Drug related mortality in NZ - What has been published so far?

1. Acute Mortality Related to Prescription and Illicit Drug Overdose in NZ 1998-2001Research submitted for MSC thesis, 2003Elizabeth MorganSupervisor: Dr Nerida SmithSenior Lecturer in Clinical Toxicology Department of Pharmacology & Toxicology University of Otago

2. Drug related mortality in NZ - What has been published so far? • Stream of literature lacks continuity – different regions over different time periods Cairns et al (1983) – Auckland Dukes et al (1992) - Wellington • A recent publications: • “NZ Drug Statistics” (MOH 2001) • “Surveillance of Chemical Induced Mortality in NZ” (ESR for MOH, 2003)

3. Summary of the NZ Data The information that is available suggests that: • Males are over-represented • Usually young – 20-30 yrs old Data not standardized/adjusted to population • ↓ in barbiturate related deaths • TCAs common in late 1970s – early 1980s • CO deaths make up the largest proportion of deaths attributed to a single chemical/drug

4. The Present Study Objectives • Examine deaths resulting acutely from prescription/illicit drugs in NZ, 1998 – 2001 using Coronial inquest data • Characteristics of the decedents & circumstances • Examine drugs involved • Identify preventable factors involved • Examine the quality & usefulness of the information available in the Coronial inquest files, for thepurposes of population-based studies

5. Data Collection • Data collected during 2002 • Case selection if death occurred between 1998 and 2001 AND if drug involvement was indicated • Deaths attributed solely to non-prescription drugs or substances not restricted by law were not included • Deaths did not have to be solely attributed to prescription/illicit drugs – additional circumstances such as disease or asphyxiation may have been named by Coroner as well

6. Exclusion Criteria • Death occurred as a result of long-term drug abuse (including disease as a result of drug use – HIV/AIDS) • Death as a result of withdrawal or abstinence syndromes • Drug/chemical implicated was available legally and without a prescription • Verdict – if verdict did not include any mention of drugs then case was excluded • Deaths among drug users where cause was not drug-related

7. Data Collected from Inquest files • File number • Date of death/date of inquest hearing • Verdict code assigned by Dept for Courts • Basic demographic data: age, gender etc. from Police Report for Coroner • Health status of the deceased • Post-mortem toxicological investigation • Cause of death – pathologist and Coroner

8. RESULTS Two parts: • Describing the decedents – demographics • Post-mortem toxicology

9. Age & Gender • 325 decedents 187 (58%) male/138 (42%) female • Aged 2-100 years – avg age 41 years • Age-specific mortality data = males died younger than females

10. Ethnicity • Ethnicity was recorded in 79% of cases • Ethnicity data from PRC in 75% of these cases

11. Marital Status • Records available in 60% cases – Police report • Of those 60% - almost three-quarters were single (single, separated, divorced, widowed) • Similar result for men & women Employment Status • 58% unemployed (S/B, unemployed, students, retired) • Proportion males > proportion of females • On the whole, unemployed people were over-represented compared to general population

12. Tauranga 15 inquests Auckland 94 inquests Palmerston North 15 inquests New Plymouth 8 inquests Wellington 29 inquests Christchurch 36 inquests Dunedin 10 inquests Place of inquest

13. Hospital 17% Other’s residence 8% Own home 59% Other 16% Place of Death

14. Health Status Very basic – decedents were defined by one of 4 categories • No record of mental or physical illness • Medical history of mental illness (incl depression) • Medical history of chronic physical illness • Medical history of mental and chronic physical illness Amount of information varied from file to file People with no medical history in inquest file = included in group 1 → undercounting of illness is likely

15. Both mental and chronic physical illness reported 12% 14% females 11% males No reported diagnoses of mental or chronic physical illness 39% 32% females 44% males Reported chronic physical illness 18% 18% females 18% males Reported clinically diagnosed mental illness 31% 36% females 27% males Health Status

16. VerdictSuicide vs Non-Suicide • 35% deaths included in this study were found to be suicide • Raw no. suicides over 4-years remained stable Even though the total no deaths each year dropped • Males outnumbered females in total… proportionally:

17. Gender, Health Status and Verdict Health Status in cases found to be suicide: Physical 13% Both 19% Neither 22% Mental illness 46% Health Status in cases that were not suicide Mental illness 22% Mental illness 22% Physical 21% Physical 21% Both 9% Both 9% Neither 48% Neither 48%

18. Gender Differences? • Females: proportions of suicide/non-suicide were similar when “health status” categories were examined separately • Males: proportions of suicide/non-suicide equal where history of mental illness was indicated BUT in contrast to females Only about 18% of deaths among males with chronic physical illness were suicide

19. Employment Status vs Suicide/Non-suicide • Proportions of suicide/non-suicide appeared to be similar for unemployed and employed decedents when “unemployment” was viewed as a whole ~ 60-65% non-suicide • Subcategories of “unemployment”: sickness beneficiary 47% suicide retired 42% suicide student 38% suicide unemployed 25% suicide

20. Post-Mortem Toxicology Examinations • PM toxicology – ESR reports • 92% cases in this study subject to tox exam • 3% of these cases – report unavailable • No tox exam in remaining 8% cases prevented by decomposition, time delay etc

21. 1 sample sites 12% 2 sample sites 31% 4+ sample sites 9% 3 sample sites 48% Of those cases subjected to testing…

22. A closer look at the sample sites • Femoral blood samples were tested in 64% of these cases • Most of these cases a biological sample from at least 1 other site was tested • 14% examined cases, blood was from “unknown” site. In most cases this was the only blood sample tested • Heart blood utilised in 5% of cases – usually blood was tested from other sites too

23. How Many Drugs Detected PM? No testing/none detected 10% 6+ drugs 4% 1 drug 21% 5 drugs 5% 4 drugs 7% 2 drugs 32% 3 drugs 21%

24. Drugs detected most frequently Alcohol 45% Morphine/heroin 16% Diazepam, methadone 14% Zopiclone 10%

25. Drugs Named by Coroner as Agents Resulting in DeathTaken from Coroners Statements 2 drugs 14% 1 drug 57% 3 drugs 5% 4 drugs 1% 5+ drugs 1% Not specified 22%

26. Drugs most frequently involved In cases where death was attributed to one drug: Morphine/heroin 12% Methadone 9% Dothiepin 6% Doxepin 5% Zopicolne 4% Where death was attributed to multiple drugs: Alcohol 12% Diazepam 5% Methadone 4% Zopiclone 3% Amitriptyline 3%

27. Gender vs Drugs Drugs most frequently detected PM: Males (specific drugs named by Coroner in 145 cases) methadone>morphine>diazepam>cannabis>zopiclone • Coroner’s statements: opioids dominated deaths among males Females (specific drugs named by Coroner in 107 cases) dothiepin>morphine>zopiclone>diazepam>amitriptyline • Coroner’s statements: TCAs dominated deaths among females • Antidepressants in general were a more prominent feature of deaths among females

28. Age vs Drugs 3 age groups: 0 – 29 years (about 29% of studied population) 30 – 49 years (about 44% of studied population) 50+ years (about 26% of studied population) Drugs detected post-mortem were different for each age group 0 -29 years: opioids>chemical>benzo’s & TCA’s 30 – 49 years: opioids>chemical>benzo’s 50+ years: chemical>TCA’s>benzo’s>opioids

29. Source of Drugs Of those deaths which underwent PM toxicological examination: Records detailing the source of the drugs detected were identified in ~41% of cases Of the most commonly detected drugs: OPIOIDS source identified in 33% cases; 62% illicit morphine – 90% illicit methadone – 60% illicit TCAs source identified in 53% cases; 95% prescribed BENZOs source identified in 55% cases; 75% prescribed

30. How complete was the data set in this study? What proportion of ALL drug related deaths occurring in this period did I gather? Deaths in 1998 = the most complete data set Looked at how many inquests were processed each year versus year of death, for example of the 107 deaths occurring in 1998: 64% of inquests were processed in 1998 27% inquests were processed in 1999 9% inquests were processed in 2000 and 2001 These results are similar to ESR’s estimates (2003)

31. Data Completeness… • For the majority of deaths examined in this study, the inquest was completed within 2 years Data sets for 1998 and 1999 = reasonably complete 2000 and 2001 less so BUT…different factors may be affecting different sub-sets of the studied population, for examplesuicides → perhaps suicide investigations are completed sooner? Perhaps the number of suicides involving drugs is actually increasing?

32. Drug Related Mortality in the Present study…OBSERVATIONS… SHARING MEDICINES & “SELF-MEDICATING” Noted by several Coroners STOCKPILING OF MEDICATIONS Opioids – cancer treatment patients Barbiturates - elderly people People being treated for illnesses known to be associated with increased suicide risk; often had access to large amounts INADEQUATE STORAGE Methadone – naive users, not necessarily seeking a high Colchicine – teenagers, lack of knowledge about medicines

33. Limitations of the Present Study • Data collection methods One person collecting data – no validation • Comparability limitations many definitions of “drug-related death” • Completeness and quality of the data… for example – the “ethnicity” results

34. Completeness and quality of the data… Study was retrospective = inherent difficulties Disparity between the objectives of the inquest and the research objectives inquest = focused on the individual case-by-case pop based study = requires uniform data How can this be addressed?

35. How can this be addressed? minimum dataset requirements these could cover the basic data needs of population based studies: demographics, circumstances of death, aspects of the inquest etc. in a way that does not impose on the Coroner This would ensure consistency in data source etc. research would be of higher quality mortality data would be more meaningful

36. Where to from here?