AimsTo compare the change in illicit opioid users’ risk of fatal drug‐related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion.DesignNational data linkage cohort study of the English National Drug Treatment Monitoring System and the Office for National Statistics national mortality database. Data were analysed using survival methods.SettingAll services in England that provide publicly funded, structured treatment for illicit opioid users.ParticipantsAdults treated for opioid dependence during April 2005 to March 2009: 151 983 individuals; 69% male; median age 32.6 with 442 950 person‐years of observation.MeasurementsThe outcome was fatal DRP occurring during periods in or out of treatment, with adjustment for age, gender, substances used, injecting status and CJS referral.FindingsThere were 1499 DRP deaths [3.4 per 1000 person‐years, 95% confidence interval (CI) = 3.2–3.6]. DRP risk increased while patients were not enrolled in any treatment [adjusted hazard ratio (aHR) = 1.73, 95% CI = 1.55–1.92]. Risk when enrolled only in a psychological intervention was double that during OAP (aHR = 2.07, 95% CI = 1.75–2.46). The increased risk when out of treatment was greater for men (aHR = 1.88, 95% CI = 1.67–2.12), illicit drug injectors (aHR = 2.27, 95% CI = 1.97–2.62) and those reporting problematic alcohol use (aHR = 2.37, 95% CI = 1.90–2.98).ConclusionsPatients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.

Fourteen general practice trainees took part in a course specifically designed to improve their psychiatric interviewing skills. The trainees were instructed in the problem-based model and were taught in a group setting with the use of videotape feedback. A significant improvement was demonstrated in the trainees' ability to identify psychiatric illness accurately, and there were significant changes in their interview behaviours after training. Those who were below average before training showed the greatest improvement. The implications of these findings are discussed. Group video feedback training is as effective as one-to-one video feedback training in improving the psychiatric interviewing skills of GP trainees, and could be more widely employed in general practice vocational training.

HighlightsOpioid user mortality is almost 6 times higher than in the general population.Mortality is elevated for a range of diseases and for homicide and suicide.Excess mortality persists into old age and for some causes is exacerbated.Drug-related poisoning (DRP) accounts for just under a half of opioid user deaths.Young female DRP mortality is lower than male but the difference narrows with age.

SynopsisIt is argued that a general practitioner's ability to make accurate ratings of psychological distress is partly determined by the rate at which patients emit cues that are indicative of such distress. This study addresses the behaviours of doctors which influence the rates at which patients emit such cues. Consultations were videotaped involving six General Practice Vocational Trainees, three of them poor, and three of them able identifiers of emotional illness. Consultations were selected so that each trainee was rated interviewing 4 patients with low GHQ scores, and 4 patients with high scores. Behaviours are described which lead to increased cue emission and which are also practised more frequently by able identifiers, while other behaviours reduce cue emission and are practised less frequently by them. Another set of behaviours is no more frequent among the able identifiers, but when practised by able identifiers is associated with increased cue emission by the patients, and when practised by poor identifiers with unaltered or decreased cue emission. Interviews that are ‘patient-led’ are associated with increased rates of cue emission, while those that are ‘doctor-led’ are associated with lower rates. The implications of these findings for training doctors working in general medical settings are discussed.

Aims To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs. Design Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting healthcare utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525). Setting and participants People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methylenedioxymethamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services. Measurements Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).Findings Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.Conclusions People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.