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CMAJ. Feb 1, 2005; 172(3): 309.
PMCID: PMC545738

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.

Mark Latowsky University of Toronto Toronto, Ont.


1. Ball JC, Ross A. The effectiveness of methadone maintenance therapy. New York: Springer Verlag; 1991.
2. Fischer B, Brissette S, Brochu S, Bruneau J, el-Guebaly N, Noël L, et al. Determinants of overdose incidents among illicit opioid users in 5 Canadian cities. CMAJ 2004;171(3):235-9. [PMC free article] [PubMed]
3. Aday LA. At risk in America: the health and health care needs of vulnerable populations in the United States. San Francisco: Jossey-Bass; 1993.
4. Cooper R, Cutler P, Desvigne-Nickens P, Fortmann SP, Friedman L, Havlik R, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the National Conference on Cardiovascular Disease Prevention. Circulation 2000; 102:3137-47. [PubMed]
5. Study findings: study of national incidence and prevalence of child abuse and neglect. Washington: US Department of Health and Human Services, National Institute of Child Health and Human Development, National Centre on Child Abuse and Neglect; 1988.
6. Goldstein P. The drugs/violence nexus: a tripartate conceptual framework. J Drug Issues 1985; 21 (2): 345-67.

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