Addiction (2001) 96, 1777–1786

RESEARCH REPORT

A 10-year follow-up study on the health status

of heroin addicts based on ofŽ cial registers

XAVIER SÁNCHEZ-CARBONELL & ANNA VILAREGUT

Blanquerna Faculty of Psychology and Educational Sciences, Ramon Llull University,

Barcelona, Spain

Abstract
Aims. To determine the health status of a cohort of heroin addicts. Design. Longitudinal follow-up study
of a cohort for 10.5 years (March/July 1985–December 1995) based on ofŽ cial registers. Setting.
Catalonia, Spain. Participants. One hundred and thirty-Ž ve heroin addicts who started treatment in four
specialized drug addiction services in Catalonia in 1985. Measurements. (a) Total and annual numbers
of AIDS and tuberculosis diagnoses and admissions to drug treatment; (b) annual morbidity rate; (c) average
annual morbidity rate; and (d) standardized morbidity ratio. Kaplan–Meier (log rank test) was used to
assess predictive factors. Findings. During the follow-up period, 34 heroin addicts were diagnosed with
AIDS (25%), the average annual morbidity rate was 2.7% and the standardized morbidity ratio was 82.
The most frequent diseases indicative of AIDS were Pneumocystis carinii pneumonia (11 cases) and
tuberculosis (seven cases of disseminated or extrapulmonary tuberculosis and two cases of pulmonary
tuberculosis). Twenty addicts were diagnosed with tuberculosis and 15 were co-infected with AIDS and
tuberculosis. Seventy-six addicts were readmitted to treatment and generated 124 drug treatment episodes, 94
of whom were drug-free and 30 on methadone maintenance. Conclusions. Follow-up through registers is
a novel, low-cost technique that may provide important and comparable information on the long-term
evolution of drug addicts in different European regions. The measures of disease frequency and association
obtained allow us to describe and compare the distribution of patterns of infectious complications (AIDS and
tuberculosis) and relapses in such a pervasive disorder as heroin addiction. Other advantages of follow-up
based on ofŽ cial registers are efŽ ciency, reliability, sensibility and comparability.

Introduction sonal and telephone interviews were used to

Despite the scope of heroin use and the re-
sources devoted to its treatment (Plan Nacional
sobre Drogas, 1999), the course of heroin addic-
tion in Spain is still unknown. The Estudio
Multicentrico de Evaluación de Tratamientos Y
Seguimiento de Toxicómanos (EMETYST Proj-
ect) has been the only long-term attempt. Per-
describe the course of the addiction during the
Ž rst 2 years and its relationship with treatment
and demographic characteristics (Sánchez-
Carbonell, Camõ´ & Brigos, 1988; Sánchez-
Carbonell, Brigos & Camõ´, 1989). In the
Catalonia subcohort, the mortality rates and the
immediate causes of death 10 years after appli-

Dr Xavier Sánchez-Carbonell, Facultat de Psicologia i Ciències de l’Educació Blanquerna, Cõ´ster, 34. 08022,
Barcelona, Spain. Tel: 1 34 93 253 30 00; e-mail: xaviersc@blanquerna.url.es
Submitted 3rd October 2000; initial review completed 30th November 2000; Ž nal version accepted 23rd May
2001.

ISSN 0965–2140 print/ISSN 1360–0443 online/01/121777–10 Ó Society for the Study of Addiction to Alcohol and Other Drugs
Carfax Publishing, Taylor & Francis Limited
DOI: 10.1080/09652140120089526
1778 Xavier Sánchez-Carbonell & Anna Vilaregut
cation for treatment have been reported recently
(Sánchez-Carbonell & Seus, 2000). In summary,
30% of heroin addicts died and their risk of
dying was 29 times higher than that of a person
of the general population. The most frequent
causes of death fell in ICD-9 chapter III (which
includes AIDS) and in chapter XVII (which
includes overdose). In comparison with other
countries in Europe, the authors observed that
the average annual mortality rate in Catalonia
was almost twice that among cohorts in Great
Britain and similar to that in Scandinavian coun-
tries. The survival rate, in comparison to the
general population, was lower than that of their
peers in other European countries.
Catalonia is a region in the Northeast of Spain
with a well-developed state health-care network
and epidemiological surveillance, which allows
the study of the course of drug addicts through
social and health care indicators, such as mor-
tality, AIDS, tuberculosis and treatments for
drug abuse. In Spain, as in Italy and Portugal,
HIV and AIDS has had a large effect on intra-
venous drug users. Forty to 80% of them are
HIV-infected (Rebagliato et al., 1995; Egea et al.,
1996) and AIDS is a frequent cause of death
(Muga et al., 1999). In fact, intravenous drug
users represent more than 60% of total cases.
The consequence among the general population
is that the Spanish rate of cumulative incidence
of 176.2 AIDS cases per million inhabitants in
1995, was the highest in Europe (Ministry of
Health and Consumption, 1997).
In Spain and Catalonia, tuberculosis is an
endemic disease that is not completely con-
trolled. Although some estimates situate the rate
in the range from 40 to 60 cases per 100 000
inhabitants (Collaborative Group for the Study
of Tuberculosis in Spain, 1995), in Catalonia the
declared incidence rate was 37.03 cases per
100 000 inhabitants in 1997 (Tuberculosis
Prevention and Control Programme, 1999).
Tuberculosis is a chronic infectious disease with
a key role in the diagnosis and development of
AIDS. Being a mandatory notiŽ cation disease
subjected to active epidemiological surveillance,
it is possible to study its effects on population
groups such as drug addicts. Drug use and the
social rejection implied may have given rise to a
resurgence of tuberculosis, the prevalence of
which had been in decline until the 1980s (Caylà
et al., 1996, 1998).
In spite of the fact that mortality registers are
used widely in follow-up studies of drug addicts
(Engstrom et al., 1991; Perucci et al., 1991;
Oppenheimer et al., 1994; Ortõ´ et al., 1996;
Frischer et al., 1997; Fugelstad et al., 1997) the
use of other ofŽ cial registers is limited. Personal
or telephone interviews are preferred, with
ofŽ cial registers being used only as an aid in
locating the cohort or to check reliability. How-
ever, personal follow-up presents some prob-
lems, such as high cost, failure to contact, use of
different independent variables, reliability of self-
report and problems of comparability. Wille
(1981) was the Ž rst to analyse, using ofŽ cial
registers, clinic attendance, abstinence and mor-
tality in a sample of 128 London heroin addicts
10 years after applying for treatment. The wide
availability of record linkage (Allgulander, 1989;
Newman & Bland, 1991; Nienhuis, Goldacre &
Seagroatt, 1992) allows reconsideration of the
strategies for drug addicts follow-up.
This phase of the EMETYST Project aims to
describe the health status of a cohort of heroin
addicts followed-up through ofŽ cial registers of
AIDS, tuberculosis and drug treatments.
Method
Subjects
The study involved 135 heroin addicts (96 men
and 39 women) who applied for treatment for
the Ž rst time in four outpatient drug-free services
in Catalonia, between 1 March and 30 July
1985. At the start of treatment they had an
average age of 23.6 years. In the last year before
admission to treatment, 70% had worked at least
1 day, 22% had been in prison at least 1 day and
73% lived with their parents (for further details
about subjects, see Sánchez-Carbonell & Seus,
2000).
Data sources
We consulted and linked registers from the
Department of Health and Social Security of
Catalonia: “Register of AIDS”, “Register of
Tuberculosis” and “Register of Individualized
NotiŽ cation of New Cases of Drug Treatment”.
The “Register of AIDS” centralizes epidemiolog-
ical information on AIDS in Catalonia. This
register was used to identify cases of AIDS and
disease indicative of AIDS, and to identify cases
of tuberculosis as a disease indicative of AIDS
not provided by other registers. The 48 countries

of the WHO European Region participating in
the surveillance of AIDS use a uniform AIDS
case deŽ nition (European Centre for the Epi-
demiological Monitoring of AIDS, 1993), that
differs from the deŽ nition used in the United
States only in that it does not include CD4
lymphocyte count criteria. From the Barcelona
City Council we used the “Register of the Tu-
berculosis Prevention and Control Programme
in Barcelona” and the “System of Information
on Drug Addictions in Barcelona”.
The Service of Information and Studies of the
Department of Health and Social Security pro-
vided census information for the general popu-
lation in Catalonia by sex and 5-year age groups
from 1985 until 1995. The Centre d’Estudis
Epidemiològics sobre la Sida a Catalunya
(CEESCAT) provided statistics on AIDS to cal-
culate the excess morbidity rate of the disease.
Data analysis and procedure
This was a longitudinal study of a cohort
through linkage of ofŽ cial registers. Unclear
cases were checked individually. The study was
started in May 1985 and the date of censure was
Ž xed at 31 December 1995, so the follow-up
period was 10.5 years.
The operational deŽ nitions of the dependent
variables were as follows. AIDS is diagnosed
when an individual appears in the “Register of
AIDS”; tuberculosis is diagnosed when they ap-
pear in one of the three registers: “Register of
Tuberculosis”, “Register of the Tuberculosis
Prevention and Control Programme in
Barcelona” or “Register of AIDS”, with tubercu-
losis diagnosis as the disease indicative of AIDS.
A person is considered readmitted to drug treat-
ment when he/she appears in the “Register of
Individualised NotiŽ cation of New Cases” or in
the “System of Information on Drug Addictions”
subsequently to the episode that motivates the
inclusion in the cohort. Although one person
could present more than one episode of tubercu-
losis and of treatment, only the Ž rst episode of
each has been taken into account in calculating
survival.
We have used different measures of disease
frequency and association (Hennekens & Buring,
1987). The Ž rst was the total and annual num-
ber of events. The second measure used was the
annual cumulative incidence rate (number of
annual cases divided by the total population at
Health status based on ofŽ cial registers 1779
risk; population at risk was obtained by subtract-
ing from 135 those deceased in previous years
and those previously diagnosed). In the case of
AIDS we were also able to calculate the stan-
dardised morbidity ratios with regard to the gen-
eral population of Catalonia, controlled by sex
and period. Mortality data were obtained from a
previous study in this cohort (Sánchez-Carbonell
& Seus, 2000).
Survival analysis (Kaplan–Meier: log-rank
test) was used to assess the predictive factors: (a)
sex; (b) age at admission to treatment (15–24
and 25–34 years); (c) living circumstances (fam-
ily of origin and other situations); (d) legal status
(with and without criminal record); (e) in prison
in the last year (yes and no); (f) work in the last
year (yes and no); (g) age at Ž rst consumption of
heroin (10–19 and 20–29 years); (h) route of
administration (injected and others); and (i) pre-
vious addiction treatments (yes and no). The
period of survival of each person was calculated
between the date of entry into this study and the
date of death or date of censure if still alive.
Although statistical signiŽ cance was initially set
at p , 0.05, we applied the Bonferroni correction
and established p at 0.002. We also analysed the
relationship among AIDS diagnosis, tuberculosis
diagnosis and readmission to treatment.
Results
AIDS
From the start of the study in March 1985 until
December 1995, 34 addicts (25.2%) were diag-
nosed with AIDS. In 1985, 1986 and 1987 no
cases of AIDS were diagnosed. The Ž rst case of
AIDS in a woman of the cohort was diagnosed in
1991. The years when more cases were diag-
nosed were 1994 (seven cases), and 1990 and
1992 (six cases). The year with the highest diag-
nostic rate was 1994 (8.53%) (Table 1). Table 2
shows the disease indicative of AIDS in the 34
cases diagnosed. The most frequent disease in-
dicative of AIDS was Pneumocystis carinii pneu-
monia (11 cases), followed by tuberculosis (seven
cases of disseminated or extrapulmonary tuber-
culosis and two cases of pulmonary tuber-
culosis). Thirty-four cases of AIDS were
diagnosed as opposed to the 0.416 expected in
the general population, so the standard morbid-
ity ratio was 81.81. That is, a heroin addict of
the cohort had a risk of being diagnosed with
AIDS 82 times higher than that of a person from
1780 Xavier Sánchez-Carbonell & Anna Vilaregut

Table 1. Evolution of AIDS, tuberculosis and readmission to treatment in a cohort of 135 heroin addicts (1985–95) in
Catalonia, Spain

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Deceased 0 1 2 0 1 5 3 8 8 5 8
AIDS diagnosis
Men 0 0 0 1 3 6 3 3 2 6 2
Women 0 0 0 0 0 0 2 3 2 1 0
Addicts at risk 135 135 134 132 131 127 116 108 94 82 70
for AIDS
diagnosis1
ACIR2 — — — 0.75 2.29 4.72 4.31 5.55 4.25 8.53 2.85
Tuberculosis diagnosis
Men 0 0 0 2 2 3 3 3 2 2 0
Women 0 0 0 1 0 0 0 1 1 0 0
Addicts at risk 135 135 134 132 129 126 118 112 100 89 82
for tuberculosis
diagnosis1
ACIR2 — — — 2.27 1.55 2.38 2.54 3.57 3 2.24 —
Readmission to
treatment
Men 0 4 6 13 5 8 8 3 1 2 3
Women 0 4 2 3 1 3 3 2 1 4 0
Addicts at risk 135 135 126 116 100 93 77 63 50 40 29
for readmission
to treatment1
ACIR2 — 5.9 6.3 13.8 6.0 11.8 14.3 7.9 4.0 15 10.3
1
Addicts at risk are obtained by subtracting from 135 those deceased in previous years and those previously diagnosed.
2
Annual cumulative incidence rate.

Table 2. Disease indicative of AIDS, by sex, in a cohort of 135 heroin

addicts (1985–95) in Catalonia, Spain

Disease indicative of AIDS Men Women Total

Cryptosporidiosis 0 1 1
Pulmonary tuberculosis 2 0 2
Toxoplasmosis of brain 2 1 3
Extrapulmonary tuberculosis 7 0 7
Mucocutaneous Herpes simplex 0 1 1
Candidiasis of oesophagus 2 0 2
Extrapulmonary cryptococcosis 1 1 2
Pneumocystis carinii pneumonia 9 2 11
Burkitt’s lymphoma 1 0 1
HIV-related encephalitis 0 1 1
Wasting syndrome due to HIV 2 1 3
Total 26 8 34

the general population in the same period. Up to
31 December 1995, 23 people (68%) of the 34
diagnosed with AIDS had died (although the
underlying cause of death may not necessarily
have been AIDS) (Fig. 1).
Tuberculosis
From the start of the study in March 1985
until December 1995, the research team had
evidence that 20 addicts (15%) had tuber-
culosis diagnosed. No cases were diagnosed in
1985, 1986, 1987 and 1995. The year 1992
presented the highest diagnostic rate (3.57%)
(Table 1). When registers of AIDS and tubercu-
losis were linked, we observed that 15 people
were co-infected with AIDS and tuberculosis
(Fig. 1).
 Health status based on ofŽ cial registers 1781

Figure 1. Interaction among AIDS, tuberculosis and drug-treatment, between themselves and in relation to death. The
numbers in brackets show the number of deceased for each group. Of the 39 people who received no diagnosis, six had died.

Table 3. Evolution of the 124 treatment episodes produced by 76 heroin addicts (1985–95) in centres recognized by the Register
of Individualised NotiŽ cation of New Cases

1987 1988 1989 1990 1991 1992 1993 1994 1995

Drug-free programs 8 20 11 13 15 17 8 0 2
Methadone maintenance 9 7 7 7
Total 8 20 11 13 15 26 15 7 9

Readmission to drug treatment treatment episodes, 94 (75.8 %) of which were

Until 31 December 1995, 53 men and 23
women (56% in total) restarted drug treatment,
and at the end of this 10.5-year period only
26.5% of living addicts had not been readmitted
to drug treatment at some time during follow-up.
The highest rates of readmission to treatment
occurred in 1988, 1990 and 1991 (Table 1).
Relapse in drug use, as opposed to death or
AIDS diagnosis, is a multi-episodic phenom-
enon. In total, the 76 addicts produced 124
drug-free and 30 methadone maintenance
(Table 3). Many addicts (57 of 76) had re-
quested a second treatment without AIDS or
tuberculosis diagnosis.
Predictive factors
No demographic or heroin use characteristics at
admission reached statistical signiŽ cance to pre-
dict AIDS, tuberculosis or readmission to treat-
1782 Xavier Sánchez-Carbonell & Anna Vilaregut
ment. The 34 addicts diagnosed with AIDS had
a greater risk of readmission to treatment (log-
rank test: 10.36; p 5 0.0013), of dying (log-rank
test: 32.38; p , 0.0001) and of being diagnosed
with tuberculosis (log-rank test: 39.82;
p , 0.0001) than those not diagnosed. The 20
cases of tuberculosis had a greater risk of being
diagnosed with AIDS (log-rank test: 42.56;
p , 0.0001) and of dying (log-rank test: 13.23;
p 5 0.0003), but not of restarting drug treat-
ment.
Discussion
To analyse the relationship between AIDS and
drug use two variables have been used in the
literature. Commonly, AIDS registers provide
the percentage of people diagnosed with AIDS
who were or had been intravenous drug users,
whereas treatment centres provide the percent-
age of drug addicts who at admission to treat-
ment were HIV seropositive. However, in this
study, we have obtained a more direct measure:
the number of cohort members diagnosed with
AIDS. AIDS has a decisive and dramatic
in uence on the health status and is the leading
cause of death among heroin addicts who started
treatment in the 1980s. This effect is pointed out
for three measures in the EMETYST cohort.
First, 25% of them were diagnosed with AIDS
between 1985 and 1995. Secondly, a member of
the cohort has a risk of contracting the disease 82
times higher than that of a person from the
general population. Besides that, mortality
among AIDS cases (68%) is higher than mor-
tality of the EMETYST cohort (30%) and of the
total cases of AIDS in Catalonia (63%)
(CEESCAT, 1999).
Pulmonary or extrapulmonary tuberculosis is
the disease indicative of AIDS that is most com-
monly diagnosed, especially in drug addicts, fol-
lowed by Pneumocystis carinii pneumonia
(Ministry of Health and Consumption, 1997;
CEESCAT, 1999). In our cohort the order is
reversed, pneumonia being the most frequent
disease indicative of AIDS, followed by tubercu-
losis, a situation similar to that observed by
Caylà et al. (1993) until 1991 in the city of
Barcelona. In the EMETYST cohort all cases of
AIDS, whose disease indicative of AIDS is tu-
berculosis, are men; a tendency shared by the
other transmission categories. As morbidity,
mortality and number of cases of AIDS has
decreased due to new antiretroviral treatments it
may be convenient to improve the AIDS indi-
cator by introducing an epidemiological surveil-
lance system for HIV infection (Center For
Disease Control and Prevention, 1999).
The impact of tuberculosis in our cohort was
dramatic and, if our data were extrapolated to
the general population, there would be 12 000
cases per 100 000 inhabitants. Moreover we
must consider that, although there are both pre-
ventive and therapeutic treatments, they are
difŽ cult to follow, especially by non-controlled
heroin addicts in a marginalized social situation.
The third aggravating factor of this problem is
that imprisonment, so common in drug addicts,
increases the risk for having tuberculosis and for
being co-infected (Bellin, Fletcher & Safyer,
1993; Martõ´n et al., 1995). The association be-
tween AIDS and tuberculosis in the collective of
drug addicts in Catalonia deŽ nes a situation that
reduces their survival and quality of life, and
moreover has repercussions on public health that
require urgent control measures. A limitation of
the indicator tuberculosis is that it was under-
notiŽ ed in the Ž rst years of follow-up because it
was not possible to link the EMETYST cohort
with the register until its computerization (1987
in the city of Barcelona; 1991 in the rest of
Catalonia).
Relapse is a common and expected phenom-
enon in the recovery of drug addicts. In Spain in
1997, of the 52 440 people admitted to psy-
choactive substance use treatment, 32 568
(62.10%) had followed previous treatments (Ob-
servatorio Español sobre Drogas, 1999). Among
others Hubbard & Marsden (1986), Oppen-
heimer, Sheeman & Taylor (1990), Simpson, Joe
& Bracy (1982) and Wille (1981) had also ob-
served high rates of ‘treatment during the follow-
up period’ and ‘in treatment at follow-up’ but
these studies are not comparable due to the
variety of operational deŽ nitions and duration of
follow-up period. Starting a new treatment is the
consequence of a continued drug use, represents
a poor health status and implies behavioural
changes to overcome the problem. Although the
risk for relapse decreases as the duration of absti-
nence increases, admissions to treatment take
place throughout the whole period. Drug addic-
tion must be viewed as a disease with a high risk
for becoming chronic (O’Brien & McLellan,
1996). The indicator treatment has two major
limitations and two conceptual problems. First,

data on treatment readmissions are not available
between 1985 and 1987. Secondly, there is a
high risk of under-notiŽ cation, either because an
addict may begin treatment in a non-ofŽ cially
recognized centre (a religious therapeutic com-
munity, for instance) or a person may use drugs
repeatedly and never apply for treatment. The
Ž rst conceptual problem of the indicator treat-
ment is that relapse is not a permanent status; it
is possible to restart drug use, but it is also
possible to overcome relapse. Our analysis gives
priority to the cumulative aspect, but it does not
allow ascertainment, for instance, of how many
addicts were abstinent at the end of the follow-
up. The second conceptual problem is that we
have used readmission as a marker of treatment
failure and in some cases a heroin addict who
returns to treatment will have a better outcome,
and a lower chance of death, than one who
continues to use drugs and remains untreated.
The predictive power of demographic or
heroin use characteristics at admission seems
very weak. It should also be noted that when we
used these variables to predict mortality among
this same group (Sánchez-Carbonell & Seus,
2000), no variable reached statistical
signiŽ cance. Social variables and addictive be-
haviour at admission to treatment in 10-year or
longer follow-up studies are not strong predic-
tors, due to changes in behavioural, psychologi-
cal and social aspects over such an extended
period. The statistical signiŽ cance of most pre-
dictor variables diminishes as outcome measures
become more temporally distant (Simpson &
Marsh, 1986) or explain only a small fraction of
the outcome variable. Although it is extremely
difŽ cult to establish causal relationships among
variables, we can observe in Fig. 1 a strong
association between AIDS and death, tubercu-
losis and death and between AIDS and tubercu-
losis. These connections would underline the
extraordinary importance that the prophylaxis of
tuberculosis should have in the collective of
heroin addicts. Infectious complications, proba-
bly related to the limitation of the therapeutic
use of agonists (Villalbõ´ & Brugal, 1999;
Sánchez-Carbonell & Seus, 2000) and to the use
of the intravenous route (De la Fuente et al.,
1999) seem to be related more with death than
relapse in heroin consumption.
The technique which has been used most
widely for collecting information in studies in-
volving follow-up of drug addicts and evaluation
Health status based on ofŽ cial registers 1783
of treatment is the interview, either face-to-face
or by telephone. Our view is that the use of
linkage of ofŽ cial registers offers a series of ad-
vantages over the interview.
(1) It is more efŽ cient. In an era of limited
resources the cost of evaluation is important
when trying to obtain funds. The methodol-
ogy employed in North American studies
such as DARP and TOPS implies an invest-
ment which is difŽ cult to sustain. Follow-up
through registers is cheaper, and conse-
quently more likely to obtain public funding.
(2) Information in ofŽ cial registers is reliable.
OfŽ cial registers have been used to verify
reliability and validity of responses obtained
through personal and telephone interviews.
(3) Information in ofŽ cial registers is sensitive.
Although the information may be obtained
more quickly by interview, in the long term
ofŽ cial registers also detect relevant health
aspects. For example, the interview would
detect a recognized relapse in drug con-
sumption sooner, but if the individual con-
tinues to consume drugs he will eventually
seek treatment, and thus be identiŽ ed by the
register. Interviews and self-reports are more
suitable for short periods of follow-up as
occur in evaluation of psychotherapy tech-
niques.
(4) The information is comparable between reg-
isters and with that of other diseases. Fol-
low-up and treatment evaluation studies use
different independent variables. The use of
ofŽ cial registers allows status and trends in
the population to be analysed using recog-
nized measures of incidence and data analy-
sis techniques (for example, average annual
mortality rate, standard morbidity ratio, sur-
vival analysis).
(5) Participation of the whole cohort is assured,
without losses due to refusals, failures to
attend, unable to locate, etc. The problem of
experimental mortality is overcome by fol-
low-up through registers.
(6) Their use can be extended to social variables
such as employment status and criminal reg-
isters.
Follow-up studies of this type, however, re-
quire certain minimum conditions, apart from
the existence of the register itself and its quality:
(1) A very important point is the potential ethi-
1784 Xavier Sánchez-Carbonell & Anna Vilaregut
cal barrier to conduct research in this area.
Some ofŽ cial registers could be very sensi-
tive about releasing information and studies
such this could be difŽ cult to conduct in
some countries. This type of research is only
possible if there is collaboration between
various institutions. One strategy to obtain
permission is to get institutional funding, or
to undertake research under the auspices of
a public health institution.
(2) The register should provide coverage of a
region that has ecological signiŽ cance in the
life-style of the addict. State or regional
coverage is preferable to municipal coverage
alone.
(3) Measures must be taken to ensure
conŽ dentiality, given that the information
being manipulated is very delicate. With ap-
propriate precautions, the use of registers
can be considered to have the advantage of
being less intrusive than personal contact,
which runs the risk of evoking unpleasant
personal memories and increasing the risk of
relapse.
(4) Due to the large number of life events,
which cannot be controlled in 10 years of an
addict’s life, information from ofŽ cial regis-
ters cannot be used to establish causal rela-
tionships between variables.
(5) Attention must be paid to the danger of
underreporting of cases. For example, a
death may not be registered due to
difŽ culties of corpse identiŽ cation. Also a
subject may leave the area or the country
and not be included in the register. There is
also a potential for exclusion of certain treat-
ment services (religious therapeutic com-
munities, as an example) from speciŽ c data
collections.
Conclusions
Follow-up through registers is a novel, low-cost
technique that may provide valuable and com-
parable information on the long-term health and
social evolution of drug addicts in different Eu-
ropean regions. The measures of disease fre-
quency and association obtained allow us to
describe and compare the distribution of pat-
terns of infectious complications (AIDS and tu-
berculosis) and relapses in such a pervasive
disorder as heroin addiction. Among others, the
advantages of follow-up based on ofŽ cial regis-
ters are efŽ ciency, reliability, sensibility and
comparability. It should be pointed out, how-
ever, that this kind of approach has some limita-
tions. It is necessary to assure conŽ dentiality and
avoid under-reporting of cases. This study cor-
roborates the poor health status of heroin addicts
in Catalonia, the high AIDS, tuberculosis and
relapse rates, and that their health is worse than
that of the general population. The demographic
characteristics and those of drug use at ad-
mission to treatment have little predictive value
in the long term.
Acknowledgements
The study was partially funded by a grant from
the Centre d’Estudis Jurõ´dics i de Formació Es-
pecialitzada and from the Blanquerna Faculty of
Psychology and Educational Sciences (Ramon
Llull University). The authors are grateful for
the information provided by the Department of
Health and Social Security, Generalitat of Cat-
alonia (Information and Studies Service,
CEESCAT, Programa de Tuberculosi and
Organ Tècnic de Drogodependències) and by
the Barcelona City Council (Service of Epidemi-
ology: Tuberculosis Prevention and Control Pro-
gramme, Register of AIDS and Drug
Information System) and Action Plan on Drug
Addictions. We gratefully acknowledge the com-
ments by J. A. Caylà, T. Brugal, A. Domingo, E.
Guardiola, P. Monsech and D. Macfarlane.
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