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Drug-related deaths in Scotland in 2009

Annex B Some other definitions of drug-related deaths

B1. Other bodies may use other definitions for other purposes: this annex gives some examples. It then discusses how some deaths from certain other causes might be counted as well, to obtain a wider view of mortality arising from drug misuse.

B2 First, there is a "wide" definition which is used by the Office for National Statistics (ONS) to provide figures for deaths from drug poisoning. It covers the following cause of death categories (the relevant codes from the International Classification of Diseases, Tenth Revision [ICD10], are given in brackets):

• deaths where the underlying cause of death has been coded to the following sub- categories of "mental and behavioural disorders due to psychoactive substance use":
  • opioids (F11);
  • cannabinoids (F12);
  • sedatives or hypnotics (F13);
  • cocaine (F14);
  • other stimulants, including caffeine (F15);
  • hallucinogens (F16);
  • volatile solvents (F18); and
  • multiple drug use and use of other psychoactive substances (F19).
• deaths coded to the following categories:
  • accidental poisoning (X40 — X44);
  • intentional self-poisoning by drugs, medicaments and biological substances (X60 — X64);
  • assault by drugs, medicaments and biological substances (X85); and
  • event of undetermined intent, poisoning (Y10 — Y14).

The main differences between this "wide" definition and the one used to produce the statistics given in this paper (the "baseline" definition for the UK Drugs Strategy) are:

• the first part also includes deaths coded to "volatile substances" (F18);
• the second part is not restricted to cases where a drug listed under the Misuse of Drugs Act (1971) was known to be present in the body at the time of death.

Therefore, the "wide" definition's figures are markedly higher.

B3. Second, there is the definition used by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) for its "general mortality register". The rules for this definition refer to particular codes for the underlying causes and the types of substance involved, and (in some cases) specify the combinations that must occur for a death to be counted under this definition. It produces figures which are broadly similar to those of the UK Drug Strategy definition, but which cover deaths which involved the use of a different (albeit overlapping) range of drugs: so some deaths which are counted under the EMCDDA definition are not counted under the UK Drug Strategy definition, and vice versa.

B4. Because GROS has details of all the deaths which were registered in Scotland, it can produce figures using the ONS "wide" definition and the EMCDDA "general mortality register" definition, as well as using the definition of the "baseline" for the UK Drug Strategy. These are given in Table X. As the table and Figure 2 show, the numbers produced using the three definitions tend to rise and fall in broadly similar ways, and so all three definitions give similar impressions of the long-term trend, although they differ regarding the numbers of deaths in each year.

B5. As explained above, the ONS "wide" definition includes all deaths coded to accidental poisoning, and to intentional self-poisoning by drugs, medicaments and biological substances, whether or not a drug listed under the Misuse of Drugs Act was present in the body. Table Y shows the numbers of deaths (on this basis) in each year from 2000 to 2009 for which a range of drugs (including anti-depressants, anti-psychotics, paracetamol or a compound, and tramadol) were reported: for example, the number of deaths for which anti-depressants were reported tended to be in the range 70-90 per year between 2000 and 2007, whereas for paracetamol or a compound the number fell from around 120 to about 60. Section 2 explains why there is a break in the series between 2007 and 2008.

B6. The Scottish Crime and Drug Enforcement Agency (SCDEA) uses a different definition. In Autumn 2007, GROS compared some of the details of the drug-related deaths (in terms of the "baseline" UK Drug Strategy definition) in 2006 that were held by GROS and the deaths that were recorded in an SCDEA database of drug- related deaths. The results may be summarised as follows:

• 321 deaths were counted by both GROS and SCDEA;
• 100 deaths were counted by GROS but not by SCDEA. These included:
  • 14 deaths occurring in December 2005 which were not registered until 2006;
  • 28 definite suicides;
  • 19 probable suicides (classified as "events of undetermined intent");
  • 8 cases coded to "accidental overdose";
  • 29 cases coded to "drug abuse".
• 53 cases were counted by SCDEA but not by GROS. These comprised:
  • 13 deaths occurring in December 2006 which were not registered until 2007 - most (if not all) of which will be included in the GROS figures for 2007;
  • 21 deaths for which drugs (whether named or unspecified) were recorded in the GROS database - but either the drugs mentioned were not covered by the "baseline" definition or the deaths were coded to causes other than drug abuse or drug overdose;
  • 19 deaths which had no mention of drugs in the GROS database (13 were coded to "unascertained" cause of death). Returns from Procurators Fiscal were still outstanding for several of these when the GROS database for 2006 was closed at the end of June 2007. SCDEA recorded the involvement of heroin or methadone in 15 deaths, so it is likely that some of them would have been counted in GROS's figures for drug-related deaths had all the relevant information been available before its database for 2006 closed.

B7. Other organisations may interpret the term "drug-related deaths" in other ways.

B8. Among the recommendations made by the National Forum on Drug-related Deaths in its annual report for 2009/10 was one which relates to this paper:

In recognition of the expanding range of causes of drug related deaths, and in keeping with the aims of the Advisory Committee on Misuse of Drugs report on Drug Related Deaths (published in 2000) to include a wider view of mortality caused by drug misuse, the forum recommends:

• that GROS include a table within their annual drug related deaths report that reflects deaths from "some causes which may be associated with present or past drug misuse";
• that in the coming year, this includes detail on deaths caused by Hepatitis C and Human immunodeficiency virus (HIV); and
• that the forum and GROS explore the possibility of including violence, trauma and road traffic accidents in future reports.
  As a result, Table Z has been added to this paper. The top part of this table gives the numbers of deaths which are counted as "drug-related" (on the basis of the "wide" definition), with separate figures for:
• the basis used for the statistics in this report (i.e. the Drug Strategy "baseline" definition, as implemented by GROS);
• deaths which are within the "baseline" definition but are excluded from the figures produced by GROS for reasons which are given in paragraph A3 of Annex A;
• all other deaths which are counted as "drug-related" in terms of the "wide" definition.
  The remainder of the table gives the information requested by the National Forum: the numbers of deaths from some causes which may be associated with present or past drug misuse. At present, this shows only the following two causes of death:
• Hepatitis C - the virus may be transmitted through sharing needles when injecting recreational drugs. It has been estimated that nearly 40% of intravenous drug users have the infection and around 35% of people with the virus will have contracted it this way (source: BBC website health section, http://www.bbc.co.uk/health/, 27 July 2010). However, the infection can be transmitted in other ways, such as through a tattoo or body piercing with equipment that has not been properly sterilised, or a blood transfusion or medical treatment in a country where blood screening for hepatitis C is not routine, or where medical equipment is reused but not adequately sterilised. Therefore, only a proportion of deaths caused by Hepatitis C will be due to drug misuse.
• HIV - using a needle or syringe that has already been used by someone who is infected is one of the two main ways to become infected, the other being unprotected sexual intercourse with an infected person. Therefore, only a proportion of deaths caused by HIV will be due to drug misuse.
  It is expected that this table will be expanded in subsequent editions of this report, in the light of discussions between GROS and members of the National Forum.

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