Deaths from drugs of abuse in Sheffield 1997 – 1999:
what are the implications for GPs prescribing to heroin addicts?
Oliver P 1, Keen J 1,2
Phillip Oliver, BSc – Research Fellow
Jenny Keen, BA, MSc, MBBS, MRCGP, DRCOG – Clinical Fellow,
Primary Care Specialist in Drug Dependence.
- 1. Department of General Practice and Primary Care, Northern General Hospital, Sheffield, S5 7AU.
- 2. Community Health, Sheffield.
Author for correspondence:
Phillip Oliver, University of Sheffield, Institute of General
Practice and Primary Care,
Northern General Hospital, Sheffield, S5 7AU. Tel: (0114) 2715925, Fax (0114) 2422136,
This work was funded by Sheffield Health.
Ethics approval was granted on 23/9/1999 by the
South Sheffield research ethics committee (SS99).
Recent reports of criminal charges being
against general practitioners
following the death of patients receiving methadone treatment have highlighted
the dilemma facing GPs considering prescribing for heroin addicts 1
Despite an extensive evidence base for the
use of methadone in the treatment of heroin dependence 2,3
, the drug
remains dangerous in overdose and drug users remain a high risk population due
to risk taking behaviours such as injecting and mixing drugs.
The introduction of the government’s orange
book on the clinical management of drug users sought to provide prescribers
with straightforward guidelines on the treatment of drug users in primary care 4
and in Sheffield has been followed by a substantial increase in the number of
prescriptions for methadone due largely to the introduction of a primary care
prescribing clinic introduced in April 1998.
The present paper aims to examine the characteristics of drug abuse
deaths in Sheffield between 1997 - 1999 with particular attention to role of
prescribed medication and the impact of increased methadone prescribing.
Participants, Methods and Results
Information was made available on all deaths
reported to the City of Sheffield Coroner between January 1st
and December 31st 1999.
were searched to identify individuals who died from a ‘drug of abuse’ related
For the purposes of this
study a drug of abuse is defined as all controlled substances (excluding
cannabis), other opioids, benzodiazepines, cyclizine and solvents.
Alcohol was included only where it was
detected in combination with another (defined) drug.
A total of 82 drug of abuse related deaths occurred
in Sheffield during the three year period.
The number of deaths rose from 16 in 1997 to 34 in 1999 (112%) with the
largest increase occurring between 1997 and 1998 when deaths doubled. The mean age over the period of study was
29.4 years (SD 7.5 years), the overwhelming majority of which were male (92%),
single (89%) and unemployed (84%).
Heroin on its own or in combination with other drugs
was considered in the coroner’s findings to be responsible for death in 70% of
all cases over the study period (table 1).
A significant increase in the number of deaths involving combinations of
heroin with other drugs was seen over the 3 years. Deaths attributable either wholly or partially to methadone
poisoning fell from 37% in 1997 to 18% in 1999.
Where heroin or methadone was implicated alongside
another drug, the most common concomitants were benzodiazepines and
alcohol. When a prescription medicine
is found to have contributed to death the coroner normally attempts to establish
the source of the drug. In these
instances prescribed methadone was found to be involved in 14 cases of which 6
were in injectable form, 4 oral and 4
half oral-half injectables. In
the remaining 6 cases the source of the methadone was unknown (i.e., diverted).
The raise in the number of drug of abuse related
deaths in Sheffield between 1997 and 1999 was probably due to a complex
interaction between a number of factors.
Increases in the number of drug users, changes in drug taking behaviours,
purity of heroin and availability of treatment services have all been suggested
as contributing to drug abuse deaths.
However given that the proportion of deaths involving methadone over
this period fell against a background of increased prescribing (there is good
reason to suspect that methadone prescriptions doubled over this period) then
it would appear that this is not one them.
Indeed there is good evidence to suggest that some lives may have been
saved if methadone had been more widely accessible to these people 5
Although the relative contribution of
benzodiazepines to opiate overdose is difficult to assess, there is some
evidence to suggest that they may have an additive or synergistic effect on
and should therefore be prescribed to drug
addicts only within the national guidelines.