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Chapter 7: Conclusions and
Implications
What is in this chapter? This chapter
reviews the findings from individual chapters and draws
together a final set of conclusions along with associated
implications for service commissioners and providers.
Where did the information come from? The
information has been drawn from the "key points" sections
from each chapter in the body of the report.
Introduction
This investigation has comprehensively examined the
circumstances of death, social circumstances and service
contacts of those dying of drug-related causes in Scotland
in 2003. It has also considered long-term trends in
drug-related deaths in Scotland and has compared the
circumstances of the 2003 Scottish deaths with data from a
concurrent study into drug-related deaths in London for the
same year. Finally the investigation has explored the
opinions, beliefs and knowledge of living injectors
regarding overdose risk.
The developing evidence-base implies that many
drug-related deaths may be preventable and this
investigation aimed to identify areas which, if effectively
addressed would impact on the rate of drug-related deaths
in Scotland.
Each chapter of the report has therefore identified "Key
Points" based on the data collected. These are summarised
below and have been used to generate implications for
service commissioners and providers arising from the
findings of this investigation.
Describing the study population and trends over
time
Most Scottish drug related deaths in 2003 were male, and
in their early 30s (mean age of 32.7 years). Most were
considered to have been accidental drug overdoses (based on
ICD-10 criteria for drug related
deaths), although a sizeable 13% were classified as
suicides. These characteristics are consistent with
previous published studies into drug related deaths.
Trends in drug-related deaths in Scotland from 1996 to
2003 were complex and showed a great deal of heterogeneity
over time in relation to geographical distribution and the
involvement of heroin/morphine or methadone. Drug-related
deaths involving heroin/morphine had increased at a
significantly higher rate than those involving methadone in
Scotland during 1996-2003 (13.8% vs -0.4% per year,
respectively). In Glasgow, however, deaths involving
methadone increased at a higher rate (average 9.7% per
year) than deaths involving heroin (which increased at an
average 6.5% per year).
Drug-related deaths involving heroin/morphine had
increased at a significantly higher rate out-with the main
urban centres of Glasgow and Lothian during 1996-2003, and
likely relates to the growth of drug use in these areas.
Overall, there were twice as many deaths involving
heroin/morphine as methadone. However, the ratio of
heroin/morphine : methadone overdose deaths varied
considerably between geographical areas - for example, from
117 : 26 in Lanarkshire to 21 : 70 in Tayside and 59 : 175
in Lothian.
A higher proportion of methadone compared to
heroin/morphine-related deaths in Scotland occurred at the
weekend (defined as Friday to Sunday). Drug-related deaths
increased at a significantly higher rate among those aged
35-54 compared to 15-24 years during 1996-2003.
Implications
The study and analysis showed important differences in
drug-related deaths over time and geographically. However
other studies will be required to test potential
explanations and hypotheses for these differences. One key
question is to what extent do the differences follow, and
are due to, the underlying trends and pattern in drug use
in Scotland? Or are there differences in the availability
and delivery of treatment, and investigation of
drug-related deaths, that may have a bearing on the
mortality statistics and mortality rate within
Scotland.
Toxicological findings and circumstances of
death
1. There were missed opportunities to
intervene and save the lives of many of the people who
died. Less than half had tried
CPR and most cases had died by the time
the ambulance arrived.
Implications
There is a need to develop and deliver training and
education for drug users and their families to increase
awareness of the risks of overdose, how to avoid it, how to
identify it and how to respond effectively.
2i). Benzodiazepines were the most common
drugs detected in drug-related deaths. Few cases were
positive for psychostimulants, in particular cocaine. The
predominant drugs found at the time of death continue to be
heroin/morphine, benzodiazepines and alcohol in
Scotland.
2ii). Nearly half of methadone related
deaths, and two-thirds of diazepam and dihydrocodeine
positive deaths involving illicitly obtained
medications.
Implications
The widespread ingestion of benzodiazepines in
particular diazepam among drug users (as indicated by the
toxicology data for the current sample of deaths, and by
the data on trends in drug-using characteristics of cases
of drug related death during 1996-2003 in Scotland) is a
matter of major concern regardless of whether these drugs
were implicated in the cause of these deaths.
Benzodiazepines are potential drugs of dependence with
risks of both acute and chronic adverse psychological,
physical and social sequelae for misusers. More research is
needed into the prevention and management of benzodiazepine
abuse.
The findings also suggest that illicit manufacture
and/or diversion of prescribed drugs is a substantial
source of drugs for users, and remains a significant issue
for health service providers and others in the field. Where
diversion of prescribed drugs
e.g. dihydrocodeine or methadone and/or
benzodiazepines, may be occurring, there is a need to
address prescribing practices in relation to these drugs.
However any further analysis of illicit sources of
medications would have involved collection of data on the
illicit manufacture of prescription medications, which did
not form part of this investigation.
3. A relatively high proportion of cases
did not inject any drugs prior to overdose and death. A
high proportion was also positive on toxicological analysis
for only orally consumed drugs. Drug users who do not
inject heroin (or other drugs) are also at risk of fatal
drug overdose.
Implications
The findings reported here suggest that overdose
prevention initiatives should continue to reinforce the
message that most fatal drug 'overdoses' are polydrug
deaths and alert drug users that for a substantial number
of cases, 'lethal' drugs are not necessarily injected
drugs.
Services must be aware of the risks of non-injecting, in
particular oral drug use, and must continue to warn drug
users and the broader community of the dangers of
combinations of drug use including alcohol. Drug treatment
services may also need to be aware that non-injecting
dependent drug (in particular licit drug) and alcohol
users, may not be attracted into seeking help because they
may not identify with these agencies' illicit drug using
and/or injecting clientele.
4. Analysis of cause of death information
showed that the same drug-related cause of death may be
recorded on the death certificate by forensic authorities
in various ways. It also found that while 'opiate
intoxication' was the most frequently recorded cause of
death for drug related deaths in Scotland, being recorded
for 131 (44%) cases, in only 12 (9%) cases was toxicology
positive only for opiates. In the vast majority of opiate
intoxication cases, toxicology identified other drugs in
addition to opiates, most frequently benzodiazepines and
alcohol.
Implications
That post-mortem toxicological results are not always
reflected in the certified cause of death could suggest
either under-reporting on the death certificate of other
drugs detected or more likely that other drugs detected
were not considered to be implicated in the cause of
death.
The task of attributing cause of death to one or more of
a number of drugs detected at post-mortem is a complex and
inherently fraught one in the case of many drug-related
deaths. However, under current cause of death nomenclature,
the prevalence of polydrug use, and in particular the
widespread involvement of 'licit' orally consumed drugs in
cases of drug related death, may be underestimated.
The systematic collation and availability of forensic
toxicological data would assist the surveillance and/or
analysis of trends in drug-related fatalities. Developing a
more standardised, uniform nomenclature for recording
drug-related deaths on medical certificates would also
improve the monitoring and researching of drug-related
deaths.
5. There were a higher number of deaths
positive for dihydrocodeine and benzodiazepines in
Scotland, and a higher number of deaths positive for
cocaine in London. There were a higher number of cases in
receipt of dihydrocodeine prescriptions in Scotland, and
lower average blood concentrations of methadone and
morphine in Scotland.
Implications
These key differences, which might reflect differences
in the pattern of drug use and treatment provision between
Scotland and London, could be explored further.
6. In Scotland, a higher proportion of
deaths (17% vs. 10%) were associated with recent prison
release (
i.e. within three months of release) compared
with London.
Implications
Part of the difference may possibly be explained by
differences in services provision between the two sites.
The larger proportion of deaths with a recent prison
history in Scotland, which is a recognised risk factor for
drug related mortality, is worthy of further
investigation.
Social circumstances prior to death
1. Information, as it is currently
collected across Scotland is sparse, inconsistent and
difficult to cross-reference.
Implications
Use of a standardised, well-validated method of
collecting agreed data on all drug deaths would
substantially facilitate the identification of relevant
social risk factors.
2. The lack of up to date relevant
information in many of the casefiles, which would be
required to organise an integrated care plan is a concern.
The availability of rich, up to date information would
allow identification and prioritisation of potential risk
factors in this vulnerable population which could reduce
future morbidity and mortality and must form part of good
practice in the management of drug misusers.
Implications
Staff in all settings should be trained to
comprehensively and holistically assess drug misusers and
to ensure that regular updates of essential information (
e.g. regarding childcare responsibilities,
life events
etc.) are recorded. Nationally, standards
could be set within the
DAT Corporate Action Plan requiring
recording of adequate information. Locally,
DATs and their health and Local
Authority partners could ensure that services are
commissioned with clear quality standards and monitoring
procedures in place.
Contact with services
1. Most people who died of drug-related
causes were known to services and many were accessing more
than one. These services were often generic (
i.e. not specialists in the field of substance
misuse) and were often accessed in an ad hoc, chaotic
manner. Following this contact, most were discharged with
inadequate follow up in place or failed to attend any such
follow up appointments resulting in discharge and no
further action.
Implications
There is a need to increase awareness of this problem
and to deliver training and improved coordination of
activity for those generic staff most likely to come into
contact with this group - General Practitioners,
Psychiatric services, Accident & Emergency and Social
Work.
2. Medical interventions were only
accessed by a minority. When accessed, the intervention was
often prescribed methadone. Quality of methadone
prescribing was often outside that contained in national
practice guidelines. Few of those prescribed methadone were
in receipt of any counselling.
Implications
Methadone replacement should be prescribed only in line
with the current evidence base - following a full
assessment of drug problems and dependency; in adequate
doses to meet need; dispensed safely and effectively under
supervision until the person is demonstrably stable.
Methadone replacement prescribing should be delivered
alongside supportive counselling.
3. Many had been in prison in the last 6
months. Ten died within 3 days of release of which 6 were
released on a Friday. Transitional Care is not being made
available to all who require it. Prisons show varying
success regarding take-up rates.
Implications
There is a need to ensure all opportunities are taken to
intervene when drug misusers are in prison. In particular,
there is a need to ensure that effective communication
takes place to ensure imprisonment does not interrupt
treatment (if in treatment before incarceration) or that it
gives an opportunity to increase access to treatment if not
already in contact with services.
DAATS should review the care pathways
across the community/prison interface and ensure adequate
accessibility to services for all newly released prisoners.
Prisons should look proactively at how they engage with
prisoners at the start of their treatment cycle.
Experiences of overdose survivors
The majority of overdoses occurred amongst those who had
taken more than one substance on the day of overdose.
Heroin had been taken in all but one overdose. Heroin and
diazepam taken together or on the same day was the most
common combination, taken in 22 cases. In fifteen overdoses
heroin and diazepam were the only drugs consumed; in the
remaining five episodes they were taken in combination with
one or two other substances and/or alcohol.
Injecting drug users are aware, to some extent, of the
overdose risks, although this knowledge is not extensive.
Less than half mentioned tolerance as a factor and less
than half considered that a mixture of drugs could be
risky. There were some misconceptions about overdose risk
factors. Some injecting drug users believed that overdose
would not occur if heroin was smoked or if it was injected
by itself. Injecting with someone else present was the most
frequently cited prevention strategy.
Inflicting physical pain was the most common
intervention used by injecting drug users. Although putting
the overdose victim into the recovery position was cited by
half the sample, the infliction of pain was still regarded
as the most effective strategy. Half of the sample was
worried about having another overdose. Among those who were
not worried, some claimed not to care whether they lived or
died.
Implications
There is a need to develop and deliver training and
education for drug users and their families to increase
awareness of the risks of overdose, how to avoid it, how to
identify it and how to respond.
Conclusion
This investigation has identified a number of
implications for services in the prevention of future
drug-related deaths in Scotland. It has highlighted some
limitations of fiscal and national registry office data on
drug-related mortality and has raised aspects of
drug-related deaths requiring further research.
Finally, the report provides some baseline indicators by
which the potential effectiveness of interventions to
prevent or reduce drug related deaths in future might be
measured. Some of these outcome measures might include
improved after care from prison, improved delivery of
methadone treatment, and increased engagement of drug users
with services especially drug treatment services.
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