Drug-Related Deaths in Grampian, Scotland

 SMJ 2003 48(4): 105-107

Grant Stenhouse¹ and James H. K. Grieve

Department of Pathology¹, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZD and Forensic Medicine Unit, Department of Pathology, University Medical Buildings, Foresterhill, Aberdeen, AB25 2ZD.

Correspondence to Dr Grant Stenhouse, Pathology Department, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZD, Tel. (01224) 552843, E-Mail, stenh02@yahoo.com

No conflict of interests and no funding.

Abstract

Aims - To analyse the demographic data from fatalities arising directly from illicit drug abuse in the Grampian area and compare the findings with trends in drug seizures in Grampian to ascertain if these reflect the recorded deaths, and to attempt to identify a subgroup of the abusing population which might be at greater danger from overdose of controlled substances.

Methods - Cases in which the cause of death was directly attributed to illicit drugs from the beginning of January 1995 until the end of December 1999 were identified, and their epidemiological and toxicological data were analysed. The information regarding drug seizures was gained from Home Office publications for the same time period.

Results - One hundred and thirteen cases were retrieved consisting of 93 males and 20 females, aged 16 to 43 years (Median 25). The most commonly isolated substance was morphine followed by benzodiazepines. In 97 cases two or more drugs were involved with five cases showing positive toxicology for four or more drugs. Of the female deaths 75% fell into the 16 – 25 year age range. Drug seizures rose by 49% from 1995 to 1998 with both heroin and benzodiazepine seizures increasing by more than five fold in the same period.

Conclusions - Deaths directly due to illicit drugs showed a significant increase over the study period and were concentrated in the young male population. The drug seizures increased but the extent of this was not mirrored in the deaths. A shift in emphasis to an older age group is also indicated; drug misuse educational programmes should continue to be targeted at all populations but information may also be targeted at the older age groups and at females under 25 years of age.

Keywords:- morphine, heroin, drug-related deaths, alcohol, benzodiazepines

Introduction 

Illicit drugs have said to been abused by around 30% of adults in Britain, with approximately 100,000 people misusing heroin.¹ The social consequences of drug abuse are far reaching with a reported 70% of all crime in the Grampian area thought to be drug related.² This was reflected in the total number of drug seizures in Grampian rising from 324 in 1990 to 1125 in 1995 and continuing to rise.³

It is more commonplace, now, to find drug users (intravenous and otherwise) abusing multiple drugs including prescribed medications such as methadone, benzodiazepines and dihydrocodeine along with heroin and alcohol.^4-7 Drug-related deaths (DRDs) are usually related to unintentional overdose but may also be as a result of trauma (road traffic accidents or homicide).

In the Grampian area heroin (diamorphine) is the drug that is associated with most such fatalities, and in these cases was almost always administered intravenously. After injection it is rapidly metabolised to 6-mono-acetylmorphine then further to morphine.

With the rising incidence of misuse, and especially the crime related figures, there is a desire to prevent drug abuse as well as DRDs, but is the rise related to a greater quantity of drugs on the street and is there a certain group within the population at which to target educational resources?

Materials and methods 

The Forensic Medicine Service in Grampian is provided for the Scottish Crown Office, by the Forensic Medicine Unit, University of Aberdeen serving a wide geographical area with a population of approximately 520,000 and deals with all sudden deaths at the instance of the Procurator Fiscal. The five year study was devised to cover the period when heroin seizures were showing a substantial rise (1995 - 1996) to the end of a full year in which the cases are complete and have no on going legal implications (1999).

A retrospective search of deaths due to illicit drugs was conducted for the study period (January 1995 to December 1999) and only those that were considered non-suicidal or non-traumatic were included. Every case had a full post mortem examination and dissection with blood and urine samples submitted for toxicological analysis. This analysis was carried out, for the Procurator Fiscal, by the Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen.

Home Office publications provided the information regarding the drug seizures.^8-11

Statistical analysis, where appropriate, was carried out using chi square (significance p<0.05).

Results 

Over the five years studied a total of 113 (93 male and 20 female), apparently, unintentional DRDs were identified, the ages of victims ranging from 16 to 43 years (median 25 years). Nine occurred in 1995, 25 in 1996, 22 in 1997, 27 in 1998 and 30 in 1999. The significant upward trend was also reflected in the percentage of the total cases dealt with in the unit (table I).(p<0.05) The DRDs involved a young population, 99 cases falling into the under 35-age group, with 60 being under 25 (table I); in the latter group, nine were less than 18 years of age, 22 were 19 – 21 and 29 were over 22. Females accounted for 15 of these 60 cases, these constituting 75% of all the drug deaths in women. 

 Table I.            Total number of deaths by year undertaken at the Forensic Medicine Unit, Aberdeen along with the number of drug-related deaths and age group breakdown. (p<0.02 for change from under to over 25 year olds over the study period)

Throughout the years, a statistical change in the demographics was noted; with an increase in the 26-35 year age group being accompanied by a fall in the 16 – 25 year group. (p<0.02) A significant rise was also present in the 36 – 45 year group from 1996 and 1997 to 1998 and 1999. (p<0.01)

The most common substances isolated were morphine (n=77), benzodiazepines (n=69), alcohol (n=36), methadone (n=36) and dihydrocodeine (n=18), ecstasy, cocaine, dextromoramide and diconal also being found. The cases showing positive toxicology for morphine and benzodiazepines increased over the five-year period (table II). Polydrug abuse was noted in 97 cases, with five deaths involving four or more drugs. The frequency of polydrug abuse also increased over the study period (table II). Of the morphine positive deaths only one showed positive analysis for ecstasy.

Table II. Number of cases showing blood positivity for a single drug (1 isolate), 2 or more and those with positive isolates for each of morphine and benzodiazepines by year.

Cannabinoids were detected in the urine samples of 57 of the cases (50%).

Examination of the total drug seizures indicated a peak of 49% increase in 1998 compared to 1995 (table III) during which time the drug related deaths tripled. Heroin seizures rose from 49 in 1995 to 238 in 1999 with benzodiazepines showing a gain from 10 to 68 in the same period (table III). Both morphine and benzodiazepine positive DRDs, along with their respective seizures, increased in the five years but showed no significant statistical correlation.

Table III.  Total drug seizures by year in the Grampian area and those relating to heroin and benzodiazepines.

Figure 1.  The percentage change in heroin seizures and morphine positive deaths by year expressed in relation to the 1995 figures.

Figure 2.  The percentage change in benzodiazepine seizures and benzodiazepine positive deaths by year expressed in relation to the 1995.

Discussion 

The data demonstrates an increase in drug-related deaths during the study period and shows they have been predominantly in the young male population with morphine and benzodiazepines being most commonly abused (68% and 61% respectively).

Although females accounted for only 17% of the total DRDs, 75% were in the under 25-age group. Despite this difference not holding significance to rigorous statistics (p<0.1) it appears to be a difference and the information should not be overlooked. This sex and age difference may indicate that females are more vulnerable at a younger age but are less prone to abuse lethal illicit drugs as they mature, and could reflect a social aspect related to family responsibilities.

Also indicated by the data, is a transition from younger abusers to those over 26, and it would be attractive to attribute this to the health and drug information and education that were so prominent through the late 1990’s. While such may be true, it may also represent a movement of a cohort of drug abusers from one age group to the other.

The information gained here confirms polydrug abuse that has been noted elsewhere.^4-7 .

The drug seizures data indicates the massive task the law enforcers undertake and shows a striking increase of both heroin and benzodiazepine seizures. Fortunately the DRDs do not follow this growth but do display the overall rising trend. Despite these figures not representing the total quantity of drugs captured, hopefully, they do reflect the trend in specific drug trafficking and reflect what is available on the street.

Conclusions

There was no specific correlation between drug seizures and DRDs other than they were both increasing. Statistics relating to drug fatalities are probably a poor indication of the extent of drug abuse in our society.

Education about illicit drugs has always been directed at the young and should continued to be as over 50% of the deaths were under 25. Hopefully, this is one of the reasons there is a decline in deaths in this group over the study period but, the percentage of females present is concerning and they may represent a population at whom the drugs related education may be focussed in the future.

We should also be concerned with the increase in the deaths of the over 26-year-olds and also take them into account in the preparation of drug information.

References

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2. Grampian Police Website, http://www.grampian.police.uk/drugs/drugs.htm

3. Corkery J.M. Drug seizure and offender statistics, United Kingdom, 1999, Area Tables. A publication of the Government Statistical                 Service

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7. Risser D, Uhl A, Stickenwirth M, Hoenigschnabl S, Hirz W, Schneider B et al. Quality of heroin and heroin-related deaths from 1987 to 1995 in Vienna, Austria. Addiction 2000; 95: 375-382

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11. Corkery J.M. Drug seizure and offender statistics, United Kingdom, 1997, Area Tables. A publication of the Government Statistical Service

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