What is a drug death?What is a drug death?

Dr Marjorie BlackDr Marjorie Black

Forensic Medicine and Forensic Medicine and ScienceScience

University of Glasgow University of Glasgow

Drug Related Deaths, 1985 - Drug Related Deaths, 1985 - 19991999

0

20

40

60

80

100

120

140

160

180

200

1985 1987 1989 1991 1993 1995 1997 1999

Year

Num

ber

of

Cas

es

All DRDsDoA Overdose

Drug Related Death - DefinitionDrug Related Death - Definition

Where there is … evidence of a fatal Where there is … evidence of a fatal overdose of controlled drugs…..recent overdose of controlled drugs…..recent drug misuse e.g. controlled drugs and/or drug misuse e.g. controlled drugs and/or a syringe found in close proximity to the a syringe found in close proximity to the body &/or the person is known to the body &/or the person is known to the police as a drug misuser….police as a drug misuser….

1994 Scottish Office ‘Ministerial Drugs 1994 Scottish Office ‘Ministerial Drugs Task Force Report’Task Force Report’

ExcludesExcludes

Deaths from infection resulting Deaths from infection resulting directly from injecting drug usedirectly from injecting drug use

Deaths from chronic disease which is Deaths from chronic disease which is a result of drug abuse e.g. Hep Ca result of drug abuse e.g. Hep C

Deaths from a pathology caused by Deaths from a pathology caused by illicit drug useillicit drug use

Suicides Suicides

Forensic Medicine and Forensic Medicine and ScienceScience

Responsible to the Crown Office for Responsible to the Crown Office for the provision of pathology and the provision of pathology and toxicology services in the West of toxicology services in the West of Scotland.Scotland.

Responsible for the toxicological Responsible for the toxicological analyses of all sudden and analyses of all sudden and unexpected deaths in Strathclyde, unexpected deaths in Strathclyde, whether or not these are initially whether or not these are initially thought to be drug-related.thought to be drug-related.

Drug Related Death - Drug Related Death - DefinitionDefinition

A sudden or unexpected death where A sudden or unexpected death where drugs of abuse were implicated as a drugs of abuse were implicated as a cause of death either through toxicology cause of death either through toxicology or circumstance.or circumstance.

Death as a result of long term drug abuse.Death as a result of long term drug abuse.

Death of a known drug abuser as a result Death of a known drug abuser as a result of an overdose of non illicit drugs.of an overdose of non illicit drugs.

Police Sudden Death Police Sudden Death ReportReport

Scene ObservationsScene Observations Drug paraphernaliaDrug paraphernalia

Terminal EventsTerminal Events Drug misuse witnessedDrug misuse witnessed Recent Prison ReleaseRecent Prison Release

Medical HistoryMedical History Known drug userKnown drug user Prescribed medicationPrescribed medication Drug rehabilitation programmesDrug rehabilitation programmes

Pathology ExaminationPathology Examination

Needle marks/sinusesNeedle marks/sinuses recent and healingrecent and healing

Signs of infectionSigns of infection InjuriesInjuries Any pathology or disease processAny pathology or disease process Congestion & oedema of lungsCongestion & oedema of lungs

Cause of DeathCause of Death

A full post mortem examination is A full post mortem examination is essential to identify accurately whether essential to identify accurately whether the death is a result of drugs to the death is a result of drugs to exclude natural disease/pathologyexclude natural disease/pathology exclude infection/traumaexclude infection/trauma

The pathologist must carefully consider The pathologist must carefully consider the toxicological results in conjunction the toxicological results in conjunction with the individual circumstances with the individual circumstances

Drugs Detected, 1995 - Drugs Detected, 1995 - 19981998

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50

100

150

200

250

300

Num

ber

of P

osit

ive

Cas

es

Mor

phine

Diazep

am

Temaz

epam

Met

hadon

e

Cocain

e

Ecsta

sy

Ampheta

min

e

Toxicology, 1995 - 1998Toxicology, 1995 - 1998

5 Drugs2%

6/7 Drugs1%

4 Drugs10%

1 Drug27%

3 Drugs23%

2 Drugs37%

Blood Alcohol Blood Alcohol ConcentrationsConcentrations

Average(mg/100ml)

Range(mg/100ml)

1995 92 5 - 256

1996 91 5 - 371

1997 110 12 - 348

1998 151 9 - 462

Blood Concentrations - Blood Concentrations - BenzodiazepinessBenzodiazepiness

TemazepamRange (mg/litre)

DiazepamRange (mg/litre)

1995 2.1 0.37

(0.05 – 29.9) (0.04 – 2.64)

1996 0.92 0.37

(0.02 – 4.23) (0.031 – 1.6)

1997 0.85 0.45

(0.05 – 6.85) (0.03 – 1.6)

1998 0.92 0.41

(0.03 – 2.24) (0.06 – 1.76)

Blood Concentrations - Blood Concentrations - OpiatesOpiates

MorphineRange (mg/litre)

MethadoneRange (mg/litre)

1995 0.45 0.6

(0.002 – 3.1) (0.004 – 5.6)

1996 0.36 0.8

(0.015 – 1.16) (0.013 – 4.59)

1997 0.25 0.55

(0.014 – 0.67) (0.003 – 2.11)

1998 0.34 0.26

(0.025 – 1.26) (0.05 – 0.85)

Interpretation of PM drug Interpretation of PM drug levelslevels

Very rapid deathVery rapid death Period of unconsciousness before Period of unconsciousness before

deathdeath Redistribution of the drug in the body Redistribution of the drug in the body

after deathafter death Site of blood samplingSite of blood sampling

Interpretation of PM Drug Interpretation of PM Drug LevelsLevels

There is no “absolute” toxic level There is no “absolute” toxic level for the interpretation of drug levelsfor the interpretation of drug levels

Drug Interactions Drug Interactions ((e.g.e.g. morphine + benzodiazepines)morphine + benzodiazepines)

Drugs with different modes of Drugs with different modes of actionaction

Amphetamines & Cocaine Amphetamines & Cocaine

Different mechanisms of deathDifferent mechanisms of death Not necessarily dose relatedNot necessarily dose related Can cause brain haemorrhage or Can cause brain haemorrhage or

cardiac arrestcardiac arrest Can cause chronic problemsCan cause chronic problems

Factors Affecting InterpretationFactors Affecting Interpretation General HealthGeneral Health

ToleranceTolerance

Periods of AbstinencePeriods of Abstinence Invaluable informationInvaluable information

Medical historyMedical history Drug historyDrug history Recent circumstancesRecent circumstances Immediate circumstances of the deathImmediate circumstances of the death

ConclusionsConclusions

Recent use of illicit drugs does not Recent use of illicit drugs does not mean that they died of a drugs mean that they died of a drugs overdoseoverdose

The finding of a drug in the blood The finding of a drug in the blood does not mean that it caused (or does not mean that it caused (or even contributed) to deatheven contributed) to death

A toxicology report does not give the A toxicology report does not give the cause of deathcause of death

ConclusionsConclusions

An accurate cause of death can only An accurate cause of death can only be determined by an experienced be determined by an experienced pathologist after review of the post pathologist after review of the post mortem findings including toxicology mortem findings including toxicology and taking into consideration the and taking into consideration the medical/drug history and the medical/drug history and the circumstances of the deathcircumstances of the death

ConclusionsConclusions

The drug(s) considered to have The drug(s) considered to have caused the death should be caused the death should be identified in the death certificateidentified in the death certificate

Accurate information on the drugs Accurate information on the drugs implicated in death is essential to implicated in death is essential to target intervention and reduce target intervention and reduce deathsdeaths

ConclusionsConclusions

If death has been caused by a pathology If death has been caused by a pathology e.g.cardiac disease or infection which has e.g.cardiac disease or infection which has resulted from illicit drug use the drug use resulted from illicit drug use the drug use should be identified on the death should be identified on the death certificatecertificate

These deaths are also directly These deaths are also directly attributable to drug misuse attributable to drug misuse

Information should be available to target Information should be available to target risk groups risk groups