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      Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis

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          Abstract

          Background

          People affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences.

          Methods

          In this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis.

          Results

          From 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, p<0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95% CI: 1.38 to 1.77), though heterogeneity was high.

          Conclusion

          People affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security.

          PROSPERO registration number

          CRD42018097189.

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          Most cited references18

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          Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline

          In systematic reviews that lack data amenable to meta-analysis, alternative synthesis methods are commonly used, but these methods are rarely reported. This lack of transparency in the methods can cast doubt on the validity of the review findings. The Synthesis Without Meta-analysis (SWiM) guideline has been developed to guide clear reporting in reviews of interventions in which alternative synthesis methods to meta-analysis of effect estimates are used. This article describes the development of the SWiM guideline for the synthesis of quantitative data of intervention effects and presents the nine SWiM reporting items with accompanying explanations and examples.
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            Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis

            Summary Background Inclusion health focuses on people in extremely poor health due to poverty, marginalisation, and multimorbidity. We aimed to review morbidity and mortality data on four overlapping populations who experience considerable social exclusion: homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals. Methods For this systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library for studies published between Jan 1, 2005, and Oct 1, 2015. We included only systematic reviews, meta-analyses, interventional studies, and observational studies that had morbidity and mortality outcomes, were published in English, from high-income countries, and were done in populations with a history of homelessness, imprisonment, sex work, or substance use disorder (excluding cannabis and alcohol use). Studies with only perinatal outcomes and studies of individuals with a specific health condition or those recruited from intensive care or high dependency hospital units were excluded. We screened studies using systematic review software and extracted data from published reports. Primary outcomes were measures of morbidity (prevalence or incidence) and mortality (standardised mortality ratios [SMRs] and mortality rates). Summary estimates were calculated using a random effects model. Findings Our search identified 7946 articles, of which 337 studies were included for analysis. All-cause standardised mortality ratios were significantly increased in 91 (99%) of 92 extracted datapoints and were 11·86 (95% CI 10·42–13·30; I 2=94·1%) in female individuals and 7·88 (7·03–8·74; I 2=99·1%) in men. Summary SMR estimates for the International Classification of Diseases disease categories with two or more included datapoints were highest for deaths due to injury, poisoning, and other external causes, in both men (7·89; 95% CI 6·40–9·37; I 2=98·1%) and women (18·72; 13·73–23·71; I 2=91·5%). Disease prevalence was consistently raised across the following categories: infections (eg, highest reported was 90% for hepatitis C, 67 [65%] of 103 individuals for hepatitis B, and 133 [51%] of 263 individuals for latent tuberculosis infection), mental health (eg, highest reported was 9 [4%] of 227 individuals for schizophrenia), cardiovascular conditions (eg, highest reported was 32 [13%] of 247 individuals for coronary heart disease), and respiratory conditions (eg, highest reported was 9 [26%] of 35 individuals for asthma). Interpretation Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised. Funding Wellcome Trust, National Institute for Health Research, NHS England, NHS Research Scotland Scottish Senior Clinical Fellowship, Medical Research Council, Chief Scientist Office, and the Central and North West London NHS Trust.
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              Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017

              The 63,632 drug overdose deaths in the United States in 2016 represented a 21.4% increase from 2015; two thirds of these deaths involved an opioid ( 1 ). From 2015 to 2016, drug overdose deaths increased in all drug categories examined; the largest increase occurred among deaths involving synthetic opioids other than methadone (synthetic opioids), which includes illicitly manufactured fentanyl (IMF) ( 1 ). Since 2013, driven largely by IMF, including fentanyl analogs ( 2 – 4 ), the current wave of the opioid overdose epidemic has been marked by increases in deaths involving synthetic opioids. IMF has contributed to increases in overdose deaths, with geographic differences reported ( 1 ). CDC examined state-level changes in death rates involving all drug overdoses in 50 states and the District of Columbia (DC) and those involving synthetic opioids in 20 states, during 2013–2017. In addition, changes in death rates from 2016 to 2017 involving all opioids and opioid subcategories,* were examined by demographics, county urbanization levels, and by 34 states and DC. Among 70,237 drug overdose deaths in 2017, 47,600 (67.8%) involved an opioid. † From 2013 to 2017, drug overdose death rates increased in 35 of 50 states and DC, and significant increases in death rates involving synthetic opioids occurred in 15 of 20 states, likely driven by IMF ( 2 , 3 ). From 2016 to 2017, overdose deaths involving all opioids and synthetic opioids increased, but deaths involving prescription opioids and heroin remained stable. The opioid overdose epidemic continues to worsen and evolve because of the continuing increase in deaths involving synthetic opioids. Provisional data from 2018 indicate potential improvements in some drug overdose indicators; § however, analysis of final data from 2018 is necessary for confirmation. More timely and comprehensive surveillance data are essential to inform efforts to prevent and respond to opioid overdoses; intensified prevention and response measures are urgently needed to curb deaths involving prescription and illicit opioids, specifically IMF. Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files, ¶ with death certificate data coded using the International Classification of Diseases, Tenth Revision (ICD-10) codes X40–44 (unintentional), X60–64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Among deaths with drug overdose as the underlying cause, the type of drug or drug category is indicated by the following ICD-10 multiple cause-of-death codes: opioids (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6)**; natural/semisynthetic opioids (T40.2); methadone (T40.3); heroin (T40.1); synthetic opioids other than methadone (T40.4); cocaine (T40.5); and psychostimulants with abuse potential (T43.6). †† Some deaths involved more than one type of drug, and these were included in rates for each drug category; thus, categories are not mutually exclusive. §§ Annual percent change with statistically significant trends in age-adjusted drug overdose death rates ¶¶ for all 50 states and DC from 2013 to 2017 and in age-adjusted death rates involving synthetic opioids for 20 states that met drug specificity criteria*** were analyzed using Joinpoint regression. ††† Age-adjusted overdose death rates were examined from 2016 to 2017 for all opioids, prescription opioids ( 5 ), heroin, and synthetic opioids. Death rates were stratified by age, sex, racial/ethnic group, urbanization level, §§§ and state. State-level analyses included DC and 34 states with adequate drug specificity data for 2016 and 2017. ¶¶¶ Analyses comparing changes in death rates from 2016 to 2017 used z-tests when the number of deaths was ≥100 and nonoverlapping confidence intervals based on a gamma distribution when the number was 80% of drug overdose death certificates named at least one specific drug in 2013–2017; 2) change from 2013 to 2017 in the percentage of death certificates reporting at least one specific drug was <10 percentage points; and 3) ≥20 deaths involving synthetic opioids other than methadone occurred each year during 2013–2017. States whose reporting of any specific drug or drugs involved in an overdose changed by ≥10 percentage points from 2013 to 2017 were excluded because drug-specific overdose numbers and rates might have changed substantially from 2013 to 2017 as a result of changes in reporting. ¶ Left panel: Joinpoint regression examining changes in trends from 2013 to 2017 indicated that 35 states and the District of Columbia had significant increases in drug overdose death rates from 2013 to 2017 (Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, and Wisconsin). All remaining states had nonsignificant trends during this period. Right panel: Joinpoint regression examining changes in trends from 2013 to 2017 indicated that 15 states had significant increases in death rates for overdoses involving synthetic opioids other than methadone from 2013 to 2017 (Connecticut, Illinois, Iowa, Maine, Maryland, Minnesota, Nevada, New York, North Carolina, Oregon, Rhode Island, Virginia, Washington, West Virginia, and Wisconsin). The five remaining states analyzed had nonsignificant trends during this period. Significant increases in trends were not detected in some states with large absolute increases in death rates from 2013 to 2017 because of limited power to detect significant effects. The figure shows age-adjusted rates of drug overdose deaths and deaths involving synthetic opioids other than methadone, by state in the United States during 2013 and 2017. From 2016 to 2017, opioid-involved overdose deaths increased among males and females and among persons aged ≥25 years, non-Hispanic whites (whites), non-Hispanic blacks (blacks), and Hispanics (Table 1). The largest relative change occurred among blacks (25.2%), and the largest absolute rate increase was among males aged 25–44 years (an increase of 4.6 per 100,000). The largest relative change among age groups was for persons aged ≥65 years (17.2%). Counties in medium metro areas experienced the largest absolute rate increase (an increase of 1.9 per 100,000), and the largest relative rate increase occurred in micropolitan counties (14.9%). Death rates increased significantly in 15 states, with the largest relative changes in North Carolina (28.6%), Ohio (19.1%), and Maine (18.7%). From 2016 to 2017, the prescription opioid-involved death rate decreased 13.2% among males aged 15–24 years but increased 10.5% among persons aged ≥65 years (Table 1). These death rates remained stable from 2016 to 2017 across all racial groups and urbanization levels and in most states, although five states (Maine, Maryland, Oklahoma, Tennessee, and Washington) experienced significant decreases, and one (Illinois) had a significant increase. The largest relative changes included a 29.7% increase in Illinois and a 39.2% decrease in Maine. The highest prescription opioid-involved death rates in 2017 were in West Virginia (17.2 per 100,000), Maryland (11.5), and Utah (10.8). Heroin-involved overdose death rates declined among many groups in 2017 compared with those in 2016 (Table 2). The largest declines occurred among persons aged 15–24 years (15.0%), particularly males (17.5%), as well as in medium metro counties (6.1%). Rates declined 3.2% among whites. However, heroin-involved overdose death rates did increase among some groups; the largest relative rate increase occurred among persons aged ≥65 years (16.7%) and 55–64 years (11.6%) and among blacks (8.9%). Rates remained stable in most states, with significant decreases in five states (Maryland, Massachusetts, Minnesota, Missouri, and Ohio), and increases in three (California, Illinois, and Virginia). The largest relative decrease (31.9%) was in Ohio, and the largest relative increase (21.8%) was in Virginia. The highest heroin-involved overdose death rates in 2017 were in DC (18.0 per 100,000), West Virginia (14.9), and Connecticut (12.4). Deaths involving synthetic opioids propelled increases from 2016 to 2017 across all demographic categories (Table 2). The highest death rate was in males aged 25–44 years (27.0 per 100,000), and the largest relative increases occurred among blacks (60.7%) and American Indian/Alaska Natives (58.5%). Deaths increased across all urbanization levels from 2016 to 2017. Twenty-three states and DC experienced significant increases in synthetic opioid-involved overdose death rates, including eight states west of the Mississippi River. The largest relative rate increase occurred in Arizona (122.2%), followed by North Carolina (112.9%) and Oregon (90.9%). The highest synthetic opioid-involved overdose death rates in 2017 were in West Virginia (37.4 per 100,000), Ohio (32.4), and New Hampshire (30.4). Discussion In the United States, drug overdoses resulted in 702,568 deaths during 1999–2017, with 399,230 (56.8%) involving opioids. †††† From 2016 to 2017, death rates from all opioids increased, with increases driven by synthetic opioids. Deaths involving IMF have been seen primarily east of the Mississippi River; §§§§ however, recent increases occurred in eight states west of the Mississippi River, including Arizona, California, Colorado, Minnesota, Missouri, Oregon, Texas, and Washington. Drug overdose death rates from 2013 to 2017 increased in most states; the influence of synthetic opioids on these rate increases was seen in approximately one quarter of all states during this same 5-year period. Overdose deaths involving cocaine and psychostimulants also have increased in recent years ( 1 , 6 ). Overall, the overdose epidemic continues to worsen, and it has grown increasingly complex by co-involvement of prescription and illicit drugs ( 7 , 8 ). ¶¶¶¶ For example, in 2016, synthetic opioids (primarily IMF) were involved in 23.7% of deaths involving prescription opioids, 37.4% involving heroin, and 40.3% involving cocaine ( 9 ). In addition, death rates are increasing across multiple demographic groups. For example, although death rates involving opioids remained highest among whites, relatively large increases across several drug categories were observed among blacks. The findings in this report are subject to at least five limitations. First, at autopsy, substances tested for vary by time and jurisdiction, and improvements in toxicologic testing might account for some reported increases. Second, the specific types of drugs involved were not included on 15% of drug overdose death certificates in 2016 and 12% in 2017, and the percentage of death certificates with at least one drug specified ranged among states from 54.7%–99.3% in 2017, limiting rate comparisons between states. Third, because heroin and morphine are metabolized similarly ( 10 ), some heroin deaths might have been misclassified as morphine deaths, resulting in underreporting of heroin deaths. Fourth, potential race misclassification might have led to underestimates for certain categories, primarily for American Indian/Alaska Natives and Asian/Pacific Islanders.***** Finally, most state-specific analyses were restricted to DC and a subset of states with adequate drug specificity, limiting generalizability. Through 2017, the drug overdose epidemic continues to worsen and evolve, and the involvement of many types of drugs (e.g., opioids, cocaine, and methamphetamine) underscores the urgency to obtain more timely and local data to inform public health and public safety action. Although prescription opioid- and heroin-involved death rates were stable from 2016 to 2017, they remained high. Some preliminary indicators in 2018 point to possible improvements based on provisional data; ††††† however, confirmation will depend on results of pending medical investigations and analysis of final data. Overall, deaths involving synthetic opioids continue to drive increases in overdose deaths. CDC funds 32 states and DC to collect more timely and comprehensive drug overdose data, including improved toxicologic testing in opioid-involved fatal overdoses. §§§§§ CDC is funding prevention activities in 42 states and DC. ¶¶¶¶¶ CDC also is leveraging emergency funding to support 49 states, DC, and four territories to broaden their surveillance and response capabilities and enable comprehensive community-level responses with implementation of novel, evidence-based interventions.****** Continued efforts to ensure safe prescribing practices by following the CDC Guideline for Prescribing Opioids for Chronic Pain †††††† are enhanced by access to nonopioid and nonpharmacologic treatments for pain. Other important activities include increasing naloxone availability, expanding access to medication-assisted treatment, enhancing public health and public safety partnerships, and maximizing the ability of health systems to link persons to treatment and harm-reduction services. Summary What is already known about this topic? The U.S. opioid overdose epidemic continues to evolve. In 2016, 66.4% of the 63,632 drug overdose deaths involved an opioid. What is added by this report? In 2017, among 70,237 drug overdose deaths, 47,600 (67.8%) involved opioids, with increases across age groups, racial/ethnic groups, county urbanization levels, and in multiple states. From 2013 to 2017, synthetic opioids contributed to increases in drug overdose death rates in several states. From 2016 to 2017, synthetic opioid-involved overdose death rates increased 45.2%. What are the implications for public health practice? Continued federal, state, and local surveillance efforts to inform evidence-based prevention, response, and treatment strategies and to strengthen public health and public safety partnerships are urgently needed.
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                Author and article information

                Journal
                J Epidemiol Community Health
                J Epidemiol Community Health
                jech
                jech
                Journal of Epidemiology and Community Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0143-005X
                1470-2738
                October 2021
                23 April 2021
                : 75
                : 10
                : 1010-1018
                Affiliations
                [1 ]departmentMRC/CSO Social and Public Health Sciences Unit , University of Glasgow Institute of Health and Wellbeing , Glasgow, UK
                [2 ]departmentCollaborative Centre for Inclusion Health , University College London , London, UK
                [3 ]departmentDepartment of Public Health , NHS Forth Valley , Stirling, UK
                [4 ]departmentDepartment of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary & Ecological Sciences , University of Liverpool , Liverpool, UK
                [5 ]The University of Edinburgh Usher Institute of Population Health Sciences and Informatics , Edinburgh, UK
                [6 ]departmentDepartment of Public Health , NHS Dumfries and Galloway , Dumfries, UK
                [7 ]departmentInstitute of Health Informatics , University College London , London, UK
                [8 ]departmentFind and Treat Service , University College London Hospitals NHS Foundation Trust , London, UK
                [9 ]departmentCentre for Urban Health Solutions , St. Michael’s Hospital , Toronto, Ontario, Canada
                [10 ]departmentDepartment of Medicine , University of Toronto , Toronto, Ontario, Canada
                Author notes
                [Correspondence to ] Dr Emily J. Tweed, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow G2 3AX, UK; emily.tweed@ 123456glasgow.ac.uk
                Author information
                http://orcid.org/0000-0001-6659-812X
                http://orcid.org/0000-0003-3698-7196
                http://orcid.org/0000-0001-6593-9092
                Article
                jech-2020-215975
                10.1136/jech-2020-215975
                8458085
                33893182
                1e319304-4faf-4e51-b493-a638c91591bf
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/.

                History
                : 03 November 2020
                : 03 March 2021
                : 08 April 2021
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 203919/Z/16/Z
                Award ID: 206602
                Award ID: 218105/Z/19/Z
                Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Award ID: MC_UU_12017/13
                Award ID: MC_UU_12017/15
                Funded by: FundRef http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;
                Award ID: DRF-2018-11-ST2-016
                Funded by: FundRef http://dx.doi.org/10.13039/501100000589, Chief Scientist Office;
                Award ID: CAF/17/11
                Award ID: SCAF/15/02
                Award ID: SPHSU13
                Award ID: SPHSU15
                Categories
                Original Research
                1506
                Custom metadata
                unlocked

                Public health
                health inequalities,homelessness,drug misuse,mental health
                Public health
                health inequalities, homelessness, drug misuse, mental health

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