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Aims: To measure all‐cause mortality risk after an ambulance‐attended non‐fatal opioid overdose and associations with number of days following attendance, and individual and clinical characteristics. Design: A prospective observational study. Setting: Oslo, Norway. Participants: Patients treated with naloxone for opioid overdose by Oslo Emergency Services between 1 June 2014 and 31 December 2018. Measurements Medical records were linked to the national Cause of Death Registry (1 June 2014–31 December 2019). Crude mortality rates (CMR) and incidence risk ratios (IRR) with 95% confidence intervals (CI) were estimated for the time periods (0–7 days, 8–31 days, 32–91 days, 92–183 days, >183 days) using multivariate Poisson regression analysis. IRR were estimated for sex, age, Glasgow Coma Scale (GCS), respiration rate, place of attendance and non‐transportation following treatment. Robust variance estimates applied due to multiple risk periods. Standardized Mortality Rates (SMR) were estimated. Findings Overall, 890 patients treated for 1764 overdoses contributed to a total time at risk of 3142 person‐years (PY). Median number of attendances was 1 (range 1–27). The majority were male (75.5%) and the mean age was 37.7 years. In total, 112 (12.6%) died; 5.2% within 183 days and 2.2% between 184 and 365 days. Acute poisoning was the most common single cause of death (52.7%). The CMR was 3.6 (95% CI = 3.0–4.2) per 100‐PY. The women had a SMR of 32 (95% CI = 15.8–57.9) and the men 24.9 (95% CI = 17.7–34.2). The CMR (22.2, 95% CI = 10.6–46.8) was particularly high in the first 7 days, and significantly higher than in the following periods. However, this finding was only valid for those with severe overdose symptoms (GCS score = 3/15 and/or respiratory rate ≤6/min). Except for increasing age, no other indicators were associated with the mortality risk. Conclusion: Patients treated by Oslo Emergency Services between June 2014 and December 2018 for a non‐fatal opioid overdose with severe overdose symptoms at attendance had an overall high mortality risk compared with the general population, but particularly during the first 7 days after attendance. [ABSTRACT FROM AUTHOR]

Background and Objectives: More knowledge is needed to identify and reach those at overdose risk with preventive measures. We examined past 12‐month health service utilization, identified the most frequently utilized service, explored this utilization in more detail, and examined correlates of overdose death. Methods: A population‐based nested case–control registry study including all drug overdose deaths (1 January 2010 to 31 December 2018) in Norway through the Cause of Death Registry (n = 2388). The year‐, age‐ and gender‐matched controls included through a population registry (n = 21,465). Data cross‐linked with population and patient registries. Multivariable conditional logistic regression analyses estimated the likelihood of overdose death. Results: The cases (vs. controls) attended a higher median number of services (3 vs. 1). The General Practitioner (GP) was the most utilized service. The majority (55.7%) of cases had 11–50 encounters, while the majority (60.7%) of the controls had 1–5 encounters. No high school diploma, no employment, urban living, social welfare benefits/disability pension, single‐person household, recent incarceration, multiple health service utilization and frequent GP encounters, as well psychological and certain physical diagnoses were correlates of overdose death among the GP attenders. Discussion and Conclusions: The cases had utilized more services than the controls and the GP was the most frequently utilized service. In addition to low socioeconomic status, psychological and certain physical diagnoses were correlates of overdose death. Scientific Significance: This is the first national case–control registry study to document the high utilization of multiple primary and secondary health care services before drug overdose death, as well as reasons for attendance and correlates of overdose death. [ABSTRACT FROM AUTHOR]

Introduction: Little international comparative work exists describing pandemic-related spikes in overdose and related implications for drug and public health policy. We compared increases in overdose deaths during the pandemic in Norway and the United States, two countries in the top 10 for per-capita overdose mortality, yet with very different approaches to the pandemic, healthcare and drug policy. Methods: We examined monthly overdoses in 2020 versus baseline rates (the monthly average across 2017–2019). We compared excess overdose mortality to shifts in human mobility and social interaction, measured using cellphone-based mobility data, an indicator of the societal response to the pandemic. Results: Both the US and Norway saw large magnitude exacerbations in overdose mortality during the pandemic-related lockdowns, reaching 46.8% and 57.0% above baseline, respectively. Maximum increases occurred 2–3 months after peak reductions in mobility, suggesting lagged mechanisms. While overdose mortality returned to baseline relatively quickly in Norway, rates remained elevated in the US to the end of 2020. Conclusions: Spikes in overdose mortality in both contexts may relate to disruptions in healthcare access and the drug supply becoming more potent. Norway's quicker return to baseline may reflect more robust access to harm reduction and addiction-related healthcare services. Nevertheless, it is notable that even in Norway – with universal access to high-quality services, low COVID-19 rates, and a highly effective public health infrastructure – a greater than 50% spike in overdose deaths was still seen at the onset of lockdown measures. This may have important implications for future pandemic and disaster planning. [ABSTRACT FROM AUTHOR]

Injecting drug use is one of the leading risk factors for infections and drug-related deaths. Despite these risks, many people who inject drugs (PWID) continue to inject despite access to alternative intake methods. In this study, we explore this seemingly paradoxical attraction. We conducted 80 qualitative interviews with PWID, recruited from low threshold settings in five Norwegian cities, where we focus on the process of injection initiation and why PWID maintain such behaviour over time, despite associated negative consequences. The analysis shows how participants' experiences evolved from a fear of the needle, to embracing it as a meaningful practice. First, this involved social interaction and learning from other PWID, second, appreciating the intensity and speed of the intoxication, third, the positive ritual aspect of injecting, and finally, a devaluation of other modes of use. The study thereby helps expand upon and provide new understandings of the interactional process and cultural context of drug use, in which the interplay of social factors influences individual actions and promotes injecting over other modes of use. Future interventions for reducing the number of PWID thus need to consider how various social contexts impinge on, or even encourage, injecting drug use. [ABSTRACT FROM AUTHOR]

Abstract Background In opioid maintenance treatment (OMT) there are documented treatment differences both between countries and between OMT programmes. Some of these differences have been associated with staff attitudes. The aim of this study was to 1) assess if there were differences in staff attitudes within a national OMT programme, and 2) investigate the associations of staff attitudes with treatment organisation, clinical practices and outcomes. Methods This study was a cross-sectional multicentre study. Norwegian OMT staff (n = 140) were invited to participate in this study in 2007 using an instrument measuring attitudes towards OMT. The OMT programme comprised 14 regional centres. Data describing treatment organisation, clinical practices and patient outcomes in these centres were extracted from the annual OMT programme assessment 2007. Centres were divided into three groups based upon mean attitudinal scores and labelled; "rehabilitation-oriented", "harm reduction-oriented" and "intermediate" centres. Results All invited staff (n = 140) participated. Staff attitudes differed between the centres. "Rehabilitation-oriented" centres had smaller caseloads, more frequent urine drug screening and increased case management (interdisciplinary meetings). In addition these centres had less drug use and more social rehabilitation among their patients in terms of long-term living arrangements, unemployment, and social security benefits as main income. "Intermediate" centres had the lowest treatment termination rate. Conclusions This study identified marked variations in staff attitudes between the regional centres within a national OMT programme. These variations were associated with measurable differences in caseload, intensity of case management and patient outcomes.

Abstract Background Research questionnaires are not always translated appropriately before they are used in new temporal, cultural or linguistic settings. The results based on such instruments may therefore not accurately reflect what they are supposed to measure. This paper aims to illustrate the process and required steps involved in the cross-cultural adaptation of a research instrument using the adaptation process of an attitudinal instrument as an example. Methods A questionnaire was needed for the implementation of a study in Norway 2007. There was no appropriate instruments available in Norwegian, thus an Australian-English instrument was cross-culturally adapted. Results The adaptation process included investigation of conceptual and item equivalence. Two forward and two back-translations were synthesized and compared by an expert committee. Thereafter the instrument was pretested and adjusted accordingly. The final questionnaire was administered to opioid maintenance treatment staff (n=140) and harm reduction staff (n=180). The overall response rate was 84%. The original instrument failed confirmatory analysis. Instead a new two-factor scale was identified and found valid in the new setting. Conclusions The failure of the original scale highlights the importance of adapting instruments to current research settings. It also emphasizes the importance of ensuring that concepts within an instrument are equal between the original and target language, time and context. If the described stages in the cross-cultural adaptation process had been omitted, the findings would have been misleading, even if presented with apparent precision. Thus, it is important to consider possible barriers when making a direct comparison between different nations, cultures and times.

Aims: To examine uptake following a large‐scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high‐risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators. Design (1) Distribution data (June 2014–August 2017) and date of implementation for each city and (2) a cross‐sectional study among a sample of illicit substance users interviewed September 2017. Setting: Seven Norwegian cities. Participants: A total of 497 recruited users of illegal opioids and/or central stimulants. Measurements Primary outcomes: naloxone possession and use. Random‐intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration). Findings Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high‐risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82–2.37], female gender (aOR = 1.97, 95% CI = 1.20–3.24) and drug‐dealing (aOR = 2.36, 95% CI = 1.42–3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15–1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02–4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13–3.78), drug‐dealing (aOR = 2.40, 95% CI = 1.27–4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04–4.38). Conclusions: A large‐scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high‐risk individuals, with programme duration in each city as an important indicator for naloxone possession and use. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To examine the mortality risk in a cohort of ‘hard‐to‐reach’ polysubstance users and its putative associations with substance use. Specifically, we estimated all‐cause mortality risk as a function of individual substance use indicators, and then as a function of their complex, ‘real‐life’ patterns as identified through latent class analysis (LCA). Design: Prospective cohort study among street‐ and low‐threshold service‐recruited polysubstance users included between September and November 2013 and followed through the National Cause of Death Registry until 31 October 2015. Setting: Seven Norwegian cities. Participants: A total of 884 users of illegal opioids and/or stimulants. Of these, 357 were in opioid substitution treatment (OST) at the time of inclusion. Forty‐four participants died during follow‐up. Measurements: Primary outcome: all‐cause mortality risk. Unadjusted and adjusted Cox proportional hazard (PH) regression models (covariates: male, age, homelessness/shelter use, overdose experience, OST status, years of injecting, individual substance use indicators, city, use patterns). LCA models estimated separately for those in and those not in OST due to measurement invariance. Findings: The crude mortality rate was 2.52 per 100 person‐years. Standardized mortality ratio was 26.11 [95% confidence interval (CI) = 10.06–54.87] for women and 10.71 (95% CI = 6.39–16.81) for men. No single drug use indicator, such as ‘heroin injection’ or ‘number of drugs used’, was associated with the mortality risk. However, meaningful use patterns were identified; three OST and non‐OST patterns each. The non‐OST patterns ‘polysubstance injectors’ [hazard ratio (HR) = 3.45, 95% CI = 0.98–12.14] and ‘low frequent injectors’ (HR = 3.17, CI = 1.05–9.56) were associated significantly with the mortality risk even when adjusted for other known risk factors. Conclusions: In a Norwegian prospective cohort study, ‘hard‐to‐reach’ polysubstance users had a more than 10 times higher mortality risk than the general population. Mortality risk was not a function of any single drug use indicator, but two distinct combinations of substances, frequencies and routes of administration were associated with the mortality risk. [ABSTRACT FROM AUTHOR]

Aims: This study compares the characteristics of those who were or were not attended by the emergency services in the year before death. It describes the reasons for emergency service attendance and the prevalence of such attendance. It reports the number of days between the last emergency service attendance and death and examines contact with other health and social services and the association of this with emergency service attendance. Finally, it examines the association between the frequency of emergency service attendance and the frequency of contact with other services.Methods: A retrospective registry study where all overdose fatalities (n = 231) in Oslo, Norway (2006–2008), was identified through the National Cause of Death Registry and linked with data from other health and social services. Results: Overall, 61% were emergency service attendees and 18% were frequent attendees. Somatic complaints were the most common reason for attendance. Attendees were more known to a number of other services compared to the non-attendees. Furthermore, there was an association between the frequency of emergency service attendance and the frequency of contact with other services.Conclusions: Screening for drug use among emergency service attendees may be a way to identify those at risk of overdose death and enable the introduction of additional interventions. [ABSTRACT FROM AUTHOR]