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Original Investigation
December 26, 2019

All-Cause and Cause-Specific Mortality Among People Using Extramedical Opioids: A Systematic Review and Meta-analysis

Author Affiliations
  • 1National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
  • 2Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 3University of Queensland School of Psychology, St Lucia, Queensland, Australia
  • 4Institute of Health Metrics and Evaluation, University of Washington, Seattle
  • 5University of Queensland School of Public Health, St Lucia, Queensland, Australia
  • 6Queensland Centre for Mental Health Research, Wacol, Queensland, Australia
  • 7Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
JAMA Psychiatry. 2020;77(5):493-502. doi:10.1001/jamapsychiatry.2019.4170
Key Points

Question  What are the mortality rates and key causes of excess mortality among people who use extramedical opioids?

Findings  In this systematic review and meta-analysis of 124 studies, people using extramedical opioids had a higher mortality rate than those of the same age and sex in the general population. Excess mortality occurred across individuals with traumatic causes of death, infectious diseases, and noncommunicable diseases.

Meaning  The findings suggest that response to elevated mortality in people using extramedical opioids should include overdose prevention and incorporate interventions to prevent and treat infectious diseases and noncommunicable diseases.


Importance  Extramedical opioid use has escalated in recent years. A better understanding of cause-specific mortality in this population is needed to inform comprehensive responses.

Objective  To estimate all-cause and cause-specific crude mortality rates (CMRs) and standardized mortality ratios (SMRs) among people using extramedical opioids, including age- and sex-specific estimates when possible.

Data Sources  For this systematic review and meta-analysis, MEDLINE, PsycINFO, and Embase were searched for studies published from January 1, 2009, to October 3, 2019, and an earlier systematic review on this topic published in 2011.

Study Selection  Cohort studies of people using extramedical opioids and reporting mortality outcomes were screened for inclusion independently by 2 team members.

Data Extraction and Synthesis  Data were extracted by a team member and checked by another team member. Study quality was assessed using a custom set of items that examined risk of bias and quality of reporting. Data were pooled using random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression.

Main Outcomes and Measures  Outcome measures were all-cause and cause-specific CMRs and SMRs among people using extramedical opioids compared with the general population of the same age and sex.

Results  Of 8683 identified studies, 124 were included in this analysis (100 primary studies and 24 studies providing additional data for primary studies). The pooled all-cause CMR, based on 99 cohorts of 1 262 592 people, was 1.6 per 100 person-years (95% CI, 1.4-1.8 per 100 person-years), with substantial heterogeneity (I2 = 99.7%). Heterogeneity was associated with the proportion of the study sample that injected opioids or was living with HIV infection or hepatitis C. The pooled all-cause SMR, based on 43 cohorts, was 10.0 (95% CI, 7.6-13.2). Excess mortality was observed across a range of causes, including overdose, injuries, and infectious and noncommunicable diseases.

Conclusions and Relevance  The findings suggest that people using extramedical opioids experience significant excess mortality, much of which is preventable. The range of causes for which excess mortality was observed highlights the multiplicity of risk exposures experienced by this population and the need for comprehensive responses to address these. Better data on cause-specific mortality in this population in several world regions appear to be needed.

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