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Executive Summary
Background
In 2003, the General Register Office for Scotland (
GROS) reported the highest ever annual
number of drug related deaths - 382 deaths during 2002
1. The Scottish Deputy Justice Minister subsequently
called for a national investigation into all drug-related
deaths in Scotland for the year 2003. This paper summarizes
the outcomes of that investigation.
Aims and Objectives
The main aims of the study were to collect and analyse
information relating to the clinical and social
circumstances surrounding all drug-related deaths in
Scotland from January - December 2003, to identify patterns
in these circumstances and the associations between them,
and to make recommendations for policy and practice which
may lead to a future reduction in drug-related deaths.
The main objectives of the investigation were to:
- Establish and explore the nature of the
individual's social circumstances prior to death
- Determine the specific combinations of drugs
associated with each death
- Establish the nature and extent of contact with
"services" prior to their death
- Investigate patterns in broad demographic variables
of drug related deaths for the period 1996 - 2003.
In addition, injectors who had survived an overdose in
the previous 6 months were interviewed to obtain more
information about their beliefs, experiences and knowledge
of overdose, and characteristics of Scottish drug-related
deaths were compared with a sample of London drug deaths
for the same year (2003).
Methods
(1) Drug related deaths in Scotland, 2003
The study population comprised 317 cases of drug-related
death in 2003 identified by
GROS2. Information on each person's clinical and social
circumstances was obtained from case records held by social
care services, specialist drug treatment services, mental
health services, and non-statutory agencies across all
health board areas in Scotland. Information was also
collected from the Scottish Prisons Service (
SPS), Scottish Criminal Records Office (
SCRO), Practitioner Services Division (
PSD) and Information and Statistics
Division (
ISD) of the Common Services Agency. Data
on the circumstances of death, post-mortem toxicological
findings and cause of death were sourced from fiscal
files.
The following variables were collected: sociodemographic
characteristics including accommodation and employment
status, circumstances of death and post-mortem toxicology
findings, cause of death, pattern of contact with health,
social and criminal justice agencies in the 6 months prior
to death. In total, 175 agencies were contacted, with 173
(99%) giving permission for access to their records.
(2) Trends in drug related deaths in Scotland,
1996-2003
Data collected by
GROS on drug-related deaths in Scotland
from 1996-2003 were examined for trends in all deaths and
those involving heroin/morphine or methadone. Analysis
focused on changes in drug-related deaths during this
period, and specifically on cause of death, day of death,
gender, age, health-board area and drugs specified on the
death certificate.
(3) Experiences of overdose survivors
A sample of 40 injecting drug users (
IDUs) were interviewed
3. A multiple site recruitment strategy generated a
representative sample of Glasgow
IDUs.
(4) Comparison of Scottish and London drug
related deaths
The Scottish data were extracted from Procurator Fiscal
files. London coronial data were extracted from seven
coronial courts, accounting for approximately 75% of drug
related deaths in London. Analyses assessed differences
between London (n=148) and Scotland (n=273) in terms of
age, gender, toxicology, homelessness, history of
imprisonment, drug treatment, place of death, number of
witnesses and ambulance attendance.
Results
The study population and trends over time
Most (81%) Scottish drug related deaths in 2003 were
male. The mean age was 32.7 years (ranging between ages 16
to 82 years). Thirty-nine per cent were aged between 25 and
34 years. Most (68%) cases were accidental drug overdoses.
Thirteen per cent were classified as suicides.
During the period 1996-2003 in Scotland, drug-related
deaths involving heroin/morphine had increased (+13.8%
yearly), while those involving methadone had decreased
(-0.4% yearly). A higher proportion of methadone compared
to heroin/morphine-related deaths in Scotland occurred at
the weekend (Friday to Sunday). Drug-related deaths had
increased at a significantly higher rate among those aged
35-54 compared to 15-24 years.
Circumstances of death and toxicological
findings
At the time of death, nearly half (48%) of overdoses
occurred in the vicinity of other persons. Most (68%)
deaths occurred in a home environment, either in their own
home or in a friend's place. Few deaths (8%) occurred
'instantaneously'. Where others were present,
CPR was attempted in 44% of cases,
however no intervention occurred (prior to the arrival of
the ambulance) in 38%. Although an ambulance was called to
the scene in 82% of cases, for most victims (81%), it was
too late.
The predominant drugs found at the time of death were
benzodiazepines (69%), heroin/morphine (60%), and alcohol
(57%). Just over a quarter (28%) of the sample was positive
for methadone. Few cases were positive for stimulants; 9%
were positive for cocaine. More than one drug was detected
in the vast majority (95%) of cases. Nearly half of
methadone positive deaths, and two-thirds of diazepam and
dihydrocodeine positive deaths, involved illicit sources of
medications. Injection was the route of administration in
46% of cases. However a relatively high proportion (44%) of
individuals did not inject any drugs prior to overdose and
death
4, and a high proportion (36%) were positive for only
orally consumed drugs.
'Opiate intoxication' was the most frequently recorded
cause of death (44% of cases). In the majority (91%) of
these cases, however, toxicology identified other drugs in
addition to opiates - mainly benzodiazepines and
alcohol.
In Scotland there was a higher proportion of deaths
positive for dihydrocodeine (19% vs. 11%) and
benzodiazepines (69% vs. 41%), a higher proportion of cases
in receipt of dihydrocodeine prescriptions (8.4% vs. 2.7%),
lower average blood concentrations (mg/L) of methadone
(0.52 vs. 0.87) and morphine (0.27 vs. 0.36) and a higher
proportion of deaths (17% vs. 10%) associated with recent
prison release
5 compared with London. A higher proportion of deaths in
London was positive for cocaine (42% vs. 10%).
Social circumstances prior to death
Most (237, or 75%) of the 317 people had been in contact
with services in the six months prior to their death. Of
this 237, 117 (49%) were living in their own house or flat.
Thirty one (31%) were in unstable or temporary
accommodation. Eight were recorded as having been roofless
during the six months prior to death. Of the 138 for whom
information on living arrangements was available, 74 (54%)
lived alone and 64 (46%) lived with others. Twenty-nine of
those were recorded as living with a partner, 32 with
parents and 3 with dependent children.
Casefiles show that 119 (50%) had children while 55
(23%) did not
6. The 119 who were identified as parents, had 185
children. Seventeen of these children (9%) were recorded as
living with a parent who died of drug-related causes.
Seventy-eight (42%) were living elsewhere and 2 were in
care. No information on where these children were living
was available in 88 (48%) casefiles. Of 59 females who
died, casefiles record that 16 (27%) had children in their
care at the time of their death.
Contact with services
The frequency of service contacts remained constant
across each of the six months prior to death. Forty-five
percent of those accessing services were in contact with 2
or more services at any one time. A significant proportion
of contact was with General Practitioners (
GPs) - 183 (77%) of all those in contact
with services accessed
GPs during this period. In most areas,
the majority of contact was with generic providers rather
than specialist drug services. Overall only 40 (17%) were
known to specialist services, while in most areas there
were significant contacts with psychiatric services (41
people, 17%), acute services - including Accident &
Emergency (59 people, 22%) and
NHS outpatients of various types (37
people, 15%). In total, 71 (30%) were known to Social
Work.
Half (138) of the 237 people in contact with services
had details of previous overdoses recorded in their notes.
During the 6 months prior to death, 31 had experienced at
least one overdose. Nine of those were recorded as
accidental, 13 deliberate and 9 not known.
Sixty-six people were prescribed methadone during the
six months prior to death, and 40 were being prescribed
methadone at their time of death. Doses ranged between 4
and 100 mg (mean 53.9 mg). Sixteen of these people (34%)
were prescribed 60 mg or more. At time of death, twenty-one
people (54%) were having their methadone dose increased and
8 (20%) were being reduced
7. Only 7 (11%) were also receiving regular counselling
during that time; there was no evidence of counselling
taking place for the remainder of this group.
Of the total 317 cases, 149 (47%) had previously had a
prison sentence. 70 (47%) died within 6 months of release.
Thirty-six of these deaths (24%) occurred within one month,
and 10 (28%) occurred within three days of release. While
Transitional Care or other throughcare support was
available to prisoners during this period, prisons show
varying success regarding take-up rates.
Experiences of overdose survivors
Overdose survivors were interviewed about their
experience of overdose in the previous 6 months. Most had
taken more than one substance that day. Heroin had been
taken by all but one, and heroin and diazepam taken
together or on the same day was the most common
combination.
Interviewees had some awareness of overdose risk.
However, this knowledge was not extensive and there were
misconceptions. Less than half mentioned tolerance as a
factor or considered that a mixture of drugs could be
risky. Some believed that overdose would not occur if
heroin was smoked or injected by itself. Injecting in
company was the most frequently cited prevention
strategy.
Inflicting physical pain was the most common
intervention used by injecting drug users to revive an
overdose survivor, and was regarded as the most effective
strategy. Putting the overdose victim into the recovery
position was cited by half the sample. Half were worried
about having another overdose. Among those who were not
worried, some claimed not to care whether they lived or
died.
Implications and conclusions
This investigation has identified implications for
services in preventing drug-related deaths, and has
highlighted limitations of the available data:
- There is a need to further develop and deliver
training and education on risks of overdose and how to
respond effectively, to drug users and their
families.
- Overdose prevention initiatives should continue to
emphasise that most fatal drug overdoses are polydrug
deaths.
- Primary care and other 'generic' services need
training to increase awareness of persons at high risk
of drug related death.
- Delivery of medical treatment to drug misusers,
including substitute prescribing, needs to be improved
in line with best practice guidelines.
- Care pathways across the prison/community interface
should be reviewed to ensure adequate accessibility to
services for all newly released prisoners.
- Developing a standardised nomenclature for
recording drug related deaths would improve
surveillance of trends in drug related deaths.
- There is a need to improve the quality of record
keeping in services.
Finally, the report provides some baseline indicators by
which the effectiveness of interventions to prevent or
reduce drug-related death might be measured.
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