Complexity of risk determination

It has been known for some time that the risks of morbidity and mortality associated with narcotic dependence are greater than among the general population. These risks are mitigated somewhat by enrolment in treatment (mostly methadone maintenance therapy),1 but the risk is less mutable in narcotic-dependent patients who also suffer from poverty, homelessness, depression or polysubstance abuse.

Benedikt Fischer and associates2 have correlated one particular risk experienced by illicit opioid users — the risk of overdose — with homelessness, other substance use and recent involvement in drug treatment, suggesting that prevention efforts targeting these factors are more likely to be effective.

The risks faced by an opiate-dependent patient are not static. They oscillate and may be greater during a variety of transition periods: on initiation of methadone maintenance treatment, upon discharge from treatment, at the start of a prison sentence or upon release from incarceration. However, prevention may be limited by difficulties in achieving effective collaboration between various treatment methods (methadone maintenance and drug-free treatment), as well as between institutional settings (jail and hospital).

Efforts to deal with homelessness and poverty are never an easy “sell,” despite significant correlations of these situations with other problems that society deems important, such as heart disease or child abuse and neglect.3^,4^,5 Injection drug users represent just one special interest group among many, but the other groups tend to be better organized, usually experience less stigmatization, and are more successful in fighting for both status and state funding.

In the end, the high level of risk associated with narcotic dependence rests with a variety of social, legal and medical factors. The drugs are illicit, and users must negotiate in a marketplace fraught with danger and crime.6 Furthermore, medicine has had limited success in changing the systemic determinants of risk, leaving a patient population that is highly stigmatized and marginalized by law and society.