As from 2013, the ADP reformulated the Fife Drug Death Strategic Group into a Fife Overdose Prevention ... Prior to October 2009 the ADP was named the Fife ...
DRUG DEATHS IN FIFE SCOTLAND
2015 The findings of the Fife Drug Deaths Monitoring Group (Fife Alcohol and Drug Partnership) Fleur Davey Michelle Hyslop A l ex B al dac c hi no
Acknowledgements Authors Dr Fleur Davey, Part Time Drug Deaths Researcher, NHS Fife Addiction Services Professor Alexander Baldacchino, Clinical Lead /Consultant Psychiatrist NHS Fife and Professor in Medicine, Psychiatry & Addiction, University of St Andrews Michelle Hyslop, Personal Assistant, NHS Fife Addiction Services Drug Death Monitoring Group 2015 Prof Alex Baldacchino, Consultant/Senior Lecturer in Addictions, NHS Fife (Chair) Michelle Hyslop, PA, NHS Fife (Minutes) Ingrid Pitt, Team Leader, NHS Fife Sgt. Davie Hayes, Community Safety Officer, Police Scotland Paul Buttercase, NHS Liaison, Police Scotland Linda Henderson, Social Work Assistant, Fife Council Ryan McCallum, Acting Team Manager, Fife Council Marion Wilson, Acting Team Leader, Prisoner Healthcare, NHS Tayside Martin Denholm, Service Manager, DAPL Margaret Lawson, Addictions Midwife, NHS Fife April Adam, Service Manager, FIRST Liz Hutchings, Specialist Pharmacist, NHS Fife Fleur Davey, Drug Death Researcher, NHS Fife David Dempster, Substance Misuse Manager, FCDS/FASS Gareth Balmer, Project Manager, Addaction OD Prevention Working Group 2015 Derek McEwan, Superintendent, Police Scotland (Chair) Kate Maxwell, ADP Support Team (Minutes) Angela Swift, Clinical Services Manager, NHS Fife (now left but previously chaired) Sally O’Brien, Acting Clinical Services Manager, NHS Fife (now left but previously chaired) Debbie Pettigrew, NHS Fife (now left but previously minutes) Sgt. Davie Hayes, Community Safety Officer, Police Scotland Paul Buttercase, NHS Liaison, Police Scotland Ingrid Pitt, Team Leader, NHS Fife Fleur Davey, Drug Death Researcher, NHS Fife Ryan McCallum, Acting Team Manager, Fife Council Delphine Easson, Case Work Manager, Scottish Prison Service Liz Hutchings, Specialist Pharmacist, NHS Fife Gareth Balmer, Project Manager, Addaction John Martin, ADP Policy Officer, Fife ADP Stuart MacArthur, Service Manager, Children & Families/Criminal Justice, Fife Council Kirsten Horsburgh, National Naloxone Co-ordinator, Scottish Drug Forum Erika McHardy, Fife Naloxone Co-ordinator, NHS Fife (former member but now left) Colin Baptie, Custody Suites, Police Scotland John Mills, Head of Housing, Fife Council Jim McSpurren, Scottish Ambulance Service, NHS Scotland Paul Raynor, Scottish Ambulance Service, NHS Scotland
Special Thanks We would like to take this opportunity to acknowledge all agencies that have completed questionnaires and contributed to the data collection for the Drug Death Monitoring Group. The continued dedication and support is greatly appreciated.
Contents Page 1
Executive Summary A Case Vignette of a Typical Drug Death Victim in Fife in 2015
2
Fife Drug Death Monitoring Group
3
Section 1
Introduction 1.1 Background 1.2 Governance and Structure 1.3 Mission Statement 1.4 Ethos and Philosophy of the Fife Drug Deaths Group 1.5 Recommendations arising from the Drug Death Group Meetings/Drug Death Report
4 4 4 4 4 5
Section 2
Methodology 2.1 Population 2.2 Definition of a Drug Death (DD) 2.3 Inclusion Criteria: ICD-10 2.4 Exclusion Criteria 2.5 Guide to the information gathering process 2015 2.6 Step-by-step Guide to Data Collection 2015 2.7 Protocol and Creation of the Drug Deaths Database 2.8 Drug Deaths Database 2.9 Data Analysis 2.10 Data Collection Sources 2.11 Missing Data 2.12 Format of Results
6 6 6 7 8 9 10 11 11 11 12 12 13
Section 3
Results 3.1 3.1.1 3.1.2 3.1.3
Demographic Characteristics Incidence and Prevalence of Drug Deaths Residency of Drug Death victims within Fife Age, Gender and Ethnicity
14 14 14 15 18
3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5
Life Context and Social Functioning Housing and Living Arrangements Relationship and Family Information Friendships and Relationships Relationships with Children Education and Employment Status
20 20 21 21 22 23
3.3
Criminal Justice and Offending
25
3.4
Significant Life Events and Physical/Psychological Health Significant Life Events Psychiatric/Psychological Problems
27
3.4.1 3.4.2
27 28
Section 4
3.4.3 3.4.4
Physical Health Problems Co-morbidity
28 29
3.5 3.5.1 3.5.2 3.5.3
Substance Misuse Histories Age at which Drug Misuse Began Drug Use Characteristics of Injecting vs. Non-Injecting Users Overdose Histories
31 31 32 32
3.6 3.6.1 3.6.2 3.6.3
Service Use Histories Services Accessed within 5 Years Prior to Death Services Accessed During the 6 months Prior to Death Pharmacological Interventions 6 Months Prior to Death
34 34 34 35
3.7 3.7.1 3.7.1.1 3.7.1.2 3.7.2 3.7.3 3.7.4
Circumstances of Death Timings of Death Month of the Year Days of the Week Circumstances of Death Snoring Immediately Prior to Death Interventions Attempted at the Scene
38 38 38 39 39 40 40
3.8 3.8.1 3.8.2 3.8.3 3.8.4 3.8.5
Toxicology Results of Drug Deaths in Fife 2015 Toxicology results Substances Implicated Concomitantly Therapeutic, Fatal and Actual Levels of Substances Substances Implicated in Cause of Death Prevalence and Diversion of Prescribed Medication
42 42 44 44 44 45
Recommendations
48
References
49
Executive Summary The Fife Drug Death Monitoring Group reviewed the circumstances of death for 31 individuals who died of a drugs death in Fife in 2015. This is the highest number in drug deaths in Fife since 2007, a year which also recorded 31 drug deaths. Most were white Scottish males who lived in areas of Fife with the highest social deprivation. The mean age at death was 37 years. On average, illicit drug use started at 16 years and 65% of individuals were known to have injected drugs at some point in their life. The majority of individuals were single, living alone, but reported a close relationship with family and/or friends. Just under half (15), had children under the age of 16. Detailed information regarding the childhood of this cohort was not always available, but considering the data reported to the Drug Death Monitoring Group; 19 individuals experienced an unstable home life, 12 an unstable secondary education and 10 reported adversity in their childhood including neglect and/or abuse. Individuals left school at 16, and the majority went into employment, further education or training. When they died, 81% experienced adversity in the 6 months prior to death and 90% were unemployed. Almost two thirds of cases (20) had diagnosed mental health problems; depression noted in all of these 20 cases, often alongside other mental health issues. Twenty-two cases had significant physical health issues. Seventeen individuals had both physical and psychological health problems alongside their substance misuse. Most of the 25 individuals with health conditions were in receipt of medication from their GP. All but one of the cohort had a criminal record, over half spending time in prison. Within the 6 months prior to death, 28 had contact with services, most commonly; GP, Social Work, NHS Fife Addiction Services and/or Prison. Nine individuals were in receipt of substitute prescribing at the time of death, 5 had been prescribed within 6 months of death but not at the time of death, and 13 had never received substitute prescribing. Furthermore, 21 of the 31 were known to have had severe problems with alcohol consumption, and this was an ongoing issue for 12 of these 21. Two thirds of the cases (21) reported ever experiencing a non-fatal overdose, 6 had overdosed in the 6 months prior to death and 2 within the week before they died. Just over half were known to have been given overdose training and 5 had been supplied with take home naloxone. Most deaths (71%) occurred in the presence of others and witnesses were known to have checked on the deceased assuming they were sleeping. Witnesses who called an ambulance for the deceased (22 cases) would generally attempt cardio-pulmonary resuscitation but did not administer naloxone. The vast majority of drug death individuals had more than one drug listed in their final cause of death, heroin/morphine the most common substance named (19 cases) and methadone was the second most common (11 cases). In 6 cases, only one drug was listed, 5 deaths were due to heroin only and 1 to methadone. Considering substances found in toxicology, benzodiazepines were the most common substance present (28 cases). Morphine was found in 25 cases, alcohol in 22 cases and methadone or gabapentin/pregablin was detected in 16 cases. Although methadone was detected in 16 cases, only 7 of these individuals were prescribed this. Page 1 of 48
A Case Vignette of a Typical Drug Death Victim in Fife in 2015 The average drug death victim from Fife in 2015 would be a White Caucasian 37 year old male. At 16 years he would have left school without formal qualifications and entered employment. His home life whilst growing up would have been unstable; his parents would not have stayed together, nor would he have had regular contact with both parents during his childhood. He would have started his substance misuse at the age of 16 years by taking cannabis, and have proceeded to misuse a cocktail of drugs. At 22 years he first smoked heroin and moved over to injecting at 23. He would have maintained meaningful and close relationships with his friends and family members throughout his life. He would have had children; however, he would have lost custody of them and they would have lived with others. He would have been known to at least 2 services intermittently, including his GP and Social Work, during the 5 years prior to his death. In this time he would have been misusing several types of substances including heroin and benzodiazepines (prescribed and/ or non-prescribed). Furthermore he would have experienced at least one non-fatal overdose. He would have a criminal record and have served a prison sentence some point during his life. He would also have encountered an adverse life event alongside physical and psychological health issues. At the time of his death he would be single, unemployed, living alone in an area of highest social deprivation, and would not have changed accommodation type during the previous 6 months. He would have been classed as single, but may have been in a volatile, on/off relationship at this time. He would have been close to friends and family members and so would not have been socially isolated. During this time he would have been only known to his GP and this was to address both physical and psychological health issues. He was prescribed medication to address his depression, and was compliant with this treatment. He would not have sought or received pharmacological treatment for his drug dependency, nor engaged with any services to address his drug misuse issues. He died at his home address in the presence of others, these individuals would have believed him to be sleeping and any attempts to revive him would therefore have been delayed. CPR was attempted by witnesses and an ambulance attended the scene. He had not been supplied naloxone, and naloxone was not used by witnesses at the time of this overdose to attempt resuscitation. At post mortem his blood sample would have revealed a cocktail of depressants such as morphine, benzodiazepines, alcohol, methadone and gabapentin. His cause of death was attributed to Morphine/Heroin intoxication in combination with at least one other substance. If used in a timely manner, naloxone may have reversed the overdose. Compared to this gentleman who died in 2015, the ‘typical’ Drug Death victim in 2013-14 was a 36 year old male; also unemployed, single, living alone. The 2013-14 victim commenced illicit drug use about 2 years earlier than in 2015 (aged 20), and started injecting drugs approximately 1 year earlier than in 2015 (aged 22). Both 2015 and 20132014, victims had a cocktail of depressants in their blood.
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Fife Drug Death Monitoring Group Background The Fife Drug Deaths Monitoring and Strategic groups evolved under the auspices of the Fife Alcohol and Drug Partnership (ADP), in order to identify a systematic approach to synthesising individual drug deaths, which includes the analysis of similarities, trends and patterns among them. This report summarises the findings of drug deaths that occurred in Fife in 2015. As from 2013, the ADP reformulated the Fife Drug Death Strategic Group into a Fife Overdose Prevention Group reflecting the activities identified as necessary processes to occur to further reduce drug deaths in Fife through the profiling of these cases between 2005-2015. Aims and Objectives The principal aims of the report included data collection and analysis pertaining to the demographic, social, criminal offending, substance misuse, physical, psychiatric/psychological and service use characteristics as well as the specific circumstances of drug deaths in the Fife area. Consequently, findings have enabled the groups to set forth recommendations to facilitate the reduction of drug deaths and inform policy and practice at a local and national level. Methods The population of drug deaths (DDs) in Fife in 2015 consisted of 31 cases. Information about these deaths were collected via dissemination of the Fife Drug Deaths Questionnaire and/or case notes held by social care services, specialist addiction services, general practice, prison and police services e.g. Scottish Criminal Records Office (SCRO). Data relating to the specific cause of death, post-mortem and toxicology was otained from the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary. Key Results Incidence and Prevalence of Drug Deaths Demographic, Social Functioning and Life Context Trends Criminal Justice Issues and Offending Patterns Physical, Psychological/Psychiatric Health and Significant Life Events Substance Misuse Histories Service Use Histories Circumstances of the Death Toxicology Findings
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Section 1: Introduction 1.1 Background The National Investigation into Drug Related Deaths (DRD) (2005) commissioned by the Scottish Executive and conducted by the Centre for Addiction Research and Education Scotland (CARES) examined the social, clinical circumstances and service contacts of those dying as a result of a drug related death in Scotland in 2003. This investigation and subsequent Scottish Advisory Committee on Drug Misuse (SACDM) report and recommendations (2005) identified the need to establish a local standing Drug Deaths Monitoring and Prevention Group that involved key agencies to reduce deaths under the auspices of local Alcohol and Drug Partnership (ADP). Prior to October 2009 the ADP was named the Fife Drug Alcohol Action Team (DAAT). 1.2 Governance and Structure A Fife Drug Deaths group was already in place in Fife since 2003, as a key-working subgroup, accountable to Fife DAAT (now ADP). Initially, the committee met regularly to consider the circumstances surrounding Drug Deaths in Fife in collaboration with services. However, in 2005, the groups made a number of recommendations to the ADP and a subsequent revision of the group structure took place. Between 2005 and 2012 the Fife Drug Death Group was divided into the Fife Drug Death Monitoring and the Fife Drug Death Strategic Group. The former’s core responsibility was to profile drug death cases, collect information from a multitude of agencies and then conclude cause of death and provide recommendations to the Fife Drug Death Strategic Group. The role of the Fife Drug Death Strategic Group together with the Fife Overdose Prevention Co-ordinator was to establish a yearly action plan that all agencies in Fife were committed to deliver. These action points contained suggested improvements in clinical and information governance structures and responses, delivering overdose prevention programmes Fife wide through service level agreements and operational guidelines together with a series of educational activities to clinicians and other service providers. In 2013 the Fife Drug Death Strategic Group was changed into the Fife Overdose Prevention Group as a reflection of past achievements in establishing a robust system that allowed a new focus on improving care pathways and further collaborative working environment that is responsive, effective and able to capture ‘hidden’ populations and others that were deemed to be chaotic but not engaging with services in Fife. 1.3 Mission Statement The mission statement of the Fife Drug Death Monitoring Group and Fife Overdose Prevention Group is to facilitate a ‘Fife wide multi-agency approach to understanding and preventing drug deaths’. 1.4 Ethos and Philosophy of Fife Drug Deaths Group The Drug Deaths Groups have two principal functions: The first aims to determine common demographic, social, criminal offending, substance misuse, physical, psychiatric/psychological, service use characteristics and circumstances of drug deaths. This is accomplished through the dissemination of an in-depth questionnaire to all agencies. All services are notified of a suspected drug death, and are asked to provide information about those individuals that they have had contact with. Page 4 of 48
Therefore all agencies involved in the provision of a service to the Drug Death (DD) victim form the monitoring component of the group. The second element uses the information gathered to draw upon trends, similarities, and key themes arising from the drug deaths and aims to formulate strategic action plans to address these issues in order to reduce the number of drug deaths in Fife. This aim fulfils the purpose of the strategic component of the group. Thus, in line with national recommendations, the strategic and/or overdose prevention group endeavours to inform and disseminate good practice, and enhance the provision of care to reduce the growing number of Drug Deaths in Fife. 1.5 Recommendations arising from the Drug Death Group Meetings/Drug Death Report The Fife Drug Death Monitoring Group considers the circumstances surrounding each drug death in detail. Based on the information available to the group, recommendations are made in this report to inform future decision making by relevant bodies, and to inform the ongoing work plan for the Fife Overdose Prevention Group. Section 3 considers in depth the information gathered on all 31 individuals who died of a drug death in Fife 2015. This section is split into 8 sub-sections to allow different characteristics to be examined separately. At the end of each sub-section there are recommendations for future actions pertaining to the information presented. As each subsection has recommendations considering the particular circumstances under discussion in that sub-section, some recommendations may be repeated throughout the report if they are applicable to more than one sub-section. With this in mind, key themes across the sub-sections have also been considered and are summarised in section 4. Most recommendations relate to three areas of; education, communication and
intervention.
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Section 2: Methodology This report is a retrospective analysis of trends, similarities and common themes occurring within victims of drug deaths in Fife over the past year (2015). The information contained in this report is descriptive in nature and does not infer that the presented information necessarily identifies risk factors attributable to a drug death. In order to accomplish such a task one would require a controlled sample of a living, drug taking and general population. Instead, the trends and patterns in this report can be treated as factors which commonly precipitate a drug death, rather than cause it. Throughout this report comparisons are made between Fife 2015 data and Scotland wide 2014 data. Unless specifically mentioned, the Scotland 2014 figures have been taken from the National Records of Scotland report on Drug-related deaths in Scotland 2014(1). At the time of writing, figures for Scotland wide 2015 drug-related deaths have not been released. 2.1 Population In 2015, the Fife Drugs Death Monitoring Group considered a total of 41 cases which were either highlighted by the police at the time of death as a suspected drugs death, or highlighted later following the release of the post-mortem report. 10 of these 41 individuals were later confirmed (by post-mortem examinations and toxicology) to have died of causes other than the direct effect of illicit substances. In Fife in 2015 there were 31 individuals who died directly from a drugs death. Not all deaths of known drug users in Fife in the period 2015 were reported to the Fife Drugs Death Monitoring Group. A total of 68 suspected drug related cases in Fife 2015 were investigated by the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary on the direction of the Procurator Fiscal where the victim was a known current or previous drug user; intravenous and non intravenous. 27 of these cases were not considered by the Fife Drugs Death Monitoring Group as a suspected drug death. Considering the recorded cause of death of these 27 individuals, death by fatal cardiovascular events was most common in this group.
The number of drugs deaths in Fife in 2015 consisted of 31 individuals, the circumstances of which are described in detail in Section 3 of this report.
2.2 Definition of a Drug Death (DD) The definition of a Drug Death (DD) is complex, with individual studies adopting specific definitions, which vary depending upon the focus of the study. The Scottish Criminal Drugs Enforcement Agency (SCDEA) defines a drug death as: ‘Where there is prima facie evidence of a fatal overdose of controlled drugs. Such evidence may be recent drug misuse, for example controlled drugs and/or a hypodermic syringe found in close proximity to the body and/or the person is known to the police as a drug misuser although not necessarily a notified addict.” The complexity of providing a suitable definition of what constitutes a drug death is demonstrated by the differences in definitions incorporated by different organisations. For example, the World Health Organisation (WHO) defines it as ‘fatal consequences of the Page 6 of 49
abuse of internationally controlled substances and/or of non medical use of other substances for psychic effects,’(2). This definition allows the incorporation of deaths indirectly associated with drug abuse, which would be excluded by the SCDEA, such as chronic intoxication, suicide, drug abuse-related accidents and drug-abuse related diseases. This definition is similar, but not identical, to the definition employed by the National Records of Scotland (NRS). The NRS definition includes instances in which toxicological findings indicate the presence of a controlled substance, but where this substance may not necessarily have been a factor contributing to the individual’s death. Any deaths directly resulting from the overdose of a drug listed under the Misuse of Drugs Act 1971 and relevant amendments, in the year 2015 have been included and considered in this report. In 2014, tramadol and zopiclone became controlled substances under an amendment to this Act, consequently 2015 is the first full year that deaths involving these substances have been considered by the Fife Drugs Death Monitoring Group. The ICD-10 inclusion and exclusion criteria of what constitutes a drug death presented below are used by various national investigations into drug deaths, e.g. The National Investigations into Drug Related Deaths 2003, Drug-related Deaths in Scotland in 2014 (National Records for Scotland) and Drug Misuse Statistics Scotland (Information Services Division, 2008). Subsequently, the Fife Drug Death Monitoring and Strategic Groups conform to this definition of a drug death. However, based on the experience of the Fife Drug Death Monitoring Group, we are aware that the interpretation of this definition can, in practice, be rather subjective. As such, we may be excluding deaths that might in other settings be considered a drug death, and vice-versa. As mentioned previously in this report, to compare the Fife 2015 data with National statistics, comparisons have been made with data contained in the National Records of Scotland report on Drug-related deaths in Scotland 2014. Differences in definitions of inclusion and exclusion criteria between these data sets may make these comparisons less robust than they may otherwise be. 2.3 Inclusion Criteria: ICD-10 Drug Deaths, where the underlying cause of death has been coded to the following subcategories of ‘mental and behavioural disorders due to psychoactive substance use’; a) (i) opioids (F11) (ii) cannabinoids (F12) (iii) sedatives or hypnotics (F13) (iv) cocaine (F14) (v) other stimulants, including caffeine (F15) (vi) hallucinogens (F16); and (vii) multiple drug use and use of other psychoactive substances (F19) b) Deaths coded to the following categories and where a drug listed under the Misuse of Drugs Act (1971) was known to be present in the body at the time of death: (i) (i) (ii) (iii)
accidental poisoning (X40-X44); intentional self-poisoning by drugs, medicaments and biological substances (X60—X64); assault by drugs, medicaments and biological substances (X85) and event of undetermined intent, poisoning (Y10-Y14) Page 7 of 49
2.4 Exclusion Criteria (a) (b) (c) (d)
deaths coded to mental and behavioural disorders due to the use of alcohol (F10), tobacco (F17) and volatile substances (F18) deaths coded to drug abuse which were caused by secondary infections and related complications (e.g. septicaemia) deaths from AIDS where the risk factor was believed to be the sharing of needles; deaths where a drug listed under the Misuse of Drugs Act was present because it was part of a compound analgesic or cold remedy, e.g.: - Co-proxamol: Paracetamol, dextropropoxyphene - Co-dydramol: Paracetamol, Dihydrocodeine - Co-codamol: Paracetamol, codeine sulphate
All three of these compound analgesics have, particularly co-proxamol, been used in suicidal overdoses.
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Guide to the information gathering process 2015 Step 1 Suspected Drug Death
Police request Post-mortem/ Toxicology results from Procurator fiscal
Police attendance & investigation
Step 2
Dissemination of DD Questionnaire to all agencies
Police inform Drug Death e-mail of Suspected DD GP notes requested
Step 3 Information on DD victim returned
Step 4 Agencies known to DD victim complete DD Questionnaire & return to DD e-mail Police return Post-mortem/ Toxicology Report, Sudden Death Report, Custody report and Conviction reports to NHS Fife Agencies not known to DD victim advise of no contact Forensic Medicine Unit, Edinburgh send Post-mortem reports of drug deaths directly to DD e-mail
Step 5
Drug Death Monitoring Group Drug Death monitoring group meet and discuss each death to decide if the Suspected DD is a Confirmed DD
Not a confirmed DD
No further action taken
Drug Death Researcher
Confirmed DD
Drug Death monitoring group make recommendations following discussion of case
All information is inputted into the Fife DD Database
Required Information is reported to ISD Database
Key Page 9 of 49
DD = Drug Death
Fife Drug Death Report 2015 2.6 Step-by-step Guide to Data Collection 2015 Step 1. A suspected Drugs Death occurs in Fife, police attend and carry out investigation into the circumstances surrounding the death. The length of the investigation depends upon the individual circumstances and can vary from a few days to a number of months. Police Scotland also request toxicology from the Procurator Fiscal. Step 2. Police informs NHS Fife via the secure Drug Death e-mail address, which in turn disseminates the Fife Drug Death Questionnaire to all relevant agencies for completion. Step 3. Agencies check records to see if the individual has accessed their respective services. If the individual is known to a particular agency, the Drug Death Questionnaire is completed by that agency and returned to NHS Fife Addiction services for the attention of the Drug Death Monitoring Group. If Individual is not known to the agency, a nil return is sent. The Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary send postmortem/toxicology reports of all deaths where the individual was a known drug user to the secure Drug Death e-mail address. Step 4. The Fife Drug Death Monitoring Group meets at least every eight weeks and discusses each death. If additional meetings are required these are scheduled accordingly. If the Death is not confirmed as a drug death, no further action is taken. If it is confirmed as a Drug Death, the group makes recommendations based on learning from the case. Step 5. The Drug Death Researcher inputs the information in the Fife Drug Death Database. The Drug Death Researcher, on behalf of the Fife Drug Death Monitoring Group, reports each Drug Death, alongside all the detail required of the death, to the national drug related death database (NDRDD).
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Fife Drug Death Report 2015 2.7 Protocol and Creation of the Drug Deaths Database The template utilised in creating the Fife Drug Deaths Database was formed from a combination of the Centre for Addiction Research and Education Scotland (CARES) questionnaire used in the Scottish Executives National Investigation into Drug Related Deaths in Scotland in 2003 (2005) and extracts from the Scottish Criminal Drug Enforcement Agency (SCDEA) questionnaire. The questionnaire contains the following domains: 1. 2. 3. 4. 5. 6. 7.
Demographic Characteristics Life Context and Social Functioning Criminal Justice Issues and Offending History Substances Use History Physical and Psychological Health Service Provisions Additional information
This questionnaire is disseminated to all relevant agencies concerned in the provision of care or services to the drug death victim (e.g. CJS, NHS Fife Addiction Services and voluntary bodies such as FIRST and DAPL). Upon completion, the questionnaire(s) are returned and information pertaining to the domains outlined above is entered into the database. In order to adhere to data protection principles, data is anonymised where possible, and coded accordingly. The database is securely held on a stand-alone machine and housed within Addiction Services, NHS Fife. All governance and data-sharing between the statutory and non-statutory agencies in Fife (known as the ‘gold standard’) have been formalised and approved. 2.8 Drug Deaths Database The main source of information for the current report was the Fife Drugs Death Database (EXCEL/SPSS), which holds all data on drugs deaths that have occurred within the Fife area since 2005. 2.9 Data Analysis For the purposes of the present report, data contained within the Drug Deaths Database was collated by one researcher. The data analysis presented in the current report is limited to descriptive statistics. The researcher is supervised by the Chairman of the drug death group. Data collection processes also involved constant liaison with group members and the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary. The process of data collection and analysis broadly involved the following stages: 1. Maintenance of the database on a regular basis, entering of new information and regular cleansing of existing data 2. Background research on past/current government directives and relevant literature 3. Extraction of relevant data pertaining to the seven domains of the questionnaire outlines above 4. Data analysis (via Excel/SPSS) and interpretation/synthesis 5. Presentation of results
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Fife Drug Death Report 2015 2.10 Data Collection Sources Outlined below are lifestyle domains and sources used in data collection: Domain
Sources Used
1. Demographic Characteristics
- Sudden Death Report - Fife Drug Death Questionnaire
2. Life Context and Social Functioning
- Sudden Death Report - GP Notes and Correspondences - Fife Drug Death Questionnaire
3. Criminal Justice and Offending
- CHS (Criminal History System) - Crime File - Sudden Death Report - Fife Drug Death Questionnaire
4. Substance Use History
- Sudden Death Report - GP Notes and Correspondences - Fife Drug Death Questionnaire - Post-Mortem/Toxicology Report
5. Physical and Psychological Health
- Sudden Death Report - GP Notes and Correspondences - Fife Drug Death Questionnaire - Post-Mortem/Toxicology Report
6. Service Use History
- Sudden Death Report - GP Notes and Correspondences - Fife Drug Death Questionnaire - Post-Mortem/Toxicology Report
7. Circumstances of the Deaths
- Sudden Death Report
8. Toxicology Findings
- Post-Mortem/Toxicology Report
2.11 Missing Data The availability or lack of information for all cases is stated clearly throughout the content of this report and it is noted that use of multiple sources may reflect variations in the data obtained. Indeed, the drug death group acknowledge this as part of an ongoing aim, rather than a limitation, whereby the aim is to continue to synthesise information from multiple sources and develop a systematic approach in identifying the lifestyle patterns of drug death victims. Liaison with the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary has provided information about the circumstances of the death of individuals in Fife who had been known to use illicit substances in life. For those individuals who did not initially come to the attention of the Police as a suspected drug death, some individuals will be identified as dying from a drug death based on the final Page 12 of 49
Fife Drug Death Report 2015 post-mortem report, but more likely their death will be attributed as a drug related death or a cause unconnected to illicit substances. There have been ongoing difficulties in obtaining information from the Scottish Prison Service regarding female offenders from Fife. Although this is a relatively small number of individuals, this information would be as valuable for this cohort as that for male offenders.
Recommendations
Continue the Fife Drug Deaths Database to produce and report data, both annually and accumulatively. Consider the future potential to examine cases not categorised as drug deaths, but as drug related deaths or suicides where illicit substances are involved. Identify contacts working with female prisoners to complete drug death questionnaires. Consider the cause of deaths of all known drug users in Fife identified by the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary to identify trends in this population. Encourage a collaborative approach to data sharing between several initiatives (e.g. suicide, alcohol related deaths, road deaths) in order to enhance the understanding of deaths in the substance using population.
2.12 Format of Results The results of the present report are, as previously stated, analysed from a descriptive perspective and are then compared and contrasted to drug deaths at a Scottish national and UK-wide level. For the purpose of clarity, the structure of the present report does not directly reflect the layout of the Fife Drug Death Questionnaire; instead, the results section (Section 3) is divided into the following series of sub-sections: 1 - Demographic Characteristics 2 - Life Context and Social Functioning 3 - Criminal Justice and Offending 4 - Physical, Psychological/Psychiatric Health and Significant Life Events 5 - Substance Misuse Histories 6 - Service Use Histories 7 - Circumstances of the Deaths 8 - Toxicology Results
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Fife Drug Death Report 2015 Section 3: Results 3.1 Demographic Characteristics
This section describes patterns surrounding the incidence and location of drug deaths. It also considers gender, age and ethnicity of drug death victims.
3.1.1 Incidence and Prevalence of Drug Deaths In 2015 the Fife Drug Death Monitoring Group reviewed 41 cases including drug related, non-drug related and drug deaths cases. All of these cases were discussed and reviewed in clusters, which enabled the group to focus on the individual circumstances surrounding each death. Additionally in 2015 there were a further 27 cases of deaths in Fife investigated by the Forensic Medicine Unit, Laboratory Medicine Edinburgh Royal Infirmary on the direction of the Procurator Fiscal where the victim was a known drug user. None of these 27 cases were considered by the Fife Drugs Death Monitoring Group as a suspected drug death. Considering the cause of death of these 27 individuals, fatal cardiovascular events were most common in this group. Considering that this cohort were known drug users, the consideration of the circumstances of their deaths may provide valuable insight into risk factors pertaining to this vunerable group of individuals. The group’s definition of a drug death considers those deaths that are directly attributable to the overdose of an illicit substance and not the broader scale of deaths including deaths from accidental injury, blood borne viruses and suicides, even if these involve illicit substances. Toxicology reports and discussions identified a total of 31 cases which conformed to the group’s definition of a drug death. However, the excluded deaths should in no way be taken as an indication of the number of drug related deaths in Fife in 2015.
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Fife Drug Death Report 2015 Prevalence of Drug Deaths in Fife 2005-2015
The above graph displays the number of drug deaths over time between 2005 and 2015 inclusive. Data points for the moving average are plotted at the centre point of the three year time period considered Since 2005, there have been a total of 261 drug deaths in Fife. In 2015, 31 individuals died of a drug death, an increase in numbers compared to the previous year. Three year moving averages were calculated from 2005-2015 and illustrated in the above graph, this representation of the data smoothes out annual fluctuations in numbers, illustrating the trend in drug death numbers since 2005. Key Points
Fife had a total of 31 drug deaths in 2015. In 2015, there were a higher number of drug deaths in Fife compared to the previous year. Drug related death cases are not officially recorded by this group In 2015 68 individuals died in Fife who were known drug users, 37 individuals were considered to have died of causes other than a direct drug death.
3.1.2 Residency of Drug Death victims within Fife We considered the location of the individuals’ last known home address as detailed on the post-mortem report. The home address was not always the same as the location of death. Compared to previous drug death reports where geographical areas were defined by Fife police divisions, in this report they are expressed in terms of Area Committees. Page 15 of 49
Fife Drug Death Report 2015 This mirrors the structure of the Fife Alcohol and Drug Partnership local community planning areas. Population projections for Fife’s local committee areas in 2015 are shown in the following table. Numbers have been adapted from information produced by the National Records of Scotland Office based on population trends observed from 2001-2008 and projected forward to 2015.(3) Population projection of the Geographic Areas within Fife in 2015 Fife Area Committee Locations Whole of Fife
Population estimate
362,431
City of Dunfermline Dunfermline
Cowdenbeath Cowdenbeath
Glenrothes Glenrothes
Kirkcaldy Kirkcaldy
Levenmouth Buckhaven Kennoway Leven Methil
North East Fife Anstruther Cupar Guardbridge St Andrews Tayport
54,712
40,184
49,657
60,362
37,420
71,891
2015 DDs in Fife by Area Committee per 1000 of the Population
Using these 2015 population projections, actual numbers of drug deaths in Fife in 2015 are expressed as death rate per 1000 population.
Fife Area Committee
Number of drug deaths 2015
Drug death rate per 1000 Based on 2015 population projections
City of Dunfermline Cowdenbeath Glenrothes Kirkcaldy Levenmouth North East Fife South West Fife No Fixed abode Fife
6 8 2 6 5 3 0 1 31
0.11 0.20 0.04 0.10 0.13 0.04 0 n/a 0.09
Scotland 2014
613
0.11*
To compare with Scotland as a whole, drug related death data, as reported by the National Records of Scotland report on Drug-related deaths in Scotland 2014 has been included in this table(1). *The National Records of Scotland used the annual average data for 2010-2014 to reduce the effect on the figures of year-to-year fluctuations on their drug death rate. For comparison with previous reports, drug death data in the historic police divisional areas and the death rates of individuals per 1000 individuals of the population has been calculated. Furthermore, 2013 and 2014 data has been included to show fluctuations over the past three years(4) Page 16 of 49
South West Fife Rosyth
48,747
Fife Drug Death Report 2015 Estimated Population of the Geographic Areas within Fife in 2015
Central Buckhaven Glenrothes Kennoway Kirkcaldy Leven
East Anstruther Cupar Guardbridge St Andrews Tayport
West Cowdenbeath Dunfermline Rosyth
147,439 14
71,891 3
143,643 13
0.09
0.04
0.09
0.10
0
0.04
0.12
0.04
0.05
Population 2015 Drug deaths 2015 Drug death rate per 1000 2015 Drug death rate per 1000 2014 Drug death rate per 1000 2013
The calculation of the number of DDs per 1000 of the population corresponding to the location of the drug death enables identification of DD hotspots. Across the whole of Fife, the rate of drug deaths per 1000 population in 2015 was 0.09, this compares with the Scottish rate of 0.11. In 2014 this rate in Fife was 0.06 compared to the then Scottish rate of 0.10(4). When considering separate geographical areas of Fife the 2015 rates vary from 0 to 0.2 drug deaths per 1000 population. However, due to low numbers in individual areas, small increases/decreases in the number of absolute fatalities can change these rates considerably. Regardless of which area of Fife the individual lived in, most deaths occurred in areas of social deprivation. Just under half of individuals lived and died in the most deprived areas (postcode) of Fife as described by SIMD 2012(5). Scottish Index of Multiple Deprivation (SIMD 2012)
Cases 2015 Quintile 1 (Most Deprived) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (Least deprived) No fixed abode
14 9 3 3 1 1
The majority of drug deaths in 2015 occurred in the individual’s own homes or their semi-permanent residence (22 cases). Two individuals died in hospital, but prior to hospital admission they had resided at their home address. One individual did not have a fixed home address, and was described as ‘No Fixed Abode’. Five individuals died at addresses different from their own, but still within their home town. Only one individual died in a town which was not their home town. Page 17 of 49
Fife Drug Death Report 2015 Together, these results indicate that in 2015 the majority of DD victims died in close proximity to their homes. Thus, we can assume that it is likely that they did not have to travel far to obtain their drugs and elevated death rates in specific locations are not as a result of individuals travelling to those areas in order to obtain the drugs. Key Points
The average drug death rate in Fife in 2015 (0.09 per 1000) was lower than the 2014 Scottish rate of 0.11 per 1000 population. However, this is an increase compared to 2014 when the drug death rate in Fife was 0.06 deaths per 1000.
3.1.3 Age, Gender and Ethnicity Age Age at time of death < 25 years 25-34 years 35-44 years 45-54 years Mean age Median age
All cases
Males
Females
1 12 12 6 37.39 years 36 years
0 8 7 4 37.74 years 36 years
1 4 5 2 36.83 years 36 years
The age of drug death victims in 2015 ranged between 22 and 52 years, with a mean age of 37.39 years (the mean age of death in Fife 2014 was 37.05 years (4)), median age 36 years. This compares to Scotland in 2014 where the median age of death was 40 years (1). Overall the Fife figures indicate a slight but steady increase in the average age of death in 2015. When considering the Scottish age ranges compared to Fife, Fife drug deaths occurred at a younger age than Scotland as a whole. However, the increase in the age of the average Fife drug death individual agrees with the national trend to an older age profile. This pattern of an increasing average age of fatal drug overdoses is also reflected Europe wide, as detailed in the EMCDDA’s 2014 European Drug Report(6) the European mean age at death was 36 years. This indicates that there is an aging cohort of vulnerable illicit drug users. Sex
Cases 2015 19 12 31
Male Female Total
% 61.3 38.7
The majority of Fife DD victims in 2015 were male (61.3%). In comparison with this, across the whole of Scotland in 2014, 74% of all drug death victims were male.
Page 18 of 49
Fife Drug Death Report 2015 Compared to previous years, the percentage of female to male victims is increasing in Fife; in 2012 8.7% of drug death victims were female, in 2013-14 this rose to 10.4% and in 2015 the number was 38.7%. This increase in percentage female deaths represents an overall increase in female numbers rather than a reduction in male ones. Furthermore, over a specified time period (averages for 2000-2004 compared to averages for 2010-2014) the 2014 National Records of Scotland report noted that the number of female victims in Scotland increased at a much higher rate than males (141% rise in female numbers compared to a 50% increase in male numbers) (1). Ethnicity
Cases 2015 30 1 31
White Scottish White British Total
% 96.8 3.2
All of the drug death victims were White Caucasian and apart from one individual, had spent all, or the majority, of their life in Scotland. This is not reflective of the Fife ethnicity as per the 2011 census where a lower 85.7% respondents indicated they were White Scottish and 11.9% White British(7).
Key Points 2015
The mean age of the Fife drug death victims increased slightly to 37.39 years (2013-2014 was 36.10 years). Drug death victims were aged between 22 and 52 years of age at the time of their deaths, with the majority aged between 25-44 years of age. 38.7% of the victims were female – a higher proportion than in previous years (10.4% in 2013-14). This represents an overall increase in the number of females who are dying 96.8% of Fife drug death victims were ethnically White Scottish
Recommendations:
Identify drug death hotspots within geographical areas and target interventions accordingly Explore female support groups to target this increasingly at risk group Target interventions at all age groups, especially those in their midthirties and older
Page 19 of 49
Fife Drug Death Report 2015 3.2 Life Context and Social Functioning This section describes drug death victims’ accommodation and living arrangements at the time of their death and in the six months preceding their death. This section also considers information relating to employment, both directly after school and at the time of death and patterns surrounding the individuals’ relationships with both family and friends.
3.2.1 Housing and Living Arrangements Living arrangements at the time of death
Cases 2015 Lived alone Lived with relative(s), partner may also be in household Lived with partner only Living with friend(s)
16 9 3 3
The majority of drug death cases were living on their own when they died. Of these 16 individuals who were alone when they died, nine had been living with others at some time in the six months prior to death. Only 7 individuals had lived alone for the whole 6 months prior to death. One individual was described by reporting services as “homeless” at the time of their death with no fixed abode. This individual stayed with a friend the day of their death and has been classified as such. Considering the information regarding these individuals, 10 of these 31 would be classified as having been homeless at some point in the 6 months prior to death. When considering the housing status of the drug death victims, it is important to recognise that in many cases the living arrangements varied frequently, and the lifestyles of a number of these individuals were described as “chaotic”. As such, 12 victims had two or more different types of living arrangements identified in the six months prior to their deaths. Four of these twelve had been detained in prison the 6 months prior to their death, one individual had ended a relationship and moved, one individual had started a relationship and moved in with their new partner, 3 individuals split their time between two households and three individuals had various temporary addresses. The majority of individuals had been living with somebody either at the time of death, or within 6 months of their death (24 individuals, 77.4%), suggesting that they may have a network of friends and families. It also indicates that amongst the chaos of their drug use they were able to sustain relationships with others.
Page 20 of 49
Fife Drug Death Report 2015 Key Points
While a substantial proportion of drug death victims lived with others, the majority were living alone at the time of their deaths. Of those 16 living alone when they died, 9 had been living with others in the 6 months prior to death. The living arrangements of drug death victims at the time of their deaths remained constant in the six months prior to death for 19 of the 31 individuals.
3.2.2 Relationship and Family Information The relationship status of the drug death victims at the time of their deaths was also considered, since it provides an indication of the level of social support available to them. Relationship status at the time of death
Cases 2015 In a relationship Recently separated (in the past 6 months) Single
11 6 14
To determine relationship status at the time of death was not straightforward. If the individual was in a relationship with a partner at the time of death they were classified as ‘in a relationship’. If there was no partner mentioned in the six months prior to death they were classified as ‘single’. However, a single individual could arguably be classified as been in a relationship depending on the time between changes of circumstances and a number of individuals had separated just prior to their death. These more fluid relationships of individuals who had separated immediately prior to their death, and those in ‘on-off relationships’ made determining relationship status difficult. To provide consistency, an individual was only considered as ‘single’ if there was no mention of a partner in the 6 months prior to death, otherwise they would be considered to be ‘recently separated’. Of the 17 drug death victims who were in, or had been in a recent relationship, six (35%) had a partner/ex-partner who also had a substance or alcohol misuse problem and 6 (35%) were known to have experienced domestic abuse within these relationships, victim or perpetrator. For these individuals, their drug misuse may have been perpetuated by their environment. Since this information is not recorded routinely, this figure may be higher. 3.2.3 Friendships and Relationships Information about relationships the drug death victims held with relatives/friends was considered, however this information can be difficult to obtain in some cases. Nevertheless, 23 individuals (74.2%) were known to have a close relationship with a family member. In most of these cases (17 of the 23), this close relationship was shared with one, or both, parents, but individuals also enjoyed close relationships with siblings and other family members. 19 individuals (61.3%) had close and lasting friendships with Page 21 of 49
Fife Drug Death Report 2015 friends, and the majority of these individuals also had support of their partners and/or family too. Only 3 individuals (9.7%) had no known partners, family or friends around for support at their time of death. However, the drug death victims also experienced difficulties in these relationships. As such of those 28 individuals with some social contacts, 7 had a relative and/or family member and 12 had at least one friend, who also had a substance misuse problem. Furthermore, 6 individuals experienced significant difficulties in these relationships, including severe and frequent altercations and even assault. Often family members appeared mistrustful of drug death victims following the victim’s previous behaviour when dependent on illicit substances. The fact that many drug death victims had engaged in a relationship shows that they were not socially isolated as a result of their drug use and had managed to maintain meaningful relationships with others, including those outside the drug using community. This suggests that there was perhaps some degree of social support available to the drug death victims as they did have relatives and friends to whom they could turn to. This support base of friends/family can be tapped into to provide important information relating to overdose and drug misuse that could be cascaded to not only the drug using, but wider spectrum of the community. 3.2.4 Relationship with Children Information pertaining to whether or not the drug death victims had any children under the age of 16 was available; if the victim had older children full details were not always collected. Although fifteen of the drug death victims had children under the age 16, this does not imply that they were directly responsible for their welfare, although in many of the cases reviewed they were. Additionally, in one case, an individual who died of a drug death was living in the same household of children under the age of 16 who they were not biologically related to.
Children Number of individuals with children Number of individuals with children under 16 years Number of individuals who lived with own children under 16 years Number of individuals who lived with other’s children under 16 years
22
(61 children in total)
15
(37 children in total)
5
(11 children in all)
1
(2 children in total)
In total, 61 individuals lost a parent as a result of a drug death in Fife in 2015, 37 of these children were known to be under the age of 16. Compared to 2013-14 where only one drug death victim individual had their child living with them for some part of the 6 months prior to death, in 2015, 6 individuals lived with their own, or partner’s, children for some part of the 6 months prior to death. Consequently, 13 children under 16 experienced an individual dying in their (at least parttime) family home. This increase in the number of children living closely with victims of a Page 22 of 49
Fife Drug Death Report 2015 drug death may be a reflection of the increase in number of female victims in 2015 who are often the primary care providers to children.
Key Points
The majority of drug death victims were not socially isolated; many reported a close relationship with a partner, family member and/or a close friendship At the same time, a substantial number of drug death victims were known to associate with other substance misuses or were victims of mistrust or violence Just under half (15) of victims had children under the age of 16; 6 of whom lived with their children or their partner’s children. 61 individuals lost a parent as a result of a drug death in Fife in 2015, 37 were under the age of 16.
3.2.5 Education and Employment Status The age at which individual drug death victims left school was unknown for 4 individuals. For the remaining twenty-seven cases considered; the mean age at which drug death victims left school was 16 years (this is the same as in 2013-14). Eight individuals (25.8%) were reported to have left school with some qualifications; this is lower than in 2013-14 when a third (33.3%) had qualifications on leaving school. Employment status on leaving school Employed Further education Training/apprentice Unemployed Unknown
Cases 2015
%
10 7 3 5 6
32.3 22.6 9.7 16.1 19.4
There was not any information for the post-school destination of 6 of the 31 individuals. Of the remaining 25 cases, twenty were known to enter employment, training or further education after school. Employment status at time of death Employed Further education Training/apprentice Unemployed Unknown
Page 23 of 49
Cases 2015
%
2 0 0 28 1
6.5 0 0 90.3 3.2
Fife Drug Death Report 2015 Employment status at time of death was known for 30 of the 31 individuals. Two were known to have been in employment and 28 were unemployed at the time of death. Those unemployed were in receipt of some kind of state benefit. Benefits were also known to be supplemented by criminal activities in six cases, loans in one case and one individual had just received a back-dated large payment of benefits. There is a large discrepancy between the employment status of individuals post-school education and immediately prior to death. This is perhaps not surprising given that drug death victims had a prior history of drug abuse starting around the age of 16 years. (see section 3.5.1 for further details). Overall, the information on employment status indicates that this is a population with a broad range of skills and occupations, many of whom entered employment, further education or training apprenticeships. Few were unemployed after leaving school. However this trend was reversed prior to death with large number of drug death victims being unemployed and few being in any meaningful form of employment. Targeting overdose awareness training, including the use of naloxone, to individuals at risk of an overdose and their acquaintances in the wider community, may reduce incidences and consequences of non fatal/fatal overdoses.
Key Points
The mean age at which the drug death victims left school was 16 years Most of the drug death victims were engaged in some form employment or education after leaving school Only 16.1% were unemployed after leaving school. However this figure was reversed before death, at which point 90.3% of drug death victims were known to be unemployed.
Recommendations
Provide overdose/naloxone awareness training in high risk areas such as shelters or hostels Explore opportunities to provide overdose/naloxone awareness to individuals who are anticipated to be homeless after leaving prison Explore opportunities to provide overdose/naloxone awareness to family/friends Explore opportunities to extend drug prevention programmes to young people prior to leaving school (approximately aged 14-16). Explore opportunities to extend drug prevention programmes to young people who leave school (approximately aged 16-20). Explore opportunities to provide overdose/naloxone awareness to unemployed individuals, linking in with benefit agencies
Page 24 of 49
Fife Drug Death Report 2015 3.3 Criminal Justice and Offending
The present section examines the drug death victims’ criminal and offending history in more detail. History of incarcerations is also considered.
Thirty of the thirty-one drug death victims had history of criminal offending and a lifetime arrest (96.7% in 2015 compared to 95.7% in 2013-14). The majority of recorded offences were drug related crimes of dishonesty or assault charges. Time since recent arrest
most
Cases 2015 Up to one week 1 week to 2 weeks 2 weeks to 1 month 1 to 6 months 6 months to a year More than a year
1 2 1 8 6 13
In 2015, 38.7% of drug death victims had been in police custody in the 6 months prior to their death, a lower figure than in 2013-14 when 50% had been in custody in the same time period. Of those 12 who had been in police custody within 6 months of their death, at the time of their arrest two individuals disclosed on-going substance misuse problems (drug and/or alcohol), one individual disclosed mental health problems and five disclosed both substance misuse and mental health issues. Seventeen (54.8%) of drug death victims were known to have served a prison sentence some point during their lives. This is similar to 2013-14 when 56.25% of individuals had a prison history. Time since most recent prison release
Cases 2015 Up to one week 1 week to 2 weeks 2 weeks to 1 month 1 to 6 months 6 months to a year More than a year
2 0 0 3 2 10
Five of these seventeen individuals (29%) had been in prison in the 6 months before their death in 2015, in 2013-14 this number was a higher 44.4%. Three of the seventeen drug death victims known to have served a prison sentence were female. Detailed information regarding interventions for female prisoners was not available. Apart from Police/ Social work reports indicating a female had been incarcerated, further information for this group was not always available. The following two paragraphs refer to the fourteen male individuals only. Page 25 of 49
Fife Drug Death Report 2015 From reports obtained, in is not always clear if the individual who served time in prison had been remanded or convicted at the time. While incarcerated, one of the fourteen individuals were known to have received and participated in overdose prevention programmes prior to their release. One individual refused overdose training when offered and two individuals were noted to have had sentences too short for overdose intervention; no individual is known to have accepted a Naloxone supply. This data was not available for the majority of the cases considered. Many of those were incarcerated at a time before overdose training was routinely offered to individuals in HMP Services. Key Points
96.7% of drug death victims had at least one lifetime arrest 38.7% of the drug death victims who had been arrested, were arrested at least once in the 6 months prior to their death. 58% of these individuals disclosed on-going substance misuse issues. 51.6% of the drug death victims had served a prison sentence at some point during their lives 33% of drug death victims died within 6 months of release from prison. Two victims died within 1 week of the date of their release from prison. Only one individual was known to have received overdose training prior to release, and no individuals accepted a supply of naloxone on liberation Recommendations
96.7% of drug death victims had been arrested at some point in their lives, and over 50% of recent arrests (6 months prior to death) disclosed on-going substance misuse issues. This provides an opportunity for early intervention through a treatment and referral scheme in Fife police custody suites. This may include o healthcare systems embedded in custody-based environments to deliver targeted overdose interventions o Close working between custody-based and community environments on liberation for opportunity to refer to services post-liberation. Information sharing between Health/Prison and referral on to services Promote overdose/naloxone education and interventions to vulnerable individuals residing in prison and prior to liberation from custody Develop means to identify individuals not in receipt of substitute medication who remain at risk of relapsing following prison release, for opportunity to refer to services post-liberation. Identify individuals from the female prisons to complete drug death questionnaires
Page 26 of 49
Fife Drug Death Report 2015 3.4 Significant Life Events and Physical/Psychological Health
This section explores the types of physical and psychological/psychiatric suffered by the drug death population in Fife, with a particular emphasis on co-morbidities and adverse life events.
3.4.1 Significant Life Events In their own childhoods, the drug death victims may have experienced adversity. Detailed information regarding the early years of the 31 individuals who died of a drug death in 2015 was not always available and the following discussion may not truly represent the childhood lived experiences of the 2015 drug death victims. Eleven individuals were known to have been brought up by both parents (or parent and step-parent where this individual was a permanent feature in their early life) who stayed together throughout their childhoods. A further 4 individuals had regular contact with both parents in their childhood despite a parental separation. Nineteen were noted to have experienced an unstable home life, often living with different family members or entering foster care for periods of time. Twelve individuals experienced instability in their secondary education, generally due to the management of their disruptive behaviour. Ten eventual drug death victims were known to have experienced significant adversity in childhood, including physical, sexual and/or emotional abuse.
Key Points
Most individuals did not have contact with both parents during their childhood The majority of individuals had an unstable home life, moving between different family members and statutory care-givers until the age of 16 38.7% individuals had an unstable secondary education in response to disruptive behavioural issues 32.3% drug death victims were known to have experienced emotional, physical and/or sexual abuse in childhood
Twenty-five drug death victims (80.7%) were known to have experienced adverse life events in the 6 months prior to death, with many individuals having suffered multiple life events. Also included are any lifetime adult experiences of abuse. The number and type of life events recorded for individuals are summarised below: Adverse Life Event (6 months prior to death) Severe Accident Abuse (physical/emotional/sexual) including domestic abuse (anytime during adulthood) Child custody issues Bereavement Homelessness Relationship break-up Relapse
No. of individuals 0 9
% of individuals (n=31) 0 29%
0 3 11 5 4
0 9.7% 35.5% 16.1% 12.9%
Page 27 of 49
Fife Drug Death Report 2015 Twelve individuals had no recorded adverse life event prior to death, 11 individuals were noted to have one event, 8 had two events. No individual had more than two adverse events in their life. In some cases the drug death victims’ siblings, parents or other family members were substance users. The adverse life events experienced by drug death victims convey a sense of vulnerability, which may have led to the formation of coping by means of substance misuse and therefore impacted negatively upon their abilities to manage adversity in their adult lives. At a basic level, the above information provides an indication of the level of instability of these individuals in their lives. Their personal histories show that these drug death victims experienced abuse, sexual/physical and/or emotional, significant losses/life events, which may have in turn been precipitating, maintaining and/or consequential factors of their substance misuse. 3.4.2 Psychiatric/Psychological Problems Twenty of the 31 drug death victims in 2015 (64.5%) were known to have on-going psychiatric or psychological difficulties (this is the same as 2013-14 where the proportion was 65%). Only two of these twenty individuals were engaging with mental health services (other than NHS Fife Addiction Services) at the time of death, one individual was noted to have a Community Psychiatric Nurse, the other was engaging with the Alcohol Related Brain Damage team. According to GP notes, it appeared that one individual had been referred to psychiatric services, but did not engage. By far the most common problems experienced were mood disorders; all twenty individuals suffered from depression as specified in their GP notes. One individual had also been diagnosed with bipolar (manic-depression) disorder. A number of individuals suffered from anxiety-related problems, in combination with depression. Ten individuals were diagnosed with anxiety, one individual had been formally diagnosed with Borderline Personality Disorder, and one person was diagnosed with panic attacks at the time of their death. Nineteen of these twenty individuals (77.42%) were prescribed medication to manage their psychiatric/psychological issues. Eleven individuals suffered from two or more psychiatric or psychological difficulties at the time of death. Furthermore, 22.6% drug death victims (compared to 25% in 2013-14) were known to have self-harmed at some point in the past, and 35.5% (compared to 18.75% in 2013-14) were noted to have attempted suicide at least once. 3.4.3 Physical Health Problems Twenty-two of the 31 drug death victims in 2015 (71%) had significant on-going physical difficulties; this is higher than in 2013-14 were 58.3% of individuals had on-going physical health issues. Fifteen of these twenty-two were in receipt of medication for these conditions Page 28 of 49
Fife Drug Death Report 2015 Common problems included Hepatitis (Hep) C (n = 4), respiratory problems (n = 8), ongoing pain issues (n=9) and deep vein thrombosis (n = 2). Fourteen individuals experienced two or more physical health problems alongside their substance misuse. None of the four individuals diagnosed with Hep C were engaging with Hep C treatment at the time of their death. Seventeen individuals experienced both physical and psychological health issue problems alongside their substance misuse. Six individuals had no reported on-going physical or psychological health issues. Health status time of death
at Physical health issues Psychological health issues Physical and psychological health issues No health issues
Cases 2015
%
5 3
16.1 9.7
17 6
54.8 19.4
Key Points
61.3% of drug death victims were known to have experienced at least one significant adverse life event prior to their death Most common adverse life events included homelessness or abuse The majority of drug death victims (71%) suffered from psychological or psychiatric difficulties, the most common of which were depression and/or anxiety The majority of drug death victims (64.5%) had significant physical difficulties Most individual with health conditions were in receipt of some medication from their G.P and hence engaged with this service
3.4.4 Co-morbidity Up until this point, the psychiatric problems, physical problems and life events of these individuals have been examined in isolation. In reality, however, individuals often suffer from a combination of these factors. The concept of co-morbidity can differ widely in terms of context and interpretation. For example, an ongoing issue is whether or not co-morbidity should be viewed over the course of a lifetime, or within a predefined context. For the purposes of this report, analysis of the victims’ co-morbid health problems precede in the context of multiple physical, psychological/psychiatric, and substance misuse morbidities over the course of their lives, as opposed to a specific point in their lives. The table below summarises the combinations of physical and psychiatric/psychological difficulties (for the purpose of this table, past self-harm or suicide attempts are included as psychological difficulties), as well as life events experienced by the DD victims in connection with their substance abuse. Page 29 of 49
Fife Drug Death Report 2015 Combinations No noted events Physical difficulties alone Psychological difficulties alone Life Event alone Physical + Psychological Physical + Life Events Psychological + Life Events Physical + Psychological + Life Events
No. of Individuals 1 2 2 4 7 3 1 11
% of Individuals 3.2% 6.5% 6.5% 12.9% 22.6% 9.7% 3.2% 35.5%
As demonstrated by the table above, the combined effects of physical and psychological difficulties, together with life events, are far more prevalent in this population than these difficulties on their own. The vast majority of DD victims had experienced a combination of life events along with significant physical or psychological difficulties, or all three comorbidities, alongside their substance misuse problems. Only one individual had no documented difficulties apart from their substance misuse. Key Points
The majority of drug death victims in 2015 had experienced a combination of psychological and physical difficulties as well as life events alongside their substance misuse problems
Recommendations
Encourage current healthcare systems to identify and monitor vulnerable individuals early in their life cycle. Improved communication between hospital departments and community agencies engaging with substance misusers Improve links between mental health services and General Practitioners Encourage information sharing between Ambulance/Health/Prison and promote referral on to services Promote/maintenance of good health and other services, including treatment for blood borne viruses Continue to monitor emerging populations with complex episodes of physical, psychological and substance misuse problems Increased frequency of screening of people on a methadone programme to ascertain that associated poly-drug use and/or deteriorating health issues will not increase the risk of overdose Encourage shared assessment and exchange of information amongst services, particularly when it comes to crisis events Refer complex cases to specialist services. Continue to closely monitor the life events of drug users and their possible impact on overdose risks.
Page 30 of 49
Fife Drug Death Report 2015 3.5 Substance Misuse Histories
The present section further examines the substance misuse histories of the drug death victims; including the age at which they started misusing illegal substances, lifetime injecting characteristics and overdose histories.
In the 6 months prior to death, 29 of the drug death victims (93.6%) were known to have misused prescribed and non-prescribed drugs in combinations of two or more. In all 29 cases the substances misused included at least one of the following; heroin, methadone, benzodiazepines, anti-depressants (prescribed and non-prescribed) and alcohol. This confirms previous findings of the Fife drug death reports which suggest that almost all drugs death victims are poly-drug users. Two individuals who died of a drugs death had never been known to any agency as a substance misuser. While the focus of this report is on drug deaths occurring as a result of illicit substances, it is nevertheless worth noting that the majority of drug death victims (21 individuals or 67.7%) were also known to have severe problems with their alcohol consumption. This is a higher figure than in 2013-14 where 54.1% of drug death individuals were known to have a lifetime problem with alcohol consumption. For 12 of those 21 individuals, alcohol problems were an on-going concern at the time of death. 3.5.1 Age at which Drug Misuse Began The age at which the drugs death victims started misusing drugs in 2015 was known for 23 individuals and ranged from 12- 35 years, with an average of 16 years. Cannabis was the first substance misused by 16 of the 23 individuals where this information was available. Twenty (64.5%) of the drug death victims in 2015 were known to have injected drugs at some point in their lives (68.75% in 2013-14). Age Substance misuse started (years)
2015
All Substances Heroin Benzodiazepines Injecting started
2013-14
Mean Age years 16 (n=23) 22.7 (n=19) 18.8 (n=11)
Age range 12-35
Mean Age 15.1
Age range 8-28
15-38
20.73
14-46
14-44
18.81
17-37
22.35
Not noted 14-36
23.2 (n=17)
Considering that the average age of a drug death victim in Fife in 2015 was 37.39 years, it suggests that drug death victims had an average drug using career of approximately 21 years prior to death. Page 31 of 49
Fife Drug Death Report 2015 Previous years considering this data have suggested that individuals first smoke heroin for some time before progressing to intra-venous usage. Over time, the gap between smoking and injecting has been closing, in 2013-14 it reduced to less than two years and in 2015 it further reduced to under a year. This assumes the data for injecting behaviour refers to heroin use, it must be remembered that other substances can also be injected, but the detail of substances injected was not available in the reports. These descriptive statistics indicate that overall illicit drug use, heroin use and injecting behaviour started at a slightly older age in 2015 than 2013-14. Benzodiazepine use in 2015 started at the same age as in 2013-2014. Additionally slightly fewer individuals had a lifetime history of injecting illicit substances in 2013-2014 than 2015. 3.5.3 Drug Use Characteristics of Injecting vs. Non-Injecting Users The substances most commonly detected in post-mortem toxicology of injecting and non injecting DD victims were examined further. Post-mortem details were available for all 31 cases considered. Individuals were considered to have a lifetime history of injecting if this was mentioned in their reports. Substance Heroin/morphine Benzodiazepines Methadone Alcohol Gabapentin NPS
Non-Injectors (n = 5)
Injectors (n = 20)
Injecting status unknown (n = 6)
3 (60%) 3 (60%) 3 (60%) 3 (60%) 2 (40%) 2 (40%)
18 (90%) 18 (90%) 10 (50%) 14 (70%) 9 (45%) 3 (15%)
4 (66.7%) 6 (100%) 2 (33.3%) 5 (83.3%) 4 (66.7%) 0
Most individuals had more than one substance present in their toxicology hence the numbers in these columns totalled more than 100%. Five individuals had NPS found in toxicology, two had phenazepam, two had diclazepam, one had 4-Methylethcathinone (4-MEC) and one had etizolam. (A compound was considered to be classified as an NPS if it was a substance listed in the National Records of Scotland report on Drug-related deaths in Scotland 20141 as an NPS for the purpose of statistics of deaths registered in Scotland). 3.5.4 Overdose Histories Twenty-one of the thirty-one (67.7%) individuals in 2015 were known to have experienced at least one drug overdose at some point in their lives. This is a similar number compared to 2013-14 where 63.50% of individuals had at least one recorded overdose. The full details of these overdoses were not always recorded. Where the lifetime number of overdoses was recorded, the number ranged between 1 and 6. Six of the drug death victims were known to have overdosed in the 6 months prior to their deaths (19.4%). Two overdosed twice in the six month period before they died, both of whom had one overdose the week before they died. Sixteen out of the thirty-one individuals were known to have had overdose training during their life (51.6%). This is higher than 2014 when the number who had had this training was 36.8%. Only five individuals were known to have been supplied with take home naloxone, all had been supplied by NHS Fife Addiction services. Page 32 of 49
Fife Drug Death Report 2015 In fourteen cases (45.2%), CPR was initiated at the scene of death by individuals other than paramedics; family, friends, bystanders, an opportunity for community members to intervene in this (ultimately fatal) overdose situation. The availability of naloxone at this time may have complemented this intervention.
Key Points 2015
Almost all drug death victims were known poly-drug users 93.6% The average age at which drug misuse began was 16 years, and age at which individuals first injected was 23.2 years Therefore, by the time of their deaths at 37.4 years, the victims had an average drug using career of over 21 years 64.5% of drug death victims were known to have overdosed at some point in their lives, often on multiple occasions 19.4% victims were known to have overdosed in the 6 months prior to their deaths
Recommendations
Extend the education provided about the dangers of illicit substances to schools and youth groups Promote education regarding the dangers of poly-drug use to at risk groups of individuals. Especially highlight the danger of using a cocktail of sedatives. Encourage information sharing about non-fatal overdoses between Ambulance/Health and promote referral on to services Utilise non-fatal overdose data obtained from the ambulance service to identify trends Facilitate communication between and within agencies to promote awareness of those individuals who have had a history of successive episodes of non fatal overdose. Increase supply of Take Home Naloxone to those who are at risk of overdose or are friends/family of individuals who are at risk of overdose.
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Fife Drug Death Report 2015 3.6 Service Use Histories
The present section outlines the service use histories and frequency of contact with services of the drug death victims in 2015 in the 6 months and 5 years prior to their deaths.
It is recognised that being engaged in a process of care and treatment has a positive impact on outcomes, including reducing drug-deaths. In order to co-ordinate and integrate the care that is provided to individuals it is important to determine the extent of contacts made with services, and the agencies most involved in providing a service to the eventual drug death victims. These contacts, even the briefest of interactions, are valuable opportunities to deliver harm reduction strategies. 3.6.1 Services Accessed within 5 Years Prior to Death Records showed all individuals who died of a drug death in Fife in 2015 had contact with at least one service within the five years prior to their deaths. The particular services involved are listed in the table below:
Service General Practitioner (GP) Social Work (inc Criminal Justice Services) NHS Fife Addiction Services Scottish Prison Service (SPS) Accident and Emergency hospital department Fife Community drug team (FCDT) Drug and Alcohol Project Limited (DAPL) Mental Health Services (Excluding Fife NHS Addiction Services) Maternity Services ADAPT Fife Alcohol Support services (FASS) FIRST
No. of individuals who had contacts 30 25 15 14 3 2 1 1
% of individuals who had contact 96.7 % 80.7 % 48.4 % 45.2 % 9.7 % 6.5 % 3.2 % 3.2 %
1 1 1 1
3.2 % 3.2 % 3.2 % 3.2 %
This table does not include multiple contacts made by an individual to any single agency. Furthermore, this information may be subject to under-reporting of contact from agencies. All but one of the drug death victims had accessed more than one service in the 5 years prior to their death. The individual who had only accessed a single service was only in contact with their General Practitioner. General Practitioner was the most accessed services, followed by Social Work Services, NHS Fife Addiction Services and the Scottish Prison Service. This pattern of contact is very similar to that of previous years. 3.6.2 Services Accessed During the 6 months Prior to Death Twenty-eight individuals were known to have had contact with a service during the 6 months prior to their death. Page 34 of 49
Fife Drug Death Report 2015 The table below shows the number of agencies accessed by individuals in the 6 months prior to their deaths. 18 individuals had contact with multiple services in the 6 months prior to their deaths. This table does not describe the multiple contacts with services within the same period, but does include different agencies accessed by the same individual. Furthermore, this information may be subject to under-reporting of contact from agencies. No. of individuals who had contacts
Service
General Practitioner (GP) NHS Fife Addiction Services Social Work (including Criminal Justice Services) Scottish Prison Service (SPS) Scottish Ambulance Service (SAS) Drug and Alcohol Project Limited (DAPL) Fife Community drug team (FCDT) Accident and Emergency hospital department FIRST YMCA Mental Health Services (Excluding Fife NHS Addiction Services)
26 12 9
% of individuals who had contact 83.8 % 38.7 % 29%
6 3 3 2 1 1 1 1
19.4 % 9.7 % 9.7 % 6.5 % 3.2 % 3.2 % 3.2 % 3.2 %
Most contact had been made with the General Practitioner, followed by NHS Fife Addiction Services Social Work Services, and the Scottish Prison Services. Again, this pattern of contact is very similar to previous years.
Key Points
All drug death victims were known to services in the 5 years prior to their deaths. 93.4% drug death victims had accessed at least one service in the 6 months prior to their deaths. General Practitioners, Social Work Services, NHS Fife Addiction Services, and Scottish Prison Services were the four most commonly accessed services at both time periods.
3.6.3 Pharmacological Intervention 6 Months Prior to Death Of particular interest is the proportion of drug death victims who received pharmacological treatment for their drug dependency problem in the 6 months prior to their death. Fourteen individuals (45.2%) of drug death victims were known to have received some form of treatment for an opiate dependency in the six months prior to their deaths. This is a higher number of individuals who were in treatment within 6 months of their death, compared to 2013-14 (31.3%). These results mirror previous findings showing that most Page 35 of 49
Fife Drug Death Report 2015 drug death victims were not in receipt of specialist addictions input that involved pharmacological interventions. However in 2015, the gap between those out of treatment compared to those in treatment in the 6 months prior to death was closing compared to previous years. Nine of these fourteen individuals were in receipt of substitute medication at the time of death, three prescribed by their GP, six by NHS Fife Addiction Services. Four individuals were noted to have accessed substitute medication at least once in their lifetime outwith the 6 months preceding their death. Thirteen individuals considered had no recorded history of ever seeking any substitute medication for their substance dependency. Of the fourteen individuals who had received pharmacological treatment for their substance misuse within the 6 months of death, three were prescribed by their GP and the remaining eleven were prescribed by NHS Fife Addiction Services. This is summarised below Time since most recent substitute prescribing Time of death Within 6 months, but not at time of death Longer than 6 months before death Not known to have ever been prescribed substitute therapy
Cases 2015
%
9
29
5
16.1
4
12.9
13
41.9
Dispensing arrangements were known for twelve of the fourteen individuals concerned. Eight individuals were collecting their dosage from a pharmacy for supervised consumption on the premises, and did so 6 days per week. One individual was dispensed their methadone supervised in prison. One individual collected their methadone from the pharmacy three days a week, and the other two individuals collected their substitute medication once a week for consumption at home. The daily dosages of methadone ranged from 30mg-80mg daily, average dose 60.7mg. Furthermore, for all of the nine individuals who were prescribed substitute therapy at the time of death, this was detected in their toxicology reports. Furthermore, methadone was involved in ten further drug deaths of individuals who were not prescribed this substance (32.3%). Section 3.8 of this report investigates the prevalence of diverted prescribed medication in more details. The Fife Drug Death Monitoring group continue to closely monitor the mode of methadone prescribing and acknowledge that non supervised methadone dispensing may lead to an intensified risk of overdose or encourage diversion of methadone treatment. Since the beginning of 2008, this type of information is submitted to the Fife Controlled Drugs Intelligence Network.
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Fife Drug Death Report 2015 Key Points
A large proportion (58.1%) of drug death victims did not seek/receive treatment for their drug problem 6 months before they died Fourteen were receiving pharmacological treatment in the 6 months prior to their death; most were prescribed methadone and nine were still receiving their substitute medication at the time of their deaths
Recommendations
Improved communication between hospital departments, community health services and community agencies engaging with substance misusers Encourage information sharing about non-fatal overdoses between Ambulance/Health and promote referral on to services Explore opportunities to make engagement with treatment services more appealing Harness opportunities for overdose/naloxone awareness training of individuals most likely to be providing support to the drug death victims Increase GP education and support for referring patients with substance misuse issues to specialist services for further help Where multiple morbidities are present and care is spread amongst various agencies, co-ordination of care should be prioritised (e.g. transition of individual from prison environment to community) Greater communication of pertinent issues affecting the physical and psychological well-being of individuals is required amongst agencies Signposting for help and support after discharge from services Increased frequency of screening of people on a methadone programme to ascertain that associated poly-drug use and/or deteriorating health issues will not increase the risk of overdose Increased frequency of screening of people on a methadone programme to ascertain that associated poly-drug use and/or deteriorating health issues will not increase the risk of overdose
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Fife Drug Death Report 2015 3.7 Circumstances of Death
The present section summarises the circumstances of the drug deaths in Fife in 2015, including the months of the year and days of the week that the drug deaths occurred, as well as specific information concerning the scene of the death, such as the presence of others and attempted interventions.
3.7.1 Timings of Deaths 3.7.1.1 Month of the Year
As can be observed from the above, there appeared to be no monthly trend in the number of drug deaths during 2015. Surprisingly there were no deaths in October or November. The reason for this welcome cessation in fatalities during these two months is unknown.
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Fife Drug Death Report 2015 3.7.1.2 Days of the Week
Weekend drug deaths have in the past been associated with the dispensing arrangements for those individuals on a drug therapy programme. Of all victims in 2015, eight individuals were in receipt of a prescribed substitute medication at the time of their deaths. As discussed in the previous section, all of these individuals appear to have been compliant with their treatment. Individuals who had supervised pharmacy dispensing would on Saturday be given their Sunday dose to take-away due to pharmacy closure. No individual died on the day they collected more than one day of substitute prescribing.
Key Points
There appeared to be no monthly trend to the time a drug death occurred. However, there were no deaths in October or November. There appeared to be no trend to the days of the week a drug death occurred Drug deaths did not occur on the day of non-supervised prescription collection.
3.7.2 Circumstances of Death The circumstances surrounding the individual drug deaths were considered, including whether or not others were present at the time of death, if bystanders recognised common signs of overdose and what, if any intervention was employed. The majority of the drug deaths (71%) were in the company or in close proximity to others at their point of death. That means that others were at least present in the same premises Page 39 of 49
Fife Drug Death Report 2015 as the victim during the episode of their death. In all cases, the individuals present were known to the victim. The relationships of those persons present were: friends of the victim (n = 10), partners (n = 6), close family members (n = 6). In the case of 8 victims, there were multiple individuals present at the time of their deaths. 3.7.3 Snoring Immediately Prior to Death It has been noted that individuals often are observed to be snoring prior to a visible adverse reaction to the drugs they have consumed, however, this was identified in a minority of cases (n = 8). Individuals present were known to have checked on the drug death victims, sometimes on several occasions, assuming they were sleeping. Whilst most cases did not report information on snoring, it may well be that it did not appear significant to those who were present (and of course would not have been identified in those cases where individuals died alone). However, awareness of such warning signs of an overdose may assist individuals in identifying overdose and intervening to prevent them becoming a drug fatality. 3.7.4 Interventions Attempted at the Scene Of cases in 2015 where a witness was present (n = 22), some form of cardio-pulmonary resuscitation (CPR) was attempted by non-medical witnesses prior to ambulance arrival in the majority of the cases (n=14). Police officers were noted to have attempted CPR prior to ambulance attendance in 1 case. It was clear from many of the sudden death reports that the victim’s heart would have been stopped for a while before CPR was attempted, and CPR was unlikely to be successful. Furthermore, in instances were CPR may have been successful, access to more advanced resuscitation equipment, such as an automated external defibrillator would have increased the chance of a successful resuscitation. Ambulances attended 22 of the drug deaths. However, in 14 of these cases the victim was immediately deemed to be irrevocably dead by the ambulance crew, and no resuscitation was attempted by paramedics. Where resuscitation was attempted, naloxone injection was administered by ambulance staff in 3 of the 8 (37.5%) scenes in a bid to revive individuals. This is a lower number than in 2015 when it was used in 48% of attempted resuscitations. In 1 instance in 2015, Naloxone was administered to victims by non-ambulance staff (friend) prior to the ambulance arriving.
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Fife Drug Death Report 2015 Key Points
The majority of DDs in 2015 (71%) occurred in the presence of others, which were in all cases known to the victim In many cases where others were present, the victim was simply believed to be sleeping at the time of their death, thus delaying any possible interventions CPR was attempted by bystanders in 63.6% of the cases where witnesses were present In 2015 naloxone was administered to 1 individual prior to the arrival of an ambulance. The source of this naloxone was not documented, but likely came from the Fife ‘Take Home Naloxone’ scheme
Recommendations
Increase the supply of Take Home Naloxone to those who are at risk of overdose or are friends/family of individuals who are at risk of overdose, including those who have experienced a non-fatal overdose. Provide information and training for partners, family members and friends of drug users in recognising the first signs of a drug overdose Provide training to partners, family members and friends of drug users to provide suitable interventions in the case of an overdose, including CPR procedures, naloxone use and contacting the emergency services. Increase awareness in the community of the signs of an overdose and appropriate interventions, especially in high risk areas.
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Fife Drug Death Report 2015 3.8 Toxicology Results of Drug Deaths in Fife 2015
This section describes the post-mortem toxicology findings of all 31 drug death cases in Fife in 2015. This section also highlights the prevalence of prescribed medication in the drug deaths occurring in Fife.
Post mortem toxicology reports of all 31 individuals were analysed to gain a greater insight into the types of substances that led to the fatal overdoses. Forensic toxicologists currently conduct blood/urine tests for the substances believed to be implicated in the drug death. A typical blood test usually tests for; basic drugs, acid/neutral drugs, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDS) and Morphine. Urine samples are analysed for opiates, amphetamines, cannabinoids, cocaine, benzodiazepines, methadone, barbiturates, trycyclic antidepressants (TCA), MDMA and methamphetamine. Other tests can be performed if the pathologist feels it is an appropriate test; for example presence of identified substances found at the scene, known presentation of the victim, particular circumstances around the death etc. Not all misused substances can be tested for, and this is a particular issue when considering the NPS whose structure is continually being modified. Consequently, only those substances tested for are likely to be detected in the toxicology, potentially biasing the outcome of toxicology findings. Where an identified NPS is detected in toxicology, the relevance of the presence of these substrates to contribute to fatalities is currently not well understood. Further research on this would improve understanding on the toxic levels of NPS. 3.8.1. Toxicology results This following graph shows all substances which were present in the toxicology results of the drug death victims in Fife, 2015. The graph shows the number of victims who were found with each substance in their toxicology results. In cases multiple substances were present in toxicology hence the sum of all substances found is greater than 31. Benzodiazepines (including metabolites) were the most common substance present in drug deaths in Fife in 2015. It was present in 26 of the 31 cases, an overwhelming majority of 90.3% of deaths. Morphine was the second most common substance detected in drug deaths, 80.7% of victims. Methadone was present in 16 of all drug deaths in 2015. However, only 7 of the individuals who died with methadone in their system had actually been prescribed the medication at the time of their deaths. These findings suggest that the remaining 9 victims had obtained their methadone illicitly. Gabapentin/Pregablin was present in 16 of the 31 cases (51.6%) from which toxicology was available in 2015. This is a higher proportion than in 2013-14 where it was present in 37.5% of cases.
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Fife Drug Death Report 2015
Antidepressants; fluoxetine, mirtazepine, amitriptyline, venlafaxine and/or citalopram were detected in 14 of the drug deaths (45.2%). This is a higher proportion than in 2013-14 where it was present in 29% of cases. Opioid based analgesics; codeine, dihydrocodeine and tramadol, were detected in 11 cases. NPS were detected in 5 cases; 2 cases of phenazepam, 2 cases of diclazepam, and methylethcathinone (4-MEC). There were 14 cases where substances were detected which did not fit into these categories these included; paracetamol, buprenorphine, cyclizine and volatile substances. In 2013-2014 benzodiazepines, heroin, alcohol and methadone were the four most common substances present in the drug deaths. In 2015 gabapentin was as prevalent as methadone in toxicology at death.
Key Points
Benzodiazepines, heroin/morphine, alcohol, methadone and gabapentin were the most common substances detected in the drug deaths of 2015. There was a rise in the number of cases with gabapentin/pregablin in the toxicology at the time of death compared to previous years Methadone was present in 51.6% of all drug deaths; however, only 7 out of 16 individuals who died with this substance in their system had Page 43 of 49
Fife Drug Death Report 2015
actually been prescribed the medication Prescribed and non-prescribed medication; including methadone gabapentin/pregablin and antidepressants were detected in many of drug deaths in Fife
3.8.2 Substances Implicated Concomitantly As demonstrated by the previous section, the vast majority of drug death victims died following the consumption of a combination of drugs. In 2013-2014 this increased to an average of 4.17 and in 2015 this had increased to 5.3 substances. All individuals had at least 3 substances in their toxicology. 3.8.3 Therapeutic, Fatal and Actual Levels of Substances Toxicology reports generally include a reference for the “therapeutic” and “fatal” ranges of a substance, based on existing literature available to the toxicologist. However, these are often based on relatively small sample sizes, and do not take into account the possibility of poly-drug use. The latter is particularly important, as the entire drug deaths in Fife occurred as a result of multiple substances. An individual’s own tolerance to a substance should also be considered when interpreting toxic substance levels as this will vary depending on the history of illicit drug use in any particular individual The actual amounts of the drugs observed in drug deaths victims in Fife are often lower than the published fatal and even therapeutic ranges of any given drug. This highlights the importance of the cocktail effect, and the above values continue to raise questions about the clinical utility of the designated ‘fatal’ and ‘therapeutic’ levels. Furthermore, as the age of individuals who die of a drugs death is increasing, personal underlying pathology may make the individual more susceptible to death at a lower level of substance exposure. 3.8.4 Substances Implicated in Cause of Death Even though substances may be present in toxicology, they may not be considered to be implicated in the cause of death when interpreting the post mortem toxicology. This could be because the level of substance does not reach the “Fatal range”, or as in the case of some of the NPS, the effect of the substance alone, or in combination with other compounds, on the body is unknown. In their final report, the Forensic Pathologists consider the interpretation and opinions of the Forensic Toxicologists and their own professional experience before they pronounce on a cause of death. Graph 12 shows the substances implicated in an individual’s cause of death as formally reported in cause of death.
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Fife Drug Death Report 2015
As this graph shows, heroin/morphine was the most commonly involved substance implemented in drug deaths in Fife in 2015. It was found in 19 of the 31 cases where information was available, an overwhelming majority of 61.3% of deaths. Methadone was the second most common substance named in the Cause of Death. Interestingly, benzodiazepines were the most common substance identified in toxicology, but were only listed once in the Cause of Death. One anti-depressant was listed in the cause of death; amitriptyline. Three NPS were listed in the cause of death; two cases of phenazepam and one diclazepam. These substances were not found in the same individuals and in all cases the NPS were found in combination with other compounds. The vast majority of drug death victims had more than one drug listed in their cause of death. Twenty-four individuals died as a result of the consumption of a combination of drugs, in fact in six cases the cause of death was listed as simply ‘multi-drug toxicity’. Of the 6 cases where only one drug was listed in cause of death, 5 deaths were reported to be due to heroin only and one case to methadone only. There were 2 cases where substances were detected which did not fit into these categories these substances included; buprenorphine and volatile substances. 3.8.5 Prevalence and Diversion of Prescribed Medication In this section, the prevalence of substitute medication, benzodiazepines, anti-depressant and analgesic medication involved in the drug deaths is examined in further detail. Of particular interest is the question of whether or not this medication was prescribed to the individual. Page 45 of 49
Fife Drug Death Report 2015 Pharmacological Substances Found Involved in Toxicology 2015 and Prescribed to Drug Death Victims
Benzodiazepines Substitute Medication Gabapentin/Pregablin Anti-Depressants Opioid based analgesics
Found
Prescribed
28 20 16 23 11
5 9 7 23 6
Found + Prescribed 4 9 5 15 1
Not Found + Prescribed 1 0 2 8 5
Found + Not Prescribed 24 11 11 8 10
To explain this table, the first column (“Found”) gives the number of substances of any type that was detected in the toxicology reports of the 31 drug deaths in Fife in 2015. If, for example 2 antidepressants were found in the toxicology of one individual, they would be counted individually. The second column (“Prescribed”) gives the number of substances of each type which was prescribed to the drug death victims at the time of death. However, these two columns alone do not imply that the victims complied with their prescription regimes. The third column (“Found and Prescribed”) gives the number of substances which were prescribed at the time of death and found in the toxicology results. As such, this third column gives an indication of compliance with prescription regimes. The fourth column (“Not Found and Prescribed”) gives the number of substances which were prescribed to the drug death victims at the time of their deaths, but which were not detected in post-mortem toxicology tests. As such, this is medication that should have been present if the individuals had been compliant with their prescribing regimes. In these cases, the individual might have diverted their own medication, or may not be taking it correctly or at all. Finally, the last column (“Found and Not Prescribed”) gives the number of substances which were detected by post-mortem toxicology tests, but which were not prescribed to the individual. These cases point to individuals who have sourced this medication from other individuals. Substitute medication includes; methadone, buprenorphine and dihydrocodeine where these substances were prescribed for the purpose of opiate replacement therapy. Opioid based analgesics include the compounds codeine, tramadol and dihydrocodeine where the intention of the prescription was for pain relief. Overall, the results suggest that when the drug death victims were prescribed a medication they were, on the whole, likely to comply with the prescribing regimes unless the prescription was for pain relief. However, there is widespread evidence that the drug death victims were sourcing potentially prescribed medication from other individuals, or more commonly anecdotal evidence suggest, the internet; medication which ultimately was involved in their eventual deaths.
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Fife Drug Death Report 2015 Key Points
All the drug deaths occurring in Fife involved a lethal combination of two or more sedative substances The “therapeutic” and “fatal” ranges of a substance (as used in the toxicology reports) are diffused in their meaning in light of these polysubstance deaths There is widespread evidence that drug death victims were sourcing prescribed medication from out with healthcare services.
Recommendations
Provide overdose education and training regarding the risks of consuming a combination of drugs, especially sedatives to service users and professionals. Acknowledgement that benzodiazepine use still forms a major component of drug deaths in Fife. Highlight the risk of sedatives such as gabapentin in combination with other substances. Closely monitor individuals who are prescribed psychoactive medication in the community. Encourage service providers prescribing opioids for a diagnosed medical condition to be aware of potential overdose risk, especially in individuals with a history of substance abuse and/or psychiatric problems. Monitor prevalence of NPS in local communities Increased frequency of screening of people on a methadone programme to ascertain that associated poly-drug use and/or polypharmacy will not increase the risk of overdose Provide GP education on the risk of prescribing of a cocktail of sedatives Increase awareness that non-prescribed methadone is as lethal as heroin and increasingly involved in drug deaths in Fife
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Fife Drug Death Report 2015 Section 4: Recommendations Reducing drug deaths is a challenge for local, national and international policy makers. Interventions consider either reducing the likelihood of an overdose, or improving survival once one has occurred. The following recommendations from this Fife 2015 report are an amalgamation of the 51 individual recommendations from each sub-section. Many of the recommendations are repetitive between sub-sections because similar themes are considered. Consequently recommendations have been summarised below into three key themes; education, communication and interventions. .
Education
Explore opportunities to provide overdose/naloxone awareness to individuals/groups of individuals who may be at risk of a fatal/non-fatal overdose including; o young people at school and youth groups o individuals in prison or homeless accommodation o social groups of adults in their mid-thirties o female support groups to target this increasingly at risk group Explore opportunities to provide information and training for partners, family members and friends of drug users in recognising and responding to the first signs of a drug overdose, including the use of naloxone. Promote education regarding the dangers of poly-drug use to at risk groups of individuals. Especially highlight the danger of using a cocktail of sedatives.
Communication
Investigate opportunities for services who intervene at the scene of a non-fatal overdose to encourage at-risk individuals to subsequently enter treatment services Encourage shared assessment and exchange of information amongst hospital departments, community health services and community agencies engaging with substance misusers Greater communication of pertinent issues affecting the physical and psychological well-being of individuals amongst agencies
Interventions
Target interventions to high risk groups; o Individuals in a custodial environment (police and prison services) o Explore opportunities to make engagement with treatment services more appealing to individuals not in treatment who remain at risk of relapsing o Signpost individuals being discharged from services to alternative support groups Encourage health/social care/voluntary services to identify and monitor vulnerable individuals early in their life cycle. Increase supply of naloxone to individuals who are at risk of an overdose and/or their friends. Co-ordinate care where multiple morbidities are present and care is spread amongst various agencies (e.g. transition from prison environment to community) Increase GP education on the risk of prescribing a cocktail of sedatives to individuals, and support GPs in referring patients to specialist services
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Fife Drug Death Report 2015
Encourage service providers prescribing opioids for a diagnosed medical condition to be aware of potential overdose risk, especially in individuals with a history of substance abuse and/or psychiatric problems
References (1) National Records of Scotland. Drug-related deaths in Scotland in 2014. http://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vitalevents/deaths/drug-related-deaths-in-scotland/2014 (2) Deaths related to drug abuse: report on a WHO consultation, Geneva, 22-25 November 1993 http://apps.who.int/iris/handle/10665/58700 (3) KnowFife Dataset http://knowfife.fife.gov.uk/ (4) Drug Deaths in Fife Scotland. 2 year report: 2013 & 2014. The findings of the Fife Drug Deaths Monitoring Group (Fife Alcohol and Drug Partnership). (5) SIMD Postcode Lookup http://www.gov.scot/Topics/Statistics/SIMD/SIMDPostcodeLookup (6) European Monitoring Centre for Drugs and Drug Addiction European Drug Report 2014: Trends and developments Luxembourg: Publications Office of the European Union 2014 (7) http://www.scotlandscensus.gov.uk/
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