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Discussion Papers. David P. Myatt, Chaloupka, Bhaskar, V. Rose, Christiern, Zambiasi, Diego, Cheng, Stephanie F. C Wolff, Diego Zambiasi, Marijuana legalization and regional innovation ,' Production and Operations Management , Production and Operations Management Society, vol. Olmstead, Todd A. Mark, Philip C. Mark Isaac, Working Papers , University of Turin. Economic literature: papers , articles , software , chapters , books. My bibliography Save this item. Help us Corrections Found an error or omission? RePEc uses bibliographic data supplied by the respective publishers.

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Official websites use. Share sensitive information only on official, secure websites. High Street, Denver, CO. E-mail: lena. The work cannot be changed in any way or used commercially without permission from the journal. First-generation immigrants, in many countries, are healthier than their native counterparts. This study examined the association between first- and second-generation immigrant status and alcohol- or drugs other than alcohol-related primarily opioids mortality for those with risky substance use. Multivariate models tested the relationship between immigration status and drugs other than alcohol or alcohol-related mortality, controlling for demographics and the 7 ASI composite scores CS. Higher ASI CS for drugs other than alcohol, employment, and health, age, male sex, and immigration status predicted drugs other than alcohol, related mortality. Individuals born in Nordic countries, excluding Sweden, were 1. Research is needed on why people with risky substance use from Nordic countries not Sweden residing in Sweden, have higher mortality rates because of drugs other than alcohol primarily opioids drugs other than alcohol compared with the other population groups in our study. Findings indicate that ASI CSs are strong predictors of future health problems including mortality due to alcohol and other drug-related causes. Keywords: alcohol-related mortality, Addiction Severity Index, drugs other than alcohol-related mortality, immigration status, opioid-related mortality. Deaths due both to alcohol and drugs other than alcohol have increased in Sweden. Given Sweden's high death rate because of alcohol and other drugs, there is a need to identify if certain subpopulations are more or less at risk of substance use disorder SUD -related mortality. One demographic variable that has been identified in countries other than Sweden as a protective factor is being a first- or second-generation immigrant see background section below. The study presented here is the next step in our Swedish national registry studies using Addiction Severity Index ASI assessment baseline data and health registry data; here, we use mortality data from to Given existing research from other countries on first-generation immigration health status, our exploratory hypothesis is that individuals who are first-generation immigrants to Sweden will, independent of country of birth, post-ASI baseline interview, have lower rates of substance use-related mortality compared with those who are Swedish born to Swedish parents. Alcohol consumption is a leading risk factor associated with both intentional and unintentional injury, as well as morbidity and premature death. According to the World Health Organization WHO , alcohol dependence is common in most European countries, affecting a vast number of individuals and contributing to elevated rates of morbidity and mortality Cherpitel et al. Approximately 3 million premature deaths occur worldwide every year as a result of the harmful use of alcohol World Health Organization, Alcohol, moreover, is often a contributing factor in deaths caused by accidents, violence, and the like. However, it is likely that the number of deaths where alcohol is regarded as a contributing factor in the statistics is underreported. Alcohol - related mortality rates in Sweden among individuals with a secondary and postsecondary education have decreased, whereas the rates remained unchanged among those with only a primary education Public Health Agency of Sweden, A analysis suggested that alcohol-related mortality was highest among individuals aged 65 to 84 and lowest among those aged 15 to 29 Public Health Agency of Sweden, Men, especially older men in compulsory care for SUD, were at greater risk of alcohol-related mortality compared with women Hall et al. Over the last decade, drug-related mortality has increased in many parts of the world United Nations, with notable increases in opioid overdoses in North America and in selected European countries eg, Sweden and Estonia; Rudd et al. The opioid-related mortality rate across the EU, among people between the ages of 15 and 64, is estimated at around 21 deaths per million inhabitants. In Sweden, the rate is deaths per million inhabitants. However, deaths because of drug use have fallen sharply in Estonia in recent years, whereas the opioid-related mortality rate in Sweden is still increasing EMCDDA, On the basis of the Swedish report Drug-related deaths: An analysis of the deaths of and the development of official statistics from the NBHW regarding drug-related mortality in , opioids accounted for of drugs other than alcohol-related deaths in Sweden, indicating that the clear majority of those dying as a result of drugs other than alcohol do so because of use of opioids. The NBHW report discussed above identified significant sex differences among those dying as a result of drug use, with men being more likely to die of drug use compared with women. A majority of the drugs contributing to premature death among men was likely to come from illegal sources rather than through legal prescription NBHW, Women who died from drugs other than alcohol, on the other hand, were more likely to be older, with a median age of 48; more prone to use of legal prescription opioids, such as tramadol and oxycodone; and more likely to suffer from comorbidity, in particular depression, compared with their male counterparts. Women were also, in comparison to men, much more likely to have died as a result of drug-related suicide NBHW, In terms of age, research is contradictory regarding who predominantly dies as a result of substance use—younger versus older individuals. In terms of opioid use, the overall number of deaths among people who use opioids is still greater in older age groups; however, in recent years, reports from Sweden and the United States indicate an increased number of deaths among the young EMCDDA, ; Rudd et al. This suggests a possible shift from older to younger individuals in who predominantly dies as a result of opioid use. With respect to education, studies show that among individuals with an opioid use disorder in drug treatment, educational levels are low and unemployment is common Onyeka et al. Data presented by the national Public Health Agency of Sweden supports these studies, with overall drug-related mortality between and highest among young individuals 15—29 years with a lower level of education The Public Health Agency of Sweden, Most European and North American analyses of mortality rates among immigrant groups have not examined substance use-related causes. However, there are some studies that have been conducted on this topic. In England and Wales, alcohol-related mortality was elevated among immigrants from Ireland, India, and the Caribbean compared with individuals born in Britain; substance-related mortality rates for these groups, moreover, had risen faster than those of the national population Harrison et al. In Spain, foreign-born Spaniards had a lower alcohol-related mortality rate than individuals born in Spain, with automobile accidents the most common cause of alcohol-related mortality for immigrants, and liver cirrhosis and cardiovascular disorders the most common cause of death for native-born Spaniards Fierro et al. In Canada, mortality because of alcohol and drug use was the least common cause of death for immigrant women compared with their counterparts Omariba, In French metropolitan areas, foreign-born individuals had a lower all-cause mortality rate than native-born individuals, however, with respect to alcohol-related mortality, there were no significant differences between the 2 groups Boulogne et al. Several studies have looked specifically at substance-related mortality in immigrants from the Former Soviet Union FSU. Ott et al. There were no significant differences in crude mortality rates by immigrant status in Israel for immigrants from countries included in the former Soviet Union Rosca et al. A subsequent study reported an increased risk for opioid-related mortality among a later wave of Israeli immigrants from former soviet countries Feingold et al. In Sweden and other Nordic countries, immigrant status had no relationship to mortality rates related to cannabis use disorder Arendt et al. Beijer et al. Interest exists in understanding differences between mortality rates of native-born and foreign-born individuals and identifying causes of immigrant mortality. Examinations of these rates in several countries tend to point to immigrants having lower early mortality rates than native-born populations. For example, Boulogne et al. Differences between immigrants and native-born populations on these variables appear to be locally dependent—neither generalizable or cross-country patterns are easily discernible in this body of literature, nor does there emerge a stable direction of relationship between these variables and immigrant mortality. Immigrant mortality has been examined in several recent Swedish studies. After adjustments for socioeconomic status, an association between country of birth and poor health status was seen among immigrants from Southern Europe and Finland, as well as among refugees from developing countries; however, country of birth was not found to be associated with all-cause mortality in this group of immigrants Pudaric et al. In this sample, homeless people from Finland were observed to have higher mortality, whereas homeless individuals from non-Nordic countries had lower mortality, as compared with Sweden. These authors concluded that socioeconomic conditions were more associated with immigrant mortality in these groups than were early life conditions in an immigrant's country of origin. Also, more recent immigrants are generally found to consume less alcohol and to exhibit less excessive drinking than established immigrants and members of native-born populations Szaflarski et al. Recent immigrants to Israel from the former Soviet Union had a much higher risk for opioid deaths than older immigrants Feingold et al. A systematic review of studies of immigrant health in Canada by Vang et al. Comparing first- and second-generation immigrants from Africa, Latin America, Asia, and Europe to native-born Americans, while controlling for sociodemographic factors, Salas-Wright et al. The largest body of research on generational differences in substance use has focused on Latino immigrants to the United States, although these studies have not examined generational differences in substance use mortality. Martinez et al. De La Rosa et al. Kopak also examined alcohol use by generational status in a group of Mexican-American immigrants. In this sample, alcohol use did not vary significantly by immigrant status, but alcohol use increased at a steady rate over time in all 3 generations. A small sex difference was found in the second-generation group, with men experiencing a greater increase in the number of drinks consumed compared with women in this generational group. Hence, first-generation immigrant status is not a health vulnerability factor but a resilience factor. The proving or disproving of the existence of an HIE has been a topic of numerous studies conducted in the United States, Canada, Australia, and Europe. Overall, these have produced mixed evidence of a general healthy immigrant effect, with some studies finding support for an HIE McDonald and Kennedy, ; Keane et al. Additional studies identified factors that appear to influence or mitigate the HIE, including race and ethnicity in the United States Bui, ; migration policies of the host country Constant et al. Salas-Wright et al. In summary, there is a diverse set of findings about the relationship between immigration status and alcohol- and drug-related mortality. Sweden, one of the countries in Europe with a significant increase in immigration in the last decade, has also one of the highest drugs other than alcohol-related mortality rates. However, little is known at the national level about the alcohol- or drugs other than alcohol-related mortality of immigrants and their Swedish counterpart. Our study responds to this need in research. This sample was broadly representative of the national Swedish population assessed for an SUD through the use of ASI, although with fewer individuals from rural municipalities. Clients may be referred to these municipal social workers by primary care offices, family, police, hospitals, courts, seek care themselves, or referred through other venues. The individuals in the study all have risky substance use or an SUD. All study data were de-identified and the study met criteria for IRB exemption. A 5-category variable assessed first- and second-generation immigrant status and country of origin: individual and their parents all born in Sweden; individual born in Norway, Finland, or Denmark first-generation immigrant ; individual born outside of Sweden, Norway, Finland, or Denmark first-generation immigrant ; individual born in Sweden with at least one parent born in Norway, Finland, or Denmark and no parent outside of Nordic countries second-generation immigrant ; and individual born in Sweden with at least 1 parent born outside Nordic countries second-generation immigrant. Category 1 was the reference group. The gender variable was dichotomous male and female and level of education at baseline was a continuous variable assessing number of years of education. The ASI composite scores for severity of alcohol, drug, mental health, health, family and social relationships, employment, and legal problems were also numeric variables McGahan et al. As recommended by the developer of the ASI CSs, equal weighting is given to all questions within a CS and we then adjust each composite for the answer range of each item and for the total number of items in the composite. The answer to each question is divided by the highest possible response, and by the total number of questions in the composite. This is the standard manner for how to calculate the scores McLellan et al. The ASI psychometric properties have been tested extensively over many years in many different countries. These tests have shown good to excellent reliability and validity for the instrument, with some older findings that the reliability of the ASI mental health CS ranges from high to low Makela, ; Samet et al. Our recent study Padyab et al. The two dependent variables were alcohol-related mortality and drugs other than alcohol, related mortality. Determination of alcohol-related deaths was based on ICD codes and defined as the assignment of a diagnosis related to alcohol consumption—diagnoses, such as alcoholism, toxic effect of alcohol, or mental and behavioral disorders because of use of alcohol, as either an underlying or a contributing cause of death. Information on causes of death was obtained from the national Cause of Death Registry. On the basis of the official Cause of Death Registry at the Swedish NBHW, a death is considered drug-related if a drug-related condition appears anywhere on the death certificate and are based on ICD codes Leifman, Descriptive statistics were used to describe the sample. Clients were followed until date of mortality, or the latest date for which they were known to be alive through December 31, , whichever came first. Those who were alive during the course of the study were treated as censored data. Multivariate Cox regression was used to both explore if immigration status remained significantly associated with alcohol- or drugs other than alcohol-related mortality and if immigration status became associated with drugs other than alcohol-related mortality if not significant at the bivariate level. Schoenfeld residual tests were used to check the key assumption proportional hazards in all Cox proportional hazard models. We tested for a nonzero slope in regression of the scaled Schoenfeld residuals on functions of time. A nonzero slope is an indication of a violation of the proportional hazard assumption. Our results confirm that Schoenfeld residuals were not correlated with survival time, suggesting that the proportional hazards assumption is satisfied in the models. See Table 1 for a description of the study sample. Seventy-one percent of the sample was men. The mean age of the sample was The crude hazard ratios identified that immigration status, age, sex, and all ASI CS other than employment were associated with alcohol-related mortality see Table 2. Also, crude hazard ratios identified that age, sex, and all ASI CS other than family and social relationship were significantly associated with drugs other than alcohol-related mortality. Immigration status, however, was not associated with drugs other than alcohol-related mortality at the bi-variate level. The results from the Cox regression analysis Table 3 identified age and ASI CS for alcohol, drugs other than alcohol, family and social relationship, and health remained significant predictors of alcohol-related mortality at the multivariate level. Specifically, the multivariate model Table 3 indicated that after controlling for demographics and the ASI SCs significant at the bi-variate level, immigration status was no longer significant. The strongest predictor of alcohol-related mortality was age, with those age 52 and over more than 13 times more likely to die of alcohol-related causes compared with the age group 18— Specifically, the higher this score the higher likelihood of alcohol-related mortality. The finding described in Table 4 below indicates that immigration status became a significant predictor of mortality related to drug use other than alcohol at the multivariate level. Six variables were significantly associated with drugs other than alcohol-related mortality, ASI CS for drugs other than alcohol, employment, health, male sex, age, and immigration status. Those born in Norway, Denmark, or Finland, conversely, had 1. A number of the control variables remained significantly associated with drugs other than alcohol-related mortality. Specifically, being a male was positively associated and age was negatively associated with mortality because of drugs other than alcohol-related causes. The ASI CS for drugs other than alcohol was the strongest predictor of mortality related to drugs other than alcohol. Other CSs that remained significant at the multivariate level were the ASI employment and physical health scores. At the bi-variate level, immigration status significantly predicted alcohol-related mortality but not drugs other than alcohol-related mortality. However, when demographics and the 7 ASI CSs were controlled for in the Cox regression models, the relationship between immigration status and mortality related to alcohol use did not remain significant whereas the relationship between immigration status and mortality because of drugs other than alcohol became significant. At the multivariate level, individuals born in Nordic countries outside Sweden were almost twice as likely, 1. Also, being born outside of a Nordic country or having parents who were born outside of a Nordic country seemed to be protective factors, significantly associated with lower likelihood of dying from drugs other than alcohol. Given that, for example, those who were age 52 and older had a more than 13 times higher likelihood of dying compared with the youngest age group 18—24 , it is not surprising that a number of other factor, such as sex and immigration status, lost their significance at the multivariate level. This finding aligns with findings from other studies that have used registry data to examine the mortality of individuals who entered mandatory treatment because of their severity of SUD Hall et al. Hence, policy and program efforts aimed at reducing alcohol- versus drugs other than alcohol-related mortality rates in Sweden need to target different age groups. It is notable that ASI CS for alcohol, drugs other than alcohol, health, and family and social relationships remained strongly significant at the multivariate level, indicating that ASI CSs have good predictability for future health of adults with risky substance use or SUD. An unexpected finding was that individuals with higher ASI CSs for family problems and needs had lower rates of alcohol-related mortality. One possibility for this finding may be that individuals dying of alcohol-related causes were socially isolated, and therefore reported fewer family problems compared with their counterparts. Also, the ASI CS for drugs other than alcohol was negatively related to dying of alcohol-related causes. This may be because of that until the late 20th century, very few individuals used drugs other than alcohol, and alcoholism was quite high in Sweden. Finally, having a higher ASI CS on health ie, reporting more problems and needs with respect to health was a significant predictor of both alcohol- and drugs other than alcohol-related mortality. First, it is clear from study findings that separate subgroups of the Swedish population have elevated risks of alcohol- and of drugs other than alcohol-related mortality. One factor that predicted mortality because of both alcohol-related causes and drugs other than alcohol-related causes was having a higher ASI CS for health, that is, reporting more physical health problems. Third, the ASI CS baseline for health seems to consistently predict later health problems, including hospitalization and disability. This is true in our current study as well as in our other registry studies Padyab et al. This is of value to know so that those who conduct the ASI baseline interviews make certain to connect individuals with high ASI health CS to medical services. Second, it is difficult to assess why individuals from Finland, Norway, and Denmark who reside in Sweden have higher drugs other than alcohol-related mortality rates even when controlling for the 7 ASI CSs and demographics compared with both Swedish individuals born to Swedish parents and those who are first- and second-generation immigrants from non-Nordic countries. Possibly, individuals in this subgroup may already have drug-related problems before immigration. Also, they may be immigrating to Sweden for very different reasons than individuals who come from non-Nordic countries, many who are first- or second-generation refugees. Some may, for example, seek treatment, or some may seek a greater sense of invisibility as people who use drugs other than alcohol. Finally, there may be normative differences in drug use other than alcohol between the Nordic countries. Fourth, it is concerning that a consistent pattern in Sweden is that young 18—24 men seem to be at a highest risk of drugs other than alcohol primarily opioid-related mortality. Significant prevention efforts need to be developed, and these prevention programs need to be provided throughout the Swedish school system, pediatric clinics, employment training programs, and other places where youth and young adults in Sweden can be reached. First, readers should be careful about making comparisons of immigrant substance-related mortality between or across countries based upon the findings of our study and studies reviewed, as many contextual, political, and intervening factors are unique to each country and may be reflected in these findings. Second, registry data always come with a range of limitations, such as variation in assessment capacity and missing data. This study is fortunate in that those who conduct ASI interviews in Sweden receive high quality and ongoing training in interview data collection to ensure accurate data and, of note, there was very little missing data in the data set used for analyses. Second, it is important to note that in using these large databases, we are not predicting the significance of the total model. The aim here was to examine the relative importance of a demographic factor, here immigration status, and identify if this factor was or remained a significant predictor when controlling for other factors known to effect alcohol- or drugs other than alcohol-related mortality. All contributing authors have no relevant financial interests pertaining to this manuscript and certify that there are no conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript. As a library, NLM provides access to scientific literature. J Addict Med. Find articles by Lena Lundgren. Find articles by Mojgan Padyab. Find articles by Nancy M Lucero. Find articles by Marcus Blom-Nilsson. Find articles by Tabitha Carver-Roberts. Find articles by Mikael Sandlund. Published by Wolters Kluwer Health, Inc. Percent or Mean SD Age years Open in a new tab. The authors declare no conflicts of interest. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Individual born in Sweden and at least one parent born in Norway, Denmark, or Finland no other country outside Sweden.

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