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Drug deaths – what’s changing?

Posted · 8 Comments

OLYMPUS DIGITAL CAMERAOne thousand nine hundred and fifty-seven people died from drug-related causes in England and Wales last year. That’s a 21% jump with a significant rise in deaths related to heroin and morphine. The data for Scotland, released last month, showed a 9% drop compared to 2012, though this was still the fifth highest on record.

What’s come as a surprise to me on the day after the release of the data is how little attention it attracted from the media. Where is the outrage?

The headlines in the England and Wales report can be found here, but I’ve picked out some things that jumped out at me.

  • Methadone related deaths are much the same at 429 (last year 414), about 15% of total deaths.
  • There was a lower rise in deaths related to NPS (new psychoactive substances) than expected (up ‘only’ 15%), though it’s too soon to know the trend. The total number of deaths was 60. Watch out for cathinones (like mephedrone) though, up 44% from 2012
  • Benzodiazepine deaths are up by 20% (342 in total). This represents the highest number of deaths for these drugs since records began.
  • Tramadol prescribing is up by 29% over five years. Deaths involving tramadol have continued to rise, with 220 deaths in 2013. This is almost 2.5 times the number seen in 2009 (87 deaths). I’ve blogged before about tramadol concerns and I think we’re going to see this trend continue.
  • Mortality rates in England from drug related causes increased from 28 deaths per million population to 33.9 deaths per million.

The full report can be found here.

Comments

I took a look at the mortality rate from drug-related causes in Scotland to make a comparison and allowing for confidence intervals and differences in the way the data are collected, it’s not easy reading. The Scottish Government’s report stated:

For Scotland as a whole, the average of 544 drug-related deaths per year represented a death rate of 0.10 per 1,000 population

Expressed per million population, this is is 100 compared to England’s 33.9. Why is mortality in Scotland two and a half times that of England? In fact if we compare rates in the EMCDDA report, we find that Scotland is second only to Estonia in Europe in the drugs deaths’ league table with most countries trailing a long way behind.

And the cause for the sharp rise in deaths in England and Wales? We don’t know.

DrugScope is one of the few agencies to respond to the report so far and highlights the Take Home Naloxone Programme as a possible response. In Scotland, we have a national programme, but it’s still in its infancy and too soon to expect it to have made an impact.

I’m a strong advocate for naloxone, having reversed overdose with it more than once, but it’s a first-aid solution to a complex problem. With more prescription medications implicated in deaths, we ought to be looking at prescribing practices. We either have an epidemic of pain such as we’ve never seen before, or prescribing for chronic pain is changing, and not for the better. The evidence for opiates in chronic pain, or lack of it, does not support the trend.

I also wonder about the protective effects of communities of recovery. Are relapses to opiate use and overdose reduced when people are strongly linked to recovery communities? This would be an interesting research question to address.

 

    8 Responses to "Drug deaths – what’s changing?"
    1. Detox Nurse says:

      An interesting article with a tragedy behind each statistic.

      A few points.

      Deaths related to heroin look to be on the increase. I’m wondering if there’s another worrying aspect to this statistic. As I understand, there is a downward trend of heroin use. Now if the 2013 figures show a downward trend of heroin use from the previous years (and I’ll hold my hands up and say I don’t know if they show this), then a greater proportion of heroin users are dying from overdose.

      I wonder if this is a reflection of a change in service provision and how services are implementing the transition from harm reduction to recovery, particularly in relation to ORT prescribing.

      I shadowed a doctor in another service last year. I recall one particular client he saw, a lady who had recently been started on 20mg methadone. She’d been providing 6AM positive urine samples and was in tears, requesting the doctor increase her prescription to 30mg. He said he wouldn’t increase her methadone until she gave some negative urine samples. I felt uncomfortable as I thought this were the wrong way round. She wanted an increase in methadone to help to stop using heroin – if she’d been able to stop using on 20mg, then she wouldn’t have been asking for an increase. I often wonder what happened to her.

      I also hear of services requiring clients to go through some sort of group program before being allowed to see a doctor to start a prescription. The implication is that there’ll be individuals using for many weeks longer than perhaps necessary, all the while increasing the risk of overdose. The benefit to the organisation, of course, is that they get to cherry pick the most motivated clients who are willing to engage with such a program, which, in terms of treatment outcomes, will do wonders for their ‘stats’, while potentially leaving the most vulnerable behind (and at risk).

      I’d love to hear other’s thoughts/experiences.

      • djmac says:

        There are many variables to be considered here and while a recovery-oriented drugs policy is one of them it wouldn’t explain why deaths in Scotland are down and deaths in Scotland up.

        I’m flabbergasted at your experience of shadowing. This makes no sense whatsoever. Titrating the dose up is exactly the right thing to do in that scenario.

        • Detox Nurse says:

          Yes, that’s a good point, though I wonder if there’s a possibility that Scotland still favors a harm reduction approach over a recovery treatment system? I guess what I’m saying is, is it easier to get on a script in Scotland than in England/Wales?

          With regards to the doctor I shadowed, I think this was his consultants interpretation of how methadone should be prescribed within a recovery service. From speaking to other workers within that organisation, this wasn’t an isolated incident (time limited prescriptions was another issue). I understand that the consultant has now left to work for one if the non-NHS addiction agencies so things might be change.

    2. I was also like to state a fact that people related with drug deaths in Scotland can stagger out of their minds on to a road, get hit by a car, and tragically die, Why is this a road incident and not a drug death????

      • Anon says:

        Because it is bascially impossible to make a clear attribution of all “drug related” deaths – sucicide, child neglect, TB, hepatitis, HIV, violence, warfare in producer and transit countries etc etc etc etc. There is an infinite regress of deaths which are linked to drugs in some way. The actual definition is fairly sensible and workable – what is misleading is the name – these are specifcally overdose deaths.

    3. Anon says:

      Re – are these people linked to recovery communities, I would say based on the experience of reviewing lots of deaths that virtually none of them were actively engaged with RC’s at the time of death. The majority are socailly isolated and increasingly they are older and in long term addiction.

      Re naloxone, although it is a very valuable intervention, our strategies for adressing DRD are far too heavily focussed on it (IMHO). Relatively few deaths are for people who are using opiates and in company with someone who might have used naloxone. It is important that naloxone is rolled out but despite the SDF and Drugscope responses focussing on it, it is not going to significantly reduce DRD at population level.

      The elephants in the room are:

      1) The contribution of methadone and prescribed benzoes and (as you say) pain killers
      This is clearly complex but an awful lot of the deaths are directly or indirectly to do with the level of methadone prescribing in Scotland and the use of pain meds and anxiolytics. Some of these are seemingly poor prescribing decisions in primary care (few of which ever seem to result in investigation or learning). Many more are down to the level of diverted methadone. I have no simple solution to the latter, but focussing on exclusively on naloxone while ignoring the fact that so many of the deaths are effectively a result of policy and practice feels disingenuous.

      2) Our failure to respond actively to non-fatal OD –
      In many areas, you can present to A&E having overdosed, be treated with naloxone and nothing ever be done to try to engage you with services. Aside from the fact that non-fatal OD is a good predictor of fatal OD, this surely would be a “teachable moment” for a lot of users. As far as I know , you can’t make a serious suicide attempt, be treated at A&E and never be followed up by a mental health professional btu we do allow this to happen to people who are known to be at risk of OD.

      Beyond that we services which engage clients, especially the long term users and whcih offer hope seem the greatest need. we are currently experiencing a cohort effect in some parts of Scotland at least and the rate is unlikely to fall but we can at least mitigate it as far as possible.

      • djmac says:

        virtually none of them were actively engaged with RC’s at the time of death

        The potential protective effect of recovery communities would be a great subject for a study, but would struggle to get funding given that it’s not a medical intervention. No pharmaceutical involved.

        It is important that naloxone is rolled out but despite the SDF and Drugscope responses focussing on it, it is not going to significantly reduce DRD at population level

        Sadly, I think you may be right on this, but each life saved is immensely precious and pretty much everyone is agreed that it’s a good idea. I would like to see some attempt to get a feel for NNT (numbers needed to treat to save a life) to see how effective it actually might be.

        On the ‘elephants in the room’, I agree. Prescribers need to look at quality and risk management around prescribing. There is so little evidence for the efficacy of long term (and even short term) benzo prescribing in dependent populations for instance, that it ought to be a rarity.

        On the failure to respond to non-fatal OD: the comparison with deliberate overdose is well made. If every case were investigated, interventions made and follow up offered, surely there would be some positive impact.

        • Anon says:

          Thanks for the agreement.

          Re naloxone: i wouldn’t for a second deny it should be rolled out (indeed its distriburtion is scandalously impeded by regulation in some areas), but the current evaluations are based on a niaive “each used set is a life saved”. based on looking at the people who actually die, I can see relatively few who would have been saved by it. I imagine that identifying the NNT is a part of the English research.

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