The Office for National Statistics (ONS) has just (6 August 2018) published an experimental “deep dive” study, commissioned by Public Health England, into a sample of 115 drug misuse deaths, with ONS staff visiting coroners’ offices across England to review the available records in detail and record selected additional information using a structured electronic questionnaire. The sample included both suicides and unintentional overdose deaths.
The study was commissioned in the context of concern at the surge in the number of drug-related deaths in England, Scotland & Wales over the last four years, now at their highest ever levels.
For example, the rate for England in 2016 increased to 44.1 deaths per million population from 42.9 deaths per million in 2015. This was a rise of 3% and an increase to 2,383 deaths. The number of deaths in 2016 was over three times higher than that in 1993, when the time series began. There has been a sharp rise in the number of deaths since 2012, with 2013, 2014 and 2015 showing the largest year-on-year rises in numbers.
The ONS collated data from a number of sources:
- coroner’s conclusion
- post-mortem and toxicology
- General Practitioner (GP) records including physical and mental health problems and prescribed
- medications
- paramedic report
- reports from hospital doctors or other specialists
- report from drug treatment clinic
- police report
- witness statements
The resulting dataset contained information on dozens of variables of varying quality and completeness for 115
individual records. This process generated a considerable amount of data, and the ONS report focuses on four main areas:
- demographics and lifestyle – ethnicity, living situation, marital status, employment, drug use history, alcohol use;
- health and contact with services – drug treatment history, mental health, physical health;
- circumstances of death – location of occurrence and other people involved; and
- other observations – issues relating to specific drugs and completeness of drug information.
Demographics and lifestyle
Of the 115 records that were investigated, 68% of individuals were identified as either White and 6% as Asian,
Black or other. There was no information on ethnicity in the remaining 26% of cases.
Most people were living alone in their own home (36%), while in 11% of cases, the deceased was recorded as living in temporary accommodation, such as a hotel, hostel or homeless shelter, or having no fixed abode. Another 27% were living with family and 10% lived with others, such as with friends or a house share, and three of the records inspected were of individuals who were inpatients at a psychiatric hospital. (Living situation was not known for the remaining 14%).
Just 10% of individuals were married, with 62% identified as single or aged under 16 years, 19% divorced and 4% widowed. The remaining 5% had no information provided.
Around half (48%) of all individuals were unemployed or economically inactive, with a further 6% not working due to a long-term condition or disability and 3% were retired. Only 24% were in employment, either as an employee or self-employed, at the time of death and 1% were classified as a student. Employment status was not known for 17% of cases.
A large majority of individuals (80%) had used drugs at least once prior to the incident that caused their death. Just 12% had no history of prior drug use and of these, half were suicides. The drug history was not known for 8% of cases. There was evidence of drug use in the six months prior to death in 51% of cases. A further 6% of cases stated that the past drug use was not within the last six months and 23% did not state how recent the past drug use was.
Of those that had a history of drug use, 62% of the records indicated the individual had taken heroin in the past. Information on previous drug use was of varying detail in different areas and between records. A history of injecting drugs was identified in 42% of cases.
54% of all cases were identified as having had a history of alcohol misuse.
Health & contact with services
Out of the 115 records reviewed, 58 (50%) provided evidence that the deceased had engaged with drug and
alcohol treatment services, with varying degrees of compliance with the treatment regime. In the majority of
cases, the length of treatment was not provided. Over one-third of those who had some contact with treatment
services had done so within the final month prior to death and 60% had had some contact in the year before
death.
Just over half (53%) of those who had engaged with treatment had been on a treatment programme that included methadone (31 cases), with 10 individuals (17%) having received buprenorphine. (There are some individuals who will appear in both of these groups, as they had previously received either methadone or buprenorphine and switched to the other, so these numbers cannot be combined due to risk of double counting.)
Where dosage levels were recorded, more than half (11/21) of those on methadone were being prescribed less than the optimal clinical dose of 60-120 mg per day. Similarly, just under half (3/7) of those on buprenorphine were receiving a recorded dosage of less than the recommended 12-16 mg per day.
Over one-quarter of individuals (29%) were recorded as having suffered from a chronic pain condition either
recently or in the past. In 26 of these cases, the chronic pain condition was current at the time of death. Many of
the individuals had been in receipt of a long-term, repeat prescription of opioid analgesics with abuse potential
such as tramadol and oxycodone.
At least two thirds of this sample of people who died from drug-related causes were recorded as having mental health issues.
Circumstances of death
In 46 cases, it was stated that no one else was present when the deceased took the drug. Someone else was
identified as having been present in 26 cases and in the remaining cases, it was not possible to tell from the
information provided. In cases where someone was present, often the other individuals had also been using
drugs or alcohol. There were some instances where people were present in the house but reported they were not aware that the deceased had taken drugs until they found the deceased; in these instances, the deaths were not exclusively suicides.
In 62% of cases (71 records), the individual took the overdose that resulted in their death in their own home. A
further 19 people overdosed (17%) in someone else’s home. Of all the cases reviewed, only one incident
occurred in what would be considered a public place. Of the 46 cases where no one else was present when the
deceased took the drug, 31 occurred in the home of the deceased.
Only 27 individuals were confirmed as having been found alive. In three cases, it was not possible to tell from the
coroners’ records.
Other information
Out of the 27 found alive, five cases were not opiate overdoses, meaning it would not have been appropriate to
use naloxone. Of the remaining 22 cases, just nine cases confirmed that naloxone was given, while in a further
four cases, naloxone was available and would have been appropriate but was not administered. In all cases
where naloxone was administered, it was done so by a paramedic who had the naloxone with them. In the
remaining nine cases where the individual was found alive, it was not known whether or not naloxone was
administered. As there is no comparable dataset, it is not possible to know how many individuals were found alive and received naloxone and as a result survived.
Conclusions
The most common characteristics of the sample (not necessarily occurring together) were that the deceased was
White, single or divorced, living alone, unemployed, and had a prior history of drug use and/or mental health
issues. The deceased was most often found having already died. It was already known that around three-quarters of drug misuse deaths are male. In line with other reports, the findings suggest a vulnerable, at-risk population engaging in unsafe drug-taking practices such as taking drugs alone and consuming multiple different types of drug alongside alcohol.
The ONS report recommends that Public Health England consider the issues raised that relate to clinical practice and specific risk factors, such as taking drugs without anyone else present and consuming multiple different types of drug alongside alcohol, in consultation with key government and academic stakeholders.
