Complementary sources of data

7.4.1 National Programme on Substance Abuse Deaths (England, Northern Ireland, the Channel Islands and the Isle of Man)

The National Programme on Substance Abuse Deaths (NPSAD) published their most recent report in September 2015 (Claridge & Goodair, 2015). This report covered drug-related deaths in England, Northern Ireland, the Channel Islands and the Isle of Man, occurring in 2013. Unlike previous NPSAD reports, Scotland and Wales are not within the scope of the report. The NPSAD report is based on a specific definition which may include deaths that are not normally within the scope of the drug misuse definition (DMD). Figures are also reported against the DMD used across the UK. NPSAD are notified of relevant deaths by coroners, and report that 75 of 92 coroners’ jurisdictions in England submitted responses in 2013, a coverage rate of 81.5%.

NPSAD reported 1,344 cases under their definition in England in 2013, with psychoactive drugs implicated in 1,237 cases (90%). This total was similar to that for 2012 (1,363); however, the figure for 2013 is likely to increase due to late registrations. The report found that there had been a marked increase in the proportion of these deaths where heroin/morphine was implicated, from 34% in 2012 to 41% in 2013, which aligns with the recent increase in mentions of heroin/morphine reported via the England and Wales GMR. There was also an increase in the proportion of deaths where heroin/morphine was the sole drug implicated, from nine per cent to 11%.

NPSAD also request information on which psychoactive drugs were prescribed. They found that 32.5%

of individuals who died from a methadone-related death (n= 86) were known to have had the drug prescribed to them. This equates to 37% of those with a known prescribing status.

Information pertaining to drug abuse/dependence history was available for 1,067 individuals, of whom 64% had a history. Those with a history of drug abuse/dependence were more likely to be male, to be younger, and/or experience accidental death, compared to those without such a history.

7.4.2 National Drug-Related Deaths Database (Scotland)

The fifth report from the National Drug-Related Deaths Database (NDRDD) in Scotland was published in April 2015, examining the personal circumstances of those who died a drug-related death in Scotland in 2013 (Barnsdale, Gordon, & McAuley, 2015). The drug-related deaths in the NDRDD report are a sub-set of the 581 drug-related deaths published by NRS in August 2014 (National Records of Scotland, 2014).¹²² In 2013, there were 448 cases identified as eligible for inclusion in the main NDRDD cohort (a decrease from 479 in 2012). As with previous years, around three-quarters (76%) were male. The proportion of these deaths where the individual was aged 35 and over has increased from half of deaths (50%) in 2009 to two-thirds (66%) of deaths in 2013, while the mean age increased from 34.4 in 2009 to 39.1 years in 2013.

Nine out of ten individuals (88%) were known to be using drugs prior to death, and almost two-thirds (64%) had a known history of intravenous (IV) drug use. Over half (51%) had been prescribed an OST drug since 2009, including 31% prescribed an OST drug when they died (up from 21% in 2009). Over one-third (37%) had been prescribed an anti-depressant in the 30 days before death, with one-fifth (21%) recently prescribed diazepam and one-tenth (10%) recently prescribed gabapentin. Almost two-thirds (63%) had a psychiatric condition recorded, the highest reported so far.

Over half (53%) of those included in the cohort had been in contact with drug treatment services before they died. Seven in ten (71%) had been in contact with at least one service (drug treatment, hospital, police or prison) which may have identified them as being at risk of drug-related death.

In 68% of cases, more than one drug was implicated in the death. Diazepam was the drug most frequently found to be present (66% of cases, although down from 77% in 2009), but implicated in fewer than one-third of these cases (19% of all cases). The most commonly implicated drugs were heroin/

morphine (44%) and methadone (42%), with opioids implicated in 76% of cases.

7.4.3 Public Health England analysis

Public Health England (PHE) produced an analysis of trends in drug-related deaths in England using the DMD in July 2015 based on extracts of data received from the ONS (Public Health England, 2015j). This followed the reported rise in deaths registered in England using the DMD by the ONS for 2013 (Office for National Statistics, 2014) and a national summit on drug-related deaths in England held in January 2015.

However, it predated the latest ONS bulletin (Office for National Statistics, 2015).

For this analysis, PHE reported figures based on year of death, highlighting that registration delays meant that later years were incomplete. The PHE analysis found that a large number of drug misuse deaths registered in 2013 had occurred in the same year (892 deaths), but that there had also been an increase in deaths registered after more than a year. It should be noted that the subsequently published data on 2014 registrations in England from the ONS indicated a further rise, and the PHE report commits to updating the analysis going forward.

The analysis also found that among deaths where heroin was mentioned on the death certificate, there was a clear long-term trend towards other substances (including alcohol) being mentioned alongside heroin, and away from heroin being the only drug mentioned. A data linkage exercise between drug poisoning data and drug treatment data was included in this report, showing that three-fifths (59%) of opioid misuse deaths in 2011 had received no treatment since at least 2006 (and possibly never).

122 Since the latest NDRDD report was published, the NRS has published figures for 2014 (National Records of Scotland, 2015)

This proportion had remained reasonably consistent over the full period studied (2008-2012). When considered in the context of prevalence estimates and treatment numbers, the analysis suggested that treatment had a significant protective effect for opioid users, supporting the findings of the previously mentioned White et al. (2015) study. However, it also suggested that there has been little change in the extent of the protective effect in recent years.

7.4.4 Relative safety of buprenorphine and methadone

Marteau et al. (2015) published an analysis looking at population-wide overdose risk emerging from the prescription of methadone and buprenorphine in OST in England and Wales (Marteau, McDonald,

& Patel, 2015). For this analysis, drug-related deaths where methadone and buprenorphine were mentioned were presented as a rate of all prescriptions issued for these drugs, between 2007 and 2012.

In this period there were 2,366 deaths where methadone was mentioned and 52 where buprenorphine was mentioned, with 17.3 million methadone prescriptions and 2.6 million buprenorphine prescriptions issued. This translates to rates of 0.137 deaths per 1,000 prescriptions of methadone and 0.022 per 1,000 prescriptions of buprenorphine, or a relative risk ratio of 6.23 (with 95% CI: 4.79 to 8.10). Therefore, the authors assert that buprenorphine is six times safer than methadone in regard to overdose risk in the general population and suggest that clinicians should be aware of this increased risk, as well as recommending that tighter regulations are needed to prevent diversion.

7.4.5 Calls for legislative change around registration of deaths in England and Wales

In a correspondence to the Lancet in May 2015 on behalf of the Royal Statistical Society (RSS), Professor Sheila Bird reiterated a call for legislation to change the process of registration of deaths in England and Wales.¹²³ Bird cited lengthy delays in relation to registration of drug-related deaths and suicides in particular, urging the Lancet and the Farr Institute of Health Informatics Research to join the RSS in lobbying the government on this issue.

7.4.6 Deaths from HIV/AIDS

Based on reports received up to the end of March 2014¹²⁴, in England and Wales, there were 1,555 AIDS deaths of people whose exposure category was recorded as either “injecting drug use” or “sex between men and injecting drug use”. This accounted for 7.9% of AIDS deaths recorded up to that date (n= 19,743). In Northern Ireland, there were 8 AIDS deaths of people who inject drugs (PWID) which accounted for between 6% and 7% of all AIDS deaths.¹²⁵ In Scotland the percentage was much higher at 45.1% of AIDS deaths (864 deaths, n= 1,915) (Public Health England, unpublished data).

7.4.7 Deaths from hepatitis C

Both hospital admissions and deaths from hepatitis C virus (HCV)-related end stage liver disease and hepatocellular carcinoma are continuing to rise in the UK (Public Health England, 2015f). Hospital admissions rose from 611 in 1998 to 2,658 in 2013, while deaths rose from 98 in 1996 to 424 in 2013.

This increase is particularly notable in Scotland where liver-related deaths among people diagnosed with hepatitis C increased 3.2-fold from 43 in 1996 to 139 in 2013. However, in the last five years (2009-2013), the annual number of liver-related deaths has remained relatively stable. Linking records from Scotland’s National Hepatitis C Diagnoses Database to the national register of deaths showed that 851 (52%) of the total 1,638 liver-related deaths during 1996-2013 among people diagnosed with hepatitis C had any mention of hepatitis C on their death certificate. Among the 139 liver-related deaths in 2013, only 110 (79%) had liver disease recorded as the underlying cause of death (alcoholic liver disease was the most prevalent underlying cause in 36). It is therefore likely that the total number of deaths recorded as HCV-related end stage liver disease is an underestimate of the true situation.

123 See: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2960920-5/fulltext?rss%3Dyes

124 Numbers for 2013 and 2014 are likely to increase as further reports are received; data presented are from reports received to the end of March 2014.

125 The total number of AIDS deaths in the period in NI was between 120 and 124. Due to suppression of statistics under five n could not be established precisely from published data.