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

5. Insights from Scotland's Drug-Related Deaths Database: 2010 Deaths

5.1 The Forum's 2010/11 annual report commented on the findings of the first report from the National Drug-Related Deaths Database (Scotland) Report which provided detail on the drug-related deaths which occurred in Scotland in 2009. The information provided gave an invaluable insight into the circumstances of individuals who died from a drug-related death during that time. Although the NRS drug-related deaths statistics provide information on the number of drug-related deaths broken down by age, gender and geographical area, as well as toxicology information on the drugs implicated in the death, in contrast, the National Drug-Related Deaths Database takes this information as its starting point and collects more detailed socio-demographic information and treatment history on each drug-related death.

5.2 The National Drug-Related Deaths Database's second report^[10] was published by ISD Scotland in February 2012. The report provided background information on a cohort of 365 drug-related deaths which occurred in Scotland in 2010. These drug-related deaths are a sub-set of the 485 drug-related deaths included in the National Records of Scotland (NRS) Drug-Related Deaths Report 2010 (published in August 2011) and represent cases where substantial further information was available. The report told us that:

• Of the 365 deaths analysed 79% were male, around half lived in the most deprived areas and the highest frequency of deaths occurred amongst the 25-34 and 35-44 year age groups (36% and 32% respectively).
• Access to drug treatment services/ability of services to meet the needs of their clients where known - 59% of the cohort had been in contact with drug treatment services at some point prior to death and 25% had been in contact with services in the month prior to death including addiction services, the patient's GP, an Accident and Emergency Service, a psychiatric service and social work services.
• Use of illicit methadone and supervision of prescribed methadone - one quarter of the cohort were receiving a substitute prescription at the time of death (89 cases) and the majority of these were being prescribed methadone (74 cases). In 64 of the 89 cases, substitute prescribing had been supervised.
• High prevalence of co-occurring psychiatric conditions and problem alcohol use - in the 6 months prior to death, an underlying psychiatric condition was present in 41% of cases (largely depression and anxiety), whilst problem alcohol use was recorded for 35% of the cohort.
• As well as mental health problems, physical comorbid conditions were common with liver, Hepatitis C and Hepatitis B or HIV problems affecting or being present in (38, 72 and 13 cases respectively). Eighty two cases had significant cardiovascular or respiratory conditions and eight had diabetes.

5.3 These findings provide a better insight into the complexity of the cases of drug-related deaths. A picture emerges which supports the clinical impression of individuals with multiple problems and conditions which are likely to affect wellbeing and in some cases survival. The ambition of the Forum's Data Collection Sub-Group and the Forum is to progress this project to analyse these results and to answer more detailed questions which might identify special sets of circumstances which may make an individual especially vulnerable to a drug-related death.

5.4 Questions about the nature of methadone prescribing and the value and protective effect of supervision are of pressing importance. There are clearly patients who die despite methadone supervision and others where methadone is implicated where the individual was not known to be in receipt of a prescription. Any clarity on the circumstances of these situations and the combination of risk factors which result in death is important.

5.5 The National Drug Related Deaths Database has helped not only profile those who die from drug-related deaths in more detail, but has also provided important context for the drug deaths statistics. This in turn should help guide the Forum's future priorities.

5.6 The summary above excludes other important findings but confirms that drug deaths occur most often in ageing, male, chronic drug users from our most deprived communities who are out of treatment. This cohort of drug users who are not in structured opiate substitute treatment and have multiple morbidities (which may be additive risks for death) may well be in contact with acute and primary care services. These services have an opportunity to recognise risks and take appropriate actions as they would for any other group of individuals with high risk of poor outcomes. Polysubstance misuse, whether the substance is implicated in the death or not, seems the norm for these individuals, as does a high prevalence of problem drinking and psychiatric co-morbidity (both of which are likely to be even higher than that recorded by the database, as so much is often not recognised). Drug death prevention services should be most targeted for drug users who match this profile.

5.7 The fact that only a quarter or less of deaths occur in opiate substitute treatment seems to confirm the international evidence of the protective role of such treatments. However, there is an urgent need to understand not only deaths in opiate substitute treatment but also methadone related deaths in those out of treatment.

5.8 With so many individuals who died having contact with services prior to their death, it is imperative that we promote the recognition of drug death risks and an appropriate and co-ordinated response by such service providers.

5.9 These are a few, but not exhaustive, range of findings and possible areas for development triggered by the information within the database. Our challenge is to understand this information as well as possible and to communicate findings and advice.

5.10 The third National Drug Related Deaths report is due to be published by ISD in April 2013 and is based on information concerning individuals who died drug related deaths in 2011. As well as providing a similar level of detail concerning the background circumstances of these deaths as the previous two reports have done, this third report will also explore some topics in greater depth. It is expected that the findings from this report will further enhance existing knowledge of the lives of those who die from drug related deaths and will be useful for continuing efforts to prevent such deaths. Following analysis of the 2011 dataset, we will have 3 years' worth of drug deaths data and our immediate priority is to understand deaths involving methadone.