Presentation Background Jeremy Dwyer Coronial insights into understanding and Case Investigator preventing drug-related harms Coroners Prevention Unit Coroners Court of Victoria Insight Audrey Jamieson Coroner Pharmaceutical Society of Australia Coroners Court of Victoria Harm Minimisation Forum Wednesday 12 September 2012 Acknowledgements Sam Pegler Lyndal Bugeja Note Coroners Prevention Unit The material presented here was generated to Register of acute drug deaths: inform Victorian coroners’ investigations. Much of • Deaths for which acute drug toxicity played a the material is derived from research that has not causal or contributory role (‘overdose’ deaths been scrutinised through a peer review process. reported to Court). Some data is preliminary in nature, as it is derived • No chronic or behavioural contribution. from deaths that have not yet been subject to coronial findings. • Deaths coded on all contributing drugs, according to expert death investigator advice. Any information presented here should be used • Register is partially populated. with caution and an understanding of these • Generates empirical evidence to underpin limitations. coroners’ investigations and recommendations.
Acute drug deaths register Background Structure: • Introduction to Victorian acute drug deaths 2010-2011 • Oxycodone contribution in focus • Methadone contribution in focus • Diazepam as ubiquitous co-contributor Themes: • Prevalence of medication contribution in deaths. • Importance of drug combinations. Annual acute drug deaths, 2010-2011 Contributing drug types Drug type 2010 2011 Drug involvement 2010 2011 Medications 261 (77.2%) 270 (75.8%) Single drug toxicity 123 (36.4%) 129 (36.2%) Illicit drugs 149 (44.1%) 153 (43%) Multiple drug toxicity 215 (63.6%) 227 (63.8%) Alcohol 88 (24.3%) 85 (23.9%) All acute drug deaths 338 (100.0%) 356 (100.0%) All acute drug deaths 338 (100.0%) 356 (100.0%)
Drug type combinations Most frequent contributing drug groups Combination 2010 2011 Drug group 2010 2011 Medications alone 139 (41.1%) 143 (40.2%) Benzodiazepines 165 (48.8%) 179 (50.3%) Medications with illicit drugs 67 (19.8%) 68 (19.1%) Illicit drugs 149 (44.1%) 153 (43.0%) Illicit drugs alone 50 (14.8%) 60 (16.9%) Opioid analgesics 140 (41.4%) 183 (51.4%) Medications with alcohol 29 (8.6%) 41 (11.5%) Antidepressants 102 (30.2%) 99 (27.8%) Medications with illicit drugs and alcohol 26 (7.7%) 18 (5.1%) Alcohol 82 (24.3%) 85 (23.9%) Alcohol alone 21 (6.2%) 19 (5.3%) Antipsychotics 64 (18.9%) 64 (18.0%) Illicit drugs with alcohol 6 (1.8%) 7 (2.0%) All deaths 338 (100.0%) 356 (100.0%) Victorian deaths involving Most frequent contributing drugs acute oxycodone toxicity, 2000-2011 Drug 2010 2011 50 Heroin 139 (41.1%) 129 (36.2%) 40 Annual frequency Diazepam 108 (32.0%) 123 (34.6%) of deaths 30 Alcohol 82 (24.3%) 85 (23.9%) 20 Alprazolam 56 (16.6%) 43 (12.1%) Codeine 55 (16.3%) 66 (18.5%) 10 Methadone 53 (15.7%) 72 (20.2%) 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Oxycodone 38 (11.2%) 46 (12.9%) Quetiapine 37 (10.9%) 33 (9.3%) Annual death rate per million 10 Amitriptyline 25 (7.4%) 21 (5.9%) Citalopram 21 (6.2%) 21 (5.9%) 8 Temazepam 21 (6.2%) 48 (13.5%) persons 6 Mirtazapine 20 (5.9%) 23 (6.5%) 4 Paracetamol 20 (5.9%) 24 (6.7%) 2 Oxazepam 19 (5.6%) 44 (12.4%) 0 Methamphetamine 14 (4.1%) 29 (8.1%) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Drug involvement in Contributing drug groups oxycodone deaths with oxycodone Drug group n % Drug involvement n % Benzodiazepines 175 66.0% Multiple drugs including oxycodone 233 87.9% Antidepressants 118 44.5% Oxycodone alone 32 12.1% Opioid analgesics 114 43.0% 60 Alcohol 68 25.7% Frequency of deaths 50 Illicit drugs 43 16.2% 40 Non-opioid analgesics 40 15.1% 30 Antipsychotics 39 14.7% 20 10 Non-benzodiazepine anxyolitics, 28 10.6% 0 sedatives, hypnotics None 1 2 3 4 5 6 7 8 9 10 11 12 Number of co-contributing drugs with oxycodone Individual co-contributing drugs Themes in oxycodone deaths with oxycodone Drug n % Diazepam 128 48.3% • Oxycodone was prescribed to the Alcohol 68 25.7% deceased. Codeine 64 24.2% • Chronic pain was overlaid with substance Alprazolam 41 15.5% abuse. Paracetamol 36 13.6% • Chronic pain, opioid dependence, Citalopram 31 11.7% depression and suicide commonly co- Amitriptyline 30 11.3% Oxazepam 30 11.3% occurred. Heroin 28 10.6% • Prescription shopping for benzodiazepines Temazepam 26 9.8% was common. Methadone 24 9.1% Tramadol 24 9.1% Quetiapine 21 7.9%
Victorian deaths involving Drug involvement in acute methadone toxicity, 2000-2011 methadone deaths 80 Annual frequency of Drug involvement n % 60 Multiple drugs including methadone 389 84.2% deaths 40 Methadone alone 73 15.8% 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 100 Frequency of deaths 80 15 60 million population 12 Annual rate per 40 9 20 6 0 None 1 2 3 4 5 6 7 8 9 10 11 12 3 Number of co-contributing drugs with methadone 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Contributing drug groups Individual co-contributing drugs with methadone with methadone Drug n % Drug group n % Diazepam 228 49.4% Benzodiazepines 278 60.2% Heroin 122 26.4% Illicit drugs 157 34.0% Codeine 78 16.9% Antidepressants 148 32.0% Alcohol 68 14.7% Opioid analgesics 125 27.1% Alprazolam 57 12.3% Oxazepam 48 10.4% Antipsychotics 76 16.5% Methamphetamine 45 9.7% Alcohol 68 14.7% Temazepam 39 8.4% Olanzapine 32 6.9% Amitriptyline 29 6.3% Nitrazepam 29 6.3% Mirtazapine 28 6.1%
Victorian deaths involving Themes in methadone deaths acute diazepam toxicity, 2000-2011 150 Annual frequency 120 • Involvement of takeaway dosing for of deaths 90 opioid pharmacotherapy. 60 • Probable diversion of methadone. 30 0 • Co-prescription of multiple 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 benzodiazepines with methadone to 30 the deceased. million population Annual rate per 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Drug involvement in Contributing drug groups diazepam deaths with diazepam Drug group n % Drug involvement n % Opioid analgesics 730 63.5% Multiple drugs including diazepam 1149 99.8% Illicit drugs 533 46.4% Diazepam alone 2 0.2% Antidepressants 529 46.0% Benzodiazepines 417 36.3% 320 Frequency of deaths Alcohol 364 31.7% 240 160 Antipsychotics 244 21.2% 80 Non-opioid analgesics 153 13.3% 0 None 1 2 3 4 5 6 7 8 9 10 11 12 Number of co-contributing drugs with diazepam
Individual co-contributing drugs The diazepam-opioid nexus with diazepam 140 Annual frequency of deaths Only heroin Heroin and pharm opioids 120 Drug n % Only pharm opioids Neither 100 Heroin 482 41.9% 80 Codeine 375 32.6% 60 Alcohol 364 31.7% 40 Methadone 228 19.8% 20 Temazepam 160 13.9% 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Oxazepam 146 12.7% Paracetamol 131 11.4% 100% Annual proportion of deaths Oxycodone 128 11.1% 80% Alprazolam 122 10.6% 60% Amitriptyline 113 9.8% Methamphetamine 102 8.9% 40% Citalopram 87 7.6% 20% Quetiapine 85 7.4% 0% Olanzapine 84 7.3% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Themes in diazepam deaths Concluding comments to background • Prescription medications are • Diazepam is widely sought after by frequently involved in acute drug opioid abusers. deaths. • Diazepam is widely prescribed to • Prescription medication involvement people suffering pain and/or opioid is often not straightforward. dependence. • Interventions can be designed to • Diazepam is widely prescribed upon target these deaths. request and without scrutiny.
Purposes of the The inquest Coroners Act 2008 (Vic) An inquest is “not a trial between opposing parties Section 1(c): but an inquiry into the death. The focus is on […] to contribute to the reduction of the discovering what happened, not on ascribing number of preventable deaths and fires guilty, attributing blame or apportioning liability. through the findings of the investigation of The purpose is to inform the family and the public deaths and fires, and the making of of how the death occurred with a view to reducing recommendations, by coroners. the likelihood of similar deaths.” Section 1(d): State Coroner of Queensland, in a finding regarding a suspected death delivered 6 June 2008. […] to establish the Coroners Court of Victoria as a specialist inquisitorial court . Coronial recommendations Responses to recommendations Under sections 72(3)-(5): Section 72(2): • Public statutory authorities and entities must A coroner may make recommendations to any provide written responses to recommendations Minister, public statutory authority or entity on within three months. any matter connected with a death or fire • Coroner must publish responses on the internet. which the coroner has investigated, including recommendations relating to public health and • All findings, comments and recommendations safety or the administration of justice. made following an inquest will be published on the internet, unless otherwise ordered by a coroner.
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