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National Investigation into Drug-Related

Deaths in Scotland, 2003

National Investigation into Drug-Related

Deaths in Scotland, 2003

Dr. Brian A. Kidd

Senior Lecturer in Addiction Psychiatry

Centre for Addiction Research & Education, Scotland

University of Dundee

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National Investigation Team

• Deborah Zador (Lead)

• Alex Baldacchino

• Tom Fahey

• Matt Hickman

• Sharon Hutchinson

• Avril Taylor

• Andy Rome

CARES, University of Dundee

CARES, University of Dundee

Tayside Centre for General Practice

Imperial College, London

Health Protection Scotland & University of Glasgow

University of Paisley

CARES, University of Dundee

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AcknowledgementsResearch assistants

• Sarah McGarrol

• Hope Stewart, Tina Bool, Keith Taylor, Lucy Gorham, Rod Wallace

Professional assistance

• Graham Jackson (GROS)

• Allison Brady & colleagues (Glasgow City Council, SW Dept)

• Karen Norrie & Emma Everett (SPS)

• Elizabeth Allen & David Young (Health Protection Scotland)

• Alan Cameron (Crown Office)

• Susan Frame & Colleagues (ISD)

• DS Gillian Wood (SDEA)

• Scottish DAAT teams, service managers and their staff

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Plan

• Background, methodology & process

• Demographics and population trends

• Toxicology & circumstances of death

• Social circumstances

• Service contacts

• Interviews with survivors

• Conclusions and implications

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Background, methodology & process

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Background, Methodology & Process

• 2002 – GROS reports 382 drug-related deaths (DRDs)• SE commissions inquiry with aims:

Collect & analyse clinical and social information on all drug-related deaths in 2003

Identify patterns in social & clinical circumstances and any associations

Make recommendations for policy & practice which may lead to future reduction in drug-related deaths

• Evidence base implies many drug-related deaths are preventable

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BackgroundWe know that DRDs are:

• Young male IV polydrug users with family histories of “trauma” etc

• Deaths are in presence of others often in home setting following a loss of tolerance

• Most “accidental” but ~10% “suicides”

• Stability of these findings

We do not know:

• What characteristics are of predictive value?

• Where should we target our interventions?

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Methodology – Drug-related deaths in Scotland 2003

• 317 DRDs identified by GROS in 2003• Ethical approval & ADSW support• Team appointed & Data collection from April 2004• Two data collection instruments developed:

Clinical & social circumstances (CSC)Fiscal file (FF)

• Also data from SPS; SCRO; PSD; ISD – SMR00, SMR01, SMR04

• SPSS database created. NB Research governance

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Methodology 1. – Drug-related deaths in Scotland 2003

• Service contacts for 6 months prior to death

• Project manager contact with each area with covering letter seeking permission to collect information

• List of local deaths supplied for services to clarify if “known”

• Data collectors visited, examined files, complete CSC fields

• 175 services approached – 41 NHS; 59 LA; 75 Voluntary sector

• 173 gave permission (99%)

• CSC & FF data entered into SPSS(v12)

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Methodology2. – Trends in DRDs in Scotland, 1996-2003

• General Register Office for Scotland data

• All drug-related deaths from 1996-2003

• Examined for trends in all deaths and those involving heroin/morphine and methadone

• Analysis to assess rates of change by: Cause of death Day of death Gender Age NHS Board area Drugs specified in death certificate

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Methodology 3. – Experiences of Overdose Survivors

• Injecting drug users being interviewed as part of ongoing study in Glasgow

• Recruitment strategy employed to recruit as representative a sample as possible

• If overdose in last 6 months, asked to consent to follow-up interview

• Audiotaped interviews transcribed and analysed

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Methodology 4. – Comparison of Scottish & London DRDs

• Scottish data extracted from Fiscal files as described• London coronial data from 7/8 coronial courts (representing

~75% of London’s DRDs)• Issues of definition – so from both samples deaths selected

which were positive for morphine/heroin, methadone, cocaine, MDMA, amphetamines, dihydrocodeine

• Yield of 273 in Scotland & 148 in London• Entered into SPSS (v12) for analyses of age, gender,

toxicology, homelessness, imprisonment history, treatments received, place of death, numbers of witnesses and ambulance attendance

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Findings: Demographics & population trends

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Demographics & Population Trends• 81% male• Age range 16-82yrs; mean 32.7yrs• 39% 25-34yrs• Known Depcats of DRDs (Carstairs Index) reflect local

Depcat scores

• Lower proportion of DRDs in affluent areas: • 6.5% of DRDs from 20% of population in Depcats 1 & 2• 42% of DRDs from 18% of population in Depcats 6 & 7

• 50.5% died on Friday-Sunday• ICD 10 categories:

216 (68%) “Drug abuse” 40 (13%) “Intentional self-poisoning”

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Trends, 1996-2003

• Annual increase 3% in DRDs in all NHS Board areas

• Massive heterogeneity over time

• Number of DRDs increased at a higher rate in older age group (35-54yrs) compared to 15-24yrs group: Rate of 16% v 0.3%

• Cocaine was involved in only 5% - but number increased from 3 to 28 over period

• Annual in heroin/morphine deaths higher in areas outside Glasgow (except Lothian)

• Glasgow heroin/morphine deaths reduced from 70%-37% over period

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Trends, 1996-2003 – Heroin v methadone

• Overall twice as many heroin/morphine deaths as methadone

• Heroin/morphine rate 13.8% v methadone -0.4%

• Significant variation in numbers by area (eg Tayside:Lanarkshire)

• Lothian & Tayside ~half involved methadone but by 11.2% & 19.3% p.a.

• Glasgow methadone rate 9.7% per yr v heroin 6.5%

• Weekend deaths: more methadone (55%) than heroin/morphine (45%)

• Rate of weekend methadone deaths reduced at 3.5% per year.

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Findings:Toxicology and circumstances of death

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Toxicology & Circumstances of Death• Fiscal files (n=300)

• Variation in recording of cause of death by forensic authorities & disparity with toxicology findings

• Demographics unremarkable

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Toxicology & Circumstances of Death

• Time elapsed “several hours or more” in 50%

• Most dead by time ambulance arrived

• Less than 50% of witnessed ODs received CPR

• High proportion of non-injectors with IV use at time of death in only 46%

• ~50% of methadone and 2/3 of benzo. & DHC deaths – drugs obtained illicitly

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Scotland:London comparisons• Similarities++ including:

80% male; half over 302/3 heroin; 30% methadone; majority polydrug Few instantaneous (ie opportunity for action)Most at home/or home of family/friendIf ambulance called, majority DOA~1/4 on substitute prescription

• Differences:Scotland likely recent prison release (17% v 10%)Scotland higher number +ve for Benzos/DHC; London for CocaineScotland more in receipt of DHC prescriptionLower blood concentrations in Scotland (heroin & methadone)

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Findings: Social circumstances

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Social Circumstances• CSC files (n=237) on those who attended any services in 6/12

• n=300 Fiscal files to add to richness of data

• Little information on upbringing or educational attainment

• Little information on employment.

• Sparse information on housing

• Little information on quality of relationships: of only 78, 69 (88%) suggested close relationship with family. Fiscal files add to this – 207 cases. 98 (33%) in a relationship; 109 (36%) unattached. From Fiscal files: of 214, 167 (78%) in contact with family in 3/7 prior to death; 37 within few weeks. 188 (93%) in contact with friends in 3/7

• Little information on life events: Only 67 (26%) of casefiles had any note of significant life events in 6 months prior to death

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Social CircumstancesChildren• 119 (50%) had children; 23% did not; no information

in 27% of files• Notes stated that the 119 had 185 children• 15% <5; 59% 5-16• 17 Children were living with a parent suffering a

DRD. But no information in records on whereabouts/ caring responsibilities for 88 of DRDs known to have children.

• Huge disparities between CSC and Fiscal files

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Findings:Service contacts

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Service Contacts

• 68 had no recorded service contacts at all in 6/12

• n=237 had a recorded service contact (including SMR)

• 136 (57%) were in contact with at least 1 service at time of death

• 183 (77%) in contact with GPs; 41 (17%) with psychiatry; 59 (22%) with A&E; 37 (15%) with NHS Outpatients

• 71 (30%) known to Social work (but difficult to determine degree of specialisation)

• Only 40 (17%) known to specialist providers – 38 records available

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Reasons for Service Contacts

• 47% of all contacts were medical consultations• 5% were for “specialist substitution prescribing

programmes”• GP consultations often related to prescribing but No

clarity regarding degree of specialisation/ shared care arrangements etc

• 12% were for Social Work/ Case management• Only 3% were for a “counselling” intervention• Most contacts were in emergency settings – A&E;

Psychiatry; SW

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SMR Data - Overview

• 1435 episodes of hospital care in 6/12 prior to death (excluding A&E)

• 734 (51%) related to admission• Of which 70% were discharged within 2 days• SMR returns record that 319 were admitted for

“observation, treatment or investigation”

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SMR Data - Psychiatry• 86 prescribed antidepressants & 20 prescribed

antipsychotic medication• 83 had at least one episode of psychiatric care• 5 had at least 5 episodes recorded in 6 months• Of the 83, 44 required admission. • Records of aftercare were available for only 29• 138 cases had a record of a previous overdose• 4 had at least 4 overdoses in 6/12 prior to death• Only 44 psychiatrically assessed and 42 (95%) offered

follow up. Only 18 attended.

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“Specialist” service contacts

• Only 38 had any recorded contact with a specialist service

• Details in records were sparse and only 47 contacts were recorded for these 38 people over 6 months.

• 78 received medical treatment of which 66 were prescribed methadone. 40 were prescribed by the time of death.

• Records sparse - one prescribed person had no records of any prescribing information at all

• Of remaining 39 prescribing practice showed huge variation and inconsistency

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Criminal Justice Contacts - General

• 274 of DRDS were known to Scottish Criminal Records Office (SCRO)

• Data could not be examined in detail

• There was little contact with community-based CJS schemes (10%)

• 21 cases had outstanding charges at time of death

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Criminal Justice Contacts - SPS

• There were no DRDs in a Scottish prison in 2003• 149 had been in prison of which 70 died within 6

months of release• 36 (24%) died within 1 month; 10 within 3 days• Of these 10 deaths, 6 were released on a Friday• “Transitional Care” showed significant variation in

uptake

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Interviews with survivors

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Interviews with Survivors• IDUs recruited to EIU study - 97 had OD’d in last

6/12, 40 agreed to interview• Representative groupMain findings:

• Limited awareness of overdose risks• Having another person available commonest safety

strategy • Greatest barrier to calling emergency services was

fear of arrest• Little knowledge of effective interventions

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Conclusions and implications

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Conclusions & Implications

• National recording of causes of death is inconsistent and does not aid investigation

Systematic standardised collation of forensic data should be a priority

• Trends analyses are complex but regional variation in death rates is striking

Further research is required to explore the significance of these findings

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Conclusions & Implications

• There were missed opportunities to avoid death – lack of CPR and time lag to arrival of ambulance or emergency services

• As well as opiates, Benzodiazepines are prominent along with alcohol. Many DRDs were not injecting drug users.

Education of drug users and comprehensive consistent harm reduction advice is required

Action regarding users’ perceptions of emergency responses may increase calls & reduce deaths

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Conclusions & Implications

• There is a striking lack of rich information about those who have died.

There is a need to improve the quality of information routinely available on service contacts to better understand DRDs and to increase the likelihood of anticipating problems and delivering appropriate responses

• Many have contact with generic services with these contacts failing to activate effective interventions

Links between generic services and specialist support & treatment agencies must be developed

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Conclusions & Implications

• Delivery of medical treatments and associated interventions shows huge variation in quality and consistency

There is a need to ensure that the evidence-based interventions are readily available and consistently delivered.

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E-mail: b.kidd@dundee.ac.uk

Telephone: 01382 424512