Title:

Deaths from drugs of abuse in Sheffield 1997 – 1999: what are the implications for GPs prescribing to heroin addicts?

 

Authors:

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, e-mail: p.oliver{at}sheffield.ac.uk.

 

Funding: This work was funded by Sheffield Health.

Ethics: Ethics approval was granted on 23/9/1999 by the South Sheffield research ethics committee (SS99).

Word Count: 635

 

Introduction

Recent reports of criminal charges being brought  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 1^st 1997 and December 31st 1999.   These records were searched to identify individuals who died from a ‘drug of abuse’ related poisoning.  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).

Comment:

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 respiratory depression⁶ and should therefore be prescribed to drug addicts only within the national guidelines.

 

Table 1 – Drug(s) considered to have contributed to cause of death

(percentage of total cases in brackets).

 

 

References:

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4. Drug Misuse and Dependence -  Guidelines on clinical management. D.O.H. 1999, London, HMSO.
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