbing rates of opioid related mortality, and,
subsequently, in 2013, saw the demand for addiction treatment double since 2004 (Fischer, et al., 2016). There was also a significant increase in overdose deaths between 2010 and 2015 in the United States (Rudd, et al., 2016). Both of these significant increases in overdose deaths occurred as the use of prescription opioids within the practice of medicine also increased. Though not as rapidly or to the same extent, the use of prescription opioids withing the practice of medicine has also increased in Europe (van Amsterdam & van den Brink, 2015), which further motivated the categorization of the final time periods used within this study.
Variables
In each aggregated data set (population, mortality and hospitalizations) there were four original variables: year, gender, age, and the number (count) of occurrences (N). The variable “year” represented the calendar year in which the event of hospitalization or mortality linked to narcotic misuse occurred. The variable “gender” represented the male/female sex of
individual presenting with the event of hospitalization or mortality, and “age” represented the age of individuals at that time. The variable “N” represented the number of narcotic related harms through the measurement of the number of episodes of hospitalizations or cases of mortality related to narcotic misuse within a calendar year. These variables collectively outlined the number of occurrences into groupings by the age and gender of the individuals affected, by year the event occurred. Two additional variables, “YearGroups” and
“AgeGroups”, were also developed within each data set transforming the continuous
variables “age” and “year” into categorical variables. This step was accomplished through the recoding method in SPSS and was completed in an effort to better characterize and assess trends of narcotic misuse among age populations in specific developmental stages, within specified time frames as represented through the use of year groupings.
stages in regard to the life course perspective as well as considering social responsibility factors such as work and productivity. The “adolescents” and “ageing population” were thought to consist mostly of the non-working population, whether it be due to not yet entering the workforce or exiting the workforce. The three stages of adulthood were also categorized in a manner that could reflect the stages of working status, with the “young adults” reflecting years that individuals may be continuing schooling and/or entering their professional careers, and “adults” and “advanced adults” reflecting time points where individuals may be very well established in careers yet face several different social factors such as familial obligations. As the aim of the research is to study narcotic misuse, the restriction against the use of data on individuals under the age of 10 years and over the age of 80 years was established in an effort to truly capture the populations most likely to be at risk for narcotic misuse. The use of data regarding individuals older than 80 years of age was also restricted for the additional purpose of limiting skewing of the data from medical interventions that could be more likely to occur among the ageing population.
The variable “YearGroups” categorized the years into four time frames, with the last time frame differing for hospitalizations and mortality, respectively: 1997-2000, 2001-2006, 2007-2012, 2013- 2016 or 2013-2017. The variation in time frames between hospitalizations and mortality resulted from the differing extent of data between the two data sets.
The variable representing number of occurrences was treated as the dependent variable in all data sets, whereas the variables age, year, “AgeGroup”, and “YearGroup” were treated as independent variables. Gender was also treated as a covariate when running certain descriptives, such as analyzing the means and medians of age among individuals with a recorded event of narcotic misuse resulting in hospitalization or mortality.
Statistical analysis
The study population included more than 4,000 individuals with recorded mortality linked to the misuse of narcotics between the years of 1997-2017, and more than 143,000
hospitalization events linked to narcotic misuse between the years of 1997-2016. The
female, and the hospitalization data totaling 143,264 occurrences with 92,450 being for males and 50,814 being for females.
Due to the nature of this explorative study, descriptives were used to best analyze the data. Cross tables were run through the SPSS application for the variables YearGroups and AgeGroups and the counts from these cross tables were used to calculate percentages and rates of occurrences. Percentages were calculated at two separate time points for mortality and hospitalizations as a method to compare any change from 1997 to 2017 or 2016, respectively. Additionally, percentages were calculated in time periods (YearGroups) by dividing the number of events per age category (AgeGroups) by the total amount of events occurring within that time period. While the percentages allowed for analysis specifically on the number of recorded occurrences of narcotic misuse, whether it be through mortality or hospitalization, the calculations of age adjusted rates are relative towards the nationwide population. The calculation of rates for hospitalizations and mortality were calculated as age-adjusted rates, as these rates are often used to determine the extent of developments within the public health sector. The age adjusted mortality rates were calculated for the entirety of the 20-year period, as well as by specific times periods as outlined by the variable,
YearGroups. The age- adjusted rates of occurrence were calculated as the total number of occurrences (mortality and hospitalizations) within each age category, divided by the total population within that same age category and then multiplied by 10,000. These rates were displayed by time periods, and in an effort to identify if any change was present in the rates over time. Confidence intervals were also calculated, with 95% confidence, to assess for significance among changes in the rates between each time period. Additionally, the total count of events of mortality and hospitalizations were included as a way to help illustrate the growth in number of occurrences throughout the years.
Comparisons of mean and median ages and T-Tests were performed through SPSS for mortality and for hospitalizations, separately, as a way to analyze if any differences were present between males and females. Comparisons of mean and median ages among males and females were analyzed annually from 1997 to 2016 and 2017 to assess if there was a change in the age over the years in which mortality and hospitalization related to narcotic misuse occurred. A simple linear regression was derived from the median ages of males and females to test for significant change throughout the respective time periods for mortality and
females were analyzed through an independent sample T-Test to determine if a significant difference in age was present between the two genders.
Results
Counts of mortality and age adjusted mortality rates
Between the years of 1997-2017, a total of 4,999 individuals, ages 10-80 years, have been identified as having a diagnosis related to narcotic misuse linked to their mortality. These 4,999 individuals are categorized by the predetermined developmental stages (AgeGroups) and time periods (YearGroups), and the counts and rates of each age group are established to allow for observation of changes amongst age groups over time. The age adjusted rates of narcotic related mortality per 10,00 people for the entirety of the 20-year period are .03 for the adolescents, .51 for young adults, .53 for adults, .34 for advancing adults, and .1 for the ageing population. Age adjusted mortality rates are displayed by age groups within specific time periods, as seen in Table 1, which allows for easy identification of trends among age groups throughout the time periods. While there is some stability in rates of mortality amongst the age groups during the first 15 years included in the study, the results in Table 1 show an increase in mortality rates during the most recent time period from 2013-2017. The confidence intervals in Figure 1 show significance among all of the age groups between the two time points of 1997 and 2017, with the exception of the adolescent age group, indicating that the increase in mortality, although small, is significant.
Table 1. Counts of mortality and age adjusted rates of AgeGroups by YearGroups per 10,000 people. mortality (n)= 4,999 Time period Adolescents (10-18 yrs) Young adults (19-27yrs) Adults (28-39 yrs) Advancing adults (40-60 yrs) Ageing population (61-80 yrs) Total count # 1997-2000 12 179 346 316 49 2001-2006 17 264 327 440 62 2007-2012 15 276 428 501 101 2013-2017 17 402 552 563 132
Age-adjusted rates (95% CI)
1997-2000 0.03 (.01,.05) 0.45 (.38,.52) 0.58 (.52, .64) 0.32 (.28, .36) 0.08 (.06, .10) 2001-2006 0.03 (.01,.04) 0.46 (.40,.51) 0.37 (.33, .41) 0.29 (.26, .32) 0.07 (.05, .08)
2007-2012 0.03 (.01,.04) 0.42 (.37,.47) 0.49 (.45, .54) 0.32 (.30, .35) 0.1 (.08, .11) 2013-2017 0.04 (.02,.05) 0.68 (.61, .75) 0.73 (.67, .79) 0.42 (.39, .46) 0.14 (.11, .16)
Counts of hospitalization occurrences and age adjusted rates of hospitalization occurrences There is a substantially larger number of recorded hospitalizations linked to narcotic use as compared to the recorded numbers of mortality linked to the same diagnosis. Between the years of 1997-2016 a total of 143,264 occurrences represented by individuals between the ages 10-80 years, were identified as events of hospitalizations with a diagnosis related to narcotic misuse. As a result, the age adjusted rates of hospitalization occurrences for the 20-year period are much higher than that of the mortality rates. These elevated rates reveal a telling contrast between age groups as the age adjusted rates for the entirety of the 19 years are 4.08 for the adolescents, 18.43 for young adults, 14.02 for adults, 8.03 for advancing adults, and 1.97 for the ageing population. The age adjusted rates of hospitalizations, along with 95% confidence intervals, are presented by age groups within specific time periods, as seen in Table 2. The age adjusted rates clearly reveal an overall increase in rates of
has a significant increase between every time period (Table 2). When comparing between the two time points of 1997 and 2017, all age groups, with the exception on the ageing
population, are shown to have a significant increase in rates of mortality (Table 2).
Table 2. Counts of hospitalizations and age adjusted rates of AgeGroups by YearGroups per 10,000 people. hospitalizations (n)=143,264
Time period Adolescents (10-18 yrs) Young adults (19-27yrs) Adults (28-39 yrs) Advancing adults (40-60 yrs) Ageing population (61-80 yrs) Total count # 1997-2000 1302 5437 8488 7098 1163 2001-2006 2152 9697 10900 11831 1573 2007-2012 2911 13214 12153 13516 2235 2013-2016 2204 12483 12080 10786 2041
Age-adjusted rates (95% CI)
1997-2000 3.40 (3.21, 3.58) 13.78 (13.42, 14.15) 14.23 (13.93, 14.53) 7.19 (7.02, 7.36) 1.95 (1.84, 2.06) 2001-2006 3.36 (3.22, 3.51) 16.88 (16.54, 17.22) 12.18 (11.95, 12.41) 7.75 (7.61, 7.89) 1.70 (1.62, 1.79) 2007-2012 4.90 (4.72, 5.08) 20.14 (19.8, 20.49) 14.03 (13.69, 14.19) 8.75 (8.60, 8.90) 2.11 (2.02, 2.19) 2013-2016 4.57 (4.38, 4.76) 21.12 (20.75, 21.49) 16.05 (15.77, 16.34) 8.14 (7.98, 8.29) 2.10 (2.01, 2.19)
Percentages of events by age category
The percentages of events focus solely on the populations of individuals who are represented with a recorded event of mortality or hospitalization linked to narcotic misuse. These
percentages are displayed by age categories (AgeGroups) within time periods (YearGroups) meaning, that of all the recorded occurrences of narcotic misuse during a time period, the percentage is reflective of the ratio for that specific age group for that specified time period. The percentages in Figure 1, calculated from raw data, show that over time there is an increase in percentage of mortality related to narcotic misuse among the young adult and ageing populations. From 1997- 2000, the total numbers of mortality events are 179 and 49, for the young adult and ageing populations, respectively. By the 2013- 2017 time period those numbers amassed to 402 and 132 events of mortality for their corresponding age groups. In contrast, the percentages among the adult and advancing adult populations show some fluctuation throughout the years, though still strongly representative as the age groups with the highest rates of mortality (Figure1). The percentages of narcotic related mortality among the adolescent population remains relatively stable.
Similar to Figure 1, the numbers presented in Figure 2 show that the percentage of
hospitalizations due to narcotic misuse amongst adolescents remained relatively stable. Also similar to Figure 1, the percentage of hospitalizations among adults seen in Figure 2 show variation through the years, though it does show an overall decline since 1997. The advancing adult population shows a small decrease in its percentage share, while the young adult
Figure 1. Percentages of mortality related to narcotic misuse within each age group per year group.
Figure 2. Percentages of hospitalizations related to narcotic misuse within each age group per year group. 1,3% 1,5% 1,1% 1,0% 19,8% 23,8% 20,9% 24,1% 38,4% 29,5% 32,4% 33,1% 35,0% 39,6% 37,9% 33,8% 5,4% 5,6% 7,6% 7,9%
Percentage of deaths by age group
Y e a r G ro u p
Percentages of mortality related to narcotic misuse within each age group per year group
n=4,999
Adolescent Young adult Adult Advancing adult Ageing population
5,5% 6,0% 6,6% 5,6% 23,1% 26,8% 30,0% 31,5% 36,1% 30,1% 27,6% 30,5% 30,2% 32,7% 30,7% 27,2% 5,0% 4,4% 5,1% 5,2%
Percentage of hospitalizations by age group
Y ea r G rou p
Percentages of hospitalizations related to narcotic misuse within each age group per year group
number of hospitalization events (n)= 143,264
Comparisons among males and females with a record of mortality associated with narcotic misuse
Of the 4,999 individuals that are identified as having a diagnosis related to narcotic misuse linked to their mortality, there is an unequal gender distribution with 79% of the population of narcotic related mortality being comprised of males and only 21% of the population being comprised of females. The youngest documented cases of male mortality related to narcotic misuse were 16 years of age and occurred in 2002 and 2006. The youngest cases of females with mortality related to narcotic misuse were 14 years of age and occurred in 2003 and 2004. When considering the total mortality for males within the 20 year time frame, 1997 accounts for 4% of the total male mortality linked to narcotic misuse while 2017 accounts for 5.7% of the total male mortality linked to narcotic misuse. These results show that there is a small increase in total mortality among males within the 20 year time period. However, there is no increase to be observed among the female population between the two time points, with 1997 and 2017 each accounting for 4.2% of the total female mortality related to narcotic misuse.
The collective median age for all occurrences of mortality linked to narcotic misuse between 1997 and 2017 is 37 years of age. Over the course of the 20 years included in the study, there is some variation in the annual median ages for both males and females. A slight upward trend, although insignificant, can be seen in Figure 3, as the median ages of females with narcotic misuse related mortality increases over time. The R2 for females, as observed in Figure 3, is rather weak indicating that there is no clear explanation for the variance associated with the declining age of females with recorded events of narcotic related
male mortality linked to narcotic misuse is 36 years in 1997 and 35 years in 2017, with the total median age of the 20 year period being 36 years of age.
Figure 3. Median age of mortality occurrences due to narcotics, from 1997-2017.
As demonstrated in Figure 3, the median ages of males and females reveal an age difference between male and female mortality linked to narcotic use. A further analysis of the mean ages is corroborated by a standard independent T-Test. A T-Test of the total mean age for
mortality linked to narcotic misuse between 1997-2017 shows that male individuals with mortality linked to narcotic misuse (n=3,955) from 1997-2017 have a mean age of 37.9 years (standard error mean .2) compared to the female individuals with mortality linked to narcotic misuse (n=1,044) with a mean age of 42.2 years (standard error mean .48). Male mortality linked to narcotic misuse is shown to be significantly (p< .001) associated with a lower mean age than that of female mortality linked to narcotic misuse (95% CI: 5.32, -3.29). R² = 0,0791 R² = 0,0342 32 34 36 38 40 42 44 46 48 ME DIA N A G E YEAR
Median age of mortality occurrences due to narcotics, from 1997-2017
*for individuals between 10-80 years of age, number of occurences (n)=4,999
Female Median Age Male Median Age
Comparisons among males and females with a record of hospitalization associated with narcotic misuse
The gender distribution among hospitalizations, while still unequal, is slightly more balanced than that of the mortalities. Of the 143,264 occurrences of hospitalizations linked to a
diagnosis related to narcotic misuse occurring between the years of 1997-2016, 65% of the hospitalization occurrences are experienced by males and 34% of the hospitalization
occurrences are experienced by females. Analyzing for growth between the two time points of 1997 and 2016, the percentages of hospitalizations related to narcotic misuse among males and females have increased. From 1997, which accounts for 3.3% of the total male
hospitalizations to 2016, which accounts for 7.4% of the total male hospitalizations linked to narcotic misuse, the results show that there is a notable increase in occurrences of narcotic related hospitalizations among the male population. There was a notable increase to be observed among the female hospitalizations as well. Between the two time points, female hospitalizations linked to narcotic misuse in 1997 accounts for only 3.8% of hospitalizations within the 19 year time period while the number of occurrences in 2016 account for 6.4% of the hospitalizations related to narcotic misuse within that same time period. The collective median age of the individuals represented in the occurrences of hospitalization is 33 years of age. Throughout the years there is some variation in the annual median ages among both males and females, yet a significant downward trend (p< .001) in age is evident for both genders, as seen in Figure 4. The R2 for females, as observed in Figure 4, shows that ~80% of the variation in age can be explained by the change over time, further indicating that the age of females with recorded events of narcotic related hospitalizations is becoming younger since 1997. The median age of females with occurrences of hospitalizations linked to narcotic misuse decreased from 35 years in 1997 to 31 years in 2016, with the total median age of female hospitalizations for the 19 year period being 34 years of age. The median age of males with occurrences of hospitalizations linked to narcotic misuse decreased from 34 years in 1997 to 32 years in 2016, with the total median age of male hospitalizations for the 19 year period being 33 years of age. The R2 for males, as observed in Figure 4, shows that 79% of the variation in age can be explained by the change over time, further indicating that the age of males with recorded events of narcotic related hospitalizations is becoming younger. These significant downward trends oppose that of the increasing median age of the general
Figure 4. Median age of hospitalization occurrences due to narcotics, from 1997-2016.
The median ages of males and females, as shown in Figure 4, reveal a small, yet shrinking age difference between male and female hospitalizations linked to narcotic use. An additional analysis of the mean ages through a standard independent T-Test provides a parallel
conclusion. TheT-Test of the total mean age for hospitalizations linked to narcotic misuse between 1997-2016 show that male individuals with a record of hospitalization linked to narcotic misuse (n=92,450) have a mean age of 34.9 years (standard error mean .04)
compared to the female individuals with a record of hospitalization linked to narcotic misuse (n=50814) with a mean age of 36.2 years (standard error mean .07). Hospitalizations linked to narcotic misuse, from 1997-2016, are shown to be significantly (p< .001) associated with a lower mean age among males compared to females (95% CI: -1.39, -1.09).
Discussion
Age and narcotic misuse
The percentages of harm related events, recognized as hospitalization encounters and
mortality related to narcotic misuse, are interesting as they provide a “story telling” effect as they illustrate the distribution of the aforementioned events among age groups, and perhaps, offer the best description as to whether the age structure is changing among individuals misusing narcotics. In every time period an inversion can be observed that as the age group
R² = 0,7904 R² = 0,7955 30 32 34 36 38 ME DIA N A G E YEAR
Median age of hospitalization occurrences due to narcotics, from 1997-2016
*for individuals between 10-80 years of age, number of occurences (n) =143,264
populations become older. As the age groups increase in age, the percentage shares in hospitalizations, which are larger in the younger age groups, are surpassed by percentage shares in mortality, which are larger in the older age groups. One explanation of this movement towards mortality is that as individuals age, the co-morbidities, and the accrued health effects of narcotic misuse, such are Hepatitis or HIV, drive the resulting mortality. Another suggestion is that a change in drug use patterns is occurring as users of narcotics become more experienced and progress to using more lethal drug forms such as transitioning from a single substance consumer to a poly consumer of narcotic substances (Harlow, 1990; Sanchez, et al., 1995). The latter suggestion is most probable and is similar to what Byqvist suggests is being observed in the Swedish context (Byqvist, 2006).
In the case of hospitalizations, it is important to emphasize that while the general population is living longer, as evidenced by the increasing median age, the median age of individuals represented in events of hospitalizations related to narcotic misuse is getting younger for both males and females. Because the hospitalizations are representative of medical events, this decrease in median age is indicative that there are more young people who are misusing narcotics than there were in the past and incurring these harms requiring medical
intervention. There is also a possibility that the younger people are using narcotics in a more dangerous way, such as the use of synthetic cannabis commonly known as K2 or spice. An increase in the use of riskier narcotics amongst individuals who are new to behaviors of narcotic misuse would, arguably, result in the need for more frequent and repetitive
hospitalizations, as compared to older individuals that are more experienced in their methods of narcotic misuse.
regarding prevention initiatives that have been and are continuing to be developed and targeted toward adolescent groups (EMCDDA, 2015).
Perhaps more concerning is that the young adult age group, which continues to increase its percentage share of narcotic related hospitalizations and mortality. The observation of hospital occurrences among the young adult age group is one of the most notable indications of a changing age structure, as young adults begin to account for more and more of all
narcotic related hospitalizations over the course of time. Not only has the percentage share of the young adult age group been increasing, the age adjusted rates in hospitalizations and mortality also show a remarkable increase in the numbers. The young adult age group consistently leads with the highest rate of hospital encounters among all age groups and has the most rapid growth in number of hospital occurrences. With reference to the social stress model of substance abuse, one possible explanation of this is the amount of change and stress that usually occurs during this developmental stage. This age group encapsulates the
population that is transitioning from youth to adulthood and moving away from
well-established familial and social support and are left to try and establish forms of social support in a new setting. There are also stressors surrounding educational and vocational goals that could also leave individuals feeling isolated and without the necessary support. These notable increases suggest that perhaps the prevention education and methods received by adolescents in Sweden may need to be revised for long term effectiveness. Further, social interventions, such as clubs or support groups, throughout primary schooling, higher education and at workplaces, could prove to serve as potential protective factors among the young adult population.
group is nearly double that of the advanced adult age group. Moreover, the growth in rates of mortality and hospital occurrences is higher among the adult group. These results reveal that, even with similar distribution of narcotic related hospitalizations and mortality throughout the years, the adult age group is affected to a much larger degree and the number of individuals in each age group is increasing faster than the advancing adult age group. One possible explanation for the large percentage of narcotic misuse among adults could be tied into the social stress model of substance abuse, as this age group occurs in the developmental stage in which most Swedes begin stabilizing their career and having children, thus forming their own family units. This could potentially result in feelings of societal pressure, dissatisfaction, and isolation, or feelings of being “left behind,” for the individuals who have not yet been able to achieve the career and family life balance they feel that they “should” achieve. It is also possible, and likely, that individuals formerly represented in the hospitalizations of young adult age group have “aged up” and transitioned to the adult age group where they are represented again through events of hospitalization or mortality due to the continued misuse of narcotics.
The ageing population is also increasing, to a small degree, its percentage share of hospitalizations and mortality related to narcotic misuse. There was an increase in age adjusted rates of hospitalizations as well as a near doubling in the rate of age adjusted mortality. However, this increase may not necessarily be a cause for concern. Rather, the increase over time could be indicative of maintenance programs in effect and the subsequent lengthening of life expectancies for individuals that struggle with narcotic misuse, which would allow for the number of individuals in this age group to increase.
The pre-defined age structure of individuals with narcotic related hospitalizations has changed from 1997 to 2016. Hospital occurrences, which most often occur among the adult age group in 1997, has shifted to the young adult age group as more and more young people are presenting with events of hospitalization linked to narcotic misuse.
While the percentages in Figure 1 and Figure 2 provide a telling look at the behaviors and trends among age groups, they do not account for the size of the general population, and thus, do not provide a clear picture as to if the misuse of narcotics is increase or decreasing over time. Age adjusted rates address this concern by specifically considering the general population by the appropriate age group. As previously noted, the age adjusted rates of narcotic related hospitalizations and mortality are increasing throughout the years in every age group, and there are significant changes between 1997 and 2017 among the young adult, adult, and advancing adult age group in both hospitalizations and mortality. These significant changes indicate that the misuse of narcotic substances resulting in need for medical
intervention, or death, is undoubtedly increasing amongst these age groups. Similarly, these results match that of the 2019 Stockholm report, which found an increase in narcotic related mortality for females growing from two to four deaths per 100,000, and from eight to ten deaths per 100,000 for males, many of which were attributed to the use of various opioid forms (Allebeck, et al., 2019). An increase in the use of narcotic and illicit drug use could be attributed to the increased accessibility and availability of substances such as prescribed painkillers through illegal marketplaces (CAN, 2014; CAN, 2019). Nonetheless, greater consideration must also be taken towards examining the influence of social factors and the function of society when trying to explain the multifaceted factors surrounding the increasing misuse of narcotic substances.
Gender and narcotic misuse
has been observed throughout Europe, as individuals seeking treatment for narcotic misuse are of increasing age (EMCDDA, 2015). One could argue that the large increase in median age could be indicative of successful implementation of public policy through legislation and care workers working towards preventative measures in adolescents and young adults. However, the hospitalization data would challenge this suggestion. The median age of females with hospitalizations linked to narcotic misuse has decreased by 4 years between 1997 and 2016. A more probable explanation of these results is that individuals misusing narcotics are starting at younger ages and the inexperience with using new narcotic
substances is cause for hospitalization. The increased frequency of hospitalizations, which nearly doubled for females from 1997- 2016, supports the possibility that more females are misusing narcotics at a younger age. It is also plausible that as females are becoming older, before reaching the time of mortality, they require medical care for the treatment of co-morbidities that often accompany, and are in conjunction with, long term narcotic misuse, thus fueling the occurrences of hospitalizations during younger years.
While observing the median age of male mortality, it can be noted that there is a divergence from the trend set by the females and general population. When comparing the two time points, the median age of males is observed as decreasing by one year from 1997 to 2017. Furthermore, the median age of males with hospitalization occurrences decreases by two years between 1997 and 2016. The declining age in both mortality and hospitality among males might suggest that there increasingly risky changes in the methods of narcotic consumption, or the types of narcotics being consumed by males that pose as a more acute health risk, such as polydrug use.
Examination of the males and females misusing narcotics through the independent T-Tests further concludes that males are generally younger than females in relation to mortality and hospitalizations linked to narcotic misuse. Furthermore, the trend in age presents itself differently for males and females when studying mortality related to narcotic misuse.
In an effort to provide explanation as to what has led to the development, growth, and trends of narcotic misuse witnessed in this study, public policy and social conditions must be considered as influential factors.
Policy implications
Changes in political policies, public funding, and policies concerning medical measures of care all have an effect on the events of harm measured within this study. During the years 1982–2000, many treatment options for individuals misusing drugs in Sweden became privatized resulting in economic stability being a key determinant in drug treatment practices rather than the best, most effective treatments (Eriksson, & Edman, 2018). In the year 2002, the Swedish government, determined to strengthen the nation’s drug policy regarding prevention and treatment, formed the agency Mobilization Against Drugs (MOB) which implemented preventative measures, provided additional resources for treatment programs, and developed care and treatment plans for individuals with a documented record of drug misuse (Blomqvist, et al., 2009). The government had dedicated significant amounts of resources to be distributed by individual municipalities across a variety of welfare services that are used by individuals struggling with narcotic misuse, however, five years later, in 2007, the MOB agency was terminated when the government changed parties (Blomqvist, et al., 2009). In an effort to better observe if there were potential effects of the changing policy, the time periods of (2001-2006) and (2007-2012) were categorized to align with this notable shift; while there was only a significant change for the adults age group when measuring events of mortality, there was a significant change between the time periods for all age groups when measuring events of hospitalizations. It is possible that the changes in policy and government resources had an effect on the occurrences of hospitalizations and mortality related to narcotic misuse and contributed to the significant changes observed in the results. Policy changes concerning replacement therapy and opioid overdose antidotes have
continued to be made in an effort to reduce the risk of premature mortality. In 2007, at the same time as the termination of the MOB, new treatment guidelines were developed
recognizing the potential benefits of methadone maintenance programs in combination with psychosocial interventions, highlighting the possible outcome of potential long term
reintegration into society for individuals struggling with narcotic misuse (Blomqvist, et al., 2009). Methadone maintenance treatment programs, which were established in 1966
20 who are identified as being a “long term opiate user” (Blomqvist, et al., 2009). The development and growth of methadone maintenance, or rather, replacement therapy
programs, has led to the increasing use of buprenorphine and other pharmaceutical treatments for individuals struggling with opiate misuse supported with the argument that substitution medications save lives and reduce risky behavior that is often associated with narcotic misuse (Blomqvist, et al., 2009). As seen in the age adjusted rates in this study, there has not been a decrease in the amount of deaths related to narcotic misuse which could allow one to
conclude that the use of narcotics has not fallen. However, the ageing population is increasing in its percentage of mortality indicating longevity and management of severity/ level of potency of the narcotics being consumed. It is possible that the substitution medications are playing a role in increasing the longevity of lives for individuals struggling with narcotic misuse. Fugelstad, et al. found that 91% of mortality, from enrollees in Stockholm methadone programs from 1988-2000, occurred due to “natural” causes or residual effects of narcotic misuse such as hepatitis C, and/or HIV. It has also been reported that those individuals who had been discharged from the program or refused the program faced a much higher risk of dying prematurely, which most frequently presented itself in the form of drug related overdoses (Fugelstad, et al., 2006; Ledberg, 2017). It could be possible that as more
individuals enter into, and remain in replacement therapy programs, which occurs only after they have been identified as a “long term opiate user”, less of these individuals would present with events of hospitalization, which is an inversion that is observed in each of the time periods in this study. These findings help to confirm that the methadone treatments do serve as a benefit and are effective in reducing mortality related to narcotic misuse among
participating individuals, and suggest that the methadone treatment programs may have a role in slowing the arrival of premature mortality and the increasing life span, as represented through the trends of median age, for individuals that misuse narcotics.
younger individuals misusing narcotics while the age structure of mortality events is shifting towards older individuals.
While the accessibility of methadone treatment programs has grown, they are still not yet available to everyone seeking these services, which may be an influential factor in the rising rates of hospitalizations related to narcotic misuse. Since 1997 there has been an increase in hospitalizations and inpatient care for narcotic misuse, which is further supported by the results in this study. This increase could be due to the expansion of new drugs as well as greater availability of drugs, such as pharmaceuticals, which coincides with the expansion of polydrug use (Rask, 2006). As the drugs have changed so have the methods in which they are consumed; drugs that were once only considered for injecting are now being consumed through smoking or oral consumption (Byqvist, 2006). It is understandable that the rates of hospitalizations and need for care would increase as the risky experimentation of combining drugs continues to increase among the individuals misusing narcotics. The increasing number of hospitalizations is a sign that policy work and treatment programs must continue to evolve, incorporate and educate in measures of harm reduction, become more readily accessible to individuals seeking treatment, and adjust to the new trends of narcotic consumption and misuse.
Strengths and limitations of the study
There are two major strengths to conducting such a study within the Swedish context, one being that the “mortality register covers 99% of all deaths and 94% of all fatal intoxications undergo medico-legal investigation,” and the second being that all registered residents within the country have a personal identification number that allows for easy identification and tracking within the data registries (Fugelstad, et al., 2006:409).
However, even with these benefits, attempting to monitor and track narcotic misuse can be a challenging and difficult task with multiple influences at play. CAN concludes that, through the analysis of previous studies, females tend to be overrepresented when it comes to care measures in regard to drug misuse, while being underrepresented when identifying
care system to give a diagnosis of substance abuse, since this was supposed to be socially stigmatizing” (Engstrom, et al., 2009:104). Moreover, as policies regarding treatment and rehabilitation develop and change, so do the accessibility of resources. As the medical profession continues to advance and develop, so do the methods of diagnosing narcotic dependency and misuse. Consequently, these changes and developments also mean changes in the identification and registrations of mortality and hospitalizations linked to narcotic misuse (Nilsson, 2017). These considerations are vital to note when monitoring longitudinal trends concerning the use of substances such as narcotics.
A limitation to be considered when observing the results is that the data utilized in this study includes and reflects events of harm experienced only by individuals that are registered residents of Sweden and does not account for newly arrived or undocumented residents, or traveling workers who may be temporarily residing within the country. This omission leads to the potential risk of omitting drug trafficking persons who may have travelled to or resided in Sweden and died or needed hospitalization due to narcotic abuse during their time in the country. The market of opioid substances, primarily that of heroin, has been shown to rely largely on the importing and smuggling of substances into Europe, and subsequently Sweden
(EMCDDA, 2015; CAN, 2019). The omission of individuals involved in transporting these substances surely alludes to the appearance of the data having smaller effect than what reality may truly be.
A limitation and important point to note regarding the data analysis is that the range between number of years in year groups, and number of years included in each year group varies. Due to the varying ranges, some individuals, in the case of hospitalizations, will only be represented within the same age group throughout all of the time periods, or represented in two different age groups within the same time period.
Conclusions
Counts of mortality and hospitalizations linked to narcotic misuse have been increasing in Sweden within the previous two decades. Two plausible explanation for these increases are that individuals who misuse narcotics are living longer, leading to an increase in older populations having higher rates of narcotic misuse, and that narcotics are becoming more accessible and therefore misused to a greater extent by a great percentage of the population. The trends in ages among males and females present themselves differently in mortality related to narcotic misuse. While the trends are not significant over the course of time, they do diverge in direction as the female median ages continue to climb in years, indicating that females who misuse narcotics are beginning to misuse narcotics at an older age or they are living longer, and this increase in median age follows the trend of the general population, which is also increasing in age. Males and females present similar significant trends in declining age in relation to hospitalizations linked to narcotic misuse, suggesting that higher amounts of younger people, both males and females, are misusing narcotics.
The age structure of individuals with a record of mortality linked to narcotic misuse has not significantly changed through the years of 1997-2017. It is worth noting that there has been some slight growth amongst the oldest age group which indicates that individuals who are misusing narcotics are getting older. The age structure of individuals with recorded hospitalizations linked to narcotic misuse has changed over time, with the majority of hospitalizations shifting from the adult age group to the young adult age group, indicating that more young people are accessing and misusing narcotics and possibly experiment with lethal combinations driving the increased need for acute medical care.
