1. Co-ordinating Action on Drug Issues DRUG RELATED DEATHS Recent trends Stephen Malloy National Training & Development Officer-Critical Incidents stephen@sdf.org.uk ScottishdrugsForum

3. Overdose Prevention/intervention- Current and recent developments

4. Naloxone across Scotland- A brief look at how we got where we are ScottishdrugsForum

5. Drug related deaths in 2009 The pessimism/optimism balance Discussing premature, early and Preventable(?) death. Co-ordinating Action on Drug Issues ScottishdrugsForum

6. European picture ‘The evidence suggests that mortality rates declined in Spain and Italy, and were stable in Germany. In addition, the other selected countries all achieved substantially greater reductions in drug-related deaths than England and Wales between 1999 and 2004/05, with Germany and Italy exceeding a 20% reduction and Spain (six cities) reducing the drug-related mortality rate by 17%’ Morgan O., et.al. Trends in overdose deaths from drug misuse in Europe: what do the data tell us? Addiction (2008) 103, 699–700) UK 20% target not met in UK ‘99/’05 DRDs not counted as a key performance indicator in 2008-2018 drugs strategy Bird M., et al. Missing targets on drugs-related deaths, and a Scottish paradox International Journal on Drugs Policy (2009) doi:10.1016/j.drugpo.2009.10.001 Scotland The rate of drug deaths in Scotland is higher than other parts of the UK and Europe (EMCDDA, 2006). Most of these deaths (66%) occurred in people who were drug dependent (GROS, 2008), in their late twenties or thirties with a history of drug use and overdose (Zador. et al, 2005). Rome A., Shaw A., Reducing drug users risk of overdose, Scottish Government (2008) Co-ordinating Action on Drug Issues ScottishdrugsForum

7. Co-ordinating Action on Drug Issues Scottish Drug related Deaths 1996-2008 131% increase in drug related deaths since 1998 * Drug deaths increased by 26% from ’07-’08 . Expected to pass 600 in 2009 ? Source: GROS 2009 ScottishdrugsForum

8. Co-ordinating Action on Drug Issues Drug related deaths in 4 Health board areas 1998-2008 Source: GROS 2009 ScottishdrugsForum

9. Drug Related Deaths in Scotland (GROS) 2008-574 DRDs by age & sex in Scotland 2008 Aged 15-24yrs- 92 (16%) Aged 25 to 34yrs- 211 (37%) 303 deaths under 35yrs Aged 35 to 44yrs- 174 (30%) Aged 45yrs and over 97 (17%) 271 deaths 35+yrs Males- 461 (80%) Females- 113 NOTE- 370 deaths were listed as drug abuse, 111 undetermined intent, 59 accidental poisoning and 34 as intentional self poisoning Co-ordinating Action on Drug Issues Brief overview 2008 (Drug deaths increased by 26% from ’07-’08) ScottishdrugsForum

10. Age- all getting older the lower quartile age at death rose from 22 years in 1996 to 27 years in 2008; the median age at death increased from 28 years in 1996 to 34 years in 2008 the upper quartile age at death rose from 34 years in 1996 to 41 years in 2008. Co-ordinating Action on Drug Issues ScottishdrugsForum

11. *Important note The figures given for 2008 are not directly comparable to figures up to 2008 due to a change in methods of collection/compilation Co-ordinating Action on Drug Issues ScottishdrugsForum

12. Co-ordinating Action on Drug Issues Main substances recorded in 2008 (GROS) ScottishdrugsForum

13. Higher Risk Times Times when tolerance may be lowered; Release from prison/custody; recent detox (planned or unplanned); illnesses; change in resources/means to procure substance; beginning/ending of substitute medication (planned or unplanned) During periods of poly substance use (Number of addictive substances used related to increased risk of unnatural death: A combined medico-legal and case-record study Brådvik L., Berglund M., Arne Frank A., Anna Lindgren A. and Löwenhielm P. (2009)) Generally ‘anytime’- Poly substance use becoming the norm; Periods of depression/low mood; significant life events (overlap with suicide, estimates suggest that up to 30% DRDs may be suicides); illnesses; festive periods; change in resources/means to procure substances; disconnected/unsupported Co-ordinating Action on Drug Issues ScottishdrugsForum

14. Co-ordinating Action on Drug Issues A quick line or two......... on Cocaine Increasing use, (particularly in younger users) increasing problem Smoking and injecting Increased toxicity with other substances, risk of overdose Mixed with Alcohol- Cocaethylene (‘The combination of cocaine and alcohol appears to exert more cardiovascular toxicity than either drug alone in humans. Alcohol appears to potentiate cocaine hepatotoxicity in both humans and mice.’Landry M.J., An overview of cocaethylene, an alcohol-derived, psychoactive, cocaine metabolite J Psychoactive Drugs, 1992 Jul-Sep, 24:3, 273-6 ). ScottishdrugsForum

15. Co-ordinating Action on Drug Issues ScottishdrugsForum So What’s being done (more recently) to help reduce Drug Related Deaths in Scotland ?

16. Co-ordinating Action on Drug Issues Overdose prevention, Intervention and Awareness Scottish Drugs Forum- Critical Incident Training & Development Post. Funded by Scottish Government. Overarching Aim To further develop and see overdose awareness information, ‘Training the Trainer’ and direct awareness sessions to become widely available to workers, families and people at risk of overdose. National Partnership agreement with British Red Cross Multi agency training being delivered across sectors, Phoenix futures staff in prisons , also piloting training to PCSO’s, Police officers. ScottishdrugsForum

17. Co-ordinating Action on Drug Issues SCOTTISH RESEARCH ‘Reducing Drug users Risk of Overdose’. Rome A., Shaw A., Scottish Government, 2008. • Need for dedicated funding • Support for prisoners • Provision of naloxone • More research • Suicide prevention • Treatment & support • Young people in care • Piloting innovative projects • National campaigns • Data collection ScottishdrugsForum

18. Ongoing National Drug Related death Forum- Recommendations National Drug Related Death Volunteer Forum- Work program Nation Drug Death Database HEAT target for accessing treatment- 90%/3 week waiting by 2013 ADP Strategic plans- Reduce DRDs’/Overdose prevention Local Overdose/drug death prevention coordinators posts. SNFAD attending/developing training for families affected by overdose Co-ordinating Action on Drug Issues ScottishdrugsForum

19. Naloxone A very brief (but interesting!) history Co-ordinating Action on Drug Issues ScottishdrugsForum

20. Naloxone- early history Allylcodine- Pohl, J: Ztschr. Exper. Path. Und Therap 18, 370, 1915 Hart (1941) and Hart &McCawley (1944) synthesized N allylnormorphine (nalorphine) and studied its effects. H. F. Fraser, A. Wikler, A. J. Eisenman, and H. Isbell USE OF N-ALLYLNORMORPHINE IN TREATMENT OF METHADONE POISONING IN MAN: REPORT OF TWO CASES JAMA April 5, 1952 148:1205-1207 N-Allylnoroxymorphone-A New Potent Narcotic Antagonist: Foldes, Francis F. M.D.; Lunn, John N. M.B.; Moore, James M.D.; Brown, Ian M. M.B. American Journal of Medical Science 1963 Co-ordinating Action on Drug Issues ScottishdrugsForum

21. Skip forward Early 70’s- heralded as the opioid antithesis. Evans JM, Hogg MI, Lunn JN, Rosen M. Degree and duration of reversal by naloxone of effects of morphine in conscious subjects. Br Med J 1974; 2: 589–591. First ‘warnings’.....1975, an editorial in Lancet warned that in opioid addicts, “the doses should be small, since intravenous naloxone can precipitate a severe withdrawal syndrome in dependent addicts.” Editorial: Naloxone. Lancet 1975;1:734. Co-ordinating Action on Drug Issues ScottishdrugsForum

22. Naloxone- Still further forward 1992- J. Strang, BMJ- Should Naloxone amps be made available to IDUs? The change Jersey Project -1998,Berlin Project-1999, San francisco-2001, Chicago- 2001, New Mexico-2001, Baltimore-2004, NYC-2004/5and many other sites. Glasgow/Lanarkshire pilots/program-2006 Inverness pilot-2009 Welsh Program -2009 June 2009- 16 site pilot in England All of Scotland-2010?? Co-ordinating Action on Drug Issues ScottishdrugsForum

23. Co-ordinating Action on Drug Issues Thanks for your attention Stephen Malloy National Training & Development Officer-Critical Incidents stephen@sdf.org.uk SDF office: 0141 221 1175 ScottishdrugsForum

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