National Forum on Drug-Related Deaths in Scotland - Annual Report 2011/12

4. Forum's Response to the National Records of Scotland Drug- Related Deaths in Scotland 2011 Statistics

4.1 The National Records of Scotland (NRS) published its annual report, Drug-Related Deaths in Scotland in 2011^[9] on 17 August 2012. There were 584 drug-related deaths in 2011. This was the highest number ever recorded since these statistics began in 1996 and was 20% higher than the 485 deaths registered in 2010. Methadone was implicated in, or potentially contributed to, 275 deaths in 2011, which was 47% of all drug-related deaths. The largest percentage increases, over time, have been amongst those aged 35-44 years and 45-54 years. There has been a fall in the proportion of drug-related deaths in those under 25 years.

4.2 The rise in drug-related deaths in 2011 is, of course, a source of great disappointment and regret. The Forum has discussed the findings in the NRS report in depth and has had time to reflect on the implications and meaning of the figures. The opportunity to further examine these data will arise when ISD's Drug Related Deaths Database report is published in April 2013. The database report will give more detail and context to the deaths where further information is available from local sources.

4.3 The initial response to the headline figure of 584 deaths is that this represents a total in keeping with the underlying long term upward trend. Despite the drop in the total number of deaths over the two preceding years, the trend over a ten year period has been upwards. Looked at more carefully, there is a suggestion that the rate of increase may be slowing down, perhaps even plateauing, because there has been little change recently in the value of the 3-year moving annual average, and this may eventually turn into a downward trend.

4.4 In the 2011 figures there is a picture of a rise in age among those dying a drug-related death. This is again in keeping with the expectation that the Scottish problem is, like many other Western European countries, representative of a mature or even ageing cohort of people who have used drugs. The fact that more deaths were in the older age range was not surprising, as was the finding that the majority were men and located in the larger conurbations where there is inevitably a larger number of people who use, or have used drugs, and therefore are at risk of dying. Importantly, when the figures produced by NRS are compared with the estimated numbers of problem drug users, the difference between localities is less noticeable, indicating, that a drug user's risk of death is more or less the same regardless of where they live. As time passes, the cohort of ageing drug users enters an age range when the impact of prolonged drug use is greater. Individuals who have contracted blood borne virus infection, most commonly Hepatitis C, are at an advanced stage of a long term illness, complicated often by problem drinking. The impact of two or three decades of heavy smoking of cigarettes and cannabis is resulting in a compromised respiratory and cardiovascular system.

4.5 The NRS then compared the annual average numbers of deaths in 1997-2001 and 2007-2011, in order to reduce the effect of year-to-year fluctuations on the figures. Between the two periods, the percentage increase in deaths was greater for women than men, and greater for the older age-groups (35+) than for the younger ones.

4.6 The headlines which attracted most attention were the increase in methadone as the most common drug found at post mortem toxicological analysis and the continued high recording of benzodiazepines. As a percentage, heroin featured less than in previous years. Alcohol was present in a significant number of cases indicating an important, and perhaps an increasingly important risk cofactor. These figures have various possible interpretations. The first is that more than one drug is almost invariably present, and sometimes three or more. When considering the impact of methadone, it is important to note that there were few deaths where methadone was the only drug present (14 drug-related deaths) and could confidently be said to have been the single cause of death. Of the majority, where there were multiple drugs detected, the amounts of methadone were variable and the relative importance of methadone as causal in the death is difficult to assess. The pathologist in many cases felt that it was sufficient to say that the death was caused by an unfortunate combination of drugs which affect the respiratory centre of the brain. The most reasonable and balanced view might be, therefore, that all these drugs are dangerous and potentially lethal if used injudiciously, and this risk is compounded when there is a combination and consequent synergistic effect.

4.7 The steep rise in methadone related deaths in 2011 is not yet well understood. It is noticeable, however, that this has coincided with a marked reduction in the purity of heroin seizures, suggesting that heroin users were perhaps taking methadone in place of poor quality heroin. However, further investigations into these deaths are required. Analysis of the Drug-Related Deaths Dataset for 2011 might clarify some of the pressing questions about methadone implicated deaths, such as the number and circumstances of cases where the individual was not receiving methadone on prescription and the sense behind the finding that individuals receiving a prescription for methadone are still, apparently, taking other drugs including heroin. For those in clinical and prescribing practice the reality is that drug-dependent patients and individuals use multiple drugs, and even when considered to be stable on a maintenance prescription, are at risk of death from situational crises causing relapse into illegal drug use, or supplementing their prescribed medication. The well-recognised risk of overdose after a period of loss of tolerance may well account for some of these fatal incidents. Further examination of these data to assess this increased risk is underway. It is recognised that a period of relative reduced tolerance can occur in various situations including custodial sentencing, detoxifications from a therapeutic intervention or even a period in hospital.

4.8 The urgency to respond to these figures is tempered by these observations but the need to maximise those services and treatments that are likely to reduce the risk of death remains. Treatment services do not need to be reminded of the importance of maximising the evidence based interventions and local services should understand that safe expansion in such interventions may well save lives.

4.9 Further clarity is required by the Forum, on behalf of the Drugs Strategy Delivery Commission and the Scottish Government, in understanding the relationship between death and recent hospital or prison experience, the relationship between injecting drug use and deaths and the complex areas of the increased risk of death from various combinations of drugs, including alcohol. The development of our understanding of drug-related deaths is being taken forward by the National Drug-Related Deaths Database group at ISD who have recently appointed a short term researcher to address some of these questions with the support of the Scottish Government.

4.10 A summary of the Forum's main observations from the NRS report:

• Although the increase in numbers is very regrettable, it is in keeping with the overall upward trend shown over the last decade. The last two years had an absolute decrease but the trend remained upwards;
• As in the rest of Europe heroin supplies had been lower in 2011 and this could account for the shift in position of the drugs implicated;
• Methadone, although present in the largest percentage of cases, was in most of these, accompanied by other drugs which clearly combined to cause the fatal incident;
• It is not possible from these figures to say whether the methadone present at death came from a prescription issued to that person or from another source;
• The ageing cohort of drug users in Scotland is represented in these figures and might be expected to continue;
• Policy should remain resolute in the prescribing of opiate substitute treatment, and recommendations made elsewhere in this and previous reports should be considered relevant.