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M o n i i t t o r r i i n g a n d S t t r r a t t e g i i c G r r o u p
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J u l l i i a N e u f f e i i n d
A b b y S t t e p h e n s o n
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A l l e x B a l l d a c c h i i n o

A c k n o w l l e d g e m e n t t s
Authors
Dr Julia Neufeind, Part Time Drug Deaths Researcher, Fife Alcohol and Drug Partnership and Researcher in CAMHS and Public Health, NHS Fife
Dr Alexander Baldacchino, Chairman of DD Groups, Consultant Psychiatrist NHS Fife and
Clinical Senior Lecturer in Addictions, Centre for Addiction Research and Education
Scotland (CARES), Dundee University
Abby Stephenson, Part Time Drug Deaths Researcher, Fife ADP and NHS Fife
Colin Steer, Drugs Liaison Officer, Fife Police
Mandy Young, Fife Overdose Prevention Coordinator, c/o Fife NHS Addiction Services,
NHS Fife
Michelle Paterson, PA, Fife NHS Addiction Services, NHS Fife.
Fife Drug Deaths Monitoring Group
Dr Alexander Baldacchino Chairman of DD Groups, Consultant Psychiatrist NHS Fife and
Clinical Senior Lecturer in Addictions, (CARES) Dundee University
Rita Keyte – Louise Bowman Co-ordinator, Fife Alcohol and Drug Partnership
Kenny Cameron, Drugs Strategy Officer, SCDEA
Colin Steer, Drugs Liaison Officer, Fife Constabulary
Mandy Young, Fife Overdose Prevention Coordinator, c/o Fife NHS Addiction Services,
NHS Fife
Michelle Paterson, PA, Fife NHS Addiction Services, NHS Fife
Ingrid Pitt, Team Leader, Fife NHS Addiction Services, NHS Fife
Susan Rose, Team Leader, Drug Court Supervision and Treatment Team, Criminal Justice
Service
Delphine Easson, Team Manager, Enhanced Addictions Casework Services (EACS), HMP
Perth and Phoenix Futures .
Dr Julia Neufeind, Part Time Drug Deaths Researcher, Fife ADP and Researcher in
CAMHS and Public Health, NHS Fife
Abby Stephenson, Part Time Drug Deaths Researcher, Fife ADP and NHS Fife
April Adam, Service Manager, Fife Intensive Rehabilitation Service (FIRST) ii

Joyce Leggate, Addictions Midwife, Forth Park Hospital, NHS Fife
Dave Dempster, Service Manager, West Fife Community Drug Team
Fiona Boyce, PA, Fife NHS Addiction Services, NHS Fife
Dr Ignacio Eguireun, Locum Consultant Psychiatrist in Addictions, NHS Fife
Liz Hutchings, Specialist Pharmacist in Substance Misuse, NHS Fife
Fife Drug Deaths Strategic Group
Dr Alexander Baldacchino Chairman of DD Groups, Consultant Psychiatrist NHS Fife and
Clinical Senior Lecturer in Addictions, (CARES) Dundee University
Rita Keyte – Louise Bowman Co-ordinator, Fife Alcohol and Drug Partnership
Kenny Cameron, Drugs Strategy Officer, SCDEA
Colin Steer, Drugs Liaison Officer, Fife Constabulary
Mandy Young, Fife ADP, Overdose Prevention Coordinator, Fife NHS Addiction Services,
NHS Fife
Michelle Paterson, PA, Fife NHS Addiction Services, NHS Fife
Ingrid Pitt, Team Leader, Fife NHS Addiction Services, NHS Fife
Susan Rose, Team Leader, Drug Court Supervision and Treatment Team, Criminal Justice
Service
Delphine Easson, Team Manager, Enhanced Addictions Casework Services (EACS), HMP
Perth and Phoenix Futures.
Dr Julia Neufeind, Part Time Drug Deaths Researcher, Fife ADP and Researcher in
CAMHS and Public Health, NHS Fife
Abby Stephenson, Part Time Drug Deaths Researcher, Fife ADP and NHS Fife
April Adam, Service Manager, Fife Intensive Rehabilitation Service (FIRST)
Dr Mike Roworth, Consultant in Public Health, NHS Fife
Paul Kelly, Clinical Governance & Quality Lead, Scottish Ambulance
Dave Dempster, Service Manager, West Fife Community Drug Team
Fiona Boyce, PA, Fife NHS Addiction Services, NHS Fife.
Dr Ignacio Eguireun, Locum Consultant Psychiatrist in Addictions, NHS Fife
Liz Hutchings, Specialist Pharmacist in Substance Misuse, NHS Fife
iii

Special Thanks
To the Fife Police Constabulary who have provided the setting and infrastructural support to collect, analyse and write the report findings.
Kenny Cameron, Drug Strategy Officer, SCEDA
To all previous members who have been acknowledged in previous reports.
iv

C o n t t e n t t s
Executive Summary
Section 1 Introduction
1.1 Background
1.2
1.3
Governance and Structure
Mission Statement
1.4
1.5
Ethos and Philosophy of the Group
Drug Deaths Monitoring Group
Section 2 Methodology
2.1 Population
2.2 Definition of a Drug Death (DD)
2.3
2.4
2.5
2.6
2.7
2.8
Inclusion Criteria: ICD-10
Exclusion Criteria
Step by Step: Information Gathering
Step by Step: Guide to Data Collection
Protocol and The Drug Deaths Database
Drug Deaths Database
2.9
2.10
2.11
2.12
Data Analysis
Data Collection Sources
Missing Data
Format of Results
Section 3 Results
3.1 Demographic Characteristics
3.1.1 Incidence and Prevalence
3.1.2 DD Victims across Fife per Population and Location
3.1.3 Gender and Ethnicity
3.1.4 Age
3.2
3.3
Life Context and Social Functioning
3.2.1 Housing and Living Arrangements
3.2.2 Relationship and Family Information
3.2.3 Relationship with Children
3.2.4 Friendships and Relationships
3.2.5 Education and Employment
3.2.6 Employment Status at the Time of Death
Criminal Justice and Offending
3.3.1 History of Offending
3.3.2 History of Incarcerations
3.3.3 History of Court Enforced Interventions
3.4 Physical/Psychological Health
3.4.1 Psychiatric/Psychological Problems
3.4.2 Physical Health Problems
3.4.3 Significant Life Events
3.4.4 Co-morbidity
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14
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11
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3.5
3.5.1 Age at which Drug Misuse Began
3.5.2
3.5.3 Drug Use Characteristics of injecting vs. non-injecting users
3.5.4 Overdose Histories
3.6
Substance Misuse Histories
Lifetime Injecting Characteristics
Service Use Histories
3.6.1 Services Accessed within 5 years of Death
3.6.2 Services Accessed within 6 month of Death
3.6.3 Pharmacological Interventions
3.7 Circumstances of Death
3.7.1 Timings of Death
3.7.2 Circumstances of Death
3.7.3 Snoring Immediately Prior to Death
3.7.4 Interventions Attempted at the Scene
31
31
31
32
32
34
34
35
36
38
38
40
40
40
Appendix E
3.8 Toxicology Results of Drug Deaths
3.8.1 Toxicology Results
3.8.2 Substances Implicated Concomitantly
3.8.3 Therapeutic, Fatal and Actual Levels of Substances
3.9 Pharmacology of Heroin in Fife
42
42
43
44
46
3.9.1
3.9.2
3.9.3
Appendix B
Appendix C
Purity Levels of Heroin
Cutting Agents
Concluding Remarks for Pharmacology of Heroin
Section 4 Conclusions
4.1 A Case Vignette of a Typical Drug Death Victim in Fife
Appendix A Map Displaying Locations of Drug Deaths in Fife 2008
–
2010
Appendix D
46
46
47
48
48
49
51 Fife Drug Deaths Action Plan 2008
– 2010
SACDM recommendations 54
Explanation of Tolerance Levels in Post-Mortem
Toxicology Reports
57
Fife Drug Death Questionnaire 58
vi

E x e c u t t i i v e S u m m a r r y
Background
Fife Drug Deaths Monitoring Group evolved under the auspices of the Fife Alcohol and
Drug Partnership (ADP) (formerly the Drug and Alcohol Action Team - DAAT), in order to identify a systematic approach to synthesising individual drug deaths, which includes the analysis of similarities, trends and patterns among them. This report summarises the findings of drug deaths that occurred in Fife between 2008 and 2010.
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 and service use characteristics as well as the specific 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 drug deaths (DDs) in Fife between January 2008 and December 2010 consisted of 81 cases, with 31, 26 and 24 occurring in 2008, 2009 and 2010 respectively.
Information about these deaths was collected via dissemination of the Fife Drug Deaths
Questionnaire (see Appendix C) 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, post-mortem and toxicology was obtained from the Procurator Fiscal.
Key Results
Incidence and Prevalence of Drug Deaths between 2008 and 2010
 Fife had a total of 135 Drug Deaths between 2005 and 2010
 In 2010 there is a 7.7% decrease in the number of drug deaths on the previous year
(2009)

Drug related death cases are not officially recorded
 The average DD rate per 1000 of the population between 2008 (0.09 per 1000) and
2010 (0.07 per 1000) fell below the Scottish average rate between 2005 and 2009
(0.09 per 1000)

Central areas of Fife have the highest incidence of DDs
 The majority of DDs occur in the victims own home
Demographic, Social Functioning and Life Context Trends
 98.8% of all DD victims were White Caucasian (all except one individual in 2008)
 Only 18.5% of DD victims were female
 The mean age of the DD victim between 2008 and 2010 was 32.4 years
 DD victims were aged between 17 and 53 years
 Half (49.4%) of all DD victims were living with others at the time of their deaths

The living arrangements of DD victims at the time of their deaths did not differ much from those of the six month prior to death, except in those cases where the person
1

had been incarcerated during that time or had a change in housing or relationship status
 While the majority (60.5%) of DD victims were classed as single, at the time of their deaths, a large number were involved in some form of romantic relationship at the time of their deaths
 The majority (61.7%) of DD victims had children; however, 79.5% of these did not live with their children

The majority of DD victims were not socially isolated; many were known to have a close relationship with a family member (71.4%) or a close friendship with another person (85.4%)

At the same time, the majority, 64.4% were known to also have significant difficulties in these relationships
 The mean age at which DD victims left school was 15.8 years

The majority of DD victims (76.3%) were engaged in some form employment/education activity after leaving school
 Only 23.7% were unemployed after leaving school. However this figure was reversed directly before death, at which point 89.5% of DD victims were unemployed
Criminal Justice Issues and Offending Patterns
 90.1% of DD victims had been arrested in the past
 52.1% of DD victims who had been arrested, were arrested at least once 6 months prior to their death
 53.1% of DD victims had served a prison sentence some point during their lives
 41.9% of DD victims who had served a prison sentence had done so in the 6 months before their death

Two DD victims (4.7%) died within the two weeks of their release from prison
 Few DD victims were subject to court enforced interventions
Physical, Psychological/Psychiatric Health and Significant Life Events
 The majority of DD victims (77.8%) suffered from psychological or psychiatric difficulties, the most common of which was depression

49.4% of the DD victims were also known to have suffered significant physical difficulties
 82.5% of DD victims were known to have experienced a significant adverse life event
 Most common adverse life events included bereavement, recent separation or marital difficulties and assault

The majority of DD victims (66.2%) had experienced a combination of psychological and physical difficulties as well as life events, rather than a single problem alongside their substance misuse problems
Substance Misuse Histories
 All but four of the DD victims were known poly-drug users, 58.0% of which were IV users
 The average age at which drug misuse began was 15.8 years, and age at which individuals first injected was 25.4 years

By the time of their deaths, the victims had an average drug using career of around
16 years
2


While injecting drug-users were relatively more likely than non-injecting users to die of an overdose that involved morphine, the non-injectors were relatively more likely to die of an overdose involving methadone

56.8% were known to have overdosed at some point in their lives, often on multiple occasions
 28.3% victims were known to have overdosed in the 6 months prior to their deaths
Service Use Histories
 All except one drug death victim were known to at least one service in the 5 years prior to their deaths
 87.7% of all DD victims had accessed at least one service in the 6 months prior to their deaths

General Practitioners, NHS Fife Addiction Services, CJS and SPS were the four most commonly accessed services
 A large proportion (72.8%) of DD victims did not seek/receive treatment for their drug problem 6 months before they died

27.2% were receiving pharmacological treatment in the 6 months prior to their death; most were prescribed methadone
 17.3% of all DD victims were still on a methadone programme at the time of their deaths
Circumstances of the Death
 A relatively larger proportion of DDs in Fife occurred in the first half of the year
 Overall, drug deaths were no more likely to occur during a weekend than during the week

Drug Deaths which occurred over the weekend were no more likely to involve alcohol than those occurring during the week
 The majority of DDs (71.6%) occurred in the presence of others, which were in all cases known to the victim
 In many cases where others were present, the victim was simply believed to be sleeping at the time of their death, thus delaying any possible interventions
 CPR was attempted by bystanders in almost two-thirds of the cases (53.4%); however, this was often partial and had to be instructed by the ambulance crew over the telephone
Toxicology Findings
 Benzodiazepines, Heroin/Morphine, Methadone and Alcohol were the four most common substances involved in DDs between 2008 and 2010
 77.8% of victims had taken benzodiazepines shortly before their death
 Methadone was involved in 43.2% of all DDs in Fife between 2008 and 2010; however, 21 individuals who died with the substance in their system had not been prescribed the medication
 All but four of the DDs occurring in Fife involved a lethal combination of two or more substances

The number of substances implicated concomitantly in DDs has risen between
2008 and 2010
 The “therapeutic” and “fatal” ranges of a substance (as used in the toxicology reports) are diffused in their meaning in light of these poly-substance deaths
3

Pharmacology of Heroin in Fife
 The average purity level of Heroin recovered in Fife broadly agrees with the
Scottish average
 Caffeine and Paracetamol are the most common inert substances used to dilute
Heroin
 Currently within Scotland, there is no capability for fully analysing all recovered drugs
4

S e c t t i i o n 1 : : I I n t t r r o d u c t t i i o n
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) (since October 2009 renamed the Fife
Alcohol and Drug Partnership
– ADP). (Appendix B)
1.2 Governance and Structure
A Fife Drug Deaths group was already in place in Fife since 2003, as a key-working subgroup, accountable to Fife ADP. Initially, the committee met regularly to consider the circumstances surrounding Drug Deaths in Fife in collaboration with the services stated 1 .
However in 2005 the groups made a number of recommendations to the ADP and a subsequent revision of the group structure took place. The position of the Drug Deaths group, with respect to other components within the ADP can be seen below:
Fife Health and Well Being
Alliance
Joint Health & Social Care
Partnership
Community Safety and
Partnership Group
Fife Alcohol and Drug
Partnership (Fife ADP)
ADP Support Team
Protection Joint Planning and
Commissioning
Prevention and
Early
Intervention
Recovery
Performance Monitoring and
Evaluation
Communication
Data Collection and Analysis
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
5

1.3 Mission Statement
‘Fife wide multi-agency approach to understanding and preventing drug deaths’
1.4 Ethos and Philosophy of Fife Drug Deaths 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 2 to all agencies outlined in the Fife ADP Directory of Services 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 in the Acknowledgements.
1.5 Drug Deaths Monitoring Group
The Drug Deaths Monitoring Group includes members from the strategic group (see
Acknowledgements) as well as representatives from the following services:
Fife Intensive Rehabilitation Service Team (FIRST)
West Fife Community Drug Team (WFCDT)
Drug and Alcohol Project Limited (DAPL)
Fife Alcohol Support Services (FASS)
Clued Up Project (CluedUp)
Specialist Midwife in Addictions NHS Fife
Others organisations involved in the care of the DD victims
2 See appendix
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S e c t t i i o n 2 : : M e t t h o d o l l o g y
This report is a retrospective analysis of trends, similarities and common themes occurring within victims of drug deaths in Fife over the past three years (2008 - 2010). 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 would require a controlled sample of a living, drug taking and general population.
2.1 Population
The population consisted of 81 cases (n=81) of Drug Deaths. Cases for the study were a consecutive sample of individuals who died from drug overdose in the Fife area between
January 2008 and December 2010 (2008, n = 31; 2009, n = 26; 2010, n = 24). All fatalities suspected of dying from a fatal drug overdose were confirmed by post-mortem toxicology reports obtained from the Procurator Fiscal. In 2010, 47 cases were reviewed by the Fife
Drug Death Monitoring and Strategic Groups. During this process, five cases that had been classed as a drug death by the Procurator Fiscal were subsequently excluded from the analyses in this report. This decision was made by the Fife Drug Death Monitoring and
Strategic Groups on the grounds that these cases did not definitively fit the definition of a drug death detailed below. In these cases it was concluded that the deaths had occurred as a result of underlying health conditions. As is discussed in section 3.1, these cases should not be taken as a reflection of the number of drug related deaths in Fife for 2010.
There is also one case in 2010 that, following review, was classified as a non drug death by the Procurator Fiscal, which is included in the report as the evidence surrounding this case was sufficient for inclusion as a drug death.
2.2 Definition of a Drug Death (DD)
The definition of a Drug Death (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 drug death 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 has been used.
This definition is similar, but not identical, to the definition employed by the General
Register Office for Scotland (GROS). The GROS definition includes instances in which toxicological findings indicate the presence of a controlled substance, but where this subs tance may not necessarily have been a factor contributing to the individual’s death.
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Any deaths resulting from the overdose of a controlled substance in the years 2008
– 2010 has been 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.
2.3 Inclusion Criteria: ICD-10
Drug Deaths, where the underlying cause of death has been coded to the following subcategories 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);
(i) intentional self-poisoning by drugs, medicaments and biological substances
(X60 —X64);
(ii) assault by drugs, medicaments and biological substances (X85) and
(iii) 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 three of these compound analgesics have, particularly co-proxamol, been used in suicidal overdoses.
8

2.5 Step-by-step Guide to Information Gathering
Suspected Drug Death
(Sudden Death Report, SDR)
Police investigate Suspected
Drug Death
ADP informed
Police request Postmortem/toxicology Report
Fife Drug Death Questionnaire disseminated to Agencies
Agencies check records and if the individual is known the Fife
Drug Death Questionnaire is completed and returned to Fife
Police Headquarters
GP Notes requested via NHS
Fife
All Fife Drug Death
Questionnaires, GP Notes and
Post-mortem/toxicology
Reports are returned to Fife
Police Headquarters
All information is entered into the Fife Drug Death Database
Each individual case is discussed at Fife Drug Death
Monitoring Group and recommendations are made
Information is finalised within the Fife Drug Death Database
Required information is reported to NHS National
Services Scotland, Information
Services Division (ISD)
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2.6 Step-by-step Guide to Data Collection
Step 1
A suspected Drugs Death occurs in Fife and police attend and carry out investigation into the circumstances surrounding the death. The length of the investigation depends upon the individual circumstances and can vary from a few days to a number of months.
Step 2
Police inform the ADP, which in turn disseminates the Fife Drug Death Questionnaire
(Appendix C) to all relevant agencies for completion. At this point, Fife Constabulary also request toxicology from the Procurator Fiscal.
Step 3
Agencies check records to see if the individual has accessed their respective services. If the individual is known to a particular agency, the Drug Death Questionnaire is completed by that agency and returned to Fife Police Headquarters (FPHQ) for the attention of the
Drug Death Monitoring Group.
Step 4
Police inform NHS Fife of the victim’s GP details and the GP notes are requested on behalf of the Drug Deaths Monitoring Group.
Step 5
All questionnaires, case notes and post-mortem/toxicology reports are returned to FPHQ where details are entered into the DD Database. This is generally achieved in a six to eight week period from the time of death.
Step 6
The Fife Drug Death Monitoring and Strategic Group meet and discuss each death and make recommendations. The group meet every eight weeks.
Step 7
All information is finalised in the Fife Drug Death Database.
Step 8
The Drug Death Researcher, on behalf of the Fife Drug Death Monitoring Group, reports each Drug Death, alongside all the detail required of the death to the ISD,
10

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 History
4. Substances Use History
5. Physical and Psychological Health
6. Service Provisions
7. Additional information
The questionnaire is updated when required, and in 2009 a new version (v3.0) of the Fife
Drug Death Questionnaire was adapted in Fife in 2009 (Appendix C). This questionnaire is 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 and voluntary bodies such as
FIRST and DAPL). Upon completion, the questionnaire(s) are returned to the committee and information pertaining to the domains outlined above is entered into 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 the Fife Police Headquarters.
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 since 2005. The data used in this report is gained from Drug Deaths which occurred between 2008 and 2010.
2.9 Data Analysis
For the purposes of the present report, data contained within the Drug Deaths Database was collated by one researcher. The data analysis presented in the current report is limited to descriptive statistics. The researcher is supervised by the Chairman of the DD group.
Data collection processes also involved constant liaison with committee member PC Colin
Steer for access to various police sources. The process of data collection and analysis broadly involved the following stages:
1. Maintenance the database on a regular basis, entering of new information and regular cleansing of existing data
2. Background research on past/current government directives and relevant literature
3. Extraction of relevant data pertaining to the seven domains of the questionnaire outlines above
4. Data analysis (via Excel/SPSS) and interpretation/synthesis
5. Presentation of results
11

2.10 Data collection sources
Outlined below are lifestyle domains and sources used in data collection:
Domain
1. Demographic Characteristics
Sources Used
- Sudden Death Report
- SCDEA
- Fife Drug Death Questionnaire
2. Life Context and Social Functioning - Sudden Death Report
- SCDEA
- Social Work Notes, Social Enquiry
- Criminal Justice Service Reports
- Psychiatric Reports
- GP Notes and Correspondences
- Fife Drug Death Questionnaire
3. Criminal Justice and Offending - CHS (Criminal History System)
- CrimeFile
- Sudden Death Report
- Post-Mortem/Toxicology Reports
- Fife Drug Death Questionnaire
4. Substance Use History - Sudden Death Report
And - GP Notes and Correspondences
5. Physical and Psychological Health - Fife Addiction Service Notes
- Psychiatric Reports
- Social Work Notes
- Fife Drug Death Questionnaire
6. Service Use History
7. Additional Information
All of the above sources
All of the above sources
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, 2008
– 2010) 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 availability/lack of information for all 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 Fife Drug Death
Questionnaire and access to GP Notes has enabled the DD group to gain a greater insight into the established life domains of the DD victims of 2008 – 2010 than has been possible in previous years. Indeed, the DD group acknowledge this as part of an ongoing aim, rather than a limitation, whereby the aim is to continue to synthesise information from
12

multiple sources and develop a systematic approach in identifying the lifestyle patterns of
DD victims.
Recommendations

Continue the Fife Drug Deaths Database to produce and report data, both annually and accumulatively on a three year basis

Continue to support National Scottish and UK Drug Death
Programmes with a view of facilitating relevant data collection

Continue to liaise with Tayside and Forth Valley Drug Deaths data collection exercises

Investigate the future potential to examine cases not categorised as drug deaths, but as drug related deaths

Explore the possibility of involving the relatives of the deceased in order to improve the quality of the data collected on these individuals.
2.12 Format of Results
The results of the present report are, as previously stated, analysed from a descriptive perspective and are then compared and contrasted to drug deaths at a Scottish national and UK-wide level. For the purpose of clarity, the structure of the present report does not directly reflect the layout of the Fife Drug Death Questionnaire; instead, the results section
(Section 3) is divided into the following series of sub-sections:
1 - Demographic Characteristics
2 - Life Context and Social Functioning
3 - Criminal Justice and Offending
4 - Physical, Psychological/Psychiatric Health and Significant Life Events
5 - Substance Misuse Histories
6 - Service Use Histories
7 - Circumstances of the Deaths
8 - Toxicology Results
9 - Pharmacology of Heroin in Fife
13

S e c t t i i o n 3 : : R e s u l l t t s
3.1 Demographic Characteristics
This section describes patterns surrounding the incidence and location of drug deaths.
It also considers gender, age and ethnicity of drug death victims as well as patterns surrounding timings of drug deaths.
3.1.1 Incidence and Prevalence of Drug Deaths
Between 2008 and 2010 the Fife Drug Death Monitoring and Strategic Groups reviewed
114 cases, 36, 31 and 47 in 2008, 2009 and 2010 respectively, including: drug related, non-drug related and drug deaths cases. All of these 114 cases were discussed and reviewed in clusters, which enabled the group to focus on the individual circumstances surrounding each death.
Toxicology reports and discussions identified a total of 33 cases, which did not conform to the group
’s definition of a drug death: five in 2008, five in 2009 and 23 in 2010. However, these excluded deaths should in no way be taken as an indication of the number of drug related deaths in Fife between 2008 and 2010.
Whilst all 80 cases of Drug Deaths have been confirmed, the committee are presently awaiting the toxicology results of one DD case in 2010. It was decided that there was enough circumstantial evidence to classify this case as a DD. It is therefore included in the analysis section of the report.
In the years between 2005 and 2010 there were a total of 135 drug deaths in the Fife area with 15 in 2005, 19 in 2006, 20 in 2007, 31 in 2008, 26 in 2009 and 24 occurring in 2010.
Graph 1 displays the difference in the trends over time between 2005 and 2010 inclusive.
Between 2005 and 2008 there was an increase in the number of drug deaths each year.
2009 was the first year which showed a reduction in drug deaths, with there being 16.1% fewer drug deaths in 2009 as compared to 2008. The trend from 2009 to 2010 reduced by
7.7%.
14

Graph 1: The Prevalence of Drug Deaths In Fife 2005-2010 (n=135)
35
30
25
20
15
10
5
0
2005
Drug Deaths in Fife 2005 - 2010
2006 2007
Year
2008 2009 2010
Key Points

Fife had a total of 135 Drug Deaths between 2005 and 2010

In 2010 there is a 7.7% decrease in the number of drug deaths on the previous year (2009)

Drug related death cases are not officially recorded
3.1.2 DD Victims within Fife per Population and Location
The calculation of the number of DDs per 1000 of the population corresponding to the location of the drug death enables identification of DD hotspots. This could also determine which geographical areas display elevated DD rates when their populations are taken into account.
The DD rate per 1000 of the population has been calculated according to geographical area. Central Fife, with an estimated population of 147000 shows the highest number of
DD
’s per 1000 of the population (n = 54 or 66.7%). This result is based upon the fact that most DD ’s occurred in this area but also as it has the largest population compared to East
Fife which has a population of 73500 and West Fife (129500). Table 1 displays the towns that constitute East, West and Central Fife.
Table 1: Population of the Geographic Areas within Fife (2009) 3
Central East West
Methil
Glenrothes
Kirkcaldy
Leven
144,259
Anstruther
Cupar
St Andrews
76,388
Dunfermline
Cowdenbeath
Rosyth
142,813
3 This information was obtained from the General Register Office (GRO)
15

When the entire population of Fife is considered, the average number of deaths in Fife per
1000 of the population calculates as 0.09 in 2008. This is above the 2007 Scottish average rate of DD’s at 0.07 per 1000. Thus the average DD rate for Fife in 2008 (0.09 per 1000) was greater than the Scottish national average DD rate for 2007 (0.07 per 1000). In 2009 the number of drug deaths per 1000 was 0.07, below the Scottish average rate 2005 –
2009 of 0.09 per 1000. In 2010 the average DD rate in Fife of 0.07 per 1000 is again below the Scottish average of 0.09 per 1000. The breakdown of DDs per area within Fife between 2008 and 2010 differs substantially but remains consistent over the three year period: most DDs occurred in Central Fife (0.12 per 1000), with little difference between
East Fife (0.04 per 1000) and West Fife (0.036 per 1000). The pattern of DD by population across Fife in 2010 is shown in Graph 2 below.
Graph 2: No. of DDs in Fife (n=24, 2010) by Geographical Area per 1000 of the Population
DDs by Geographical Area in Fife per 1000 of the Population
DDs in Area Scottish Average 2005-2009 Fife Average 2010
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
Central East West
Geograpical Area in Fife
The majority of DDs in between 2008 and 2010 occurred in the victim’s own homes (n =
53 or 65.4%); in these cases the hometown reflects the town of death. 21 victims died at addresses different to their own (n = 21 or 25.9%); however, in each case the locus of death was either in hospital or in their hometown, and no farther than 15 miles from their own homes. The remaining seven victims had no fixed abode (n = 7 or 8.6%).
These results show that between 2008 and 2010 all DD victims died in close proximity to their homes. Thus, they did not have to travel far to obtain their drugs and elevated death rates in specific locations are not as a result of individuals travelling to those areas in order to obtain the drugs.
Key Points

The average DD rate in Fife in between 2008 (0.09 per 1000) and
2010 (0.07 per 1000) fell below the Scottish average rate between
2005 and 2009 (0.09 per 1000)

Central areas of Fife have the highest incidence of DDs

The majority of DDs occur in the victims own home
16

3.1.3 Gender and Ethnicity
The majority (75.0%) of DD cases in 2010 were male. While this is consistent with previous patterns (77.0% in 2009 and 90.0% in 2008), there was nevertheless a noticeable increase in the number of female DDs victims in 2009, which held constant in 2010, as compared to previous years. The male:female gender ratio in 2010 was 18:6, in 2009 the ratio was 20:6, compared to 28:3 in 2008.
All DD victims (n=80) were white Caucasian, the predominant ethnicity in Fife, with one exception of a DD victim of mixed race in 2008.
3.1.4 Age
The age of DD victims between 2008 and 2010 ranged between 17 to 53 years, with a mean age of 32.4 years. The average age of DD victims in 2010 (33.2) very slightly decreased from the mean age in 2009 (34.0), which showed an increase in the average found in 2008 (30.0). The Scottish average between 2008 and 2010 showed that DD victims typically died aged 34 years (GROS, 2009) 4 .
The DDs in Fife between 2008 and 2010 span a wide range of ages. When broken down into separate age categories spanning ten years each, the results show a relatively even distribution of ages of the DDs victims. 35.8% of victims fell into the 20-29 years age group, with 34.56% of victims falling into the 30-39 years category. A further 24.7% were aged 40 years and over. Only four victims (4.9%) were aged 19 years and under, which challenges the commonly held public belief that DD victims are in their late teens. In 2010, the age group with the most DDs was 30-39 years (54.2%), increased from 30.8% in 2009 and 22.6% in 2008.
Graph 3: Drug Death Victims and Individuals Seeking Substance Misuse Treatment in Fife By Age
Group (2008 – 2010) (n=81)
Percentages of Individuals per Age Group dying of a DD (2008-2010) and Seeking
Treatm ent for the First Tim e in Fife (2009)
20
15
10
5
0
45
40
35
30
25
<19 20-29 30-39
Age Groups
Drug Deaths Treatment Seeking
40+
4 National figures are calculated using median as opposed to the mean which was used to calculate the average age of Fife DD victims.
17

Graph 3 above also demonstrates that there are similarities between age distribution of the treatment seeking and DD populations who are aged between 20-29 and 30-39 years.
This indicates that this age group is most likely to encounter problems related to drug misuse in general and not only a drug death. There are fewer similarities in the 40 years and over age group with 12.8% of individuals seeking treatment fall into this category and
24.7% of DD victims. Only 4.9% of DD victims fall into the aged 19 and under category compared to 12.8% of the treatment seeking population. Between 2008 and 2010 This is reflective of the trend to treatment seek in the under 19 age group, where individuals are twice as likely to seek treatment than to die of a DD. Conversely, individuals over the age of 40 are twice more likely to die a DD than to seek treatment.
Key Points

98.8% of all DD victims were White Caucasian

Only 18.5% of DD victims were female

The mean age of the DD victim between 2008 and 2010 was 32.4 years

DD victims were aged between 17 and 53 years
Recommendations

Service providers should be aware of the disproportionate number of drug deaths in Central Fife, which should be reflected in the service provisions within this locality

Identify other possible sociodemographic variations between the three regions of Fife that might be contributing to the higher than average drug death prevalence in Central Fife

Relate present DD data to ambulance data from non-fatal drug overdoses
18

3.2 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 are also described.
3.2.1 Housing and Living Arrangements
Graph 1 below specifies the living arrangements of the DD victims at the time of their deaths.
Graph 1: Living Circumstances of DD Victims Immediately Prior to Death (2008 – 2010) (n=81)
Living Arrangem ents of DD Victim s at the Tim e of Their Deaths
2008 2009 2010
11
10
9
8
7
6
5
4
3
2
1
0
Living Alone With
Spouse/Partner
With Friends With
Parents/Relatives
Other No Fixed Abode
Living Arrangem ents
While 34.6% of DD victims were living on their own at the time of their deaths, half (49.4%) were living with others; that is, their partners, parents, relatives or friends at the time of their death.
A total of six other individuals were described by reporting services as “homeless” at the time of their deaths, with five of these living in homeless accommodation (“other”). A further seven individuals had no fixed abode at all, living what was often described in reports as a “nomadic lifestyle”. The exact sleeping arrangements prior to their death are difficult to ascertain, but it appears that these people were primarily staying with various friends, with one individual in 2008 described as “sleeping rough”.
When considering the housing status of the drug death victims, it is important to recognise that in many cases the living arrangements varied frequently, and the lifestyles of a number of these individuals were described as “chaotic”. As such, for 21 (26.0%) victims, two or more different types of living arrangements were identified in the six months prior to their deaths. In eleven of these cases between 2008 and 2010 (13.6%), they had been incarcerated in the 6 months prior to their death. One person had just returned home from
19

the army (in 2010) in the six months prior to death. In the remaining ten cases across 2008
– 2010 the changes in living arrangements were either as a result of changes in their housing or relationship status.
Whilst the living arrangements were known for the majority of DD victims, the exact accommodation type was not known for a large proportion, that is, whether the home was owned, rented privately or rented from the council. The lack of information is due to the fact that this type of information is not routinely recorded by all agencies and therefore did not always exist i n the DD victim’s case notes/drug death questionnaires.
Overall, these results suggest that the majority of DD victims were living in stable environments. Furthermore, the fact that the majority of DD victims were living with others, suggests that they were supported by a network of friends and families. It also indicates that amongst the chaos of their drug use they were able to sustain relationships with others. The context in which the DD victims lived provides an indication of the level of stability that surrounded them.
Key Points

Half (49.4%) of all DD victims were living with others at the time of their deaths

The living arrangements of DD victims at the time of their deaths did not differ much from those of the six month prior to death, except in those cases where the person had been incarcerated during that time or had a change in housing or relationship status
3.2.2 Relationship and Family Information
The relationship status of DD victims was also considered, since it provides an indication of the level of support available to the DD victim. Graph 2 below shows the relationship status of individuals at the time of their deaths.
Graph 2: Relationship Status of DD Victims at Time of Death (2008 – 2010) (n=80)
Relationship Status of DD Victim s
2008 2009 2010
16
14
12
10
8
6
4
2
0
Married/Civil Partnership Divorced/Seperated
Relationsip Status
Single
20

Whilst a large proportion (73.8%) of DD victims were not married/cohabitating at their time of death, the majority of individuals were or had been engaged in a relationship of some duration immediately prior to their death. As such, 21 victims who were classed as single, divorced or separated were actually in some form of relationship at the time of their deaths
(52.4%, 2008; 57.1%, 2009; 14.3%, 2010). However, in at least eight of these cases
(which are classed as single in graph 2 above) the relationships were described as “very volatile, on/off relationships”.
Between 2008 and 2010, 27%, 34.6% and 43.8% respectively, of DD victims had a partner who also had a substance or alcohol misuse problem. For these individuals, their drug misuse use was probably perpetuated by their environment. Since this information is not recorded routinely, this figure may, in reality, be higher.
3.2.3 Relationship with Children
Information pertaining to whether or not DD victims had any children was available for all
81 DD victims and was collected mainly from police reports.
Although the majority (n = 50 or 61.7%) of DD victims had children, this does not imply that they were directly responsible for their welfare. In fact, only eleven DD victims’ children were living with them at the time of their death.
Details of where the children of the remaining 39 DD victims were living at the time of death are incomplete. This specific information does not appear to be routinely collected.
In the police reports, it is often merely noted that the children were “living elsewhere”. This was the case for 31 out of the 39 DD victims who had children which were not living with them at the time of death. In four cases it was known that the children were living in foster care, and in six cases the reports stated that the children were living with the other parent.
In one case the DD victim had weekend access to their children.
3.2.4 Friendships and Relationships
Information about the nature of relationships DD victims held with family members and friends was also considered. However, information relating to the relationships and the friendships was sparse and difficult to ascertain. Of the 81 DD victims, it was not known in
17 cases whether or not the victim had any relatives they felt close to. It was also not known whether 41 of victims had any friends to whom they felt close.
However, for those individuals for whom this information was available, records indicated that the majority (45 out of 63 or 71.4%) had at least one relative they felt close to, and 35 out of 41 or 85.4% had someone with whom they had a close friendship.
Of those individuals who had a family member to whom they felt close, the majority of individuals share this relationship with a parent (42.6%) or sibling (16.7%). Also reported were close relationship with their spouse/partner (5.6%), children (13.0%) and other family members (5.6%), such as grandparents, aunts/uncles and cousins. At least 15 individuals had close relationships with more than one family member.
The fact that many DD victims had engaged in a relationship shows that they were not socially isolated as a result of their drug use 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
21

did have relatives and friends to whom they could turn for support if it was needed. There is a support base, that can be tapped into provide important information relating to overdose and drug misuse that could be cascaded to not only the drug using, but wider spectrum of the community.
To this end, an Overdose Training and Prevention Co-ordinator post was created in Fife in
2009 (based on recommendations of the Fife Drug Death Action Plan 2008-2010 and from the 2005-2007 Drug Death Report). The post-holder is responsible for the provision of education, information and training to individuals regarding overdose prevention and intervention.
Although a large number of DD victims held a close, meaningful relationship with at least one other individual at their time of death, over half of these (64.4%) were known to also have significant difficulties in their relationships. This does not imply that the remaining individuals did not have any difficulties; it is merely the case that this information was not known for those individuals. The difficulties were recorded as being directly attributed to the drug use of the person and domestic abuse (with the DD victim being either the perpetrator or the victim of the abuse). In the some cases, the exact nature of the difficulties was unknown (e.
g. “frequent arguments”).
Key Points

While the majority (60.5%) of DD victims were classed as single, at the time of their deaths, a large number were involved in some form of romantic relationship at the time of their deaths

The majority (61.7%) of DD victims had children; however, 79.5% of these did not live with their children

The majority of DD victims were not socially isolated; many were known to have a close relationship with a family member (71.4%) or a close friendship with another person (85.4%)

At the same time, the majority, 64.4% were known to also have significant difficulties in these relationships
3.2.5 Education and Employment
The mean age at which DD victims left school was 15.8 years. However, this information was only known for 44 cases. Four victims had never attended mainstream education at all, but instead grew up in various social work and other residential care institutions, including secure schools.
The employment status immediately after leaving school was known for 76 individuals.
The majority of DD victims (76.3%) were engaged in some form of activity, including employment, further education, vocational training or apprenticeships. The remaining
23.7% were unemployed.
22

Graph 3: Employment Status of DD Victims after Leaving School (2008 – 2010) (n=76)
Em ploym ent Status After Leaving School
2008 2009 2010
14
12
10
8
6
4
2
0
Further Education Employed Vocational
Training/Apprenticeship
Unemployed
Em ploym ent Status
The type of activities DD victims engaged in after school are displayed in Graph 3 above.
The specific details of the employment or courses studied were generally not known.
3.2.6 Employment Status at the Time of Death
At the time of their deaths, the vast majority of DD victims were unemployed. In fact, of those victims for which employment status at the time of death was known (n = 76), only eight (including one apprenticeship and training course) individuals were employed
(10.5%). The remaining 89.5% were unemployed at the time of their death.
There is a large discrepancy between the employment status of individuals post school education and immediately prior to death. This is perhaps not surprising given that DD victims had a prior history of drug abuse starting around the age of 15.6 years.
5 Although on average, individuals did not die as a result of their drug abuse until the age of 32.4 years, they were abusing drugs from around the age of 16, providing an indication of the chronicity of their substance misuse and subsequent impact of this on their quality of life.
Overall, the information on employment status shows that this is a population with a broad range of skills and occupations, of which many entered employment, pursued training apprenticeships and a minority went into further education after leaving school. Few were unemployed after leaving school. However this trend was reversed immediately prior to death with large number of DD victims being unemployed and few being in any meaningful form of employment. These findings are consistent with the national investigation into drug related deaths (Zador et al ., 2003)
5 Based on mean age of 28 individuals for whom exact age of start of substance misuse was known.
23

Key Points

The mean age at which DD victims left school was 15.8 years

The majority of DD victims (76.3%) were engaged in some form employment/education activity after leaving school

Only 23.7% were unemployed after leaving school. However this figure was reversed directly before death, at which point 89.5% of DD victims were unemployed
Recommendations

Harness opportunities for overdose training of individuals most likely to be providing support to the DD victims

The specific type of accommodation of the DD victims at the time of their deaths was difficult to ascertain. If this is to be analysed in future reports, this data needs to be collected routinely by services

Equally, the type and quality of relationships which drug taking individuals experience need to be further examined within therapeutic settings

Service providers need to respond timeously to individuals identified as vulnerable as a result of social circumstances (e.g. homelessness, difficulties in relationships)
24

3.3 Criminal Justice and Offending
The present section examines the DD victims’ criminal and offending history in more detail. History of incarcerations is also considered.
3.3.1 History of Offending
The criminal justice and offending histories were available for all 81 DD victims at the time of writing this report. 73 of these 81 individuals (90.1%) had been arrested at some points in their lives; in 38 (52.1%) of these cases the individual had been arrested, at least once, in the six months prior to their death. In eight of these 38 cases, the arrest was known to be related to drug use (i.e. driving while under the influence of a controlled substance). In other cases, for instance theft of shoplifting, it is likely that these offences were committed in order to fund a drug habit.
39.5% (n = 32) of all DD victims had outstanding charges or court cases at the time of their deaths. These charges included misuse of drugs, various forms of assault, theft, breach of peace, breach of bail and wasting police time.
3.3.2 History of Incarcerations
43 (or 53.1%) of DD victims were known to have served a prison sentence some point during their lives. 18 of these individuals (41.9%) had been in prison in the six months before their death.
Table 1: Number of DDs Occurring Following Prison Release (2008 – 2010) (n=43)
Time since most recent prison release
No. of Individuals % of Individuals
Less than 2 weeks
2 weeks to 1 month
1 to 6 months
6 months to a year
2
3
13
7
4.7%
7.0%
30.2%
16.3%
More than a year 18 41.9%
As shown in Table 1, of the 43 individuals who had served a prison sentence at some point in their lives, two (4.7%) died within two weeks of being released from prison. This finding is contrary to the 2005-2007 Fife DD Report (Baldacchino et al ., 2008), which found that 17% of all drug deaths occurring between 2005 and 2007 had been in prison in the two weeks prior to their deaths. These individuals would have been more susceptible to a
DD due to a reduction in tolerance levels and subsequent overdose.
3.3.3 History of Court Enforced Interventions
The question of whether DD victims had been subject to any legal interventions prior to their deaths was also considered for all 81 DD victims. The results are presented in Table
2, and overall suggest that the majority of individuals were not subject to any particular intervention in the 12 months preceding their death. Of the 14 individuals who were placed on a Community-based Alternative to Custody Scheme, seven of these occurred in 2008, with five in 2009 and two in 2010.
25

Table 2: Number of DDs who were subject to particular legal intervention (2008 – 2010) (n=81)
Intervention No. of Individuals % of Individuals
Diversion from Prosecution Scheme
Community-based Alternative to Custody
Scheme
Drug Treatment and Testing Order
Enhanced Probation Order
Appearance before Drug Court
Key Points
0
14
2
3
2
0.0%
17.3%
2.5%
3.7%
2.5%

90.1% of DD victims had been arrested in the past

52.1% of DD victims who had been arrested, were arrested at least once 6 months prior to their death

53.1% of DD victims had served a prison sentence some point during their lives

41.9% of DD victims who had served a prison sentence had done so in the 6 months before their death

Two DD victims (4.7%) died within the two weeks of their release from prison

Few DD victims were subject to court enforced interventions
Recommendations

The fact that 90.1% of DD victims had been arrested at some point in their lives provides an opportunity for early intervention through the development of an arrest treatment and referral scheme
26

3.4 Physical/Psychological Health and Significant Life Events
This section explores the types of physical and psychological/psychiatric suffered by the
DD population in Fife between 2008 and 2010, with a particular emphasis on comorbidities and life events
3.4.1 Psychiatric/Psychological Problems
63 of the 81 DD victims (or 77.8%) were known to have psychiatric or psychological difficulties.
By far the most common problems experienced were mood disorders; 32 individuals suffered from clinical or sub-clinical depression and one individual had been diagnosed with post-natal depression.
At least 15 individuals suffered from anxiety-related problems and were prescribed medication to manage their anxiety at the time of death.
A further five individuals suffered from personality disorders, and displayed psychotic behaviours (having been diagnosed with Borderline Personality Disorder and/or
Schizophrenia). Two further individuals had suffered from Post Traumatic Stress Disorder.
14 of the above cases suffered from complex and multiple psychiatric difficulties.
Furthermore, 14 DD victims (or 17.3%) were known to have self harmed at some point in the past, and 15 had either expressed suicidal ideation, or attempted suicide at least once in their lives.
In five cases (or 6.2%) the victim experienced new psychological or psychiatric difficulties or experienced deterioration in existing symptoms in the six months prior to their deaths.
3.4.2 Physical Health Problems
40 of the 81 DD victims (or 49.4%) were known to have suffered from significant physical difficulties.
Common problems included Hepatitis C (n = 11). Other problems included severe pulmonary and cardiovascular problems, as well as debilitating orthopaedic injuries.
Isolated physical problems in this population included: fibromalgia, osteomylitis, pancreatitis, cirrhosis and asthma.
In at least eleven DD victims there was an identifiable connection between chronic pain and substance dependence.
In only 13 cases (or 36.1%) the victim experienced a new severe physical problem or deterioration in existing physical symptoms in the 6 months prior to their death.
27

3.4.3 Significant Life Events
Information pertaining to the childhoods of the DD victims was not available for all individuals. This information was generally not available for the DD victims in the older age groups. However, 31 of the 47 individuals for whom this information was available (or
66.0%) were known to have experienced significant difficulties in childhood. 11 DD victims had grown up in foster care; also 16 were known to have suffered either physical and/or sexual abuse during their childhoods.
Furthermore, the records showed that at least 12 victims had a familial history of psychiatric difficulties (25.5%) and a further 20 victims had family members who also had substance misuse problems (42.6%).
66 DD victims (or 82.5%) were known to have experienced significant adverse life events, with most individuals having suffered multiple life events. The number and type of life events recorded in case notes/Drug Death Questionnaires are summarised in Table 1 below.
Table 1: Number and Type of Life Events Recorded in Case Notes/DD Questionnaires (2008 – 2010)
(n=80 6 )
Life Event No. of individuals % of individuals
Bereavement
Serious recent relationship problems
Domestic abuse (perpetrator and victim)
Child custody issues
Homelessness
Severe Injury or Assault
32
30
14
20
12
10
40.0%
37.5%
17.5%
25.0%
15.0%
12.5%
The most common life event impacting the lives of DD victims was bereavement, which
40.0% of this population had suffered. The loss was often recorded as that of a parent, child, or close friend. Recent separation due to marital difficulties or breaking off a steady relationship was also commonly experienced by 37.5% of the DD population in between
2008 and 2010, 14 of which involved incidences of domestic abuse (where the DD victim was either the victim or perpetrator of the abuse). Serious injury or assault was also commonly suffered by the DD victims (n = 10 or 12.5%).
At a basic level, the above information provides an indication of the level of instability of these individuals in their lives. Their personal histories show that these DD victims experienced abuse, sexual/physical and/or emotional, significant losses/life events, which may have in turn been precipitating, maintaining and/or consequential factors of their substance misuse. There is also an indication that drug use is generational.
Sadly, in some cases the DD victim’s siblings and/or parents were not only substance users but also DD victims themselves. The life events of DD victims convey a sense of vulnerability, which may have led to the formation of coping by means of substance misuse and therefore impacted negatively upon their abilities to manage adversity in their adult lives.
6 This information was not available for one case in 2008
28

Key Points

The majority of DD victims (77.8%) suffered from psychological or psychiatric difficulties, the most common of which was depression

49.4% of the DD victims were also known to have suffered significant physical difficulties

82.5% of DD victims were known to have experienced a significant adverse life event

Most common adverse life events included bereavement, recent separation or marital difficulties and assault
3.4.4 Co-morbidity
Up until this point, the psychiatric problems, physical problems and life events of these individuals have been examined in isolation. In reality, however, individuals often suffer from a combination of these factors. 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.
The table below summarises the combinations of physical and psychiatric/psychological difficulties 7 , as well as life events experienced by the DD victims in connection with their substance abuse.
Table 2: Combinations of Co-morbidity with Substance Misuse Experienced by DD victims
(2008 – 2010) (n=77)
Combinations
Physical difficulties alone
Psychological difficulties alone
Life Event alone
Physical + Psychological
Physical + Life Events
No. of Individuals
3
8
15
10
12
% of Individuals
3.9%
10.4%
19.5%
13.0%
15.6%
Psychological + Life Events
Physical + Psychological + Life Events
16
13
20.8%
16.9%
Only four individuals were not known to have suffered any difficulties. As demonstrated by the table above, the combined effects of physical and psychological difficulties, together with life events, are far more prevalent in this population than these difficulties on their own. The majority of DD victims (n = 51 or 66.2%) had experienced a combination of significant physical and/or psychological difficulties and/or life events alongside their substance misuse problems.
7 For the purpose of this table, past self-harm or suicide attempts are included as psychological difficulties
29

Key Points

The majority of DD victims (66.2%) had experienced a combination of psychological and physical difficulties as well as life events, rather than a single problem alongside their substance misuse problems
Recommendations

Continue to monitor emerging populations with complex episodes of physical, psychological and substance misuse problems and incorporate into the assessment process of all agencies

Facilitate the process of identifying complex cases and establish a means of providing therapeutic support to vulnerable adults such as via the Adult Vulnerability Act

Encourage shared assessment and exchange of information amongst services, particularly when multiple morbidities have been identified

Aim for more assertive outreach to vulnerable individuals

Encourage an integrative and consultation led model of care for individuals experiencing multiple morbidities

Encourage meaningful dialogue between community, hospital and substance misuse services within NHS Fife, especially in cases where severe underlying pathologies have been identified

Continue to closely monitor the life events of drug users and their possible impact on overdose and suicide risks

Increase awareness of underlying pathologies and investigate accordingly
30

3.5 Substance Misuse Histories
The present section further examines the substance misuse histories of the DD victims; including the age at which they started misusing illegal substances, lifetime injecting characteristics and overdose histories.
In the six months prior to death, all but four of these DD victims (n = 81) were known to abuse illicit substances in combinations of two or more, including at least one of the following; Heroin, Benzodiazepines, Methadone (prescribed and non-prescribed) and
Cannabis. This confirms previous findings (Baldacchino et al ., 2008) that almost all DD victims were poly-drug users.
Furthermore, all but eight DD victims (90.1%) were known to have consumed prescribed or non-prescribed drugs in the seven days leading up to their deaths.
While the focus of this report is on drug deaths occurring as a result of illicit substances, it is nevertheless worth noting that half of the DD victims (51.9%) were also known to have severe problems with their alcohol consumption.
3.5.1 Age at which Drug Misuse Began
The age at which the DD victims started misusing drugs was known for 28 individuals
(34.6%), and ranged from five – 33 years, with an average of 15.8 years. This is also roughly the age at which most of the DD victims left school. A common trend was for the individuals to start abusing cannabis (and alcohol) at that age, followed by a combination of Ecstasy, LSD, Amphetamines and Cocaine some months after that.
The average age at which victims started abusing heroin was 17.1 years in 2008, 21.3 years in 2009 and 19.6 years in 2010. However, this figure is based on the 18 individuals for whom this information was known.
The average age of a DD victim in Fife between 2008 and 2010 was 32.4 years – suggesting that the DD victims of Fife had an average drug career of approximately 16 years prior to their deaths.
3.5.2 Lifetime Injecting Characteristics
The injecting behaviour of DD victims were considered in order to gain a more detailed profile of the drug use histories and characteristics of this population.
47 (or 58.0%) of the DD victims between 2008 and 2010 were known to have injected at some point in their lives. The age at which these individuals first injected was known for 27 of these individuals and ranged from between, 14 – 45 years, with an average age of 25.4 years. Considered together with the age at which these individuals first stated using heroin, these figures confirm a known trend whereby individuals tend to first smoke heroin for some time before progressing to intra-venous use of the drug.
31

3.5.3 Drug Use Characteristics of Injecting vs. Non-Injecting Users
The substances most commonly detected in the post-mortem toxicology findings of injecting and non injecting DD victims was examined further, and these are summarised in the table below.
Table 1: Substances Detected in Toxicology of Injecting and Non-Injecting DD Victims (2008 -2010)
(n=80 8 )
Substance
Non-Injectors
(n = 34)
Injectors
(n = 46)
Heroin/morphine
Benzodiazepines
Methadone
Alcohol
61.8%
70.6%
58.8%
74.0%
82.6%
37.0%
43.5% 35.3%
As can be seen from the table, Benzodiazepines were overall the most commonly abused drugs by all users, regardless of injecting status. However, these figures suggest that the injectors were more likely than the non-injectors to abuse morphine. Also, it appears that the non-injectors were more likely than injectors to die as a result of an overdose which involved methadone.
3.5.4 Overdose Histories
46 of the 81 individuals (or 56.8%) were known to have experienced at least one drug overdose at some point in their lives. For the remaining 35 individuals no overdose had been recorded.
For those individuals that were known to have overdosed in the past, the number of recorded overdoses ranged between one and seven. 23 of those who were known to have overdosed in the past had done so on multiple occasions.
Furthermore, 13 DD victims (or 28.3%) were known to have overdosed in the 6 months prior to their death.
The type of the last overdose, whether accidental or deliberate, was only recorded for 22 individuals. They were accidental (n = 15) and deliberate (n = 7).
8 This information was not available for 1 case in 2008
32

Key Points

All but four of the DD victims were known poly-drug users, 58.0% of which were IV users

The average age at which drug misuse began was 15.8 years, and age at which individuals first injected was 25.4 years

By the time of their deaths, the victims had an average drug using career of around 16 years

While injecting drug-users were relatively more likely than non-injecting users to die of an overdose that involved morphine, the non-injectors were relatively more likely to die of an overdose involving methadone

56.8% were known to have overdosed at some point in their lives, often on multiple occasions

28.3% victims were known to have overdosed in the 6 months prior to their deaths
Recommendations

Encourage service providers to identify drug use career of their clients
(e.g. age of onset, dependence severity) during assessment processes

Utilise a formal means of identifying non fatal overdoses in partnership with ambulance services

Facilitate communication between and within agencies to promote awareness of those individuals who have had a history of successive non-fatal overdose

Identify common risk factors in injecting versus non-injecting drug users

Acknowledgement that benzodiazepine with opiod use forms a major component of drug deaths in Fife
33

3.6 Service Use Histories
The present section outlines 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 reducing the number of 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.
3.6.1 Services Accessed within Five Years Prior to Death
Records showed that all but one (in 2010) of the DD victims over the past three years had contact with at least one service in the five years prior to their deaths, 68 of which were known to two or more services. The particular services involved are listed in the table below:
Table 1: Contact with Services for DD victims in the 5 years prior to death (2008 – 2010) (n=80)
Service
No. of individuals who had contacts
% of individuals who had contact
General Practitioner (GP)
Social Work Criminal Justice Services (CJS)
Fife NHS Addiction Services
Scottish Prison Service (SPS/EACS)
Other Agencies (e.g. The Zone, FASS, FIOT)
Psychiatric Services
Housing Services
Hospital/A&E*
FIRST
Drug and Alcohol Project Leven (DAPL)
74
45
37
31
17
16
16
13
10
9
92.5%
56.3%
46.3%
38.8%
21.3%
20.0%
20.0%
16.3%
12.5%
11.3%
West Fife Community Drug Team (WFCDT)
Next Steps
5
4
6.3%
5.0%
* This figure is likely to underestimate the real extent of the Ambulance and A&E contacts of the DD victims, as this information was only included in the above table if it was contained in the GP notes.
Table 1 illustrates the types of agencies that DD victims were involved with 5 years before their death. This table does not include multiple contacts made by an individual to any single agency.
The majority of DD victims (68 or 85.0%) had accessed more than one service in the 5 years prior to their death. The 12 individuals who had only accessed a single service had either had contact with their General Practitioners (n=11) or with
Cornerstone (n=1)
General Practitioner was the most accessed services (92.5%), followed by Social Work
CJS (56.3%), NHS Fife Addiction Services (46.3%), and SPS/EACS (38.8%). This pattern of contact is very similar to that of previous years (Baldacchino et al ., 2009)
It should be noted that needle exchange services are often accessed anonymously.
Therefore, the numbers presented here are only those instances where the person was known to the staff by (their real) name.
34

3.6.2 Services Accessed During the Six Months Prior to Death
71 individuals (87.7%) were known to have had contact with a service during the six months prior to their death, twenty-three of which had at least one contact with a service in the month prior to their deaths.
The table below shows the number of agencies accessed by individuals in the six months prior to their deaths. This table does not describe the multiple contacts with services within the same month, but does include different agencies accessed by the same individual.
Table 2: Contact with Services of DD victims in the 6 months prior to death (2008 – 2010) (n=71)
Service
General Practitioner (GP)
Fife NHS Addiction Services
Social Work Criminal Justice Services (CJS)
Scottish Prison Service (SPS/EACS)
Hospital/A&E*
Housing Services
Other Agencies (e.g. The Zone, BBV Team)
FIRST
Drug and Alcohol Project Leven (DAPL)
West Fife Community Drug Team (WFCDT)
Next Steps
Psychiatric Services
No. of individuals who had contacts
53
26
18
14
10
6
3
3
3
1
1
0
% of individuals who had contact
74.6%
36.6%
25.4%
19.7%
14.1%
8.5%
4.2%
4.2%
4.2%
1.4%
1.4%
0.0%
* This figure is likely to underestimate the real extent of the Ambulance and A&E contacts of the DD victims, as this information was only included in the above table if it was contained in the GP notes.
Table 2 displays the number of contacts of DD victims made with a statutory and/or nonstatutory agency six months prior to death. 32 individuals had contact with multiple services in the six months prior to their deaths.
Most contact had been made with the General Practitioner (74.6%), followed by NHS Fife
Addiction Services (36.6%), Social Work CJS (25.4%), and SPS (19.7%).
Consistent with the findings of the Fife Drug Death Report 2005-2007 (Baldacchino et al .,
2008), specialist addiction services were frequently accessed by drug users in Fife prior to their deaths, with 57.7% 9 of all contacts made to such services.
Key Points

All except one drug death victim were known to at least one service in the 5 years prior to their deaths.

87.7% of all DD victims had accessed at least one service in the 6 months prior to their deaths.

General Practitioners, NHS Fife Addiction Services, CJS and SPS were the four most commonly accessed services.
9 Specialist addiction services include the following: WFCDT, NHS Fife Addiction Services, EACS (SPS) and
DAPL
35

3.6.3 Pharmacological Intervention Six Months Prior to Death
Of particular interest is the proportion of DD victims who received pharmacological treatment for their drug dependency problem in the six months prior to their death.
22 individuals (27.2%) of DD victims had received some form of treatment for a drug misuse problem in the six months prior to their deaths. This means that the vast majority of victims (72.8%) did not receive or seek pharmacological treatment in the six months prior to death.
Of the 2008-2010 DD victims in Fife, 22 individuals (27.2%) were in receipt of a pharmacological intervention six months before their death, 19 of which received methadone. Three individuals were in receipt of Suboxone® (n = 2, 2008; n = 1, 2009).
Of these 19 individuals who received methadone, 14 (17.3% of all 81 DD victims) were still receiving their substitute medication (i.e. methadone) when their death occurred. The five individuals who were not in receipt of their methadone at the time of death had either failed to engage, been known to be taking illicit drugs on top of their methadone prescription or the programme had ended.
Methadone dispensing arrangements were known for 13 individuals concerned. This information was not available for one individual in 2008. Seven individuals collected their dosage from the pharmacy for supervised consumption on the premise, and six individuals took the methadone at home. Three individuals collected their prescription every day of the week (including Sunday), and seven individuals collected their methadone on six days per week. One individual collected their prescription twice a week and the remaining two collected their methadone once a week. The daily dosages ranged from 40mg-190mg. The length of time each individual had remained on their final dosage ranged between two days to 16 months (2 days – 9 weeks, 2008; 3 days – 13 months, 2009; 8 weeks – 16 months, 2010). The duration of their final dosage was not known for two individuals in
2009, however it was noted that one individual was on a reduction programme.
Furthermore, for those individuals on a methadone treatment programme (n = 14) at their time of death, methadone was detected in the toxicology reports of all 14 cases. However, methadone was also known to have been involved in 21 further drug deaths where it was not prescribed to the individuals at point of death.
The Fife Drug Death Monitoring and Strategic Group continues to closely monitor the mode of methadone prescribing and acknowledge that non supervised methadone dispensing may lead to an intensified risk of overdose or encourage diversion of methadone treatment (NTS, 2007). Since the beginning of 2008, this type of network information is submitted to the Fife Controlled Drug Intelligence Network.
36

Key Points

A large proportion (72.8%) of DD victims did not seek/receive treatment for their drug problem six months before they died

27.2% were receiving pharmacological treatment in the six months prior to their death; most were prescribed methadone

17.3% of all DD victims were still on a methadone programme at the time of their deaths
Recommendations

Where multiple morbidities are present and care is spread amongst various agencies, co-ordination of care should be prioritised (e.g. transition of individual from prison environment to community)

Greater communication of pertinent issues affecting the physical and psychological well-being of individuals is required amongst agencies

Assertive outreach support is encouraged in cases where vulnerability is identified as a risk factor

Increased frequency of screening of people on a methadone programme to ascertain that associated poly-drug (e.g. benzodiazepines) use will not increase the risk of overdose

Identify rationale for prolonged and sustained methadone maintenance in individuals’ care plans

Revisit the rationale of dispensing arrangements in individual care plans

Establish an inter-agency information gathering system for Specialist
Addiction Services in Fife to inform future service development

Encourage improved communication between primary care (GPs, pharmacies, prescribing services) with regards to safe and effective prescribing practice
37

3.7 Circumstances of Death
The present section summarises the circumstances of the drug deaths in Fife between
2008 and 2010, including the months of the year and days of the week that the drug deaths occurred, as well as specific information concerning the scene of the death, such as the presence of others and attempted interventions.
3.7.1 Timings of Deaths
3.7.1.1 Month of the year
Graph 1: Month of the Year of DDs between 2008 and 2010 (n=81)
Months of the Year of DDs 2008-2010
2008 2009 2010
7
4
3
2
1
6
5
0
Ja nu ar y
Fe br ua ry
M ar ch
Ap ril
M ay
Ju ne
Ju ly
Au gu st
Se pt em be r
Month of the Year
O ct ob er
N ov em be r
D ec em be r
As can be observed from Graph 1 above there was a peak in DDs in 2008 in May, as compared to 2009 and 2010, where the highest number of DDs occurred in January.
Taken together across 2008 to 2010, the first quarter of the year (January to March) has the highest proportion of DDs (30 or 37.0%). This declines into the spring with (22 or
27.2% occurring between April and June, and again into the summer (14 or 17.3% between July and September). The pattern levels off into the winter months with 15 or
18.5% of all DDs occurring between October and December. As can be seen from above there were no DDs in Fife in 2009 in November and December.
3.7.1.2 Days of the Week
The days of the week in which drug deaths occurred between 2008 and 2010 are shown below in Graph 2 below.
38

Graph 2: The days of the week of DDs between 2008 and 2010 (n=81)
Days of the Week of DDs 2008-2010
2008 2009 2010
7
6
5
4
9
8
3
2
1
0
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Day of the Week
As can be seen from the graph above, overall drug death victims in Fife over the last three years were no more likely to die on a weekend, with 47.0% dying on a Friday, Saturday or
Sunday. In comparison, if over the course of the three years, DDs were evenly distributed over the seven days of the week, 11.6 DDs would be expected every day. This equates to
43.0% over the weekend.
Overall, there was no noticeable trend that drug deaths which occurred over the weekend may be more likely to involve alcohol. In previous years, a possible trend has been proposed that drug deaths which occurred over the weekend are more likely to involve alcohol (Baldacchino et al ., 2009). While 50.0% of drug deaths which occurred over the course of the weekend involved alcohol, this is less than the overall proportion of drug deaths involving alcohol (56.8%).
While these number are too small to assume that they are indicative of any trends, it may be worth noting that of the seven individuals who were receiving methadone 6 days a week (that is, all days except for Sunday), five individuals actually died on a Saturday or
Sunday (n = 3, 2009; n = 2, 2010).
Key Points

A relatively larger proportion of DDs in Fife occurred in the first half of the year

Overall, drug deaths were no more likely to occur during a weekend than during the week

Drug Deaths which occurred over the weekend were no more likely to involve alcohol than those occurring during the week
39

3.7.2 Circumstances of Death
The circumstances surrounding the individual drug deaths were also considered, including whether or not others were present at the time of death, if bystanders recognised common signs of overdose and what, if any intervention was employed.
The majority of DD victims (n = 58 or 71.6%) were in the company or in close proximity to others at their point of death. That means that others were at least present in the same premises as the DD victim during the episode of their death. In all cases, the individuals present were known to the victim. The relationships of those persons present were: partners (n = 18), close family members (n = 9), friends of the victim (n = 27), and other (n
= 4).
3.7.3 Snoring Immediately Prior to Death
It has been noted that individuals often are observed to be snoring prior to a visible adverse reaction to the drugs they have consumed. This however was only identified in a small number of cases (n = 17), forming 29.3% of all 58 DD victims who died in the presence of others. In 23 cases the victim was simply thought to be asleep at the time of their death and this may have inhibited further intervention.
Other common observations included: salivating, pale/yellow face and blue lips. Individuals present were known to have checked on the DD victims, sometimes on several occasions.
Whilst most cases did not report information on snoring, it may well be that it did not appear significant to those who were present (and of course would not have been identified in those cases where individuals died alone). However, awareness of such warning signs of an overdose may assist individuals in identifying overdose and intervening to prevent them becoming a drug fatality.
3.7.4 Interventions Attempted at the Scene
Of cases where a witness was present (n = 58), some form of cardio-pulmonary resuscitation (CPR) was attempted by bystanders in prior to ambulance arrival in the majority of cases (n = 31 or 53.4%). Details pertaining to the exact nature of the CPR procedures carried were not always fully recorded, however, in most cases the CPR had to be instructed by the ambulance crew to those present over the telephone.
Often the nature of CPR conducted was partial, e.g. checking the airways, putting the DD victim in the recovery position, and in most cases was instructed over the telephone by emergency services. Other interventions were also attempted in bid to revive the DD victim. These included; shaking the DD victim, calling the out to the DD victim, pinching the victim, and splashing the victim with cold water.
As in previous years,
Narcan® (Naloxone injection) was administered to nine (or 11.1%) of the victims. However, from the reports it is difficult to quantify this information – for instance, it is not always clear whether or not Narcan was available, and in some cases, whether the use would have been appropriate (or if the victim was irrevocably dead at the time of ambulance arrival).
40

Key Points

The majority of DDs (71.6%) occurred in the presence of others, which were in all cases known to the victim

In many cases where others were present, the victim was simply believed to be sleeping at the time of their death, thus delaying any possible interventions

CPR was attempted by bystanders in almost two-thirds of the cases
(53.4%); however, this was often partial and had to be instructed by the ambulance crew over the telephone
Recommendations

Provide training for partners and family members of drug users in recognising the signs of an overdose and suitable intervention strategies, including the training of proper CPR procedures and
Narcan® (Naloxone injection) use in high risk populations

Further information should be collated by the Fife Police Force when preparing a Sudden Death Report on the exact timing and form of resuscitation attempted by bystanders

Revisit guidelines and other instructions to when Naloxone is administered by the Scottish Ambulance Service
41

3.8 Toxicology Results of Drug Deaths in Fife between 2008 and 2010
This section describes the post-mortem toxicology findings of the Drug Death victims in context of the poly-substance misuse culture in Fife between 2008 and 2010.
Post mortem toxicology reports of the 81 DD victims were analysed to gain a greater insight into the types of substances that led to the fatal overdoses.
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
Morphine. Urine samples are analysed for opiates, amphetamines, cannabinoids, cocaine, benzodiazepines, and methadone, barbiturates, trycyclic 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.
3.8.1. Toxicology results
Graph 1 below shows all substances which were found in the toxicology results of the DD victims in Fife between 2008 and 2010. The graph also shows the number of victims who were found with each substance in their toxicology results.
Graph 1: Substances involved in the DDs in Fife (2208 – 2010) (n=81)
Substances Involved in DDs 2008-2010
2008 2009 2010
30
25
20
15
10
5
0
Be nz od ia za pi ne s
H er oi n/
M or ph in e
M et ha do ne
Al co ho l
Pa ra ce ta m ol
An tid ep re ss an ts
D ih yd ro co de in e
Ps yc ho st im ul an ts
Substance
As this graph shows, benzodiazepines were the most common substances involved in
DDs in Fife between 2008 and 2010. It was involved in all but 18 cases, playing a role in
77.8% of deaths. To compare, benzodiazpines were implicated in 64.5%, 92.3% and
79.2% in 2008, 2009 and 2010 respectively.
Heroin/morphine was the second most common substance involved in DDs in Fife between 2008 and 2010, having been detected by toxicology in 57 (or 70.4%) of victims.
42

The involvement of heroin/morphine between 2008 and 2010 has remained stable being involved in 71.0%, 2008; 69.2%, in 2009 and 70.8% in 2010. However, in 2009 three of the cases (16.7%), the victim died of morphine that had been prescribed to them for pain management.
Methadone was involved in 43.2% of all DDs in Fife between 2008 and 2010. As has been found in previous years (Baldacchino et al ., 2008), there is an increasing trend in the number of DDs involving methadone across the three years: 35.5%, 2008; 42.3%, 2009 and 51.2%, 2010. In total, methadone was detected in 35 individuals, only 14 of which had actually been prescribed the medication at the time of their deaths. These findings suggest that the remaining 21 (25.9%) victims had obtained their methadone illicitly.
As compared to 2008 (38.7%) and 2009 (34.6%), just over half of the individuals in 2010 died with alcohol in their system in 2010 (54.2%).
Paracetamol was detected in 18 DDs and antidepressants such as Fluoxitine and
Citalopram were found in 14 of the DDs, and Dihydrocodeine was detected in five victims.
Overall, benzodiazepines, heroin/morphine, methadone, alcohol and were the four most common substances involved in Fife drug deaths between 2008 and 2010.
Key Points

Benzodiazepines, Heroin/Morphine, Methadone and Alcohol were the four most common substances involved in DDs between 2008 and
2010

77.8% of victims had taken benzodiazepines shortly before their death

Methadone was involved in 43.2% of all DDs in Fife between 2008 and
2010; however, 21 individuals who died with the substance in their system had not been prescribed the medication
3.8.2 Substances Implicated Concomitantly
As demonstrated by the previous section, the vast majority of DD victims died as a result of the consumption of a combination of drugs. On average, 2.70 substances were discovered in the toxicology of a Fife DD victim. Only four victims died of an overdose of a single substance (n = 1, morphine and n = 3, methadone). Table 1 below shows the number of substances detected in the toxicology of DDs between 2008 and 2010 10 .
10 For the purpose of these statistics, Diazepam and Nordiazepam (the metabolite) were counted as a single substance
43

Table 1: Number of Substances Detected in Toxicology of DDs (2008-2010 (n=79) 11
Number of
Substances
1
2
3
4
5
2008 (n=30) (%)
2 (6.67%)
12 (40.0%)
11 (36.7%)
4 (13.3%)
1 (3.3%)
2009 (n=25) (%)
1 (4.0%)
7 (28.0%)
10 (40.0%)
6 (24.0%)
1 (4.0%)
2010 (n=24) (%)
1 (4.2%)
6 (25.0%)
9 (37.5%)
8 (33.3%)
0 (0.0%)
As demonstrated by the table above, the number of substances implicated in a DD between 2008 and 2010 has risen. Between 2008 and 2010 the number of DDs with only two substances present in toxicology has fallen, whereas the number of DDs with four substances detected at the time of death has risen from 13.3% in 2008 to 33.3% in 2010, reflecting an increase in poly-drug use.
As would be suspected from the above figures, by virtue of being most common, benzodiazepines, heroin/morphine, methadone and alcohol were the most common substances implicated in combinations.
The number of times each combination of two of the four most common substances occurred is as follows:
Benzodiazepines and Morphine (n = 46)
Benzodiazepines and Methadone (n = 24)
Benzodiazepines and Alcohol (n = 21)
Morphine and Alcohol
Morphine and Methadone
Methadone and Alcohol
(n = 25)
(n = 13)
(n = 10)
Benzodiazepines and morphine are found most frequently in combination across the three years (40.0%, 2008; 68.0%, 2009 and 70.8%, 2010). Morphine and methadone in combination has risen being found in only 6.67% of DDs in 2008 as compared to 29.2% in
2010.
The number of times the combination of three of the four most common substances occurred is as follows:
Benzodiazepines, Morphine and Alcohol
Morphine, Methadone and Alcohol
(n = 17)
Benzodiazepines, Morphine and Methadone (n = 12)
Benzodiazepines, Methadone and Alcohol (n = 8)
(n = 3)
A similar pattern between 2008 and 2010 is found with combinations of three substances.
Benzodiazepines, morphine and methadone were found in 6.67% of DDs in 2008, rising to
16.0% in 2009 and again in 2010 to 25.0%. The three DDs in which morphine, methadone and alcohol were found all occurred in 2010.
11 This information was not available for 2 individuals, 1 in 2008 and 1 in 2009
44

3.8.3 Therapeutic, Fatal and Actual Levels of Substances
Toxicology reports generally include a reference for the “therapeutic” and “fatal” ranges of a substance, based on the existing literature. However, these are often based on relatively small sample sizes, and do not take into account the possibility of poly-drug use. The latter is particularly important, as the vast majority of the DDs in Fife occurred as a result of multiple substances.
Table 2 below shows the published therapeutic and fatal ranges for the four most common substances found to be involved in the DDs in Fife between 2008 and 2010. For comparison, it also shows the actual ranges observed in the victims in Fife.
Table 2: Therapeutic, Fatal and Actual Ranges of Substances Involved in DDs (2008-2010) (mg/l)
“Therapeutic”
Morphine
0.02
Diazepam Nordiazepam Methadone
– 2.30 0.70 – 1.15
0.35
– 0.52
0.57
– 1.06
Alcohol
Range*
“Fatal”
Range*
0.14 < 0.89 < 1.48 < 0.52 <
0.20
– 2.30 0.70 – 1.50
0.35
– 0.52
0.57
– 1.06
11
– 260
Actual Range
(in Fife 2008)
Actual Range 0.001 – 1.1 0.09 – 2.42 0.38 – 6.27 0.13 – 10.1 15 – 346
(in Fife 2009)
Actual Range 0.02 – 1.35 0.0 – 1.14 0.0 – 2.30 0.02 – 2.59 11 – 234
(in Fife 2010)
*Toxicological analysis of all 382 drug deaths for 2002 in Scotland (Zador et al ., 2005)
Fatal levels were not stated in toxicology reports for diazepam, nordiazepam and alcohol.
In one case it was stated that ‘there are very few well documented cases of fatal diazepam intoxicat ion arising from sole use of this drug’. Published diazepam levels in two such fatalities were 5mg/l and 19mg/l. Most fatalities involved a type of benzodiazepine taken together with other drugs or alcohol and this is now acknowledged in toxicology reports more frequently, as a “cocktail” of substances leading to fatal overdose.
The actual amounts of the drugs observed in DD victims in Fife are often lower than the published fatal and even therapeutic ranges of any given drug. This highlights the importance of the cocktail effect, and the above values continue to raise questions about the clinical utility of the designated ‘fatal’ and ‘therapeutic’ levels.
Key Points

All but four of the DDs occurring in Fife involved a lethal combination of two or more substances

The number of substances implicated concomitantly in DDs has risen between 2008 and 2010
 The “therapeutic” and “fatal” ranges of a substance (as used in the toxicology reports) are diffused in their meaning in light of these polysubstance deaths
45

Recommendations

Provide overdose education and training regarding the risks of consuming a combination of drugs

Provide detailed information on the increasing use of opioids (other than heroin and methadone) either as a perceived safer alternative or as an adjunct to current practice by the drug taking population (e.g. painkillers)
46

3.9 Pharmacology of Heroin in Fife
This section describes the affordability, widespread availability and purity levels of
Heroin in Fife between 2008 and 2010.
3.9.1 Purity Levels - Heroin
The average purity level of Heroin recovered in Fife broadly agrees with the Scottish average for 2010. The average purity has decreased generally over 2010 and is now in line with the averages for the first quarter of 2009.
It is important to note, however, that the average purites quoted for Fife are based on the analysis of a relatively small amount of samples (20 samples) of the overall Heroin seized as not all drugs recovered are subject to full analysis
Graph 1: Average Heroin Purity in Fife and Scotland
3.9.2 Cutting Agents
It should be noted that very few recovered drugs are tested for cutting agents. Street deals (tenner bags) of Heroin are presumptively tested within Force. Very few of these samples are transferred to the laboratory for further analysis. The ideal practice would be for every sample, immaterial of size, to be analysed to establish purity and the cutting agents present. The analysis of cutting agents would possibly identify whether the cutting agents present have a negative affect on the users health.
Where information is available analysis of Heroin seizures has revealed that as previously found caffeine and Paracetamol are the most common inert substances used to dilute
Heroin. The samples taken in this period have also revealed Benzocaine as the cutting agent within Heroin.
Reliable data on cutting agents has only become available to the Police, however, as stated previously, until such time as a comprehensive analysis of all recovered drugs is
47

undertaken interpretation of trends in relation to cutting agents should be treated cautiously.
3.9.3 Concluding remarks for pharmacology of heroin in Fife
The comprehensive analysis of seized drugs is of great importance as it informs the local intelligence picture and, in turn, assists in reducing harm to drug users.
In Scotland, at the present time, there is no capability for fully analysing all recovered drugs. The Scottish Police Service are working towards this, however it will require the support of all relevant authorities and our partner agencies. In addition there would be a substantial monetary cost implication. It may be useful however and worthy of further consideration for a time limited trial of full analysis of Heroin to be undertaken in a specific area.
Key Points

The average purity level of Heroin recovered in Fife broadly agrees with the Scottish average

Caffeine and Paracetamol are the most common inert substances used to dilute Heroin

Currently within Scotland, there is no capability for fully analysing all recovered drugs
Recommendations

A comprehensive analysis of seized drugs in Fife will inform the local picture and, in turn, assists in reducing harm to drug takers

Continue regular sharing of information between police, health and social care on local and contextualised drug use
48

S e c t t i i o n 4 : : C o n c l l u s i i o n s
4.1 A Case Vignette of a Typical Drug Death Victim in Fife between 2008 and 2010
The average Drug Death victim from Fife would be a White Caucasian 33 year old male who lived in Central Fife. He would have started his substance misuse at the age of 16 years; around that time he would also have left school. He would have gained employment or started an apprenticeship. His childhood would have been disrupted; he would have had a family history of psychiatric difficulties and/or substance misuse. He may have suffered physical/sexual abuse and/or spent some time in care.
From the age of 16 years onwards, he would have proceeded to misuse a cocktail of drugs including cannabis, amphetamines, LSD and ecstasy. Approximately four years after leaving school later he would have started taking heroin. He would have started injecting at around 24 years of age. He would have maintained meaningful and close relationships with his friends and family members throughout his life. He would have had children; however, they would not have lived with him and he would have lost custody of them.
He would have been known to at least two services, intermittently, including his GP, criminal justice services and specialist substance misuse 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 and benzodiazepines (prescribed and/ or non-prescribed). 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 other adverse life events, such as bereavement and the loss of a close relationship. He would have a criminal record and would have served a prison sentence some point during his life.
In the six months before his death he would have been arrested at least once. He would have committed crimes linked to his drug use with charges such as misuse of drugs or theft. At the time of his death, he would be unemployed, living alone or living with other adults and would not have changed accommodation type during those six months. He would have been classed as single, but may have been in a volatile, on/off relationship at this time. He would have been close to friends and family members and would not have been socially isolated. In the six months before his death he would have been known to
GP but would not have sought or received pharmacological treatment for his drug dependency. During this time, he would be misusing a cocktail of illicit and prescribed substances.
On the day of t his death he would have purchased at least one ‘tenner’ bag of heroin alongside alcohol and benzodiazepines. He would have shared these amongst friends/ cousers and injected in the presence of them. He would have died in the presence of others and would have been believed to be sleeping and any attempts to revive him would therefore have been delayed. Any means of formal resuscitation such as CPR, would have only been conducted when instructed to do so by the ambulance, and would usually be partial in nature. He would have died at his resident home address or in close proximity, over a weekend, during the winter months.
At post mortem his blood sample would have revealed a cocktail of depressants such as morphine, benzodiazepines, alcohol and/or methadone. His cause of death would most likely have been classed as “Adverse Effects of Heroin/Morphine”.
49

A p p e n d i i x A
Maps Displaying Locations of Drug Deaths in Fife 2008 – 2010
Map 1 below shows the locations of all DDs between 2008 and 2010 (n = 81). As can be seen from the map, the highest concentration of DDs occurred in Central Fife.
Map 1: Location of DDs across Fife (n=81) (2008-2010)
The average DD rate in Fife per 1000 of the population fell in between 2008 (0.09 per
1000) and 2010 (0.07 per 1000). The DD rate per 1000 of the population has been calculated according to geographical area. The breakdown of DDs per area within Fife between 2008 and 2010 differs substantially but remains consistent over the three year period: most DDs occurred in Central Fife (0.12 per 1000), with little difference between
East Fife (0.04 per 1000) and West Fife (0.036 per 1000). The location of DDs in Central
Fife between 2008 and 2010 is shown in Map 2 below.
50

Map 2: Location of DDs in Central Fife (n=54) (2008-2010)
Map 3 below shows the location of DDs in Fife for 2008, 2009 and 2010.
Map 3: Location of DDs across Fife (n=81) (2008, 2009 and 2010)
KEY: BLUE = 2008 RED = 2009 GREEN = 2010
51

A p p e n d i i x B
Fife Drug Deaths Action Plan (2008
– 2010)
Recommendations
The following recommendations were based upon the Fife 2005-2007 Drugs Deaths
Report and approved by Fife ADP in September 2008.
Demographic Characteristics
As a number of deaths occurred within a short period of prison release, recommendations are made towards an integrated care approach.
Action 1: To encourage joint working between the Fife DD group, Community
Justice Partnerships and Scottish Prison Services. Integrate strategic direction on drug deaths and identify potential interventions that can reduce drug deaths from prisoners released from prison.
Life Context and Social Functioning
A review of education inputs relating to lifestyle education/drug and alcohol misuse for individuals aged 15 and 16 to ascertain whether those inputs presently delivered are sufficient.
Action 1: To support a multidisciplinary and multi-agency approach to looking at the evidence of what works with drug/alcohol education in schools in Fife.
Action 2: To support a research project led by the Fife Alcohol Action research
Group on identifying the best model to determines the best approach/s to drug/alcohol education in schools.
As individuals had others close to them at the time of their death, this provides the opportunity for overdose training for these individuals.
Action 3: Fife ADP to commission and support a Fife wide Overdose Coordinator who will lead in the education, integration and delivery of effective interventions to reduce the rate of overdoses and potential mortality as a result of these events within the drug using population. A subgroup from the Drug Deaths Strategic
Group is to present a business plan to Fife ADP in December 2008.
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.
Action 1: Fife Police Constabulary to lead in delivering a proposal to Fife ADP with discussion with other Fife partners for a Fife assertive ‘arrest referral/treatment’
52

model that will be able to identify and manage individuals who are dependent and need proper and early interventions.
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.
Action 1: To utilise opportunistically the Adult Vulnerable Act that has recently been introduced in Fife to support this recommendation. Social Work to lead with
Fife ADP members and Chair of DD Strategic and Monitoring Group.
Action 2: Single shared assessment and further integration of services should encourage sharing of information and treatment plans.
Physical and psychological health must be incorporated into the core assessment process in any agency.
Action 3: NHS Fife should lead following 2007 Scottish Government publication of
Commitment 13 to support the implementation that all services should be assessing for physical and psychological health in order to improve the awareness and improve the support and service provision of co-occurring mental health and substance misuse.
Sharing of information between agencies should be encouraged alongside awareness of cardiac pathology in some cases, which should be investigated adequately e.g. ECG
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 also wider training and implementation of Naloxone.
Action 1: Fife ADP to commission and support a Fife wide Overdose coordinator who will lead in the education, integration and delivery of effective interventions to reduce the rate of overdoses and potential mortality as a result of these events within the drug using population. A subgroup from the Drug Deaths Strategic
Group is to present a business plan to Fife ADP in December 2008.
Action 2: To utilise opportunistically the Adult Vulnerable Act that has recently been introduced in Fife to support this recommendation. Social Work to lead with
Fife ADP members and Chair of DD Strategic and Monitoring Group.
There should be better exchange of information and recording of near misses.
Action 1: Closer liaison with Fife Choose Life Campaign on this issue.
Time frame: Ongoing.
53

Action 2: Await result from the EASTREN funded EDROS study in March 2009 in order to understand better the interface of the DD, suicide and overdose population in Fife.
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.
Action 1: To support robust clinical and ethical governance structure in the recording of relevant clinical and social information of the individuals accessing treatment and other drug related agencies. Fife DAAT to lead with governance structures within NHS Fife, Fife Council and Fife Constabulary on this since it will be directly relevant to determining outcomes.
Action 2: To encourage joint working between the Fife DD group, Community
Justice Partnerships and Scottish prison Services. Integrate strategic direction on drug deaths and identify potential interventions that can reduce drug deaths from prisoners released from prison.
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 and good links should be consolidated toxicologists to produce detailed and accurate reports.
Action1: Fife ADP to commission and support a Fife wide Overdose coordinator who will lead in the education, integration and delivery of effective interventions to reduce the rate of overdoses and potential mortality as a result of these events within the drug using population. A subgroup from the Drug Deaths Strategic Group is to present a business plan to Fife ADP in December 2008.
Action 2: To meet on a regular basis with Procurator Fiscals in Fife.
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 also need to be taken into consideration in formulating overdose strategies.
Action 1: Police Constabulary to lead and finance to help shape and share mutually important intelligence with treatment providers in Fife and create an environment where such information has a Fife context.
54

A p p e n d i i x C
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.
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.
55

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 Use rs, 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
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
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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.
57

A p p e n d i i x D
Explanation of Tolerance Levels in Post-Mortem Toxicology Reports:
‘The interpretation of post mortem morphine levels is complicated by the phenomenon of
‘tolerance”, whereby a regular heavy user may survive high drug levels in blood. Tolerance is unpredictably variable, both between individuals and within the same individual.
Conversely, deaths have been reported even at low opiate levels, particularly when the individual is a naïve or irregular user or has survived for a period of time following drug administration. During this period, which is often recognised by witnesses as normal sleep associated with snoring, coma is often deepening but the elimination of alcohol and drugs is ongoing. For these reasons there is considerable overlap between the published therapeutic and fatal levels. In practice this means that the levels found in dead opiate users are often no different from those found in life. Interpretation of drug levels is further complicated by post mortem changes within the body which may artefactually change the level of the drug.’
58

A p p e n d i i x E
Drug Death Questionnaire (Fife and Tayside and Forth Valley)
- Guidelines for Completion
The Drug Death Fife Questionnaire v3.0 has been established by the Drug Deaths 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 does not 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
59

Service:
D r r u g D e a t t h s R e l l a t t e d E n q u i i r r i i e s a n d M o n i i t t o r r i i n g F o r r m
( F i i f f e a n d T a y s i i d e )
Date:
Person completing:
Name and address of deceased:
CHI number of the deceased:
© Centre for Addiction Research and Education Scotland (CARES), 2004
60

Day Month Year
02
Scottish 00
Other British 01
Irish 02
Polish 03
Any other white 04
Black: Caribbean 05
Black: African 06
Any other black 07
Asian: Indian 08
Asian: Pakistani 09
Asian: Bengali 10
Asian: Chinese 11
Any other Asian 12
Mixed: Any mixed 13
Other (please specify) 14
Other (specify) 08
Retail/Business 01
Residential 02
And
02
61

Temporary/Unstable
Unknown
Living Alone
With Spouse/Partner
With Friends
With Parents
With Relatives
With Others (specify) 06
Unknown 99
01
02
03
04
05
Own home /Rented 01
Temporary/Unstable
Outside 06
Unknown 99
Years ____
Further Education
Employed
Vocational
Training/Apprentice
Unemployed
Unknown
01
02
03
04
99
No
Don’t know 99
62

Employed with a regular
Unemployed with regular unemployment/sickness
Unemployed but with no
05
06
Other (specify)
Unknown
Married/Civil
Partnership/Co-habiting
Divorced/Dissolved Civil
Partnership
Separated
Single
Widowed
Other (specify)
Unknown
03
04
05
06
99
10
99
01
02
No
Don’t know
99
Living elsewhere 02
Unknown
Unknown
No
Don’t know 99
63

No
Don’t know
99
Don’t know
Don’t know
No
Don’t know
99
No
Don’t know
99
No
Don’t know 99
No
Don’t know
99
64

65

Don’t know 99
No ( go to section 4 )
Don’t know
02
99
No
Don’t know
99
No
Don’t know 99
Don’t know 99
No
Don’t know 99
No
Don’t know
99
No
Don’t know 99
Don’t know 99
66

No
Don’t know
99
Don’t know 99
67

Heroin/Morphine
Methadone
Suboxone
Buprenorphine
Alcohol
Diazepam
Temazepam
Cocaine
Cannabis
Ecstasy/MDMA
Amphetamines
Volatile Substances
Dihydrocodeine
Other (please specify)
Heroin/Morphine
Methadone
Suboxone
Buprenorphine
Alcohol
Diazepam
Temazepam
Cocaine
Cannabis
Ecstasy/MDMA
Amphetamines
Volatile Substances
Dihydrocodeine
Other (please specify)
Powder
Tablet
Liquid
Resin
Gas
Other
Unknown
Injection
Oral
Inhaled
Snorted
Smoked
Other
Unknown
04
05
06
99
01
02
03
04
05
06
99
14
01
02
03
01
02
03
04
05
06
07
08
09
10
11
12
13
01
02
03
04
05
06
07
08
09
10
11
12
13
14
68

Yes
No
01
02
Specify
Specify
Yes
No
Yes
No
Culpable Homicide
Misuse of drugs
Other
01
02
01
02
01
02
03
69

70

71

D D M M Y
No
Y
02
Methadone
Suboxone
01
02
D D M M Y
No 02
99
Yes 01
No 02
Don’t know 99
Y
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
72

Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
liquid linctus 02
injectable 04
73

Yes 01
No (If no go to 4.81) 02
Don’t know 99
Yes 01
No 02
Don’t know
99
Needle exchange
(Pharmacy) 01
Needle exchange
Wound management 03
Yes 01
No 02
Don’t know 99
Accidental 01
Deliberate 02
Don’t Know 99
Accidental 01
Deliberate 02
Don’t Know 99
D D M M Y Y
Accidental 01
Deliberate
Don’t Know
02
99
Yes (please specify) 01
No 02
74

Yes 01
No 02
Don’t know
99
Yes 01
No 02
Don’t know
99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know 99
Yes 01
No 02
Don’t know
99
Yes 01
No 02
Don’t know
99
Yes 01
No 02
Don’t know
99
75

76

6. SERVICE UTILISATION
6.1 Service
Provider
Month 1 of death )
( Month Month 2
6.2 Services used by client in the past 5 years:
Date:
Service Provider:
Referred:
Assessed
Discharged:
Month 3 Month 4 Month 5 Month 6
77

Acknowledgements:
1. Centre for Addiction Research and Education Scotland (CARES), University of Dundee: 2006
2. Scottish Drug Enforcement Agency, National Drugs Death Database: 2006
78