Transcript Illicit Drug Overdose - Asia Pacific Coroners Society

Acute Mortality Related to
Prescription and Illicit Drug
Overdose in NZ
1998-2001
Research submitted for MSC thesis, 2003
Elizabeth Morgan
Supervisor: Dr Nerida Smith
Senior Lecturer in Clinical Toxicology
Department of Pharmacology & Toxicology
University of Otago
Drug related mortality in NZ What has been published so far?
•
Stream of literature lacks continuity – different
regions over different time periods
Cairns et al (1983) – Auckland
Dukes et al (1992) - Wellington
•
A recent publications:
•
•
“NZ Drug Statistics” (MOH 2001)
“Surveillance of Chemical Induced Mortality in NZ”
(ESR for MOH, 2003)
Summary of the NZ Data
The information that is available suggests that:
 Males are over-represented
 Usually young – 20-30 yrs old
Data not standardized/adjusted to population
 ↓ in barbiturate related deaths
 TCAs common in late 1970s – early 1980s
 CO deaths make up the largest proportion of
deaths attributed to a single chemical/drug
The Present Study
Objectives
 Examine deaths resulting acutely from
prescription/illicit drugs in NZ, 1998 – 2001 using
Coronial inquest data
 Characteristics of the decedents & circumstances
 Examine drugs involved
 Identify preventable factors involved
 Examine the quality & usefulness of the
information available in the Coronial inquest files,
for the purposes of population-based studies
Data Collection
 Data collected during 2002
 Case selection if death occurred between 1998
and 2001 AND if drug involvement was indicated
 Deaths attributed solely to non-prescription drugs
or substances not restricted by law were not
included
 Deaths did not have to be solely attributed to
prescription/illicit drugs – additional
circumstances such as disease or asphyxiation
may have been named by Coroner as well
Exclusion Criteria
 Death occurred as a result of long-term drug
abuse (including disease as a result of drug use –
HIV/AIDS)
 Death as a result of withdrawal or abstinence
syndromes
 Drug/chemical implicated was available legally
and without a prescription
 Verdict – if verdict did not include any mention of
drugs then case was excluded
 Deaths among drug users where cause was not
drug-related
Data Collected from Inquest files
 File number
 Date of death/date of inquest hearing
 Verdict code assigned by Dept for Courts
 Basic demographic data: age, gender etc. from
Police Report for Coroner
 Health status of the deceased
 Post-mortem toxicological investigation
 Cause of death – pathologist and Coroner
RESULTS
Two parts:
 Describing the decedents – demographics
 Post-mortem toxicology
Age & Gender
 325 decedents
187 (58%) male/138 (42%) female
 Aged 2-100 years – avg age 41 years
 Age-specific mortality data = males died younger
than females
50
45
40
30
25
20
15
10
5
59
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
+
0
04
frequency
35
age group
Ethnicity
mortality rate per 100,000 population
 Ethnicity was recorded in 79% of cases
 Ethnicity data from PRC in 75% of these cases
4.00
3.00
2.00
1.00
0.00
male Maori
male non-Maori
gender/ethnicity
female Maori
female non-Maori
Marital Status
 Records available in 60% cases – Police report
 Of those 60% - almost three-quarters were single
(single, separated, divorced, widowed)
 Similar result for men & women
Employment Status
 58% unemployed (S/B, unemployed, students, retired)
 Proportion males > proportion of females
 On the whole, unemployed people were overrepresented compared to general population
Place of inquest
Auckland
94 inquests
New Plymouth
8 inquests
Tauranga
15 inquests
Palmerston North
15 inquests
Wellington
29 inquests
Christchurch
36 inquests
Dunedin
10 inquests
Place of Death
Hospital 17%
Other’s
residence 8%
Other 16%
Own home 59%
Health Status
Very basic – decedents were defined by one of 4
categories
1.
2.
3.
4.
No record of mental or physical illness
Medical history of mental illness (incl depression)
Medical history of chronic physical illness
Medical history of mental and chronic physical illness
Amount of information varied from file to file
People with no medical history in inquest file
= included in group 1
→ undercounting of illness is likely
Health Status
Both mental and
chronic physical
illness reported
12%
14% females
11% males
No reported
diagnoses of
mental or
chronic physical
illness
Reported
chronic physical
illness
18%
18% females
18% males
39%
Reported clinically
diagnosed mental
illness
31%
36% females
27% males
32% females
44% males
Verdict
Suicide vs Non-Suicide
 35% deaths included in this study were found to
be suicide
 Raw no. suicides over 4-years remained stable
Even though the total no deaths each year dropped
 Males outnumbered females in total…
proportionally:
1998-2001
male
Female
non-suicide
72%
(135)
54%
(75)
suicide
28%
(52)
46%
(63)
Gender, Health Status and Verdict
Health Status in cases found to be suicide:
Mental illness
46%
Physical
13%
Both
19%
Neither
22%
Health Status in cases that were not suicide
Mental illness
22%
Physical
21%
Both
9%
Neither
48%
Gender Differences?
 Females: proportions of suicide/non-suicide were
similar when “health status” categories were
examined separately
 Males: proportions of suicide/non-suicide equal
where history of mental illness was indicated
BUT in contrast to females
Only about 18% of deaths among males with
chronic physical illness were suicide
Employment Status
vs
Suicide/Non-suicide
 Proportions of suicide/non-suicide appeared to be
similar for unemployed and employed decedents
when “unemployment” was viewed as a whole
~ 60-65% non-suicide
 Subcategories of “unemployment”:
sickness beneficiary
47% suicide
retired
student
unemployed
42% suicide
38% suicide
25% suicide
Post-Mortem Toxicology Examinations
 PM toxicology – ESR reports
 92% cases in this study subject to tox exam
 3% of these cases – report unavailable
 No tox exam in remaining 8% cases
prevented by decomposition, time delay etc
Of those cases subjected to testing…
1 sample sites
12%
2 sample sites
31%
4+ sample sites
9%
3 sample sites
48%
A closer look at the sample sites
• Femoral blood samples were tested in 64% of
these cases
• Most of these cases a biological sample from at
least 1 other site was tested
• 14% examined cases, blood was from “unknown”
site. In most cases this was the only blood
sample tested
• Heart blood utilised in 5% of cases – usually
blood was tested from other sites too
How Many Drugs Detected PM?
No testing/none detected
10%
6+ drugs
4%
5 drugs
5%
1 drug
21%
4 drugs
7%
2 drugs
32%
3 drugs
21%
Drugs detected most frequently
Alcohol
Morphine/heroin
Diazepam, methadone
Zopiclone
45%
16%
14%
10%
Drugs Named by Coroner as Agents
Resulting in Death
Taken from Coroners Statements
2 drugs
14%
1 drug
57%
3 drugs
5%
4 drugs
1%
5+ drugs
1%
Not specified
22%
Drugs most frequently involved
In cases where death was attributed to one drug:
Morphine/heroin
12%
Methadone
9%
Dothiepin
6%
Doxepin
5%
Zopicolne
4%
Where death was attributed to multiple drugs:
Alcohol
12%
Diazepam
5%
Methadone
4%
Zopiclone
3%
Amitriptyline
3%
Gender vs Drugs
Drugs most frequently detected PM:
Males
(specific drugs named by Coroner in 145 cases)
methadone>morphine>diazepam>cannabis>zopiclone
 Coroner’s statements: opioids dominated deaths among
males
Females
(specific drugs named by Coroner in 107 cases)
dothiepin>morphine>zopiclone>diazepam>amitriptyline
 Coroner’s statements: TCAs dominated deaths among
females
 Antidepressants in general were a more prominent feature
of deaths among females
Age vs Drugs
3 age groups:
0 – 29 years (about 29% of studied population)
30 – 49 years (about 44% of studied population)
50+ years (about 26% of studied population)
Drugs detected post-mortem were different for
each age group
0 -29 years: opioids>chemical>benzo’s & TCA’s
30 – 49 years: opioids>chemical>benzo’s
50+ years: chemical>TCA’s>benzo’s>opioids
Source of Drugs
Of those deaths which underwent PM toxicological
examination:
Records detailing the source of the drugs detected
were identified in ~41% of cases
Of the most commonly detected drugs:
OPIOIDS
source identified in 33% cases; 62% illicit
morphine – 90% illicit
methadone – 60% illicit
TCAs
BENZOs
source identified in 53% cases; 95% prescribed
source identified in 55% cases; 75% prescribed
How complete was the data set in this study?
What proportion of ALL drug related deaths
occurring in this period did I gather?
Deaths in 1998 = the most complete data set
Looked at how many inquests were processed each
year versus year of death, for example of the 107
deaths occurring in 1998:
64% of inquests were processed in 1998
27% inquests were processed in 1999
9% inquests were processed in 2000 and 2001
These results are similar to ESR’s estimates (2003)
Data Completeness…
 For the majority of deaths examined in this
study, the inquest was completed within 2 years
Data sets for 1998 and 1999 = reasonably complete
2000 and 2001 less so
BUT…different factors may be affecting different
sub-sets of the studied population, for example
suicides
→ perhaps suicide investigations are completed sooner?
Perhaps the number of suicides involving drugs is actually
increasing?
Drug Related Mortality in the Present study…
OBSERVATIONS…
SHARING MEDICINES & “SELF-MEDICATING”
Noted by several Coroners
STOCKPILING OF MEDICATIONS
Opioids – cancer treatment patients
Barbiturates - elderly people
People being treated for illnesses known to be associated with
increased suicide risk; often had access to large amounts
INADEQUATE STORAGE
Methadone – naive users, not necessarily seeking a high
Colchicine – teenagers, lack of knowledge about medicines
Limitations of the Present Study
1. Data collection methods
One person collecting data – no validation
2. Comparability limitations
many definitions of “drug-related death”
3. Completeness and quality of the data…
for example – the “ethnicity” results
Completeness and quality of the data…
Study was retrospective = inherent difficulties
Disparity between the objectives of the
inquest and the research objectives
inquest = focused on the individual case-by-case
pop based study = requires uniform data
How can this be addressed?
How can this be addressed?
minimum dataset requirements
these could cover the basic data needs of
population based studies: demographics,
circumstances of death, aspects of the inquest
etc. in a way that does not impose on the
Coroner
This would ensure consistency in data
source etc.
research would be of higher quality
mortality data would be more meaningful
Where to from here?