DRUG DEATHS IN FIFE SCOTLAND

2005 - 2007

A report on the findings of the Fife Drug Deaths Monitoring and Prevention Group (Fife Drug and Alcohol Action Team)

Alex Baldacchino Shehnaz Iqbal Sarah Walls Kenny Cameron

Foreword

In 2005 the Scottish Executive published “ Taking Action to Reduce Scotland’s Drug Related Deaths”1 in which it made clear its commitment to reducing drug deaths. Fife Drug and Alcohol Action Team share this commitment to reduce and prevent drug deaths and the publication of ‘Drug Deaths in Fife, Scotland 2005 – 2007’2 is evidence of the partnership approach being adopted to respond effectively to the challenge of reducing drug deaths.

The work of the multi agency Drug Deaths Monitoring and Prevention Group in Fife is an excellent example of partnership working at its best. Equally it is an example of how Drug and Alcohol Action Teams can harness the energy, expertise and commitment of a wide variety of colleagues from different disciplines to address a multi faceted problem. The partnership approach has shaped the collation, analysis and sharing of data. It has fostered trust, increased understanding of each other’s roles and engendered a sense of ownership. Maintaining a focus on identifying areas for improvement rather than attributing blame has been central to the process. The outcome is a decision making process based on evidence aimed at making a difference.

The report makes for sombre reading and the reader is asked to bear in mind that behind every statistic lies a story of personal and family tragedy that demands our respect. With this in mind, Fife Drug and Alcohol Action Team will produce an Action Plan based on the report’s recommendations and liaise closely with partners to ensure its implementation.

Finally, I wish to thank all organisations, services and colleagues who have worked tirelessly to create an effective framework and process to monitor and prevent drug deaths in Fife under the leadership of Dr. Alex Baldacchino.

Stephen Moore Chairperson Fife Drug and Alcohol Action Team

February 2008

1. Taking Action to Reduce Scotland’s Drug- Related Deaths’ The Scottish Executive Response to the Scottish Advisory Committee on Drug Misuse Drug Related Deaths Working Group Recommendations 2005 2. Drug Deaths in Fife 2005 – 2007 A Report on the findings of the Fife Drug Deaths Monitoring and Prevention Group (Fife Drug and Alcohol Action Team) 2008

Acknowledgements

Authors

Dr Alexander Baldacchino Chairman of DRD Group, Consultant Psychiatrist NHS, Fife and Senior Lecturer in Addictions, Centre for Addiction Research and Education Scotland (CARES), Dundee University

Shehnaz Iqbal, Drug Deaths Research Assistant, Fife DAAT, Clinical Associate in Applied Psychology, NHS Fife

Sarah Walls, EDROS Researcher, Universities of St Andrews and Dundee, Centre for Addiction Research and Education Scotland (CARES)

Kenny Cameron, Police Constable, Fife Constabulary

Fife Drug Deaths Monitoring and Prevention Group - Strategic Committee

Dr Alexander Baldacchino- Chairperson of DRD Group, Consultant Psychiatrist NHS, Fife and Senior Lecturer in Addictions, Dundee University

Dr Margaret Hannah NHS Fife Public Health Consultant and Choose Life Campaign Co- ordinator

Rita Keyte Co-ordinator, Fife Drug and Alcohol Action Team

Catherine Skinner Principal Analyst, Fife Constabulary

Kenny Cameron Police Constable, Fife Constabulary

Martin Thom, Team Leader, Drug Court Supervision and Treatment Team, Criminal Justice Service

Delphine Easson, Prison Addictions Team Manager, (EACS)

Dr Lucy Cockayne Lead Clinician and Consultant in Addictions Fife NHS Addiction Services, NHS Fife

Shehnaz Iqbal Part-time Drug Deaths Research Assistant

Special Thanks

To the Fife Police Constabulary who have provided the setting and infrastructural support to collect, analyse and write the report findings. To the Centre for Addiction Research and Education Scotland (CARES) supporting this project by freeing the EDROS researcher for 2 months to help in the report writing and completion.

Contents Page

Executive Summary 1

Section 1: Introduction 6

1.1 Background 6 1.2 Governance and Structure 6 1.3 Mission Statement 7 1.4 Ethos and Philosophy of Fife Drug Deaths Monitoring and Prevention Group 7 1.5 Drug Deaths Strategic Group 7 1.6 Drug Deaths Monitoring Group 7 1.7 Summary of Fife’s Actions on Scottish Executive’s Recommendations: 8 Taking action to reduce Scotland’s Drug Related Deaths (Scottish Executive, 2005) 1.8 Literature Review of Patterns Surrounding Drug Deaths 10

Section 2: Methodology 13

2.1 Population 13 2.2 Definition of a Drugs Death (DD) 13 2.3 Inclusion Criteria; ICD-10 14 2.4 Exclusion Criteria 14 2.5 Step by Step Processes Involved in Information Gathering 15 2.6 Step by Step Guide to Data Collection 16 2.7 Protocol and Creation of the Drug Deaths Database 17 2.8 Drug Deaths Database 17 2.9 Data Analysis 17 2.10 Data Collection Sources 18 2.11 Missing Data 19 2.12 Format of Findings 20

Section 3: Results 21

1: Demographic Characteristics 21

3.1.1 Prevalence and Location of Drug Deaths 21 3.1.2 Prevalence in Specific Towns Within Fife 22 3.1.3 Social Deprivation 25 3.1.4 Gender and Ethnicity 27 3.1.5 Age 29 3.1.6 Timings of Deaths 32 3.1.6.1 Month of the Year 32 3.1.6.2 Days of the Week 34

2: Life Context and Social Functioning 36

3.2.1 Housing 36 3.2.2 School and Employment Information 39 3.2.3 Relationship and Family Information 41 3.2.4 Friendships and Relationships 43

3: Criminal Justice and Offending 44

4: Pharmacology of Heroin in Fife 46

3.4.1 Purity Levels 46 3.4.2 Illicit drug seizures in Fife 46

5: Toxicology Findings 48

3.5.1 Toxicology results from post mortem 48 3.5.2 Substances Implicated Concomitantly 49 3.5.3 Blood/Urine Drug/Alcohol Concentrations 50 3.5.4 Cause of Death Findings 50

6: Substance Misuse Histories of Drug Death Victims 6 Months Prior to Death 52

3.6.1 Injecting Characteristics 52 3.6.2 Lifetime Overdose Histories 54 3.6.3 Instances of Overdose 6 Months Prior to Death 55 3.6.4 DD Victims Dying Alone or in the Presence of Others 55 3.6.5 Snoring Immediately Prior to Death 55 3.6.6 CPR Intervention Immediately Prior to Death 56

7: Physical, Psychological/Psychiatric Health and Significant Life Events of DD Victims 57

3.7.1 Co-morbidity 57 3.7.1.2 Combinations of Morbidities 58 3.7.1.3 Common Types of Psychiatric/Psychological Problems 58 3.7.1.4 Types of Physical Health Problems Encountered 59 3.7.2 Significant Life Events 59

8: Service Use Histories 62

3.8.1 Services Commonly Accessed by DD Victims 5 Years Prior to Death 62 3.8.2 Services Accessed by DD Victims 6 Months Prior to Death 63 3.8.3 DD Victims in Receipt of a Pharmacological Intervention 6 Months Prior to Death 64

Section 4: Conclusions 67

4.1 A Case Vignette of a Typical Drug Death Victim in Fife 67 4.2 Summary of Recommendations 68

Section 5: Appendices

Appendix A: Sacdm recommendations 70 Appendix B: Fife drug deaths questionnaire & guidelines for completion 73 Appendix C: Explanation of tolerance levels in post-mortem toxicology report 91 Appendix D: Map to show location of drug deaths in Fife 92

Section 6: References 94

Executive Summary

Background

The Fife Drug Deaths Monitoring and Prevention Group evolved under the auspices of the Fife Drug and Alcohol Action Team, in order to identify a systematic approach to synthesising individual drug deaths, similarities, trends and patterns among them. This report summarises the findings of drug deaths in Fife over the past 3 years; 2005, 2006 and 2007.

Aims and Objectives

The principal aims of the report included data collection and analysis pertaining to the demographic, social, criminal offending, substance misuse, physical, psychiatric/psychological, service use characteristics and circumstances of drug deaths in the Fife area. Consequently, findings have enabled the committee to set forth recommendations, to facilitate the reduction of drug deaths and inform policy and practice at a local and national level.

Methods

The population of Fife drug deaths (DDs) consisted of 54 cases (2005-2007). Information was collected via dissemination of the Fife Drug Deaths (DD) Questionnaire (see Appendix B) and/or case notes held by social care services, specialist addiction services, general practice, prison and police services e.g. Scottish Criminal Records Office (SCRO). Data relating to the specific cause of death was obtained from the Procurator Fiscal.

Results

Demographic, Social Functioning and Life Context Trends

• The DD figure in Fife was higher in 2006 (19) and 2007 (20) than in 2005 (15) and the DD rate in Fife is below average for Scotland • Most DDs occur in the large towns in Fife, although when population was taken into consideration these areas did not display elevated DD rates • The majority (83%) of individuals’ home town and town of death matched. The remaining individuals died within 10 miles of their home town • DDs are more likely to occur in socially deprived areas and the number of DDs in the most socially deprived areas increased each year. • DD rates in Fife towns provide an indication of other drug-related problems in these areas such as drug crime. East Wemyss and Benarty appear to be areas of concern with both elevated DD and drug-related crime rates. • 100% of DD victims in Fife were white and 93% of DD victims between 2005 and 2007 in Fife were male. • 29% of drug-related crime charges in Fife in this period were made against female individuals • In 2006/2007, 34% of individuals seeking drug treatment in Fife were female and factors other than non-involvement in the drug culture are involved in protecting females from DD. • The mean age of DD victims was 31 years old and DD victims were between 17 and 48 years of age Multiple morbidities were present in the youngest and oldest

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• individuals, with the youngest tending to experience psychological conditions and the oldest to suffer from physical conditions. • Most DDs occur during Spring time. This may be linked with victims’ release from prison. Most DDs occur at the weekend. This is unlikely to be linked with prison release patterns • DD victims were most likely to live alone and in council accommodation at the time of their death and had only one type of accommodation in the 6 months before death • DD victims’ living situation type and accommodation type did not differ greatly between the 6 months before death and the time of death • The mean age that DD victims left school was 16 • Only 21% were unemployed following school, however directly before their death 81% were unemployed, providing an indication of the effect of substance misuse on their everyday lives • 80% of DD victims were single at the time of their death, 39% had children although 85% did not live with their children. Individuals had close family members (72%) or friends (86%) indicating they were not socially isolated

Criminal Justice Issues and Offending Patterns

• 96% of DD victims had an arrest history and almost all DD victims had committed a crime linked to their drug abuse • 46% of DD victims had served a prison sentence during their life and 17% of those who died had been in prison in the two weeks prior to their death • Only a small minority of victims were subject to court enforced interventions in the six months before their death.

Pharmacology of Heroin in Fife

• Cutting agents contribute to an average of 55% of Heroin composition • In the last 3 years in Fife the quantity of Heroin has doubled from 0.125 grammes to 0.2 grammes, therefore the concentration has increased • Purity levels have remained relatively stable potentially leading to an increase in individuals overdosing and dying • The supplies of drugs are temporarily displaced despite yearly increases in the number of drugs seizures in Fife

Toxicology Findings

• Heroin/Morphine (80%), Diazepam (43%) and Alcohol (35%) were the 3 main substances of misuse detected in cases of drug deaths in Fife • Benzodiazepines as a class, are the substances most commonly implicated in drug deaths in Fife (89%) • Psychostimulants (e.g. MDMA) involved in 10% of deaths, however there is a recent emergence of deaths involving cocaine (2007) • These findings are consistent with Scotland-wide research (Zador et al 2005; GROS,2007) but not reflected in UK national research where Morphine, Alcohol and other Opiods are the most frequently detected substances of misuse (Ghodse et al 2007)

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• The majority of DD cases were positive for 2 or more combinations of drugs in toxicology reports; Morphine appeared in 7/10 combinations, Benzodiazepines featured in 5/10 and Alcohol in 3/10 • Benzodiazepines and Morphine combined were most frequently misused substances in 41% of DD cases in Fife, followed by Alcohol and Morphine (19%) & few overdoses on Heroin alone • Overall Morphine/Heroin was the most heavily implicated drug in drug combinations of Benzodiazepines and Alcohol • Fife DD victims consume within or below the toxic range, but the cocktail of drugs (namely, Heroin, Benzodiazepines and Alcohol) potentially results in lowered tolerance levels

Substance Misuse Histories

• Majority of DD victims (89%) were intravenous (IV) polydrug users, typically with a 10 year history of IV drug use • Almost half of all DD victims (46%) had overdosed at least once before in their lifetime • Majority of DD victims (56%) were in the presence of others at point of death • Persons present were often family/friends of the DD victim

Physical, Psychological/Psychiatric Health and Significant Life Events of DD Victims

• 63% of DD victims (n=34) had experienced significant life events including instances of overdose and self harm, physical and psychiatric health problems • Of this population a large proportion (55%) had experienced complex psychiatric/psychological, substance misuse morbidities with or without overdose/self harm issues • 18% a range of physical health problems with or without overdose • 15% a range of psychiatric/psychological problems with or without overdose • 12% had solely encountered drug overdoses exclusive of any co morbidities

Service Use Histories

• 85% of DD victims in Fife were known to services 5 years prior to death • Specialist services were the most accessed during this time period • Majority (55%) of DD victims were known to services in the 6 months prior to their death • GP services were the most accessed service in this time period • An overwhelming majority (72%) of DD victims did not seek/receive pharmacological treatment for their drug problem 6 months prior to death • 22% were receiving pharmacological treatment, most were prescribed methadone (18%) • Of these DD victims16% were still on a methadone programme at point of death

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Recommendations

Demographic Characteristics

• As a number of deaths occurred within a short period of prison release, recommendations are made towards an integrated care approach.

Life Context and Social Functioning

• A review of education inputs relating to lifestyle education/drug and alcohol misuse to individuals aged 15 and 16 to ascertain whether those inputs presently delivered are sufficient.

• As individuals had others close to them at the time of their death, this provides the opportunity for overdose training for these individuals.

Criminal Justice Issues and Offending

• The fact that 96% of individuals had been involved in the criminal justice system suggests there should be consideration for an arrest referral scheme within Fife so early intervention can occur in terms of referring these individuals to drug and alcohol agencies.

Pharmacology of Heroin

• The composition of Heroin should be analysed at a local level for a breakdown of the composition of cutting agents as well as purity levels • Purity levels, composition and quantity of Heroin need to be taken into consideration in formulating overdose strategies

Toxicology Findings

• The therapeutic range should be reconsidered when a cocktail of drugs are consumed • The role of Benzodiazepines should be incorporated into overdose training • Consolidate the good links with toxicologists to produce detailed and accurate reports

Substance Misuse Histories

• Family members of drug users should be provided with overdose training so they can recognise signs of overdose such as snoring • Family members ought to be provided with CPR training, this would also allow them to intervene and perhaps prevent the death. • Wider training and implementation of Naloxone • Individuals with a history of overdose should be considered on a case by case basis and proactive discussion necessary regarding using the Child Protection • Better exchange of information and recording of near misses

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Physical, Psychiatric/Psychological Health and Significant Life Events

• Complex cases should be prioritised enabling specialist services, with the relevant competencies to be able to provide an integrated care approach • Physical and psychological health must be incorporated into the core assessment process in any agency • Sharing of information between agencies should be encouraged • Awareness of cardiac pathology in some cases and to investigate adequately e.g. ECG

Service Use Histories

• Further inform on the dosage of pharmacological interventions prescribed and their relation with drug deaths • To encourage services to include the age at which individuals begin using drugs IV • A more integrated approach to identify a high risk drug taking population released from prison who tend to access a multitude of services in short space of time

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Section 1. Introduction

1.1 Background

The National Investigation into Drug Related Deaths (DRD) (2005) commissioned by the Scottish Executive and conducted by the Centre for Addiction Research and Education Scotland (CARES) examined the social, clinical circumstances and service contacts of those dying as a result of a drug related death in Scotland in 2003. This investigation and subsequent Scottish Advisory Committee on Drug Misuse (SACDM) report and recommendations (2005) identified the need to establish a local standing Drug Deaths Monitoring and Prevention Group that involved key agencies to reduce deaths under the auspices of local Drug Alcohol Action Team (DAAT).

1.2 Governance and Structure

A Fife Drug Deaths committee was already in place in Fife since 2003, as a key-working sub-group, accountable to Fife DAAT. Initially, the committee met regularly to consider the circumstances surrounding Drug Deaths in Fife in collaboration with the services stated1. However in 2005 the committee made a number of recommendations to the DAAT and a subsequent revision of the group structure took place. The Overdose Intervention Training Group evolved as part of recommendations made by SACDM and is now considered a sub-component of the Fife Drug Deaths Monitoring and Prevention Group. The position of the Drug Deaths group, with respect to other components within the DAAT can be seen below:

(Source: Fife DAAT Directory of Services)

1 Statutory and non-statutory agencies involved in any or all services involved in the provision of a service or care package to the individual prior to their death 6

1.3 Mission Statement

‘Fife wide multi-agency approach to understanding and preventing drug deaths’

1.4 Ethos and Philosophy of Fife Drug Deaths Monitoring and Prevention Group

The Drug Deaths Group has two principal functions. The first aims to determine common demographic, social, criminal offending, substance misuse, physical, psychiatric/psychological, service use characteristics and circumstances of drug deaths. This is accomplished through the dissemination of an in-depth questionnaire to all agencies outlined in the Fife DAAT Directory of Services2 as well as Prison Services (SPS). All services are notified of a suspected drug death, and are asked to provide information about those individuals that they have had contact with. Therefore all agencies involved in the provision of a service to the Drug Death (DD) victim, form the monitoring component of the committee. The second element uses the information gathered, to draw upon trends, similarities, key themes, and strategic issues to be formulated. This aim fulfils the purpose of the strategic component of the group. Thus, in line with national recommendations, the committee endeavour to inform and disseminate good practice, and enhance the provision of care to reduce the growing number of Drug Deaths in Fife. Members of the Monitoring and Strategic Group are outlined below;

1.5 Drug Deaths Strategic Group

Member Position

Dr Alexander Baldacchino Chairman of DRD Group, Consultant Psychiatrist and Senior Lecturer in Addictions Dr Margaret Hannah Public Health Consultant and NHS Fife Choose Life Campaign Rita Keyte Co-ordinator, Fife DAAT Catherine Skinner Principal Analyst, Fife Constabulary Kenny Cameron Police Constable, Fife Constabulary Martin Thom Team Leader, Drug Court Supervision and Treatment Team, Criminal Justice Services Delphine Easson Prison Addictions Team Manager, Enhanced Addictions Casework Service Shehnaz Iqbal Part-time Drug Deaths Research Assistant3 Dr Lucy Cockayne Lead Clinician and Consultant in Addictions, NHS Fife Addiction Services

1.6 Drug Deaths Monitoring Group Includes Members from the Strategic Group and Representatives From:

Fife Intensive Rehabilitation Service Team (FIRST) West Fife Community Drug Team (WFCDT) Drug and Alcohol Project Levenmouth (DAPL) Fife Alcohol Advisory Services (FAAS) Specialist Midwife in Addictions NHS Fife Others organisations involved in the care of the DD victims

2 See appendix 3 Funded by Fife DAAT for creation and maintenance of the Drug Deaths Database and analysis of Drug Deaths information in Fife 7

1.7 Summary of Recommendations Contained within “Taking Action To Reduce Scotland’s Drug Related Deaths”(Scottish Executive, 2005)

‘Taking Action to Reduce Scotland’s Drug Related Deaths’ (Scottish Executive, 2005) made a number of recommendations to help future reduction of Drug Related Deaths in Scotland. As part of the ongoing work of the Fife Drug Death Monitoring and Strategic Group it was felt useful to highlight where Fife had taken on and in some cases exceeded the recommendations.

Recommendation 1 – Improving Responses to Overdoses Recommendation 12 – Training for Services Professionals, Staff and the Voluntary Sector

Fife

Through the work of the Drug Death Monitoring Group it was realised that a number of deaths were preventable but death had occurred as friends/family had failed to recognise symptoms of overdose in individuals.

The Fife Drug Death Monitoring Group established a sub group to specifically look at this recommendation and that of its own findings, this sub group was formed from members of NHS, Police, Social Work, Addiction Services, Scottish Drug Forum and numerous voluntary and statutory agencies.

Funding was applied for successfully to the DAAT and the Overdose Intervention Group commenced training in 2007. Initially training was directed at frontline drug/alcohol agency staff. Scottish Ambulance Service, Scottish Drug Forum and Fife Police gave the training. 26 persons were trained on basic first aid, symptoms of overdose, trends etc. These trained individuals can then cascade train within their own work environments to staff. Sessions have also been undertaken with both users and also family members.

Recommendation 2 - Perceived Barriers to Contacting Emergency Services

Fife

In being specific to Fife through overdose training it was highlighted the priority of Police attendance was to preserve life. There is still a concern amongst the drug using community of contacting the ambulance service due to concerns of Police attendance. Work has also been undertaken amongst users by the Police to highlight this specific concern.

Recommendation 3 – Need for Further Research

Fife

A research project currently being conducted in Fife is considering the commonalities between individuals who succumb to a drug-related death and individuals who commit suicide and die of an opiate overdose. This project will help to understand the relationship between these three processes and the risk factors involved in their manifestation. It will involve gathering data relating to opiate overdoses in the Fife area and so will allow better understanding of the frequency and related outcomes of these. Greater knowledge of the processes involved in non-fatal overdose will be useful during the consideration of those,

8 which did prove fatal. The EDROS project has also led to stronger links between organisations within Fife, as it is jointly conducted by members from St Andrews University, Fife Constabulary, NHS Fife and The Centre for Addiction Research and Education Scotland at the University of Dundee.

Recommendation 4 - Improving the Quality of Existing Responses

Fife

This has been achieved and NHS Fife Board working through information and common strategy on

NHS Boards and their primary care management components should be encouraged to employ the nGMS and nGPS frameworks to increase access to high quality, evidence based treatment programmes for substance misusers.

Recommendation 5 - New and Innovative Treatments

Fife

Fife has a strong clinical governance structure and therapeutic options available throughout the Kingdom. The group has been monitoring trends in drug-related deaths in Fife to establish the factors, which contribute to a reduction in the number of deaths. Also information sharing with SADAAT and other organisations on drug deaths.

Recommendation 6 - Developing Existing Approaches

Fife

During 2006 Fife DAAT entered into a process of review to identify how effectively it was responding to the needs of people in Fife affected by substance misuse. The findings will result in strategic direction and priorities that more accurately reflect need and unmet need.

The redesign of NHS Addiction Services, with the establishment of drop in assessment facilities, has significantly improved rapid access with a resulting increase in the number of people entering treatment. Enhanced partnership working, work to develop care pathways, shared assessment tools and outcomes to complement the national outcomes being developed by Scottish Government, are aimed at delivering a more effective, co- ordinated response.

Recommendation 7 - Targeting those at Greater Risk

Fife

Fife members of the Drug Death Monitoring Group were involved in the cross- departmental advisory group and has helped introduce the concepts of looking more carefully at the issues related to suicides and drug related deaths. In the spirit of understanding individuals rather than just drug deaths the Fife data collection system involves detailed collection of psychiatric and physical morbidities of the case in question. The Fife group also has a close link with the Fife Choose Life Campaign Co-ordinator in order to look at ways of working better together.

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The detailed information available in the Fife drug deaths database will provide the knowledge necessary to understand better the hard to reach populations such as prisoners, homeless, older age group and other populations. This is achieved through different methods used including psychological autopsy techniques, geographical information systems and clustering and looking at the discordance between the provision and utilisation of services offered to these populations.

Recommendation 9 - Service Integration, Recording and Information Sharing

Fife

Agencies such as all Fife wide Addiction Services, Scottish Prison Service Addiction Services, General practice services and Fife Constabulary all participate, communicate and share information in order to complete the Drug Death database. All services adhere to the Information Sharing Protocol, which is in place. When required, onsite access to notes with various agencies is also conducted. All information is held securely on the database at the Fife Police Headquarters in Glenrothes

Recommendation 13 - Planning and Co-ordination of Response Recommendation 14 - Monitoring Drug-related Deaths Recommendation 16 - Toxicological Findings and Circumstances of Death

Fife

These have all been achieved in Fife

Recommendations - 8, 10, 11, 12, 15

These recommendations are at a national level and not Fife specific.

1.8. Literature Review of Patterns Surrounding Drug Deaths

1.8.1. Peer-reviewed journal articles

The risky nature of drug misuse means that individuals who misuse substances on a regular basis are at risk of both fatal and non-fatal overdose (Kerr et al, 2007). Understanding the factors correlated with the likelihood of a drugs overdose may allow better preventative measures to be developed and a better understanding of the drug using community to be formed. A number of studies have been conducted which have identified a number of different factors, which may be linked to the occurrence of an overdose.

It is the male substance misusers who appear to be most at risk of overdose as well as individuals who require assistance with injection, inject in public places and have a history of being denied addiction treatment (Kerr et al, 2007). As well as these factors, on average, those who overdose tend to have a long history of substance abuse as well as a tendency to engage in polydrug use (Darke and Zador, 1996). The use of heroin combined with alcohol and benzodiazepines poses a particular threat, as the central nervous system depressants contained in these can cause a drug user’s normal heroin dosage to prove fatal (Darke and Zador, 1996). An individual’s tolerance to a particular

10 substance can also be reduced during a period of forced abstinence such as during, but not limited to, incarceration. For this reason, recent prison release poses a particular threat for individuals who misuse substances and has been shown to increase the likelihood of a DRD (Seaman, Brettle and Gore, 1998).

A number of variables have also been identified which may be involved in the original manifestation of substance misuse itself and as such may be important when considering adverse clinical outcome with this population. The literature suggests a complex interaction between substance misuse, psychopathology and psychosocial variables. Substance misuse in adolescence has been shown to be linked with delinquency, inappropriate sexual behaviour, misbehaviour and poor academic performance (Dorus and Senay, 1980) and substance misuse in later life has been linked with a number of adverse childhood experiences such as childhood abuse, neglect and household dysfunction (Dube et al, 2003)

Comorbidity of substance misuse and mental illness is highly prevalent (Weaver et al, 2003), however establishing the temporal order of the development of each of these is difficult. Based on previous studies, it appears likely that substance misuse develops first, indicating that it is not attributable to attempted self-medication (Silver and Abboud, 1994; Kovaszney et al, 1993). In terms of the specific psychopathology involved, studies suggest a correlation between drug abuse and depression scores (Coelho et al, 2000) schizophrenia (Regier et al, 1990), affective disorders and personality disorders (Weaver et al, 2003).

1.8.2 Findings of Previous Drug Deaths Reports

Previous reports have been published which have considered the patterns surrounding drug deaths in Europe, the UK, Scotland and within smaller regional sites such as Lanarkshire. These reports tend to consider the trends associated with DD rather than stating risk factors which can be linked with its occurrence.

An example of a report which considered drug deaths across Europe was a report titled Drug-Related Mortality: Perspectives Across Europe (2002). This report described drug- related mortality in fourteen countries across Europe and identified methodological constraints in comparisons between these countries. Constraints include the fact that the definition of a drug death varies between countries as well as the fact that there is no uniform requirement for conducting toxicological analysis, even within a country.

An annual report is also produced by the International Centre for Drug Policy (ICDP) and National Programme on Substance Abuse Deaths (np-SAD) which specifically considers drug deaths in the UK. The latest report (2007) provided information relating to drug deaths which occurred in 2006. This reported that the number of DDs in the UK had increased by 7% since the previous report produced in 2006. The demographic characteristics of DD victims were consistent with those reported in previous years in that the majority of DD victims were male (76%), were under 45 years of age (71%) and were white (96%). The mean age of DD victims in the UK was reported to be 38 years and only 13% of victims were aged 24 or under. This highlights that in the UK, against intuition, it is the older drug users who are most at risk of DD. It was also reported that individuals were equally likely to live alone as they were to live with others at the time of their death. They were likely to be unemployed, although 33% were actually employed at the time of their death.

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It was reported that a large proportion of the DDs in the UK in 2006 involved opiates. In 68% of DD cases in the UK, toxicological analysis indicated these had been consumed, and in 46% of DD cases heroin was present. There was also an increase in both the number of DDs which involved methadone (5% increase) and those which involved alcohol (6% increase). In 32% of cases alcohol was consumed in combination with other substances. This indicates that DDs are often ‘drug and alcohol deaths’ and that alcohol is an important factor in the manifestation of DDs in the UK. The involvement of anti- depressants was also high, with these being implicated in 18% of deaths.

Findings have also been published which consider DD in Scotland alone. The General Register Office for Scotland produces an annual report with up to date statistical information relating to drug-related deaths in Scotland. The most recent report (2007) considered DDs in Scotland between 1996 and 2006. This reported that the majority of drug deaths in Scotland were categorised as drug abuse related (72%) followed by intentional self-poisoning (17%). The majority of drug deaths occurred in the Greater Glasgow and Clyde NHS Board area (38%) followed by Grampian (11%). According to this report, 83% of the DD victims were under 45 years of age with 16% being under 25 years of age. There was a male dominance of 79% of the deaths in 2006 in Scotland. The most common drugs involved in drug deaths were heroin/morphine (260 deaths) followed by methadone (97 deaths) and then diazepam (78 deaths). It was found that deaths were often attributed to consumption of multiple drugs, adding to evidence for polysubstance use amongst drug users.

Areas within Scotland have also been considered, for example in the Lanarkshire Drug Related Deaths Report (2007). This considered patterns surrounding drug deaths in 2006 in the Lanarkshire area of Scotland. This replicated findings reported on a national level of a male dominance in drug deaths, that a majority of drug deaths are aged between 25 and 34, tend to be single and that DD victims often experience psychological ill-health. This report also acknowledged that the majority of drug deaths involve heroin.

The purpose of this report is to produce a similar knowledge base relating to drug deaths in Fife. Consideration of trends relating to DD and drug misuse on a national level allows trends observed within Fife to be compared and contextualised.

Due to the fact that the literature identifies trends surrounding individuals who succumb to a drug death, the current study considered whether these trends also applied to the drug deaths of individuals in Fife. Trends surrounding the lives of DD victims in Fife were therefore considered in terms of factors identified as important in previous reports and peer-reviewed journal articles (such as gender, age, ethnicity, psychopathology, substance use history and drug type used, living arrangements and employment status). Previous research therefore played an important role in informing the methodology of the current study.

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Section 2. Methodology

This report is a retrospective analysis of trends, similarities and common themes occurring within Drug Deaths in Fife over the past 3 years (2005 -2007). Information has been analysed from a descriptive perspective and does not infer that the data collated necessarily identifies risk factors attributable to a drug death. In order to accomplish such a task one requires a controlled sample of a living, drug taking and general population.

2.1 Population

The population consisted of 54 cases (n=54) of Drug Deaths. Cases for the study were a consecutive sample of individuals who died from drug overdose in the Fife area over the 3 years stated. All fatalities suspected of dying from a fatal drug overdose were confirmed by post-mortem toxicology reports obtained from the Procurator Fiscal. Whilst all 54 cases of Drug Deaths have been confirmed, the committee are presently awaiting 3 toxicology reports. Cases corresponding to the definition of a drugs death qualified for analysis.

2.2 Definition of a Drugs Death (DD)

The definition of a DD is complex, with individual studies adopting specific definitions, which vary depending upon the focus of the study. The Scottish Criminal Drugs Enforcement Agency (SCDEA) defines a DD as:

‘Where there is prima facie evidence of a fatal overdose of controlled drugs. Such evidence may be recent drug misuse, for example controlled drugs and/or a hypodermic syringe found in close proximity to the body and/or the person is known to the police as a drug misuser although not necessarily a notified addict.”

The complexity of providing a suitable DD definition is demonstrated by the differences in definitions incorporated by different organisations. For example, the World Health Organisation (WHO) defines it as ‘fatal consequences of the abuse of internationally controlled substances and/or of non medical use of other substances for psychic effects,’ (WHO, 1993; p7). This definition allows the incorporation of deaths indirectly associated with drug abuse, which would be excluded by the SCDEA, such as chronic intoxication, suicide, drug abuse-related accidents and drug-abuse related diseases.

For the purpose of the current report, the definition adopted by the SCDEA will be incorporated. This definition is similar, but not identical, to the definition employed by the General Register Office for Scotland (GROS). The GROS include instances in which toxicological findings indicate the presence of a controlled substance, but where this substance may not necessarily have been a factor contributing to the individual’s death.

Any deaths resulting from the overdose of a controlled substance in the years 2005, 2006 and 2007 will be included and considered in this report.

The Inclusion/Exclusion criteria presented below incorporates the ICD-10 codes used by various national Drug Related Deaths investigations e.g. GROS, 2007 and The National Investigations into Drug Related Deaths 2003 (Zador et al, 2005) and Drug Misuse Statistics Scotland (ISD, 2007). Subsequently the Drug Death Monitoring Group conforms to this definition of a DD.

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2.3 Inclusion Criteria; ICD-10

Drug Deaths, where the underlying cause of death has been coded to the following sub- categories of ‘mental and behavioural disorders due to psychoactive substance use’; a) (i) opioids (F11) (ii) cannabinoids (F12) (iii) sedatives or hypnotics (F13) (iv) cocaine (F14) (v) other stimulants, including caffeine (F15) (vi) hallucinogens (F16); and (vii) multiple drug use and use of other psychoactive substances (F19) b) Deaths coded to the following categories and where a drug listed under the Misuse of Drugs Act (1971) was known to be present in the body at the time of death:

i) accidental poisoning (X40-X44); ii) intentional self-poisoning by drugs, medicaments and biological substances (X60—X64); iii) assault by drugs, medicaments and biological substances (X85) and iv) event of undetermined intent, poisoning (Y10-Y14)

2.4 Exclusion Criteria a) deaths coded to mental and behavioural disorders due to the use of alcohol (F10), tobacco (F17) and volatile substances (F18) b) deaths coded to drug abuse which were caused by secondary infections and related complications (e.g. septicaemia) c) deaths from AIDS where the risk factor was believed to be the sharing of needles; d) deaths where a drug listed under the Misuse of Drugs Act was present because it was part of a compound analgesic or cold remedy e.g.: - Co-proxamol: Paracetamol, dextropropoxyphene - Co-dydramol: Paracetamol, Dihydrocodeine - Co-codamol: Paracetamol, codeine sulphate

All 3 of these compound analgesics have, particularly co-proxamol, been used in suicidal overdoses.

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2.5 Step by Step Processes Involved in Information Gathering

Step. 7 Step. 1

All information is inputted into the Fife DD Database Suspected Drugs Death

Step. 2 Step. 6 Police inform

DAAT & request Drug Deaths monitoring Police attendance & dissemination of DD group meet, discuss investigation Key Questionnaire to all each death & make DAAT = Fife Drug Alcohol recommendations agencies Action Team DD = Drug Deaths FPHQ = Fife Police Head Quarters Step. 3 GPASS = General Step. 5 Toxicology requested Practitioner Patient Notes from Procurator Fiscal Agencies known to Data from DD DD victim complete questionnaire & DD Questionnaire & GPASS added to DD return to FPHQ database at FPQHQ

Confirmed Drugs Death

Step. 4

DD victims GPASS (GP case notes) Requested via NHS Fife 15

2.6 Step-by-step Guide to Data Collection

Step 1.

Suspected Drugs Death in Fife occurs - police attend and carry out investigation into the circumstances surrounding the death. The length of the investigation is dependant upon the circumstances and can vary widely from a few days to a number of months.

Step 2.

Police inform the DAAT and request that the DD Questionnaire is disseminated to all relevant agencies for completion.

At this point, Fife Constabulary also request toxicology from the Procurator Fiscal.

Police inform NHS Fife at this time of the Drugs Death the GP’s details in order for notes to be accessed on behalf of the Drug Deaths Monitoring Group.

Step 3.

Agencies on receipt of information from the DAAT check records to see if the individual has accessed their respective services. If there was any contact then relevant part of the questionnaire is completed and returned to FPHQ for the attention of the DD Monitoring Group.

Step 4.

All questionnaires, case and toxicology notes are returned to FPHQ where details are entered into the DD Database. This is achieved in a 6-8 week period.

Step 5.

Drug Death Monitoring and Strategic Group meet and discuss each death and make recommendations. The group meet every 8 weeks.

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2.7 Protocol and Creation of the Drug Deaths Database

The template utilised in creating the Fife Drug Deaths (DD) Database was formed from a combination of the Centre for Addiction Research and Education Scotland (CARES) questionnaire used in the Scottish Executives National Investigation into Drug Related Deaths in Scotland in 2003 (2005) and extracts from the Scottish Criminal Drug Enforcement Agency (SCDEA) questionnaire. The questionnaire contains the following domains:

1. Demographic characteristics 2. Life context and social functioning 3. Criminal justice issues and offending 4. Substances use history 5. Physical and psychological health 6. Service provisions 7. Additional information

As a result a new (Drug Related Death) V 2.0 questionnaire (Appendix B) was adapted and piloted in Fife in 2006. Specifically, the questionnaire was disseminated to all relevant agencies concerned in the provision of care or services to the Drug Death victim (e.g. CJS, NHS Fife Addiction Services, Voluntary bodies i.e. FIRST, DAPL). Upon completion the questionnaire (s) are returned to the committee and information pertaining to the domains outlined are entered onto the database. In order to adhere to data protection principles, data is anonymised where possible, and coded accordingly. The database is securely held on a stand-alone machine and housed within Fife Constabulary.

2.8 Drug Deaths Database

The main source of information for the current report was the Fife Drugs Death Database (EXCEL/SPSS), which holds all data on Drugs Deaths that have occurred within the Fife area in 2005, 2006 and 2007 respectively.

2.9 Data Analysis

For the purposes of the present report, data contained within the Drug Deaths Database was collated and analysed by 2 researchers 4from a descriptive perspective. The researchers were under the management of and regular supervision of the Chairman of the DD group. Data collection processes also involved constant liaison with committee member, PC Kenny Cameron for access to various police sources and further research assistance was sought from the EDROS Research Assistant. The process of data collection and analysis involved several stages. These are outlined below:

1. Maintaining the database on a regular basis to collate new and cleanse existing data on a regular basis 2. Extracting relevant data pertaining to the seven life domains 3. Data analysis (via Excel/SPSS) and interpretation/synthesis 4. Background research on past/current government directives and relevant literature 5. Reporting/presenting findings

4 Drug Deaths Researcher (Fife DAAT) and EDROS Researcher (Suicide, Overdose and Drug Deaths) 17

2.10 Data collection sources

Outlined below are lifestyle domains and sources used in data collection:

2.11 Missing Data

The committee are aware of and adhere to the policy regarding restricted access. Therefore, whilst current regional socio-demographic trends/figures for Drug Deaths in Scotland (SCDEA, 2007) were obtained and analysed, they are not contained within the present report. Conversely, some information, pertaining to the life domains outlined in the questionnaire was not available for analysis because it did not exist consistently in the case notes e.g. school leaving age.

The Domain

Sources Used

1. Demographic Characteristics -Sudden Death Report -SCDEA - Fife DRD Questionnaire

2. Life Contexts and Social Functioning Sudden Death Reports SCDEA Social Work Files/Criminal Justice Services > Social Enquiry Reports, Psychiatric Reports, Case Notes, Referral letters -Fife DRD Questionnaire

3. Criminal Justice Issues and Offending Checking/SCRO files (criminal record histories), CrimeFile Sudden Death reports (immediate circumstances surrounding death) Toxicology Reports -Fife DRD Questionnaire

4. Substance use history & Clinical Notes from FAS > SMR23/24, Nurses notes, Mental Health notes, Specialist 5. Physical and Psychological Health Assessment Tool, Referral letters, GP summaries, and correspondence Social Work Notes -Fife DD Questionnaire

6. Service Use History All of the above sources

7. Additional Information Any of the above sources 18

Furthermore, data collection for years 2005 was conducted retrospectively by obtaining onsite access to clinical notes from Fife wide addiction services (21/34 individuals had clinical notes); which were made available following permission granted by the NHS Fife Caldicott Guardian, Scottish Prison Services and Police Service as well as the Social Work Department (20/34 individuals had case notes).

The availability/lack of information for all 54 cases is stated clearly throughout the content of this report and it is noted that use of multiple sources may reflect variations in the data obtained. However the availability of additional sources such as the DD Questionnaire and access to GPASS in 2007 has enabled the DD group to gain a greater insight into the established life domains of the DD victims of 2007, than has been possible in previous years. Indeed the DD group acknowledge this as part of an ongoing aim, rather than a limitation, to continue to synthesise information from multiple sources and develop a systematic approach to identifying the lifestyle patterns of DD victims.

Recommendations

• Need to continue the Fife Drug Deaths Database to produce and report data, accumulatively on a 3 yearly basis • Recruit a part time Fife Drug Deaths Researcher to facilitate this process • Encourage services to complete the Fife Drug Deaths Questionnaire • To examine cases not diagnosed as drug deaths but as drug related deaths • To explore the possibility of doing psychological autopsy techniques with the relatives of the deceased in order to improve the quality of the data collected on these individuals.

2.12 Format of Findings

The results of the present report are, as previously stated, analysed from a descriptive perspective and compared/contrasted to drug deaths at a national and UK-wide level. The structure of the present report does not directly reflect the layout of DD Questionnaire and for the purpose of clarity the results section will take the form of a series of sub-sections:

1- Demographic Characteristics

2- Life Context and Social Functioning

3- Criminal Justice and Offending

4- Pharmacology of Heroin in Fife

5- Toxicology Findings of Drug Deaths in Fife

6- Substance Misuse Histories

7- Physical, Psychological/Psychiatric Health and Significant Life Events

8- Service Use Histories

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Section 3. Results

(1) Demographic Characteristics

This section describes patterns surrounding the prevalence and location of drug deaths and the relationship between location and social deprivation. Additionally, this section considers the gender, age and racial ethnicity of drug death (DD) victims and patterns surrounding the timings of DDs.

3.1.1 Prevalence and Location of Drug Deaths

In 2005, 2006 and 2007 there were a total of 54 DDs in the Fife area with 15, 19 and 20 deaths taking place in each year respectively. These have all been confirmed as official drug deaths as all toxicological results have been returned for this period. The number of deaths which occurred in Fife during these three years contributed to the 336, 393 and 375 deaths which occurred as a result of accidental overdose in these three years in Scotland as a whole.

In order to place this DD rate in context, the number of DDs in Fife can be compared with the number of deaths in other regions of Scotland. As confirmation of drug deaths which occurred in particular Scottish regions is not yet available, comparisons will be made between 2005 and 2006 only. In Scotland in 2006, as in previous years, most DDs occurred in the Strathclyde area, with 54% of all Scottish DDs occurring in this region. There were more than ten times as many confirmed and suspected DDs in Strathclyde than there were in Fife during 2006. Figure 1 shows the number of drug deaths in each Police force area of Scotland. It shows that the number of drug deaths has increased overall between 2005 and 2006. It is known that within Fife, the figure increased slightly further in 2007.

Total Number of Confirmed DDs in Each Region of Scotland During 2005 and 2006 (n=642)

250 200 150 2005 100 2006 50 0 Fife Number of Drug Deaths Number and Tayside Central Borders Northern Scotland Dumfries Galloway Lothian & Grampian Strathclyde Scottish Police Force Area

Figure 1. The number of drug deaths which occurred in each region of Scotland during the years 2005, 2006 and 2007.

The larger number of deaths in the region of Strathclyde is not surprising as this area is also that with the largest population in Scotland. In order to take population into consideration, the number of DDs per 1000 of the population was calculated for each region.5 This is shown below in Figure 2.

5 The population figures used to calculate these results were based upon the population of each of these regions in mid 2006 as provided by The Register General’s Annual Review of Demographic Trends (2007). 20

Number of DDs per 1000 of the Population for Each Scottish Region in 2005 and 2006

0.12 0.1 0.08 2005 0.06 2006

Region 0.04 0.02 0 Scottish Police Force Central Dumfries Fife Grampian Lothian & Northern Strathclyde Tayside Scotland and Borders Galloway Number of DDs per 1000 of the Population

Figure 2. The number of DDs in each Scottish Region per 1000 of the population.

Figure 2 shows that the DD rate in Fife is not high in comparison to other regions in Scotland. The average number of deaths per region in Scotland during 2005 and 2006 was 0.041 and 0.064 per 1000 of the population whilst the DD rate in Fife during these three years was 0.042 and 0.054.

This indicates that the DD rate in Fife was below the Scottish average during 2006 and only marginally above the Scottish average during 2005. When considered together, the number of DDs in Fife was below the national average for this period. The three regions with the highest DD rate per 1000 of the population during 2005 and 2006 are Grampian, Strathclyde and Tayside.

Key Points • The DD figure in Fife was higher in 2006 and 2007 than in 2005. • The DD rate in Fife is below average for Scotland

3.1.2 Prevalence in Specific Towns Within Fife

The distribution of DDs in Fife is also of interest. The location of the deaths which occurred in Fife between 2005 and 2007 is shown below in Table 1. Individuals’ addresses were used in order to calculate these figures and as such this information may differ slightly from the actual location of the DDs. A map showing the location of these drug deaths can be found in Appendix D (p92).

Table 1. Number of DDs in specific towns in Fife during 2005, 2006 and 2007 (n=54)

Town Number of DDs Town Number of DDs Benarty6 6 Methil 3 Inverkeithing 2 St.Andrews 1 Kelty 1 Burntisland 1 Kennoway 2 Comrie 1

6 Deaths in Benarty occurred in Ballingry and Lochore. This is typically considered as one area with a population of only 5665. 21

Kincardine 1 Cowdenbeath 2 Kingskettle 1 Cupar 2 Kirkcaldy 11 Dunfermline 7 Leven 2 East Wemyss 2 Lochgelly 1 Glenrothes 8

9 Individuals died in a town different to that stated on their address. In all cases the distance between the town stated on their address and the town in which they died was less than ten miles. This shows that individuals who succumbed to a DD stayed close to home and that elevated death rates in particular locations are not a result of individuals travelling to these areas.

Table 2. Individuals whose home town and location of death differed, and the distance between these locations.

Town stated Location of Distance apart on address death (miles) Glenrothes Dysart 6.3 Thornton Kirkcaldy 4.4 Inverkeithing Dunfermline 4.7 Glenrothes Cardenden 9.8 Dunfermline Aberdour 7.7 Crossgates Lochore 6.9 Comrie Dunfermline 5.8 Methil Kirkcaldy 8.7 Leven Methil 1.3

The number of deaths per 1000 of the population can also be used to better understand the pattern of DRDs within Fife, as hotspot areas may still display an average DD rate per 1000 of the population. This would indicate that although these are the places where most DDs occur in Fife, this could simply be attributed to the fact that these are the largest towns in Fife.

Number of DDs in Fife Towns between 2005 and 2007 per 1000 of the Population

2.5 2 1.5 1

Population 0.5 0

g y il s Number of DDs per 1000 of DDs of 1000 of per Number ty ty n l e s l tle ldy h nd i e el la line ys the nar ithin K oway dine et ca eve s m e ar L hg Met beathCupar m o ke sk nti Comr n er B nc f er ng Kirk Loc de t-We Kenn Ki Ki Bur w s Glenr Inv St Andrews Dun Co Ea Fife Town

22

Figure 3. Number of DDs in Fife Towns per 1000 of the Population.

Although Kingskettle displays the highest number of DDs per 1000 of the population, this result is based upon only one DD which occurred in 2005, but due to its very small population this created a large DD rate per 1000 of the population. It still remains a possibility that there is a drug problem in this area but the occurrence of a DD does not provide evidence of this as such.

The results also show an elevated DD rate in Ballingry, Comrie and East Wemyss. These figures correspond to three, one and two DDs in each of these locations respectively. This finding could again, be attributed to the small population size of these locations. However, it is concerning that more than one death occurred in both Ballingry and East Wemyss. This may indicate that there are problems relating to drug misuse in these areas.

The question of whether DDs were representative of other indicators of substance misuse in the population was considered by investigating the distribution of drug crime7 in Fife.

Table 3. The number of drug-related crimes in the 15 Fife towns with the highest drug- related crime rate during 2005, 2006 and 2007.

Location Number of Location Number of Location Number Drug Drug of Drug Crimes Crimes Crimes Kirkcaldy 351 Cupar 60 Leven 33 Dunfermline 291 Lochgelly 49 Cardenden 31 Glenrothes 245 Kelty 36 Buckhaven 30 Methil 92 Cowdenbeath 34 Kennoway 27 Benarty 87 St Andrews 33 Rosyth 24

The highest rates of drug-related crime were found in the main towns of Kirkcaldy, Dunfermline and Glenrothes which reflects the highest rates of DDs in Fife, and also the highest population figures. A large number of drug-related crime charges were made against individuals in both Methil and Benarty during these three years. The drug crime rate displayed for Benarty suggests that the elevated DD rate at this location is not an isolated finding in terms of general drug problems in this area.

The number of drug-related crimes per 1000 of the population is shown below in Figure 4. The towns shown are those in which a DD occurred and not necessarily those with the highest drug crime rates as shown in Table 3.

7 Drug crime was defined as a charge of supplying or concerned in the supplying of a controlled drug, production of a controlled drug, possession of a controlled drug with intent to supply, the offer to supply a controlled drug and obstructing police with or without warrant when drug crime was suspected. 23

Number of Drug-Related Crime Charges in 2005, 2006 & 2007 per 1000 of the Population in Locations in Fife where DDs Occurred

18 16 14 12

e Population 10 8 6 4 2

per 1000 of th 1000 of per 0

Number of Drug Related Crimes Crimes Related Drug of Number y y n l d r lt le n e a e ve nart K oway ett la e Le Methi s Cup myss B nn cardinesk Comri nrothes erkeithing e in Kirkcaldy Lochgelly We e v K K King Burni st Gl In St Andrews Dunfermlinea Cowdenbeath E Fife Town

Figure 4. The number of Drug-Related Crime Charges which occurred in 2005, 2006 and 2007 in Fife in the Fife Towns in Which DDs Occurred.

The fact that there were no drug charges in Kingskettle is consistent with the fact that the elevated DD rate per 1000 of the population at this location is due to a single incident in a small area.

Benarty and East Wemyss, which were highlighted as potentially problematic in terms of drug-related problems on analysis on the DD rate, are implicated again when the number of drug-related crime charges per 1000 of the population in considered. These areas have the highest number of drug crime charges per 1000 of the population, suggesting that DD figures do provide an indication of other issues relating to drug culture.

3.1.3 Social Deprivation

Another factor which may be of importance when considering the distribution of DDs in Fife is whether individuals lived in areas of social deprivation. It is possible that a reason for elevated DD rates in the areas indicated relates to deprivation at these locations. In order to consider whether DD victims were living in socially deprived areas of Scotland, the Carstairs Index (McCloone, 2004) was used to calculate a social deprivation score (DepCat) for each individual. This was calculated using the postcode relating to the individual’s place of residence at the time of their death.

The Carstairs Index is often used to indicate the social deprivation or affluence of a particular area. The DepCat scores used here were devised based on information provided during the 2001 census using a number of variables which suggested social disadvantage (proportion of households with male unemployment, lack of car ownership, overcrowded housing and the head of the household being in social class IV or V). A DepCat score of ‘one’ is the highest possible score and indicates an affluent location whereas a DepCat score of ‘seven’ provides an indication of great deprivation.

24

It was not possible to calculate the DepCat score of one individual’s home location as this individual had no fixed abode at the time of their death. However, the DepCat scores for the remaining 53 DD victims were calculated, 15 of whom died in 2005 and 19 who died in both 2006 and 2007. Results indicated that DD victims were living in socially disadvantaged areas, although not in the most deprived areas. No individuals lived in an affluent area with a DepCat score of one. Most individuals lived in areas with a DepCat score of four, with 40% of all DRD victims between 2005 and 2007 falling into this deprivation category. The DepCat scores of all 53 individuals are shown in Figure 5.

Depcat Scores for Individuals who succumbed to DD in 2005, 2006 and 2007 in Fife (n=53) 10

8

6

4 Category 2 Number of individuals falling intofalling Deprivation 0 1 2 3 4 5 6 7 112233445 6 775 6 2005 2006 2007 Year of death and Deprivation Category

Figure 5. Deprivation Categories of individuals who succumbed to a DRD in Fife between 2005 and 2007.

Figure 5 shows that the distribution of social deprivation in 2005 and 2006 was relatively equal, with almost the same number of individuals falling into DepCat categories one to five. However, in 2006, a much larger percentage of individuals lived within an area with a DepCat score of six.

In 2007, a large number of individuals had a DepCat score of five (37%) and for the first time individuals living in an area with a DepCat score of seven succumbed to a DD. These individuals both lived in Methil. Overall, the deprivation of DD victims appears to have increased between 2005 and 2007. This is demonstrated by the fact that in 2005, 93% of DRD victims had a DepCat score between one and four, in 2006 this figure fell to 64% and in 2007 it decreased again to 42%.

Key Points

• Most DDs occur in the large towns in Fife, although when population was taken into consideration these areas did not display elevated DD rates • The majority (83%) of individuals’ home town and town of death matched. The remaining individuals died within 10 miles of their home town.

DDs are more likely to occur in socially deprived areas. • • The number of DDs in the most socially deprived areas increased each year. • DD rates in Fife towns provide an indication of other drug-related problems in these areas such as drug crime. • Specifically, East Wemyss and Benarty appear to be areas of concern with 25 both elevated DD and drug-related crime rates.

3.1.4 Gender and Ethnicity

100% of the 54 individuals who succumbed to a DD in Fife during 2005, 2006 and 2007, were white and 93% of them were male, with four females in total dying due to an accidental drug overdose in this period.

The circumstances of these four individuals were considered. The table below shows that the females who succumbed to a DD in Fife had all been exposed to drug abuse by individuals close to them during their lives. Two of the individuals had suffered bereavement with both having lost a son as well as one or both of their parents. The remaining two individuals’ parents were divorced which might indicate that none of the four individuals had a strong parental unit within their family. The information presented in Table 4 shows that a number of negative influences were present in the lives of the females who succumbed to a DD.

Table 4. Circumstances of female individuals who succumbed to a DD in Fife.

Parents’ Two of the female individuals’ parents were divorced. The status remaining two individuals had at least one parent who was deceased. Children Two of the female individuals did not have children and two had experienced the death of one of their children. Exposure to All four had close family members who were known to misuse drug abuse drugs. Health One individual had a history of a psychiatric condition, and one of a physical condition.

The dominance of male deaths in the DD figures is not a phenomenon specific to Fife. A large proportion of the DDs in Scotland were also observed to be male during these three years. The GROS reported that 77% of the DDs in Scotland in 2005 were male and that 79% were male in 2006. This is a finding which has also been reported for the UK as a whole. In the Annual Report of drug-related deaths in the UK, Ghodse et al (2007) reported that 77% of the UK drug-related deaths in 2006 were male.

As the figures above for Scotland and the UK show, the large proportion of male DDs is a pattern observed nationally and not just on a Fife basis. In every region of Scotland in 2007, there were substantially more males who succumbed to a DD than there were females. A comparison of Fife to the other Scottish regions can be seen below in Figure 6. This figure shows the percentage of male and female in each Scottish Police Force area during 2007.

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Total Drug-Deaths in Scotland During 2007 by Gender

120 100

80 Female 60 40 Male 20 0

Percentage of Deaths Fife D&G Tayside Central Northern Borders Scotland Lothian & Grampian

Strathclyde Scottish Police Force Area

Figure 6. The Number of Confirmed DDs in Each Scottish Region in 2007 by Gender.

Although, more males were dying of a DD between 2005 and 2007, this does not necessarily indicate that more males were abusing drugs during this period, or engaging in drug-related activities. When drug-related crime is considered, the proportion of males to females is much smaller than when DD is considered, although the majority of drug-related crime charges were still made against male individuals. This is shown below in Figure 7.

The Number of Males and Females Involved in Drug-Related Crime in Fife Between 2005 and 2007 (n=1765)

600 500 400 male 300 female 200 100 Related Crimes Number ofDrug- 0 2005 2006 2007 Year

Figure 7. Gender differences in drug-related crime in Fife between 2005 and 2007.

Figure 7 shows that a large number of drug-related crimes are committed by female individuals in Fife. In 2005, 27% of drug-related crime charges were made against female individuals, in 2006 this figure remained relatively stable at 26% but in 2007 it rose to 35%. This shows that females are not protected from DD by the fact that they do not become involved in Fife’s drug culture and so other more complex factors are involved.

To further emphasis this, according to the International Statistics Division 34% of new clients seeking drug treatment in Fife were female in 2006-2007. In Scotland this figure was similar as 31% of new clients were female. This can be contrasted with the fact that 7% of DD victims in Fife between 2005 and 2007 were female. The difference in the gender divide between individuals dying of a DD and individuals who are seeking drug

27 treatment/involved in drug-related crime suggests that the low female DD rate is not entirely attributable to the fact that less females abuse drugs in Fife.

3.1.5 Age

The age of individuals who succumbed to a DD between 2005 and 2007 in Fife ranged from 17 to 48, with a mean age of 31 years old. When each year is considered separately, the mean age is not found to show much variation. In 2005 the mean age of those who experienced a DD was 30, in 2006 it was 32 and in 2007 the mean age was 31. When individuals over the age of 42 and under the age of 20 were removed from the sample, to consider the effect of these outliers, the mean age of DD victims remained at 31. The age of each individual in Fife who succumbed to a DD during the three years is displayed below in Figure 8.

The Age of Individuals who Experienced a DD in Fife Between 2005 and 2007 (n=54)

4

3

2

1 Number of victims of Number 0 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 Age

Figure 8. The age of those who succumbed to a DD in Fife between 2005 and 2007.

This figure shows that DD poses a threat to individuals across a wide age range. This is emphasised when individuals are categorised into age groups. This is shown below in Figure 9. The largest proportion of individuals are aged 20 to 29, with 44% of all DD victims falling into this group. However, 33% are aged 30 to 39 and 19% are aged 40 and over. Only 4% of DD victims were aged 19 and under. This is an interesting finding as it contradicts the public perception of the typical DD victim who would be in his late teens or early twenties.

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Percentage of Individuals in Each Age Group who A) Succumbed to a DD & B) Who Sought Treatment for the 1st Time in Fife

50 40 DDs (n=54) 30 20 Treatment Seeking 10 (n=1269) Age Group

Percentage of 0 Individuals in Each Each in Individuals 19 and 20-29 30-39 40 and under over Age Group

Figure 9. Drug Death Victims and Individuals Seeking Substance Misuse Treatment in Fife by Age Group

Figure 9 also demonstrates that there are great similarities between age distribution of the treatment seeking and DD populations who are aged 20 to 39. This indicates that this age group is the most likely to encounter problems relating to drug misuse in general, not only a DD. Differences emerge outwith this age group as although only 4% of DD victims are aged 19 and under, 13% of individuals seeking treatment for the first time fall into this age group. Inversely, in the 40 and over age group only 11% of individuals seeking treatment fall into this category whereas 19% of DD victims do. This difference may indicate reluctance by older individuals with substance dependency to seek treatment.

It may be of interest to consider differences in patterns surrounding the deaths of older and younger victims. In order to do this, factors which may have contributed to the deaths of the three oldest and the three youngest drug death victims were considered. Of the three oldest drug death victims two were aged 48 and one was 46. The three youngest victims were aged 17, 19 and 20.

29

Table 5. Patterns Surrounding Oldest and Youngest DD victims

Youngest Victims (n=3) Oldest Victims (n=3) Bereavement Two of these individuals’ All of the oldest victims had fathers were deceased experienced bereavement. Between them they had lost a son, a sister, a long-term partner and a number of close friends. Two of the oldest victims had also lost both their parents.

Children None of the youngest All three of the oldest victims victims had children had children

Exposure to Two of the youngest One of the oldest victims had a drug abuse victims were known to close family member who was have close family a drug user and who died of an members who were overdose. drug users

Health Two of the youngest All three of the oldest victims victims were known to were known to suffer co- have a psychiatric morbid physical conditions. history. These included asthma, organ abnormalities, HIV and hepatitis C.

Indication of Two of the youngest No OD history was known for suicide or victims had a history of the three oldest victims. OD history OD and had received CPR in the past.

The table above does not shows some differences between the youngest and oldest DD victims. The oldest individuals had children and the youngest did not. This is not surprising due to the age difference of the two groups of individuals. It was only known that two of the youngest individuals had a history of overdose and had required CPR in the past. Two of the youngest individuals had been exposed to drug misuse by a member of their immediate family, whereas only one of the older DD victims had. Differences in the medical conditions of the youngest and oldest individuals were also visible. The youngest victims tended to suffer from psychological conditions whereas the older victims suffered from physical conditions. Overall five out of six of these individuals had either a physical or psychological condition and the same proportion of individuals had experienced the death of an immediate family member. This may highlight the importance of influences within the family unit in the development of drug misuse and subsequent DD.

30

Key Points

• 100% of DD victims in Fife were white. • Only 7% of DD victims between 2005 and 2007 in Fife were female. • 29% of drug-related crime charges in Fife in this period were made against female individuals • In 2006/2007, 34% of individuals seeking drug treatment in Fife were female. • Factors other than non-involvement in the drug culture are involved in protecting females from DD. • The mean age of DD victims was 31 years old • DD victims were between 17 and 48 years of age • Multiple morbidities were present in the youngest and oldest individuals, with the youngest tending to experience psychological conditions and the oldest to suffer from physical conditions.

3.1.6 Timings of Deaths

3.1.6.1 Month of the Year

Month of Death of DDs Between 2005 and 2007 in Fife (n=54)

10 8 6 4 2

Number of DDs of Number 0

y r ril e ly er er rch p n u b be A Ma Ju J ob Ma August JanuaryFebruary Oct Septem NovemberDecem Month

Figure 7. Month of the Year in which DDs Between 2005 and 2007 occurred.

As can be seen in Figure 7, Spring time appears to show the highest rate of DDs, with 41% of deaths occurring between March and May. The death rate was lowest during the summer months of June, July and August with only 13% of deaths occurring during this period. This result is consistent with the fact that it is often observed that there is a peak in the number of suicides which occur during Spring (Rock et al, 2005).

The pattern displayed in Figure 7 suggests that there may be an influence of public holidays on DDs. The peaks shown in Figure 7 correspond to public and school holidays i.e. in March/April (Easter), May (Two bank holidays occur in this month), July (School summer holidays), October (Half-term) and December (Christmas break). It is therefore a possibility that there is a link between the occurrence of DDs and public holidays.

31

The question of whether differences existed between individuals succumbing to a DD in each season was considered by examining the prevalence of particular factors amongst these individuals for example comorbid mental health disorders, bereavement or separation from a partner. This comparison is shown below in Table 5.

Table 6 – Comparison of individuals who died in Winter, Spring, Summer and Autumn.

Winter- Dec- Spring - Mar- Summer- Autumn - Feb (n=11) May (n=22) June-Aug Sept-Nov (n=7) (n=14) Physical condition 10% 14% 43% 36% Mental health 50% 41% 29% 36% condition Bereavement of close 50% 41% 29% 36% family member Served a prison 40% 50% 29% 43% sentence

The information presented above shows that individuals who succumbed to a DD in Spring are more likely to have suffered from bereavement of a close family member than those who died in Summer and Autumn, although not more likely to have than those who died in Winter. In 78% of cases where individuals died in Spring and had suffered bereavement, their close family member had died within the year. In comparison, for those who died in Winter or Autumn and had suffered bereavement only 25% had a close family member die within the year.

The percentage of individuals who succumbed to a DD and had a psychiatric history was highest for those who died in Winter, followed by those who died in Spring. This information may suggest that Winter and then Spring are the most vulnerable periods for substance misusers with a psychiatric history or a history of bereavement.

The seasonal trends above also show that individuals who succumbed to a DD in Spring are more likely to have served a prison sentence than individuals who died in other seasons. It is of interest to consider this further to investigate whether these individuals were released close to their death. Table 7 below considers this for individuals in each season.

Table 7. Time after prison release that DD occurred for individuals who had served a prison sentence (n=23)

Winter- Dec- Spring - Mar- Summer- Autumn- Feb (n=4) May (n=11) June-Aug Sept-Nov (n=2) (n=6) 1 week 0% 27% 0% 17% 1 to 2 weeks 25% 9% 50% 33% 2 weeks to one month 0% 9% 0% 0% 1 to 2 months 0% 18% 0% 17% 2 to 6 months 25% 9% 0% 0% 6 months to a Year 25% 0% 0% 17% More than a Year 25% 27% 50% 17% The information presented above in Table 7 shows that individuals who succumb to a DD in Spring (and who have served a prison sentence) are more likely to have been released

32 from prison in the same week as their death than individuals who succumb to a DD in other seasons. 63% of individuals who succumbed to a DD in Spring (and who had served a prison sentence at some point in their life), died within two months of being released from prison. In comparison, 75% of individuals who died in Winter had been released from prison for over two months before they died.

This suggests that the season in which a substance misuser is released from prison may affect their likelihood of succumbing to a drug death. It suggests that perhaps those who are released in Spring are at greater risk in the period immediately following their release than individuals who are released at other times of the year. There is a possibility that this pattern is linked to the presence of undiagnosed psychiatric disorders.

3.1.6.2 Days of the Week

The days of the week on which DDs occurred between 2005 and 2007 are shown below in Figure 8.

Day of the Week of DDs for all Deaths Between 2005 and 2007 in Fife (n=54)

16 12

of DDs of 8 4

Number 0

y y y a ay a d d n sd s nda Friday Mo ue ne Su T Thursday Saturday Wed Day of the week

Figure 8. The days of the week in which a DD occurred

Figure 8 shows that there is a clear trend towards DDs occurring on Fridays and Saturdays with 48% of DDs occurring on these two days alone. It is interesting that the majority of deaths occurred at the weekend. As only 13% of DRD victims were employed at the time of their death, this is unlikely to indicate a link to their working patterns. It may suggest that they were influenced by the working patterns of other individuals involved in their drug use and were more likely to engage in risky behaviour when in the presence of these individuals. It is also likely that this pattern may be caused by drugs supplies becoming more abundant at the weekend and that this is the period when drug users purchase their substances.

A further possibility is that the peak of deaths on a Friday relates to prison release patterns. Table 8 shows the day of death and day of prison release for the 9 individuals who had been released from prison closest to their death. This is shown in Table 8 below

Table 8. The days of death and days of prison release for the 9 individuals who died closest to their date of release 33

DD case Day of Death Day of prison Time Between Release Release & Death 1 Thursday Friday 8 days 2 Sunday Friday 9 days 3 Saturday Friday 1 day 4 Sunday Thursday 8 days 5 Thursday Wednesday 1 day 6 Tuesday Friday 4 days 7 Friday Wednesday 2 days 8 Wednesday Friday 12 days 9 Friday Thursday 15 days

The information presented above suggests that prison release patterns cannot explain the occurrence of a higher rate of DDs on Fridays and Saturdays. The percentage of individuals who had recently been released from prison and succumbed to a DD on a Friday or Saturday was lower (33%) than that observed in the whole sample (48%).

Recommendations • As a number of deaths occurred within a short period of prison release, recommendations are made towards an integrated care approach is introduced.

34

(2). Life Context and Social Functioning

This section describes DD victims’ accommodation and living arrangements at the time of their death and in the six months preceding their death. Information relating to employment, both directly after school and at the time of death is also considered. Patterns surrounding individuals’ relationships with both friends and family will also be described

3.2.1 Housing

As well as demographic characteristics, information on the life context and social functioning of individuals was gathered. A point of interest is the accommodation and living arrangements of deceased individuals at both the time of their death and in the six months leading up to their death. It was found that the majority of individuals who succumbed to a DD in Fife between 2005 and 2007 were living alone and in council accommodation at the time of their death. Figure 9 below shows the different living circumstances of these DD victims.

Living arrangements of DD victims at time of death (n=54)

25 20 15 10 5 0 Number victims of DD

ts y y) ne er en n il il ed wn o tn r m r Al r ild re a m ha no a h f a s Pa r -f r t k c e n e o se/P th o N u r & th O (n O po s S artne dult P A Individual(s) with whom DRD victims were living

Figure 9. Living arrangements of DD victims at time of death.

As is shown in Figure 9, individuals who succumbed to a DD had a number of different living arrangements in the period directly before their death. The most common living arrangements were for DD victims to live alone, with their parents or with other adults who were not a member of their family. 44% of individuals lived alone in the period directly before their death, 17% lived with their parents and 19% lived with other adults outwith their family. On the other hand only a small proportion of DD victims lived with their partner and/or children in the period before their death. Only 2% of victims lived with their partner and 4% lived with both their partner and child.

In terms of the type of accommodation of those individuals who succumbed to a DD, the majority of individuals lived in housing association or council accommodation (56%) or

35 lived in an owner-occupied property (26%). Individuals classed as ‘homeless’ were roofless with no fixed abode. In relation to individuals living in owner occupied accommodation, this was mainly due to the fact that they were living with a family member who owned their own property. It was uncommon for individuals to be homeless/roofless (6%), privately renting (2%), or living in a hostel (7%). This information is displayed in graphical form below in Figure 10.

DD victims accommodation at time of death (n=54)

30 20 10 0 Number of DD victims renting Owner- Privately hostel occupied hostel Homeless Not known Supervised Unsupervised Council/Housi ng Association ng Accommodation type

Figure 10. Accommodation arrangements of DD victims at time of death

It is also of interest as to whether DD victims remained in the same accommodation type in the 6 months prior to their death so as to provide an indication of the stability of this aspect of their lives. Results show that individuals were most likely to have only one type of accommodation in the 6 months before their death. This shows that the majority of individuals were not facing great change in this aspect of their lives in the lead up to their death and so were not facing constant adjustment to accommodation changes. More than one type of accommodation, was however still found for 35% of individuals, showing that this is a relatively common element of the lifestyle of DD victims. Common reasons for individuals changing accommodation type were release from prison into the community, individuals staying with a family member on a temporary basis and individuals staying in temporary accommodation until moving into a council property.

Number of Types of Accommodation in the 6 months Before Death (n=54)

35 30 25 20 15 10 5

Number of DRD victims 0 1234 Number of different types of Accommodation

36

Figure 11. The number of types of accommodation of each DD victim in the 6 months leading up to their death.

The accommodation of the DD victims in the 6 months before their death is considered below. For individuals who had more than one type of accommodation in the six months before death, each of these accommodation types were counted. A comparison of Figure 10 and Figure 12 does not reveal any large differences between the types of accommodation individuals had at the time of their death and in the six months before their death. Individuals who were classified as homeless had no fixed abode at the time of their death and were known to be living in public areas.

DD victims' accommodation in 6 months before death

40 30 20 10 0 6 months before months 6 death Number of DD victims with this accommodation type in type accommodation this cupied meless odation stel orary Housing Owner- y renting pervised pervised ciation hostel oc ho Ho Su Temp Unsu Asso Privatel accomm Council/ Accommodation Type

Figure 12. Accommodation types of DD victims in the 6 months before death.

The living situations of individuals were also considered for the six months before their death. For individuals with multiple living arrangements (n=9) during this period, each instance was included. The living arrangements in the six months before individuals’ deaths do not appear to differ much from those at the time of their death.

Living arrangements of DD victims at time of death

30 20 10 0 Number of victims Alone er Parents children family) Partner & Not known Other family Adults (non- Other shared Spouse/Partn Living arrangements

Figure 13. Living arrangements of DD victims in the 6 months before death.

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3.2.2 School and Employment Information

The age at which DD victims left school and their employment status at this time is also of interest. Of those whose school leaving age was known (n=38), it was found that the mean age for all individuals who succumbed to a DD between 2005 and 2007 was 16, with 75% of individuals leaving school at this age. This was also the mean age found when each year was considered separately. Of the remaining 25% of individuals, only one individual left school at 18 years old, six individuals left school at 15 and one left school at 14 years old having been permanently expelled.

This shows that only one individual who succumbed to a DD remained in education after the compulsory period enforced by the government. In 2006, the government announced plans to increase the minimum age at which an individual can leave education to 18. This would make it compulsory for those leaving school before they are 18 to find a training placement or to enrol in further education. Analysis of DDs in the future, if the compulsory school leaving age is raised, may provide a better indication of the influence of education on the rate of DDs.

Case notes provided information on the employment status of 38 individuals following school. The most common activity following school was to find employment with 47% of individuals taking on a job after leaving school. Typically this employment involved manual work with half of those employed taking a labouring position and the remaining half taking posts such as machine operator, window cleaner, supermarket trolley collector and factory worker.

Those individuals who did not find employment following school went into further education (8%) or found training or apprenticeships (24%). 21% of individuals were unemployed following school. The number of individuals who were unemployed following school, and who had no other training or education in place, is double that expected for individuals of this age group in the UK. According to the Commons Education and Skills Select Committee (2007) up to 10% of 16 to 18 year olds have left the education system, are not engaging in any form of training and are unemployed.

Employment Status of DD victims after Leaving School (n=54)

20 15 10 5 0 n r on ed ed pre Number of DD Victims Furthe Educati Employ Not know nticeship Unemploy Training/Ap Type of Activity Following School Leave

Figure 14. The employment status of DD victims after leaving school

38

This shows a difference between the early lifestyle patterns of individuals who succumb to a DD and those of an average individual. This is not surprising as many of the individuals who succumbed to a DD began abusing drugs at a young age. Data relating to the age that drug misuse began was available for 15 of the 20 individuals who succumbed to a DD in 2007. The mean age that this occurred was 17, with 73% of individual’s drug use beginning at the age of 16 or younger.

Although, on average individuals did not die as a result of their drug abuse until 31 years of age, they were abusing drugs from the age of 17, providing an indication of the chronicity of their substance misuse. During this period, changes in lifestyle patterns can be observed. Whilst only 21% of individuals were unemployed following school, immediately prior to death a much larger proportion (81%) of the DD victims were unemployed. Only 6% of the individuals were employed full-time and 7% were employed part-time. The employment status of individuals at the time of their DD is shown below in Figure 15.

Employment Status Directly Before DD (n=54)

50

40

30

20 Category 10

0

Number of DD Victims in this this in Victims DD of Number Employed Employed Unemployed Sick or Student full-time part-time Disabled Employment Status

Figure 15. Employment status of individuals at time of DRD

The change in lifestyle pattern, with regard to employment status, provides an indication of the impact of chronic substance misuse on the everyday lives of these individuals.

Key Points

• DD victims were most likely to live alone and in council accommodation at the time of their death and most had only one type of accommodation

in the 6 months before death

• DD victims’ living situation type and accommodation type did not differ

greatly between the 6 months before death and the time of death

The mean age that DD victims left school was 16 • • Only 21% were unemployed following school, however directly before their death 81% were unemployed, providing an indication of the effect of substance misuse on their everyday lives

Recommendation A review of education inputs relating to lifestyle education/drug and alcohol misuse to individuals aged 15 and 16 to ascertain whether those inputs presently delivered are sufficient. 39

3.2.3. Relationship and Family Information

Information on the relationship status of individuals who have succumbed to a DD may assist in understanding factors which have contributed to drug misuse and subsequent death. Figure 10 below shows the relationship status of individuals at the time of their death and shows that the majority (80%) of individuals were single. Of the 43 individuals who were single, 9 were separated from their marital partner and 1 was divorced at the time of death.

Relationship Status of DD victims (n=54)

50

40

30

20

10

Number victims of DD 0 Single Married Long-term relationship Relationship Status

Figure 16. Relationship status of DD victims at the time of their death

This shows there is a clear pattern amongst DD victims to be single at the time of death. It is difficult to interpret whether this is caused by the lifestyle which results from drug misuse or whether being alone acts as one of the causal factors in the manifestation of an individual’s drug misuse.

However, a number (20%) of individuals were in a long-term relationship at the time of their death, including three individuals who were married. This is perhaps an indication of an element of stability in their lives which they upheld despite the problems they were facing elsewhere in their lives in relation to their drug addiction. Although this could suggest an element of support in the lives of these individuals, there was evidence to suggest that 55% of these individuals’ partners also had a drug problem. It is possible that this figure is even higher as information relating to the drug use of DD victims’ partners was not readily available.

It is also interesting to consider whether DD victims had any children at the time of their death. It was unknown whether three of the individuals had any children based upon the information available. Of those whose parental status was known, 39% had at least one child at the time of their death. This is displayed below in Figure 17.

40

Whether DD Victims had any Children (n=54)

35 30 25 20 15 10 5 Number of DD Victims 0 Had Children Did not have children Not known Whther DD Victims Had Children

Figure 17. Whether DD victims had any children at the time of their death

Although a large number of DD victims had children, this does not mean that they were responsible for these children. As can be seen in Figure 18, the majority (85%) of DD victims’ children did not live with them at the time of their death. One DD victim had custody of his child at weekends; another was caring for his child but only on a temporary basis and another was living with his child on a permanent basis.

Where DD Victims' Children Were Living (n=20)

20 16 12

8

4

Number of DD Victims 0 With Person With Person - With Person - Elsewhere Temporary only Weekends only Children's Living Arrangements

Figure 18. Living arrangements of the DD victims’ children at the time of their death

The only DD victim who lived with his child, was also one of the few DD victims to be married and living with his wife at the time of his death. He was also one of the few DD victims to be employed on a full-time basis. This individual was also one of only 9% of DD victims who lived in an area with a DepCat score of two, indicating that this individual lived in an affluent area. This individual does not fit the typical profile of a DD victim. He appeared to continue to successfully manage many aspects of his life prior to his death despite his opiate addiction.

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3.2.4. Friendships and Relationships

The question of whether DD victims had a friend or relative to whom they felt close at the time of their death was also considered. However, information relating to the relationships and the friendships of DD victims was sparse. Of the 54 DD victims, it was unknown whether 25 had a relative to whom to they felt close and whether 33 had a friend to whom they felt close. For those individuals for which this was known, 21 (72%) had a relative with whom they had a close relationship and 18 (86%) had a friend with whom they had a close friendship.

Of those individuals who had a family member to whom they felt close, the majority (60%) shared this relationship with a parent. The remaining individuals had a close relationship with a sibling (15%), wife (10%), grandparent (5%), child (5%) or uncle (5%). It was also found that at least 9 of the DD victims had a close relationship with more than one family member.

The fact that these individuals were able to engage in a relationship shows that they had not been socially isolated as a result of their drug problem and had managed to maintain meaningful relationships with others, including those outside the drug using community. This suggests that there was perhaps some degree of social support available to the DD victims as they did have relatives and friends to whom they could turn for support if it was needed. This is also important in terms of prevention of DDs, as these friends and family members could be informed of important information relating to overdose and drug misuse which they could pass onto those individuals with a drug dependency. It also informs us that these individuals could be trained to recognised the signs of overdose and how to respond if this does occurs.

Although a large number of DD victims held a close relationship with at least one other individual at the time of their death, a large number also had difficulties in their relationships. It was unknown whether this was true for 19 of the DD victims, however of the 35 remaining individuals, 34% had relationship difficulties at the time of their death. This provides another indication of the difficulties that the DD victims were facing in the period before their death. In all cases, these relationship difficulties were a result of individuals’ drug misuse. In the majority of cases this was due to the individual’s family member worrying about the impact of their drug use on their life although in other cases individuals’ drug misuse led to behavioural change which relatives found difficult to tolerate, causing tension in their relationships.

Key Points

• 80% of DD victims were single at the time of their death • 39% had children although 85% did not live with their children • Individuals had close family members (72%) or friends (86%) indicating they were not socially isolated

Recommendation

As individuals had others close to them at the time of their death, this provides the opportunity for overdose training for these individuals.

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(3.) Criminal Justice and Offending

This section describes DD victims’ history of criminal activity and imprisonment

3.3.1 History of Offending

It was considered whether those who succumbed to a DD in Fife had a history of offending and imprisonment. 96% of individuals had in fact been arrested in the past and of these 39% of these arrests were drug-related. Only 4% of individuals had appeared before the drug court in the 6 months prior to their death. Although not all arrests were drug-related, of those who were not arrested under the Misuse of Drugs Act, the majority (87 %) had committed a crime which involved theft and so could be linked to their drug misuse. Of the six individuals whose crime was not drug-related or theft, three individuals had convictions for both breach of the peace and relating to the road traffic act, two had convictions relating only to the road traffic act and one had a conviction for breach of the peace only.

46% of DD victims had served a prison sentence during their lives. This proportion is higher than that observed in the general substance misuse treatment seeking population. The ISD reported that in Fife between 2005 and 2006, 21% of individuals seeking treatment for substance misuse for the first time reported having served a prison sentence. This is comparable to the proportion of individuals in Scotland as a whole, as 22% of individuals in Scotland seeking treatment for their drug use reported a history of imprisonment. This shows that individuals who die from a DD are twice as likely to have served a prison sentence than new substance misuse clients.

For those individuals in Fife who succumbed to a DD and had served a prison sentence, it was considered how long after release their DD occurred.

Table 9. Number of DDs which occurred following prison release categorised by time after release Number of DD victims who died within period stated following prison release (n=23) 1 week 4 1 to 2 weeks 5 2 weeks to one month 1 1 to 2 months 3 2 to 6 months 1 6 months to a Year 2 More than a Year 7

The information above shows that of the 22 individuals who were imprisoned and succumbed to a DD, 39% died within 2 weeks of being released from prison. This means that 17% of all the individuals who succumbed to a DD in Fife between 2005 and 2007 had been imprisoned in the 2 weeks before their death. This suggests that recent incarceration is likely to play a role in accidental overdose. This supports previous findings (Seaman et al, 1998) that incarceration can lead to a reduction in tolerance and as such poses a threat to drug users by increasing the likelihood of accidental overdose on release.

43

It was also considered as to whether DD victims had been subject to interventions prior to their death. The figures presented below in Table 10 show that the majority of individuals were not subject to any particular intervention in the six months preceding their death.

Table 10. Individuals known to be subject to particular intervention in the 6 months before their death.

Intervention Percentage of Individuals known to be subject to this in the 6 months before death Diversion from Prosecution Scheme 2% Community-based Alternative to 8% Custody Scheme DTTO 6% Enhanced Probation Order 6%

Key Points

• 96% of DD victims had an arrest history • Almost all DD victims had committed a crime linked to their drug abuse • 46% of DD victims had served a prison sentence during their life • 17% of those who died had been in prison in the two weeks prior to their death • Only a small minority of victims were subject to court enforced interventions in the six months before their death.

Recommendations

The fact that 96% of individuals had been involved in the criminal justice system suggests there should be consideration for an arrest referral scheme within Fife so early intervention can occur in terms of referring these individuals to drug and alcohol agencies.

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(4). Pharmacology of Heroin in Fife

This section describes the affordability, widespread availability and purity levels of Heroin in Fife from 2005-2007.

3.4.1: Purity levels

An important aspect of DDs revolve around the quantities of licit and illicit drugs that lead to fatal overdose and the potential role that purity levels may play in DDs. In line with this recent data regarding the purity levels of Heroin from drugs seizures, Fife and Scotland wide were obtained from the SCDEA. These are outlined in the table below:

Table 11. Purity levels of Heroin seized by Fife Police in Fife 2005-2007

Year Drug Fife Mean Scotland Mean 2005 Diamorphine 47.25 46 2006 42.75 41.25 2007 43.75 45.5

As Table 11 shows, the pattern of purity levels of Diamorphine, its presence found in Heroin, are higher in Fife in 2005 (48%) and 2006 (43%) compared to the national average of 46% in 2005 and 41% in 2006. Interestingly, the trend for 2007 show purity levels in Fife to be marginally less (44%) than nationally (46%).

This pattern of results suggests that the cutting agents contributing to Heroin account for, on average 55% of the composition. Purity levels over the 3 years (2005-2007) show a reduction, indicating that the composition of Heroin is increasingly becoming diluted by the presence of other, unknown substances. It is recognised that forensic reports do not require adulterants to be explored, therefore little is currently known regarding the types of ‘cutting agents’/adulterants involved in Heroin composition at a national level (SCDEA, January 2008).

The affordability and widespread availability of drugs commonly implicated in Drug Deaths in Fife, was confirmed recently during Fife Constabulary’s drugs Test Purchase Operation which revealed that the weight of a ‘tenner’ bag had almost doubled from 0.125 grammes to 0.2 grammes per bag over the past 3 years.

3.4.2 Illicit drug seizures in Fife

Table 12. Number and types illicit drugs seizures by Fife Police in Fife 2004/2005- 2005/2006

2004/2005 Polic Crack Cocain Heroin Methadon LSD Ecstasy Amphet Cannabis Benzo e e e -type - 8 diazep Force amines ines9

8 Figure includes seizure (s) of Cannabis plants, herbal and resin. 9 Figure includes seizure (s) of Temazepam 45

0 21 129 1 4 36 55 576 40 Fife 2005/2006 1 33 167 9 1 37 59 676 51

The variety of drugs available to drug users in the locality can be further observed in the types of drugs commonly seized by police forces in the Fife area. These are displayed in the table above (Table 12) and show that there has been a consistent yearly increase in the number of illicit drug seizures in Fife. On a UK level, drug seizures may on one hand reflect the emergence and existence of substances commonly involved in Drug Deaths, as well as variances in ‘intelligence-led activities of law enforcement agencies’ in the accessibility of street drugs (Schifano and Corkery, 2008). In Fife, it is recognised that although police enforcement activity leads to temporary displacement in the supply of illicit drugs, its supply is quickly restored (Fife Constabulary, Force Strategic Assessment, 2007/2008).

Key Points

• Cutting agents contribute to an average of 55% of Heroin composition • In the last 3 years in Fife the quantity of Heroin has doubled from 0.125 grammes to 0.2 grammes, therefore the concentration has increased • Purity levels have remained relatively stable potentially leading to an increase in individuals overdosing and dying. • The supplies of drugs are only temporarily displaced despite yearly increases in the number of drugs seizures in Fife.

Recommendations

• The composition of Heroin should be analysed at a local level for a breakdown of the composition of cutting agents as well as purity levels • Purity levels, composition and quantity of Heroin need to be taken into consideration in formulating overdose strategies

46

(5) - Toxicology Findings of Drug Deaths in Fife

This section describes the post-mortem toxicology findings, injecting characteristics, and substance misuse and overdose histories, of the 54 Drug Death victims in context of a growing poly-substance misuse culture in Fife from 2005-2007.

It is observed in the current findings and recognised across Europe that DD victims often misuse a variety of drugs; sedative and illicit either in isolation or in combination with Heroin (Baldacchino and Corkery, 2006). Specifically post-mortem toxicology reports of the 54 Drug death victims were analysed to gain a greater insight into the types of substances that led to the fatal overdoses of the 54 DD victims.

3.5.1 Toxicology results from post mortem

Forensic toxicologists, currently conduct blood/urine tests for the substances believed to be implicated in the drug death. A typical blood test usually tests for; basic drugs, acid/neutral drugs, Benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDS) and Morphine10. Urine samples are analysed for opiates, amphetamines, cannabinoids, cocaine, Benzodiazepines, methadone, barbiturates, tricyclic antidepressants (TCA), MDMA and methamphetamine. Therefore, only those substances tested for are likely to be detected in the toxicology, potentially biasing the outcome of toxicology findings.

The chart below shows the Heroin, Alcohol and Benzodiazepines as the three most frequently involved substances in drug deaths in Fife from 2005-2007.

2005 2006 2007 20 18 16 14 12 10 8 6 4 2

No. of occassions involved 0 r e e is e m A e ol e n n b ine a in tes h a ain e p M h a m cohol mi n c d Ot l a iazpi n o o ze MD rp zepam A d a C C thadone o Opi azepam a C ia e M x zo D raceta n M O a e P Tem Amphet B

DesmethlydiazepamSubstance (s) involved

Figure 19. Results of Post-mortem toxicology reports; substances involved in a DD in Fife 2005-2007(n=51)11

The graph shows Heroin and/or Morphine (as a result of its presence in Heroin) as the most prominent substance implicated in DDs in Fife. Heroin was involved in a total of 80% (n=41) of drug deaths, Diazepam in 43% (n=22) and Alcohol in 35% (n=19) over the 3 years (2005-2007). Yearly increase (s) in the identification of Morphine, Diazepam and

10 The term Morphine will be used interchangeably with Heroin, as a result of its presence in Heroin. 11 Awaiting 3 toxicology reports, detailing the specific breakdown of substances involved in the drug deaths 47

Alcohol as being involved in DRDs in Fife, are also visible in the graph. Psycho stimulants such as Cocaine, MDMA, Amphetamine and Other substances (DHC and Paracetamol) contributed to less than 10% of deaths, indicating that these drugs, presently, feature in only a small proportion of drug related deaths in Fife. However, the committee are aware of the recent emergence of MDMA (n=2) and Cocaine in 2007 (n=2) and will continue to monitor this trend.

Over the course of the 3 years there appears to be marked changes of the involvement of Cannabis and Methadone. The number of DDs involving Cannabis appears to fluctuate, increasing from 2/15 in 2005 to 4/19 in 2006 then fell to 1/20 in 2007. Methadone was involved in only 1 death in 2005, but increased to 5 in 2006 and then dropped to 3 in 2007. However, upon classification of Benzodiazepines, post-mortem toxicology reports reveal that Benzodiazepines are the most frequently detected class of drug, implicated in 89% of all DDs in Fife from 2005-2007.

These results are consistent with research in Scotland regarding the involvement of substances implicated in drug deaths e.g. Zador et al (2005) and GROS (2007), which both showed that Heroin/Morphine and Benzodiazepines were more frequently involved in DDs Scotland-wide. However, these trends are not reflected on a UK level, where the principal substances implicated in drug deaths in 2006 were Heroin/Morphine (46%), alcohol (32%) and other opiates/opioid analgesics (22%) (Ghodse et al 2007).

3.5.2 Substances Implicated Concomitantly

25 20 15 10 5 0

Morphine Morphine Methadone Alcohol Methadone + Methadone

phine zipines

+Benzodiazpines nes+Morphine phine+Codeine Alcohol +Morphine Codeine + Morphine Benzodiazipines+Mor Benzodiazipines+Mor Alcohol+Benzodiazipi Methadone+Benzodia

Figure 20. Most frequent combinations12 of substances detected (n=51)

Illicit substances detected in post-mortem toxicology reports were analysed in order to explore the most common/frequent combinations of consumption (Figure 20). Figures for combinations of illicit substances consumed were ascertained from toxicology reports where multiple drugs were implicated in a drug death. There were 8 combinations of drugs most commonly detected in multiple drug combinations of drug deaths in Fife.

The majority of deaths were positive for 2 or more combinations of drugs (n=43) and few cases were positive for only one drug at post mortem, namely Morphine (n=6), Methadone (n=1) and Diazepam (n=1)13 and none with combinations greater than 7 drugs.

13 1 death in 2006, presumed neutral (involvement of Diazepam only) ‘above therapeutic levels’ 48

Benzodiazepines14 and Morphine combined were the most frequently misused substances in cases of drug deaths in Fife (n=22). Alcohol and Morphine were implicated in a total of 19 (n=19) drug deaths. Combinations of Alcohol, Benzodiazepines and Morphine (n=10) and Alcohol and Benzodiazepines (n=10) were implicated equally over the past 3 years.

Morphine was included in 7 of the 10 most frequently occurring combinations detected, followed by alcohol and Benzodiazepines occurring 5 and 3 of the most common drug combinations. Overall, Morphine was the most heavily implicated substance in drug combinations, including alcohol and/or Benzodiazepines, consumed by DD victims (n=49) (methadone (n=2 (2007)) and (n=3 awaiting).

Thus, DD victims in Fife, consumed, most commonly morphine, alcohol and/or some form of benzodiazepine, concomitantly. It has been suggested that the presence of other depressants can lower the tolerance levels, leading to fatal overdose, alcohol and Benzodiazepines, in particular, have been associated with this phenomenon (Oliver et al, 2007).

3.5.3 Blood/Urine Drug/Alcohol Concentrations

The mean blood morphine concentration was 0.276 mg/l (n=43) with a range of 0.011-1.9 mg/l, this was slightly higher than the national average of 0.269 mg/l (Zador et al 2005). Of these DD victims (n=43), twenty-five DD victims (n=25) were within the toxic range, and the remaining 18 DD victims were not (n=18), where levels of morphine recorded in deaths typically range from 0.2 – 2.3mg/l, with an average of 0.7mg/l (Baselt, 2000).

The mean Diazepam concentration was 1.03 mg/l (n= 21) with a range of 0.04 – 5.68 mg/l, however when the 2 higher values (n=2) are removed (5.62 & 5.48 mg/l) the mean concentration is almost halved (0.55 mg/l) (n=19). The mean urine alcohol concentration for the group was 107 mg/l (n=21) with a range of 6 – 343 mg/l. There were two deaths as a result of ‘adverse effects of methadone’ (n=2), one was 1.1 mg/l and therefore above the therapeutic range for methadone (range 0.57-1mg/l), the other was 1.44mg/l, also exceeding the therapeutic range. The actual published range used in determining toxic levels for Diazepam and alcohol were not stated in post-mortem toxicology reports of any of the DD victims.

The phenomenon of tolerance is acknowledged in toxicology reports (see Appendix D). However the presence and potential effects of concomitant substances on lowering tolerance levels is not mentioned, which is perhaps surprising, given the fact that the majority of DD victims in Fife, nationally and within the UK consume combinations of 2 or more substances alongside Heroin (Zador et al, 2005; GROS, 2007; Ghodse et al 2007).

3.5.4 Cause of Death Findings (n=54)

Adverse effects of intravenous Heroin was the single most common cause of death, recorded in post-mortem toxicology reports for 34% of the DD population (n=17). However Heroin related deaths were reported in various forms; ‘Adverse effects of Heroin and Chronic Drug Abuse (n=1), Adverse effects of IV Morphine (n=1), Adverse effects of Morphine (n=3), Acute and Chronic Adverse effects of Heroin (n=2), Heroin Overdose (n=3), Morphine Overdose (n=2). A summary of the other cause of death diagnoses of drug deaths recorded on post-mortem toxicology reports can be found below:

14 This figure included all detected Benzodiazepines in post mortem toxicology reports, as a class, of Diazepam, Desmethyldiazepam, Oxazepam, and Tamazepam. 49

Heroin and Alcohol; ‘Adverse effects of Heroin and Acute Alcohol Intoxication’ (n=2), Adverse effects of Heroin and Chronic Alcohol intoxication (n=1), Alcohol and Heroin toxicity (n=1), Adverse effects of Alcohol and Morphine (n=1), Adverse effects of Opiates and Alcohol (n=1), Acute and chronic adverse effects of Heroin and Alcohol (n=1), Adverse effects of Heroin and Acute alcohol Intoxication (n=1).

Heroin and Diazepam; Adverse effects of Heroin and Alcohol and Diazepam Intoxication (n=1), Adverse effects of Diazepam (n=1), Adverse effects of Morphine and Diazepam (n=3)

Methadone; Adverse effects of Methadone (n=2), Adverse effects of Heroin and Methadone (n=1), Adverse effects of Ecstasy, Methadone and Temazepam (n=1) and Adverse effects of Methadone and Diazepam (n=1).

Other; Adverse effects of Heroin and Ecstasy (n=1) and Adverse effects of Morphine and Citalopram (n=1), Adverse effects of IV Amphetamine (n=1) and Acute drug Abuse (n=1).

Key points

• Heroin/Morphine (80%), Diazepam (43%) and Alcohol (35%)were the 3 main substances of misuse detected in cases of drug deaths in Fife • Benzodiazepines as a class, then these are the substances most commonly implicated in drug deaths in Fife (89%) • Psychostimulants (e.g. MDMA) involved in 10% of deaths, however there is a recent emergence of deaths involving cocaine (2007) • These findings are consistent with Scotland-wide research (Zador et al 2005; GROS,2007) but not reflected in UK national research where Morphine, Alcohol and other Opiods are the most frequently detected substances of misuse (Ghodse et al 2007) • The majority of DD cases were positive for 2 or more combinations of drugs in toxicology reports; Morphine appeared in 7/10 combinations, Benzodiazepines featured in 5/10 and Alcohol in 3/10 • Awareness of Cocaine and Alcohol use and its relevance to future drug deaths is required • Benzodiazepines and Morphine combined were most frequently misused substances in 41% of DD cases in Fife, followed by Alcohol and Morphine (19%) • Overall Morphine/Heroin most heavily implicated in drug combinations of Benzodiazepines and Alcohol • Fife DD victims consume within or below the toxic range, but the cocktail of drugs (namely, Heroin, Benzodiazepines and Alcohol) potentially results in lowered tolerance levels

Recommendations • The therapeutic range should be reconsidered when a cocktail of drugs are consumed • The role of Benzodiazepines should continue to be incorporated into overdose training

• Consolidate the good links with toxicologists to produce detailed and

accurate reports

50

(6). Substance Misuse Histories of Drug Death Victims 6 Months Prior to Death

The substance use histories of DD victims were obtained in order to gain a more accurate insight into the drugs of choice, consumed 6 months prior to their death.

In the 6 months prior to death 46% of (n=25) the individuals falling victim to a DD in Fife were known to have misused a variety of illicit and prescribed drugs in combinations of at least 3 or more, including at least 1 of the following substances; Heroin, Alcohol, Benzodiazepines (prescribed and non-prescribed) and increasingly Cannabis. In terms of the frequency of use, these individuals were known to have persistently misused in the past week, 1 month and 6 months prior to their death (s). The fact that high levels of such substances were consumed persistently and in varying combinations suggest that almost half of DD cases in Fife were chronic poly-drug users.

3.6.1 Injecting Characteristics of DD Victims in Fife

Yes No

20

15

10

5

No. of DRD victims No. 0 2005 2006 2007 Year

Figure 21. Number of DD victim’s known to have ever injected drugs during their drug career (n=48) 2005-2007

The injecting behaviour’s of DD victims were considered in order to gain a more detailed profile of the drug use histories and characteristics of this population. The graph illustrates an increasing trend of intravenous drug use among DD victims over the 3 years In 2005, of individuals 26% (n=14) were known to be misusing drugs intravenously, this figure increased only slightly in 2006 to 29% (n=16) and 33% (n=18) in 2007. Therefore the injecting population of DD victims in Fife appears to have gradually increased over the three years and the majority of the drug death population were IV drug users (n=48). However there also appears to be a fluctuating trend over the years of minority non- injectors (n=6); with 1 in 2005, increasing to 3 in 2006, and then dropping to 2 in 2007. Upon further analysis, of injectors vs. non injectors age did not appear to be an influencing factor in prolonging life, as mean age of death was actually, lower for injectors (m=32.2) than non injectors (m=35.1).15

In contrast to the national investigation, where 46% of DD victims were known IV drug users, the current findings revealed that an overwhelming majority (89%) individuals (n=48) were known have misused drugs IV during their drug careers. Currently in Fife,

15 Maybe due to small sample size (n=6) 51

62% of the new treatments seeking population are injecting Heroin, which is higher than the national average of 50% (Drug Misuse Statistics Scotland, 2007).

The table below outlines the types of drugs commonly detected in the post-mortem toxicology reports of those who were known to have injected throughout their drug use career.

Table 13. Post-mortem Toxicology reports of substances detected in IV drug users (n=48)

Substance Injectors Alcohol 12 (26%) Amphetamine 2 (4%) Benzodiazepines 3 (6%) Cannabis 5 (11%) Cocaine 2 (4%) Codeine 9 (19%) Desmethyldiazepam 4 (15%) Diazepam 20 (43%) MDMA 1 (2%) Methadone 8 (17%) Heroin/Morphine 38 (81%) Opiates 5 (11%) Oxazepam 4 (9%) Paracetamol 1 (2%) Temazepam 5 (11%) Other 1 (2%)

Table 13 displays a breakdown of substances16 detected in toxicology’s of the injecting population of drug death victims over the past 3 years (n=48). The three most commonly detected substances involved in the deaths of the injecting drug death population were as follows; Heroin/Morphine in 70% of drug deaths (n=38), 43% Diazepam (n=20) and 26% Alcohol (n=12). Therefore many DD victims consumed a variety of substances IV, but had also misused drugs by oral means e.g. alcohol, Benzodiazepines.

25

20

15

10

No. of DD victims 5 0 13-16 17-25 26-30 31-40 Age ranges

Figure 22. Age at which DD victims began to use drugs intravenously (IV) (n=36) 2005- 2007

16 Where more than one substance is detected in the toxicology of a drug death 52

Of the injecting drug death population (n=48) the actual ages at which they began to misuse drugs, intravenously, were obtained (n=36). The age at which DD injectors began their IV drug career ranged between 13 – 40 years of age and the mean age was (m=22.7). The graph depicts this finding by age group. These results are consistent with the respect to the current population of individuals seeking treatment for their drug problem in Fife, where 22 is the average age at which individuals first reported injecting (Drug Misuse Statistics Scotland, 2007). Five individuals were aged between13-16 (n=5), 20 DD injectors began to inject between the ages of 17-25, 4 individuals began to inject between the ages of 26-30 and a minority of individuals between the age range of 31-40 (n=2). Of the DD injectors (n=48), most began to inject between the ages of 17 and 25 (n=20). The average age at which victims succumbed to a DD was 31, and drug misuse typically began at the age of 1617 indicating that individuals potentially injected drugs 4-5 years (at the age of 22) after they first misused, and succumbed victim to a drug death 9-10 years later, around the age of 31.

Of the DD injecting population (n=47) 42% had utilised needle exchange services/wound management/harm reduction services 6 months prior to their death via pharmacy or specialist services (n=20).

3.6.2 Lifetime Overdose Histories of DD victims

15

10

5

No. of DD victims 0 2005 2006 2007

Year

Figure 23. No DD victims known to have ever experienced a drug overdose in their drug career (n=25),

In consideration of the drug misuse histories of the individuals who succumbed to a DD over the past 3 years (n=54) 46% were known to have experienced an overdose at some point in their lives (n= 25), which is slightly below the national level of 50% (Zador et al 2005). Of these individuals, three were unknown as to how many times they had experienced an overdose (n=3).

Twenty-two DD victims were known to have overdosed at least once and the frequency of overdose ranged between 1 and 8 times (n=22); overdosed on one occasion (n=10), two (n=5), three (n=2), 5 (n=3), 6 (n=1), and 8 occasions (n=1). The exception was one individual who was known to have overdosed on 20 occasions (n=1). The care of this individual was part of a comprehensive care plan in conjunction with a number of specialist services. The type of overdose, whether accidental or deliberate was recorded for six individuals (n=6) as follows; accidental (n=4), deliberate (n=1) and accidental and

17 Data relating to the age that drug misuse began was available for 15 of the 20 individuals who succumbed to a DRD in 2007. The mean age that this occurred was 17, with 73% of individual’s drug use beginning at the age of 16 or younger.

53 deliberate (n=1)). Therefore almost half of all drug death victims were known to have overdosed on at least one occasion and the majority held a previous history of multiple drug overdose (s) (n=25) in their lifetime.

3.6.3 Instances of Overdose 6 Months Prior to Death

Five drug death victims, who held a previous history of drug overdose, overdosed within the 6 months prior to their death (n=5).

3.6.4 DD Victims Dying Alone or in the Presence of Others

Others present Alone

12

10

8

6

4

2

0 2005 2006 2007

Figure 24. Drug Death victims dying alone or in the presence of others at point of death (n=54), 2005-2007

The specific circumstances of death were also explored to establish whether or not others were present, and if so, recognised common signs of overdose and/or intervened by attempting resuscitation. The graph above (Figure 24) displays the number of DD victims dying alone or in the presence of others.

Over half of drug death victims (56%) were in the presence of others (n=30) at their point of death. In two cases (n=2) others were within the same premises but in different rooms and in one case (n=1) the DD victim was with ambulance paramedics. The exact presence of others was unknown in a total of 3 cases (n=3). Thus a total of 24 (n=24) DD victims were in the direct presence of others at their point of death. Of the 24 individuals present, 88% (22/24) were known to the victim. The relationships of those persons present were as follows; close-family members18 (n=8), friends (n=12) of the victim or co-users (n=2). In two cases (n=2) the relationship of the person present at the scene of the drug death was not known.

3.6.5 Snoring Immediately Prior to Death

It has been suggested that individuals who overdose on drugs often snore prior to a visible adverse reaction to the drugs they have consumed. In 31% (n=17) of the DD cases in Fife, it was reported that individuals had been snoring in the period immediately preceding their

18 Close family included wife/partner/sibling/parent/relative 54 death. Although snoring was not noted in the remaining cases, this does not mean it did not occur as a number of individuals were alone at the time of their death. Also, those present at the time of death may not have reported the occurrence of snoring, as it did not appear to be of importance to them. It appears from this finding that snoring could act as a significant indicator of overdose. Awareness of this fact could assist individuals in identifying others who have overdosed and preventing them becoming a DD victim.

3.6.6 CPR Intervention Immediately Prior to Death

It was known that in 13% (n=7) of the DD cases, CPR was attempted prior to paramedics arriving. Findings show that 56% of individuals were with someone at the time of their death. This suggests that a number of individuals were with others but that CPR was not attempted, potentially reducing their chances of survival. However as it was unknown whether CPR had been attempted in 87% of cases it is difficult to infer this.

Key points

• Majority of DD victims were intravenous (IV) polydrug users, typically with a 10 year history of IV drug use • Almost half of all DD victims (46%) had overdosed at least once before in their lifetime • Majority of DD victims (56%) were in the presence of others at point of death • Persons present were often family/friends of the DD victim

Recommendations

• Family members of drug users should be provided with overdose training so they can recognise signs of overdose such as snoring • Family members ought to be provided with CPR training , this would also allow them to intervene and perhaps prevent the death • Wider training and implementation of Naloxone • Individuals with a history of overdose should be considered on a case by case basis and proactive discussion necessary regarding using the Child Protection • Better exchange of information and recording of near misses

55

(7). Physical, Psychological/Psychiatric Health and Significant Life Events of DD Victims

This section explores the types of physical and psychological/psychiatric morbidities and life events of the DD population in Fife

Physical, psychiatric and psychological issues were mentioned in 63% (n=34)19 of cases. Generally, it was observed that individuals were known to have experienced significant/traumatic physical conditions as well as co-morbid substance misuse and mental health problems at some point in their lives.

3.7.1 Co-morbidity

The concept of Co-morbidity can differ widely in terms of context and interpretation. For example, an ongoing issue is whether or not co-morbidity should be viewed over the course of a lifetime, or within a predefined context (Todd et al, 2004). For the purposes of this report, analysis of DD victim’s co-morbid health problems precede in the context of multiple physical, psychological/psychiatric, and substance misuse morbidities over the course of their lives, as opposed to a specific point in their lives.

Substance Misuse & Psychol/Psychiatric/Physical/OD/SH

16 14 12 10 8 6 4

No. Of DD victims victims Of DD No. 2 0 Psychol = Psychological OD = Overdose 2005 2006 2007 SH = Self Harm Year

Figure 25. Number of DD victims with previous histories of co-morbid substance misuse and psychological/psychiatric or physical health problems/instances of overdose/self harm (n=34)

Figure. 25 shows the number of drug death victims who were known to have experienced co-morbid substance misuse and/or psychiatric/psychological/ physical /overdose/ self harm issues at some point in their lives (n=34). In 2005, there were four DD victims (n=4), in 2006 there were 14 DD victims (n=14) and in 2007 there were 12 (n=14) DD victims who had experienced co-morbidity of a physical and or psychiatric/psychological nature.

19 This figure includes individuals who had self-harmed and/or overdosed 56

3.7.1.2 Combinations Morbidities

20

18

16

14 SM = Substance Misuse 12 Psychol=Psychological SH= Self Harm 10 OD=Overdose

8

6

No. Of DD Victims 4

2

0 SM+OD SM+Psychol/Psychiatric+OD/SH SM+Psychol/Psychiatric+Physical+OD SM+Physical+OD

Figure 26. Combinations of co-morbidity with substance misuse, experienced by drug death victims, (n=34)

Figure 26 shows the combinations of substance misuse, psychological/psychiatric and physical, problems, overdose and self-harm encountered by the DD population (n=34) during their lifetime. Of this DD population (n=34), a large proportion (55%) had experienced co-morbid substance misuse alongside either a psychological/psychiatric problem and/or overdose/self harm issue at some point in their lifetime, however a minority of individuals were also known to have encountered physical illness (15%) alongside these difficulties. A further 18% had experienced physical health problems and overdose issues, whilst 12% had solely encountered drug overdoses. The lives of this DD population (n=34) were complicated by the fact that they not only suffered from co-morbid physical, psychological/psychiatric health problems, but that these difficulties occurred alongside other traumatic life events, experiences of overdose and self harm.

3.7.1.3 Common Types of Psychiatric/Psychological Problems

Table 14. Types of Psychiatric/Psychological problems, (not including physical health problems) DD victims encountered during their lifetime (n=23)20

Psychiatric/Psychological Problem 2005 2006 2007

Anger 1 Anxiety 4 0 Depression/low mood 3 3 2 Drug Induced Psychosis 1 221 PTSD 1 1 Sectioned Under No.26 MHA 1 1 Schizoaffective Disorder 1 Suicidal Ideation/Intent 1 1 Overdose only 2 2

20 N.B. some DD victims had experienced more than 1 types of psychiatric/psychological problem (successive & concurrent), these are included in the table. However multiple episodes of the same psychiatric/psychological problem are not. 21 (N=1)‘Paranoid Ideation & Hallucintion’ 57

Table 14. shows the most common psychological problems, consistently affecting the lives of the DD population over the past 3 years. The following is a summary of the types of psychiatric/psychological problems impacting upon the lives of DD victims experiencing substance misuse and a psychiatric/psychological disorder (n=15); depression/low mood (n=5), anxiety (n=1), drug induced psychosis (n=2), paranoid ideation and hallucination (n=1), suicide risk plan (n=1), sectioned under the mental health act (n=2), schizoaffective disorder (n=1), suicidal ideation/intent (n=2). As mentioned previously, 4 DD victims were known only to have experienced overdose during their drug careers (n=4).

It became apparent that within the DD population who experienced co-morbid psychiatric/psychological problems, were individuals who had experienced more than one psychiatric/psychological problem at the same time (n=4). In 2005, two individuals were known to have experienced co-morbid substance misuse and psychological/psychiatric problems; depression and PTSD (n=1), and depression and anger (n=1). In 2006, two DD victims also followed this pattern; PTSD, Anxiety and depression (n=1)22, anxiety and low mood (n=1).

3.7.1.4 Types of Physical Health Problems Encountered (n=11)

Co-morbid substance misuse and mental health problems (Psychiatric and Psychological) are recognised as being linked to increased morbidity and mortality (Boland et al, 2006). Indeed, upon closer inspection of the data, it became apparent that a minority of individuals reflected this pattern. These 11 DD victims (n=1123), (not included in the above) were known to have experienced chronic, debilitating physical/psychological/psychiatric problems with or without instances of overdose, such as:

Adjustment disorder, Hep C and overdosed (n=1) Bipolar, Schizoaffective Disorder and Cerebral Palsy (n=1) Born with one lung/kidney, dyslexic (n=1), Chronic Obstructive Pulmonary Disease (n=1), Chronic Pancreititis and overdosed (n=1). Depression, HIV, Epileptic and overdosed (n=1) Epileptic anxious and overdosed (n=1) Hep C (n=1) Hep C, Cancer, phobia and overdosed (n=1), HIV (n=1), Umbilical Hernia, and overdosed (n=1)

3.7.2 Significant Life Events

The number and type of life events recorded in case notes/DD questionnaire were available for 34 individuals. Bereavement appeared to be the most frequently occurring negative life event, followed by relationship difficulties and psychiatric/physical illness, potentially impacting DD victims in their lifetime.

22 DD victim had invididualised care plan 23 This is a description of physical health problems that DD victims typically encountered, than an accurate portrait of co-morbidity, which is displayed below in graphical form. 58

Table 15. Number and type of life events recorded in case notes/DD questionnaire of DRD victims (n=34)

Life event (s) 2005 2006 2007 Total

Serious injury, illness or assault to close relative 0 1 6 7 Bereavement 3 3 8 14 Separation due to marital difficulties or broken off 4 3 6 13 steady relationship Serious problem with close friend or neighbour 1 2 1 4 Child custody issues 0 1 1 2 Psychiatric illness presented for 1st time in 6 months 2 5 2 9 Physical illness presented for 1st time in 6 months 1 6 3 10 Total 11 21 27 59 * This table includes multiple counts of life events as DD victims frequently experienced more than one life event during their lifetimes.

Table 15 shows 62% (n=34) of DD victims (n=54) had experienced at least one significant and/or traumatic life event. The most common life event, potentially impacting the lives of DD victims was bereavement, affecting 44% (n=15) of this population (n=34). The bereavement itself was often recorded to be an immediate family member e.g. parent/sibling or friend, which is consistent with information regarding DD victims sustaining close friendships and relationships with friends (n=18) and family (n=21) members. Separation due to marital difficulties or broken off a steady relationship affected 24% of DRD victims (n=13). DD victims also experienced relationship difficulties with other close family members e.g. grandparents/parents/siblings (n=3). Serious injury, illness or assault to close relative was recorded to have affected 7 individuals (n=7) and included such events such as diagnoses of terminal illnesses e.g. Cancer. Four individuals were known to have had a serious problem with a close friend or neighbour (n=4).

As stated previously, DD victims were often able to engage in relationships, however difficulties within the relationships were known to have emerged as a result of concern for the individual and their chaotic/chronic drug misuse problems. Other traumatic and/or significant life events recorded in the ‘additional information’ section of the database, known to have potentially impacted the lives of DD victims, included childhood sexual abuse (n=2), sexual assault/rape (n=2) and close friends/family also victims of drug deaths (n=2).

Table 16. First presentations of physical and/or psychiatric/psychological health problems 6 months prior to death (n=17)

2005 2006 2007 Physical 1 4 3 Psychological 2 3 2 Both 0 2 0

Specifically, in the six months prior to death, seven DD victims (n=7) had presented with psychiatric/psychological health issues e.g. depression. In terms of physical health, 8 DD victims (n=8) had presented with a physical illness e.g. Stomach Ulcer, Hep C, Septic Sores, Diabetes and two DD victims had presented with both physical and psychiatric/psychological health problems (n=2).

59

Key Points

• 63% of DD victims (n=34) had experienced significant life events including instances of overdose and self harm, physical and psychiatric health problems • Of this population a large proportion (55%) had experienced complex psychiatric/psychological, substance misuse morbidities with or without overdose/self harm issues • 18% a range of physical health problems with or without overdose • 15% a range of psychiatric/psychological problems with or without overdose • 12% had solely encountered drug overdoses exclusive of any co morbidities

Recommendations

• Complex cases should be prioritised enabling specialist services, with the relevant competencies to be able to provide an integrated care approach • Physical and psychological health must be incorporated into the core assessment process in any agency • Sharing of information between agencies should be encouraged • Awareness of cardiac pathology in some cases and to investigate adequately e.g. ECG

60

(8) Service Use Histories

The present section outlines where possible, the service use histories and frequency of contact with services of the DD victims 6 months and 5 years prior to death.

It is recognised that being engaged in a process of care and treatment has a positive impact on outcomes, including drug-deaths. In order to co-ordinate and integrate the care that is provided to individuals it is important to determine the extent of contacts made with services, and the agencies most involved in providing a service to DD victims.

3.8.1 Services Commonly Accessed by DD victims 5 Years Prior to Death

Of those 54 people who died of drug deaths in Fife from 2005-2007 and for whom records were available (n=46), the service use histories were examined. The service use histories not available (n=8) to the DD committee were either not known to have been in contact with statutory and non-statutory agencies (n=4 from 2005 and n=1 from 200624) or not available at point of writing (n=3, 200725).

Table 17. Percentage No. of contacts recorded to have been made to a specific service by Drug Death victims 5 years prior to death, 2005-2007 (N= 46) Comment [d1]: remember to footnote the non-statutory agencies Services Contacted 2005 2006 2007 Total

Scottish Prison Service 5 6 2 28% Psychiatry 2 2 4 17% General Practitioner 0 2 14 34% Accident & Emergency/Hospital 0 7 6 28% Social Work 2 1 0 6% Social Work Criminal Justice Services 5 9 5 40% Addiction Services Fife 6 16 10 68% Clued Up 0 1 0 2% FIRST 0 0 1 2% Next Steps 0 2 1 6% Fife Rape & Sexual Assault Centre 0 1 0 2% CHANT26 0 1 1 4% Fife Alcohol Support Service 0 0 1 2% Drug Alcohol Project Leven (DAPL) 0 0 1 2% Cornerstone 0 0 1 2% Oasis Project 0 1 0 2%

Table 17 illustrates the types of agencies that DD victims were involved with 5 years before their death. This table does not include multiple contacts made to any single agency. Many DD victims were known to have accessed more than one service, however none were known to have accessed more than 7. Specialist services (Fife Addiction Services) appeared to be the most accessed services (68%) followed by Social Work Services (Criminal Justice) (40%), GP (34%), Scottish Prison Service (SPS) 28%, A&E (28%), Psychiatry (17%), Social Work (6%). Other services included those from non-

24 The service use histories of these individuals were not known 25 Information had not yet been received from any of the relevant agencies regarding the service use histories of these individuals 26 Community Homeless Addiction Nursing Team (CHANT) is part of Fife Addiction Services, NHS Fife 61 statutory agencies such as CHANT (4%), Next Steps (6%), FIRST (2%), Clued up (2%), DAPL (2%), Cornerstone (2%), Fife Rape and Sexual Assault Centre (2%). These findings are to be interpreted with a degree of caution as they reflect more accurately the accumulation of data over the 3 years; 2005, 2006 and 2007, respectively than the service use histories of the individuals themselves.

3.8.2 Services Accessed by DD Victims 6 Months Prior to Death

Thirty individuals (n=30) were known to have had contact with a service 6 months prior to their demise. Table 8 shows the number of agencies accessed by individuals in each of the 6 months prior to death. This table does not describe the multiple contacts with services within the same month. In their last month prior to death 22% of DD Victims were known to be in contact with a service (n=12), on at least one occasion, which is significantly lower in comparison to the national average of 57% (Zador et al 2005). The table illustrates that the pattern of contact fluctuates over the course of the 6 months with an increase in the number of contacts in months 3 and 4 prior to death.

Table. 18 Number of contacts with any services at any time of a month 6 months prior to death (n=30) 2005-2007 Month (prior to 2005 2006 2007 Total contacts death) (68) 1 2 1 9 12 2 0 5 10 15 3 3 3 6 12 4 3 4 5 12 5 0 3 7 10 6 1 3 3 7

Table 18 displays the number of contacts of DD victims made with statutory and non- statutory agencies in the 6 months prior to death. Most contact had been made with the General Practitioner (GP) (27%), followed by Fife Addiction services (23%) Scottish Prison Service (SPS) 11%, Social work criminal justice services (2%), Acute services (A&E) (9%), Social work (3%) and Psychiatry (3%). Other services included CHANT (part of Fife Addiction Services), Clued Up and Next Steps (5%). This pattern of results is also reflected nationally, where 77% of contact was with GP’s and 17% with specialist services (Zador et al 2005). Whilst the committee are unable to provide definitive data regarding the purpose of contact at present, it is recognised that over time the service use histories will provide sufficient data for the committee to determine the most common nature of contact for each service involved.

Specialist addictions services were the most accessed service, with 33%27 of all contacts made to them, in the 6 months prior to death. Over the course of the 3 years 15 drug death victims were known to have accessed specialist addiction services in the 6 months prior to death. A total of 11 individuals (n=11)28 accessed Fife Addiction Services; 6 in 2005, 3 in 29 2006 and 2 in 2007. In 2007 2 drug death victims had accessed WFCDTT (n=2) and a further 2 had accessed the Enhanced Addictions Casework Service (SPS) (n=2).

27 Figure includes contacts made to WFCDT, Fife Addiction Services, and EACS (SPS) 28 Remember 1 individual who was in receipt of a pharmacological intervention was collecting their prescription from the IDU at QMH Dunfermline – so wasn’t registered with specialist addiction services. 29 West Fife Community Drug Team 62

Table 19. Number and Percentage of service contacts of DD victims 6 months prior to death (n=30), 2005-2007

No. of % of Agency Contacts Contacts Hospital 2 3% GP 18 27% SPS 7 11% Fife Addiction Services 17 23% A&E 6 9% Psychiatry 2 3% Social Work 2 3% EACS 2 2% Paramedics 1 2% CJS/SW 1 2% DTO 2 3% WFCDT 5 8% Other 3 5%

Other services DD victims were involved with 6 months prior to death included non- statutory agencies such as CHANT, Clued UP and Next Steps. Purpose of contact was explored, in particular, whether or not DD victims attending specialist services, had received pharmacological treatment for their drug dependency problem, in the 6 months prior to death.

3.8.3 DD Victims in Receipt of a Pharmacological Intervention 6 Months Prior to Death

Yes No Don’t Know

16 14 12 10 8

6

4 No. of DD victims 2 0 200520062007 Year

Figure. 27 shows the number of drug death victims who received pharmacological treatment 6 months prior to death. There were 3 individuals who were known to have received medical treatment for their drug dependency problem, 6 months prior to death, however sufficient information did not exist to determine whether or not they received a pharmacological treatment for their drug problem and so were excluded from further discussion (n=3).

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As displayed, only (22%) 12 of the 54 people had at least one contact with a specialist drug misuse service, the overwhelming majority, (72% of individuals) did not receive/seek pharmacological treatment (n=39) 6 months prior to death. This figure is higher than the national average, but overall, evidence that only a small proportion (12%) of cases had been in contact with specialist drug misuse services in the 6 months leading up to their death. In 2005 20% of DD victims (n=3) had received treatment 6 months prior to their death, the following year, in 2006, this figure increased to 26% (n=5) and dropped to 20% (n=4) in 2007; Thus a total of 35% (n=12) DD victims received pharmacological treatment for a drug problem 6 months prior to their death. A tabular breakdown of individuals in receipt of methadone treatment 6 months (Table. 20) and immediately (Table. 21) prior to their death can be found below:

Table 20. DD victim’s known to be in receipt of methadone 6 months prior to death (n=12)

2005 2006 2007

3 5 4 Yes No 12 14 13

Don’t Know 330

Of those individuals in receipt of pharmacological treatment (n=12), two drug death victims had commenced home detox (n=2); of these 2 DD victims, one was receiving Naltrexone (n=1) and another was prescribed Buprenorphine (n=1). However the majority of individuals receiving a pharmacological treatment 6 months prior to death were prescribed methadone (n=10).

Table. 21 shows the DD victims still receiving methadone when their death occurred (n=9). Reasons for the 1 individual not receiving methadone treatment at their time of death were recorded as ‘lack of compliance’. The number of individuals receiving methadone 6 months prior to death appears to be increasing on a yearly basis. However, post-mortem toxicology reports (Graph. 1) show that Methadone was more commonly detected in 2006 (n=5), than 2005 (n=1) and 2007 (n=3) and do not compliment the yearly rise in methadone prescribing. Therefore, in contrast to findings obtained by the National Forum on Drug Related Deaths Scotland (2007) these findings do not reflect the increase in methadone prescribing per se, ‘rising by 45% over the past 5 years’, but do evidence the general increase of methadone-related deaths since 2005.

Table 21. DRD victims still receiving methadone treatment at point of death (n=9)

2005 2006 2007 Yes 3 3 3 No 12 16 13 Don’t Know 3

30 Known to have received pharmacological treatment, but no sufficient information received to decipher the type of pharmacological treatment as yet. 64

Methadone dispensing arrangements were known for the 7 individuals concerned (n=7). Five individuals were collecting their dosage from a pharmacy on a daily basis (including Sunday) where consumption was supervised (n=5). One individual was collecting their prescription from the Infectious Diseases Unit at a hospital in the locality, on a weekly basis to consume at home (n=1), another individual was also collecting their dosage once a week (n=1) and the dispensing arrangements were not known for the other individuals (n=2). The dosages ranged from 25mg – 100mg. The duration each individual remained stable on their final dosage ranged between 14 days and 6 months.

Furthermore, for individuals on a methadone treatment programme (n=9), methadone was detected in the toxicology reports of 5 deaths (n=5). However, methadone was also known to have been involved in drug deaths (n=3) where it was not a prescribed substance at point of death. The first death as a result of prescribed methadone at point of death was recorded in 2007 (n=1)31. The Fife DD group continue to closely monitor the mode of methadone prescription and acknowledge that non-supervised methadone dispensing may lead to an intensified risk of overdose or encourage diversion of methadone treatment (NTA, 2007).

Key points

• 85% of DD victims in Fife were known to services 5 years prior to death • Specialist services were the most accessed during this time period • Majority (55%) of DD victims were known to services in the 6 months prior to their death • GP services were the most accessed service in this time period • An overwhelming majority (72%) of DD victims did not seek/receive pharmacological treatment for their drug problem 6 months prior to death • 22% were receiving pharmacological treatment, most were prescribed methadone (18%) • 16% were still on a methadone programme at point of death

Recommendations

• Further inform on the dosage of pharmacological interventions prescribed

and their relation with drug deaths

• To encourage services to include the age at which individuals begin using drugs IV • A more integrated approach to identify a high risk drug taking population released from prison who tend to access a multitude of services in short space of time • Finalise governance structures with special reference to information sharing and communication between agencies, with the service users and the public

31 Post-mortem toxicology report described death as ‘Adverse effects of Methadone’ 65

Section 4. Conclusions:

4.1 A Case Vignette of a Typical Drug Death Victim in Fife

The typical DD victim from Fife would be a white 31 year old male who started to misuse drugs at the age of 15 or 16. He would have left school at the age of 16 and would have then found employment as a labourer or obtained some other type of manual work. He would have proceeded to misuse a cocktail of drugs and approximately seven years later, started injecting at the age of 22. He would have been known, intermittently, to a number of services, including GP and specialist addiction services in Fife during the five years prior to his death. In this time he would have been misusing several types of substances including Heroin, Benzodiazepines, Cannabis and Alcohol. During this period he would also have encountered at least one complex episode of a co-morbid psychiatric or physical health problem with or without instances of drugs overdose and/or self-harm. He would also have experienced significant life events, such as bereavement and/or the breakdown of a relationship.

In the six months before his death he would have been unemployed. He would have had a criminal record; having committed crimes linked to his drugs misuse. These could have been either specific drug related crimes (for e.g. possession) or theft/shoplifting in order to support his drug addiction. He would have had multiple convictions, but would not have served a prison sentence (however, although the majority had not, 46% had served a prison sentence). At the time of his death, he would have been living alone in council housing accommodation, in a socially deprived area and would not have changed accommodation type in the 6 months prior to his death. He would have been single, and would not have had any children. He would have been close to family members and friends and so would not have been socially isolated. During this time it is likely that he would have been known to GP and specialist addiction services in Fife but would not have sought/received pharmacological treatment for his drug dependency. He would have been persistently misusing a cocktail of illicit substances during this time.

On the day of his death, he would have purchased at least one tenner bag of Heroin and shared and/or injected in the presence of friends/co-users. He would have consumed depressants such as Diazepam and Alcohol at the same time. It is most likely that he would have died on a Friday evening during Spring. He would have died in the presence of others and would have been snoring in the hours leading up to his death, any formal means of resuscitation e.g. CPR would not have been attempted.

At post-mortem his blood/urine sample would have revealed a cocktail of depressants such as Morphine, Benzodiazepines and/or Alcohol. His cause of death would most likely have been classed as ‘Adverse effects of Intravenous Heroin’.

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4.2 Summary of Recommendations

Demographic Characteristics

• As a number of deaths occurred within a short period of prison release, recommendations are made towards an integrated care approach is introduced.

Life Context and Social Functioning

• A review of education inputs relating to lifestyle education/drug and alcohol misuse to individuals aged 15 and 16 to ascertain whether those inputs presently delivered are sufficient.

• As individuals had others close to them at the time of their death, this provides the opportunity for overdose training for these individuals.

Criminal Justice Issues and Offending

• The fact that 96% of individuals had been involved in the criminal justice system suggests there should be consideration for an arrest referral scheme within Fife so early intervention can occur in terms of referring these individuals to drug and alcohol agencies.

Pharmacology of Heroin in Fife

• The composition of Heroin should be analysed at a local level for a breakdown of the composition of cutting agents as well as purity levels • Purity levels, composition and quantity of Heroin need to be taken into consideration in formulating overdose strategies

Toxicology Findings

• The therapeutic range should be reconsidered when a cocktail of drugs are consumed • The role of Benzodiazepines should be incorporated into overdose training • Consolidate the good links with toxicologists to produce detailed and accurate reports

Substance Misuse Histories

• Family members of drug users should be provided with overdose training so they can recognise signs of overdose such as snoring • Family members ought to be provided with CPR training , this would also allow them to intervene and perhaps prevent the death. • Wider training and implementation of Naloxone • Individuals with a history of overdose should be considered on a case by case basis and proactive discussion necessary regarding using the Child Protection • Better exchange of information and recording of near misses

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Physical, Psychiatric/Psychological Health and Significant Life Events

• Complex cases should be prioritised enabling specialist services, with the relevant competencies to be able to provide an integrated care approach • Physical and psychological health must be incorporated into the core assessment process in any agency • Sharing of information between agencies should be encouraged • Awareness of cardiac pathology in some cases and to investigate adequately e.g. ECG

Service Use Histories

• Further inform on the dosage of pharmacological agents e.g. methadone prescribed and its relation with drug deaths • To encourage services to include the age at which individuals begin using drugs IV • A more integrated approach to identify a high risk drug taking population released from prison who tend to access a multitude of services in short space of time

Others

• To examine cases not diagnosed as drug deaths but as drug related deaths • To explore the possibility of doing psychological autopsy techniques with the relatives of the deceased in order to improve the quality of the data collected on these individuals.

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Appendix A

TAKING ACTION TO REDUCE SCOTLAND'S DRUG-RELATED DEATHS:

The Scottish Executive Response to the Scottish Advisory Committee on Drug Misuse Drug-related Deaths - Recommendations. (December 2005)

Recommendation 1

The Scottish Executive and Alcohol and Drug Action Teams (ADATs) should consider methods to raise the level of resuscitation skills among drug users, family members, friends, and social networks. It is recommended that the provision of information and training for families and friends of drug users and drug users themselves is further developed across Scotland.

Recommendation 2

Association of Chief Police Officers in Scotland (ACPOS) and the Scottish Executive should jointly explore ways in which contact with the police can be used as an opportunity to intervene with vulnerable individuals in order to prevent future drug-related deaths. In particular, the Memorandum of Understanding (MOU) between ACPOS and the Scottish Ambulance Service should be reviewed in order to ensure that, in the event of an overdose, help is available as quickly as possible. The police attending the scene of an overdose should ensure that preservation of life should take precedence.

Recommendation 3

The Scottish Executive should commission applied research to explore drug user perceptions, and those of their friends/family, with a view to understanding how delays in contacting the emergency services can be reduced.

Recommendation 4

NHS Boards and their primary care management components should be encouraged to employ the nGMS and nGPS frameworks to increase access to high quality, evidence based treatment programmes for substance misusers.

Recommendation 5

The Scottish Executive should develop and fund a co-ordinated process of introduction and evaluation of new or more innovative treatments across Scotland, with the aim of ensuring that substance misusers in all ADAT areas have access to a range of evidence based treatments.

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Recommendation 6

The Scottish Executive should require ADATs and their partners to demonstrate that services are delivered in an effective and co-ordinated way with the aim of delivering clear evidence based outcomes, including improved engagement with drug users, reduction in waiting times and improvements in retention rates with services.

Recommendation 7

The Scottish Executive should review services for groups where drug related deaths occur at a higher rate than the overall population of problem drug users (people recently released from prison, the homeless/roofless, people with co-morbidity and complex needs, and the over thirties) with the aim of developing services and responses that are specifically targeted at these vulnerable populations.

Recommendation 8

ACPOS, ADATs and NHS Boards should consider how best to address the issue of illicit manufacture and/or diversion of prescribed drugs such as benzodiazepines and dihydrocodeine, given their prominence in the drug related deaths examined by the National Investigation.

Recommendation 9

Priority must be given to greater development of the Single Shared Assessment (SSA11 ) as highlighted by the EIU in ‘Integrated Care for Drug Users, Principles and Practice’; improving and standardising clinical note taking; and developing effective methods for dealing with clients’ case files across Scotland. To support these efforts, it is essential that robust systems for sharing of information between local generic, specific and voluntary services are developed as a matter of urgency.

Recommendation 10

The NHS in Scotland and relevant partners (e.g. Royal Colleges and academic institutions) should consider supporting the development of a national process to promote good practice in the delivery of medical treatment to drug misusers. This should include availability of a comprehensive range of accredited training (Scottish Training on Drugs and Alcohol (STRADA)), The Royal College of General Practitioners (RCGP); and the development of meaningful prescribing guidance, such as a (Scottish Intercollegiate Guidelines Network (SIGN) guideline); and the creation of clinical governance (managed care) networks.

Recommendation 11

Resources should be made available to allow prison medical and nursing staff to undertake the RCGP Certificates in the Management of Drug Misuse in Primary Care and the Universities of Nottingham and Lincoln Prison Medicine programmes. In addition, the

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SPS in conjunction with the SDF should adapt critical incident resuscitation awareness training for use within the prison setting.

Recommendation 12

Training aimed at raising awareness and improving co-ordination of activity for those generic staff most likely to come into contact with people vulnerable to overdose should be provided as a matter of urgency.

Recommendation 13

Under the auspices of the ADATs each area should establish a local standing drug deaths monitoring and prevention group that involves key agencies in order to manage rapid sharing of information on near misses, deaths and street drug trends, to instigate action and report on progress in implementing proposals to reduce deaths.

Recommendation 14

The definition of a drug-related death must be standardised nationwide with the same definition being used by all involved in its investigation. For instance, a drug-related death could be defined as any death, at any age group, that is directly or indirectly related to the use of controlled substances. This would include accidental, suicidal, homicidal deaths, including those in the very young and in older age groups and excludes deaths from overdoses of other medicinal drugs. This definition would trawl all deaths from benzodiazepines.

Recommendation 15

A National ‘Preventing Drug-related Deaths Forum’ should be established with a remit to report to Ministers annually on trends and causes of drug related deaths in Scotland.

Recommendation 16

In order to enable a long term, meaningful interpretation of post-mortem toxicological data, Procurators Fiscal, who instruct autopsies on these deaths, should insist that the pathologists carrying out the autopsies follow a nationally agreed protocol based on an agreed best practice model.

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Appendix B

DRD Fife Questionnaire - Guidelines for completion

The DRD Fife Questionnaire V 2.0 has been established by the Drug Related Deaths (DRD) committee Fife to identify circumstances surrounding each drug related death in order to identify trends and patterns within such deaths with the aim of preventing future incidences. Information is therefore sought from each of the relevant agencies concerned in the delivery of a particular (voluntary or statutory) service or care package to the deceased.

When completing the form please complete each section to the fullest – it doesn’t matter if there are blanks, just complete what you know from each section. There are a number of sources that can be used to complete the form some generic sources are noted below under the content headings:

1. Demographic Information - Case notes/Clinical Notes - SDEA - Sudden Death Report

2. Life Context and Social Functioning - Social Work Files/Criminal Justice Services - Social Enquiry Reports (Criminal Justice Services) - Psychiatric Reports - Case notes/Clinical notes - Referral letters - Conversations/interviews with deceased

3. Criminal Justice Issues and Offending - SCRO reports - Sudden Death Report - SDEA Form - Criminal Justice Services (Social Enquiry Reports/Social Work Files)

4. Substance use history and 5. Physical/Psychological Health - Clinical Notes - GP Notes - Conversations/ Interviews with deceased

6. Service Use History - Any/All of the above

7. Any other information - Anything you feel is important

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Drug Deaths Related Enquiries and Monitoring Form (Fife)

Service:

Date:

Person completing:

Name and address of deceased:

Contents:

1. Demographic Characteristics

2. Life Context and Social Functioning

3. Criminal Justice Issues and Offending

4. Substance Use History

5. Physical and Psychological Health

6. Service Provisions

7. Any Other Additional Information

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1. DEMOGRAPHIC CHARACTERISTICS

Q Questions Codes Core Data 1.1 Date of Birth Day Month Year

1.2 Gender Male 1 Female 2

1.3 Race/Ethnicity White 00 Black Caribbean 01 Black African 02 Black other 03 Indian 04 Pakistani 05 Bengali 06 Chinese 07 Other ethnic group 08 Not known 09 1.4 Postcode

Location and Circumstances 1.5 Date Day Time (pronounced extinct)

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1.6 Dwelling 01

Workplace 02 Licensed 03 Type of place/premises Premises 04 Open Space 05 Hospital 06 Prison 07 Police Custody 08 Other (specify) 09 1.7 Retail/Business 01 Residential 02

Description of and Neighbourhood Urban 01 Rural 02

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2. LIFE CONTEXT AND SOCIAL FUNCTIONING

2.1 What was the person’s Own home /Rented 01 1 accommodation in the last Temporary/Unstable 6 months before death? accommodation 02 (Can choose more than Supported one) Accommodation 03 Residential Rehab 04 In Prison 05 Roofless 06 Unknown 07 2.1 What was the person’s With spouse /partner 01 2 living arrangements in the With parents 02 last 6 months before With dependent children 03 death? (Can choose more Alone 04 than one) Unknown 05 With Others (e.g. 06 Brother) 2.1 What was the person’s Own home /Rented 01 3 accommodation /place of Temporary/Unstable death accommodation 02 Supported Post Code: Accommodation 03 In Prison 04 Roofless 05 Outside 06

2.2 At what age did the person Years ____ 1 leave school? 2.2 What did the person do Further Education 01 2 just after leaving school? Employed 02 Vocational 03 Training/Apprentice 04 Unemployed

2.2 Did the person have a Yes 01 3 place on a training or No 02 educational course at the Don’t know 03 time of their death?

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2.3 What was the person’s Employed with a regular 1 main source of income salary 01 during the last 6 months? Unemployed with (Can choose more than regular one) unemployment/sickness 02 benefit Unemployed but with no regular state income 03 Temporary work 04 Benefit fraud 05 Partner or relative’s income 06 Unemployment insurance 07 Self-employed 08 Illegal income 09 Other /Unknown 10

2.4 What was the person’s Married 01 .1 relationship at time of Divorced 02 his/her death? Separated 03 In a relationship 04 Not in a relationship Widowed 05 06 2.4 Did the person have any Yes 01 .2 children? No 02 Don’t know 03 2.4 If yes, how many children Living with the person 01 .3 were: Living elsewhere 02 In care 03 Deceased 04 Unknown 05 2.4 What is the parents marital Married 01 .4 status? Separated 02 Divorced 03 Unknown 04 2.4 Did the person have any Yes 01 .5 relatives that he/she felt No 02 close to? Don’t know 03 2.4 What was the relationship? .6 (e.g. mother, brother etc)

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2.4 Did the person have any Yes 01 .7 friends that he/she felt No 02 close to? Don’t know 03

2.4 Is there evidence to suggest that there were any .8 difficulties in the person’s relationship(s) with their friend(s), relative(s) or partner? Yes 01 No 02 Don’t know 03

2.4 If yes, give details. 9

2.5 Is there evidence to suggest that the person’s partner .10 had a drug or alcohol problem?

Yes 01 No 02 Don’t know 03 2.1 If yes, give details. .1

LIFE CONTEXT AND SOCIAL FUNCTIONING FURTHER INFORMATION

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3. CRIMINAL JUSTICE ISSUES AND OFFENDING

Q. Questions Codes Core Data 3.1 Has the person ever been Yes 01 1 convicted? No 02 Don’t know 03 3.1 If ‘yes’ what is the Number: 2 SCRO/PNC number?

3.2 Has the person ever been Yes 01 1 arrested? No (go to section 4) 02 Don’t know 03 3.2 If “yes”, in last 6 months? Yes 01 2 No 02 Don’t know 03 3.2 If “yes”, was the offence(s) Yes 01 3 drug related? No 02 Don’t know 03 3.3 In the last 6 months, has Yes 01 1 the person been on a No 02 Diversion from Prosecution Don’t know 03 Scheme? 3.3 In the last 6 months, has Yes 01 2 the person been on a No 02 Community-based Don’t know 03 Alternative to Custody Scheme? 3.3 In the last 6 months, has Yes 01 3 the person been subject to No 02 DTTO? Don’t know 03 3.3 In the last 6 months, has Yes 01 4 the person appeared No 02 before the Drug Court? Don’t know 03 3.3 In the last 6 months, has Yes 01 5 the person been subject to No 02 an Enhanced Probation Don’t know 03 Order? 3.4 Has the person ever been Yes 01 .1 in prison? No 02 Don’t know 03 3.4 If “yes”, how many times in .2 the last 12 months?

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3.4 What are the dates of the From____To_____ .3 prison sentence in the last From____To_____ 12 months? From____To_____ 3.5 Were there any serious Yes 01 .1 outstanding charges or No 02 court cases at time of Don’t know 03 death? 3.5 If “yes”, give details. .2

3.5 Any additional documents available .3 (Circle as appropriate)

Sudden death report

Crime report

Intelligence report (if applicable)

Toxicology report (if applicable)

Photographs (if available)

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3.5. Drugs suspected Morphine 01 4 Amphetamine 02 Methamphetamine 03 Cocaine 04 Methadone 05 Ecstasy 06 Cannabis 07 LSD 08 Alcohol 09 Solvent 10 Unknown 11

Other 12 Prescription_____ 3.5. Drugs confirmed Morphine 01 6 Amphetamine 02 Methamphetamine 03 Cocaine 04 Methadone 05 Ecstasy 06 Cannabis 07 LSD 08 Alcohol 09 Solvent 10 Unknown 11 Other 12 Prescription 3.5. Form of drug Powder 01 7 Tablet 02 Liquid 03 Resin 04 Gas 05 Other 06 Unknown 07 3.5. Method of ingestion Injection 01 8 Oral 02 Inhaled 03 Snorted 04 Smoked 05 Other 06 Unknown 07

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Items found 3.5. Syringe Yes 01 9 No 02 3.5. Site of injection if Specify______10 applicable 3.5. Drugs Specify______11 3.5. Any information on Yes 01 12 source of drugs? No 02 3.5. Any person charged? Yes 01 13 No 02 3.5. Charge details Culpable Homicide 01 14 Misuse of drugs 02 Other 03 3.5. Crime/Case no 15 3.5. Officer in charge 16 3.5. PF Area 17 3.5. Force 18

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4. SUBSTANCE USE HISTORY

4.1. Drugs used in last 6 months prior to the death

Code Type Used Usual Used in Usual Used Prescribed Drug Career and in the route previous route in the ? other relevant last 30 days last 6 information week month A Heroin B Methadone (liquid) C Dihydrocodeine D Other opioid (1) E Other opioid (2) F Diazepam G Temazepam H Other benzodiazepine

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I Alcohol J Cocaine (powder) K Crack L Amphetamines M LSD N MDMA (etc) O Cannabis P Tobacco Q Other e.g. cyclizine, ecstasy

4.2.2 Treatment for a drug or alcohol problem during lifetime (open/closed and reasons)

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Methadone treatment in the last 6 months:

Q. Questions Codes Core Source Data 4.31 Did the person receive Yes 01 medical treatment for a No 02 drug problem over the Don’t know 03 last 6 months? 4.32 If “yes”, had the person Yes 01 been prescribed No 02 methadone? Don’t know 03 4.33 If “yes”, what date did the prescription begin? 4.34 Was the person still Yes 01 taking methadone when No 02 death occurred? Don’t know 03 4.35 If “no”, what date did the prescription end? 4.36 If “no”, what was the reason why the prescription ended?

How did the person collect and consume their Methadone?

Q. Method of In the last 6 Time of Death consumption months (week prior) 4.41 Collection from Yes 01 Yes 01 Pharmacy – Supervised No 02 No 02 consumption on DK 03 DK 03 premises 4.42 Collection from Yes 01 Yes 01 Pharmacy – No 02 No 02 Consumption at home. DK 03 DK 03 4.43 Collection from Yes 01 Yes 01 Pharmacy – Supervised No 02 No 02 and subsequent DK 03 DK 03 consumption at home.

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How often did the person collect their Methadone?

Q. Frequency In the last six No. of weeks months 4.51 Daily (including Sunday) Yes 01 No 02 DK 03 4.52 Six days a week Yes 01 No 02 DK 03 4.53 3 times a week Yes 01 No 02 DK 03 4.54 Once a week Yes 01 No 02 DK 03 4.55 Every two weeks Yes 01 No 02 DK 03 4.56 Other (Specify) Yes 01 No 02 DK 03

Methadone prescription at death

Q. Questions Dose/Duration Core Data 4.61 What was the last dose of Methadone before death? (mg/day) 4.62 How long was the person on this dose? 4.63 In what form did the liquid mixture person take his/her 01 methadone? liquid linctus 02 tablets 03 injectable 04

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Injecting Behaviour

No. Questions and filters Coding Core Data categories 4.71 Has the person ever Yes 01 injected? No (If no go to 4.81) 02 Don’t know 03 4.72 Age first injected? (yrs)

4.73 Was harm reduction Yes 01 information dispensed No 02 to the person in the last Don’t know 03 6 months? 4.74 Harm reduction action Needle exchange taken: (Pharmacy) 01 Needle exchange (specialist service) 02 Wound management 03

Overdose History

No. Questions and filters Coding Core Data categories 4.81 Had the person ever had Yes 01 a drug overdose? No (Skip to section 5) 02 Don’t know 03 4.82 If “yes”, how many times Accidental 01 in his/her lifetime? Deliberate 02 Don’t Know 03 4.83 How many times in the Accidental 01 last 6 months before Deliberate 02 death? Don’t Know 03 4.84 What was the date of the last occasion? 4.85 Last Occasion Accidental 01 Deliberate 02 Don’t Know 03

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4.86 Is there any indication Yes 01 (Specify) that this death was No 02 suicide?

5. PHYSICAL AND PSYCHOLOGICAL HEALTH

No. Questions and filters Coding Core Data categories 5.2 Has a serious illness, Yes 01 injury or assault No 02 happened to close Don’t know 03 relative? 5.3 Has the person suffered Yes 01 bereavement? No 02 Don’t know 03 5.4 Has the person had a Yes 01 separation due to marital No 02 difficulties or broken off a Don’t know 03 steady relationship? 5.5 Has the person had a Yes 01 serious problem with a No 02 close friend, neighbour Don’t know 03 or relative? 5.6 Has the person has any Yes 01 child custody issues No 02 Don’t know 03 5.7 Has a psychiatric illness Yes 01 presented for the first No 02 time? Don’t know 03 5.8 Has a physical illness Yes 01 presented for the first No 02 time e.g. cancer? Don’t know 03 Details of family health practice

5.9 Name Address

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5.9 Any significant event, which has happened to the person in their life?

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6. SERVICE UTILISATION

6.1 Service Month 1 (Month Month 2 Month 3 Month 4 Month 5 Month 6 Provider of death)

6.2 Services used by client in the past 5 years:

Date:

Service Provider:

Referred:

Assessed

Discharged:

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7. ADDITIONAL INFORMATION FROM ANY SECTION AND OPINION

Acknowledgements:

1.Centre for Addiction Research and Education Scotland (CARES), University of Dundee: 2006

2. Scottish Drug Enforcement Agency, National Drugs Death Database: 2006

Version 2.0

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APPENDIX C

‘The interpretation of post-mortem morphine levels is complicated by the phenomenon of ‘tolerance’, whereby a regular heavy user may survive high blood morphine levels. Tolerance is unpredictably variable, both between individuals and within the same individual. Conversely, deaths have been reported even at low morphine levels, particularly when the individual is a naïve or irregular user or has survived for a period of time following drug administration. For these reasons there is considerable overlap between the published therapeutic and fatal levels. In practice this means that the levels found in dead drug addicts are often no different from those found in living addicts. Interpretation of drug levels is further complicated by post-mortem changes within the body which may artefactually change the level of the drug’

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Appendix D

Map to show location of drug deaths in Fife

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More detailed map of Drug Death locations in Fife

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