1. What is a drug death? Dr Marjorie Black Forensic Medicine and Science University of Glasgow

2. Drug Related Deaths, 1985 - 1999

3. Drug Related Death - Definition Where there is … evidence of a fatal overdose of controlled drugs…..recent drug misuse e.g. controlled drugs and/or a syringe found in close proximity to the body &/or the person is known to the police as a drug misuser…. Where there is … evidence of a fatal overdose of controlled drugs…..recent drug misuse e.g. controlled drugs and/or a syringe found in close proximity to the body &/or the person is known to the police as a drug misuser…. 1994 Scottish Office ‘Ministerial Drugs Task Force Report’ 1994 Scottish Office ‘Ministerial Drugs Task Force Report’

4. Excludes Deaths from infection resulting directly from injecting drug use Deaths from infection resulting directly from injecting drug use Deaths from chronic disease which is a result of drug abuse e.g. Hep C Deaths from chronic disease which is a result of drug abuse e.g. Hep C Deaths from a pathology caused by illicit drug use Deaths from a pathology caused by illicit drug use Suicides Suicides

5. Forensic Medicine and Science Responsible to the Crown Office for the provision of pathology and toxicology services in the West of Scotland. Responsible to the Crown Office for the provision of pathology and toxicology services in the West of Scotland. Responsible for the toxicological analyses of all sudden and unexpected deaths in Strathclyde, whether or not these are initially thought to be drug- related. Responsible for the toxicological analyses of all sudden and unexpected deaths in Strathclyde, whether or not these are initially thought to be drug- related.

6. Drug Related Death - Definition A sudden or unexpected death where drugs of abuse were implicated as a cause of death either through toxicology or circumstance. A sudden or unexpected death where drugs of abuse were implicated as a cause of death either through toxicology 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 of an overdose of non illicit drugs. Death of a known drug abuser as a result of an overdose of non illicit drugs.

7. Police Sudden Death Report Scene Observations Scene Observations Drug paraphernalia Drug paraphernalia Terminal Events Terminal Events Drug misuse witnessed Drug misuse witnessed Recent Prison Release Recent Prison Release Medical History Medical History Known drug user Known drug user Prescribed medication Prescribed medication Drug rehabilitation programmes Drug rehabilitation programmes

8. Pathology Examination Needle marks/sinuses Needle marks/sinuses recent and healing recent and healing Signs of infection Signs of infection Injuries Injuries Any pathology or disease process Any pathology or disease process Congestion & oedema of lungs Congestion & oedema of lungs

9. Cause of Death A full post mortem examination is essential to identify accurately whether the death is a result of drugs to A full post mortem examination is essential to identify accurately whether the death is a result of drugs to exclude natural disease/pathology exclude natural disease/pathology exclude infection/trauma exclude infection/trauma The pathologist must carefully consider the toxicological results in conjunction with the individual circumstances The pathologist must carefully consider the toxicological results in conjunction with the individual circumstances

10. Drugs Detected, 1995 - 1998

11. Toxicology, 1995 - 1998

12. Blood Alcohol Concentrations

13. Blood Concentrations - Benzodiazepiness

14. Blood Concentrations - Opiates

15. Interpretation of PM drug levels Very rapid death Period of unconsciousness before death Redistribution of the drug in the body after death Site of blood sampling

16. Interpretation of PM Drug Levels There is no “absolute” toxic level for the interpretation of drug levels There is no “absolute” toxic level for the interpretation of drug levels Drug Interactions (e.g. morphine + benzodiazepines) Drug Interactions (e.g. morphine + benzodiazepines) Drugs with different modes of action Drugs with different modes of action

17. Amphetamines & Cocaine Different mechanisms of death Different mechanisms of death Not necessarily dose related Not necessarily dose related Can cause brain haemorrhage or cardiac arrest Can cause brain haemorrhage or cardiac arrest Can cause chronic problems Can cause chronic problems

18. Factors Affecting Interpretation General Health General Health Tolerance Tolerance Periods of Abstinence Periods of Abstinence Invaluable information Invaluable information Medical history Medical history Drug history Drug history Recent circumstances Recent circumstances Immediate circumstances of the death Immediate circumstances of the death

19. Conclusions Recent use of illicit drugs does not mean that they died of a drugs overdose Recent use of illicit drugs does not mean that they died of a drugs overdose The finding of a drug in the blood does not mean that it caused (or even contributed) to death The finding of a drug in the blood does not mean that it caused (or even contributed) to death A toxicology report does not give the cause of death A toxicology report does not give the cause of death

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

21. Conclusions The drug(s) considered to have caused the death should be identified in the death certificate The drug(s) considered to have caused the death should be identified in the death certificate Accurate information on the drugs implicated in death is essential to target intervention and reduce deaths Accurate information on the drugs implicated in death is essential to target intervention and reduce deaths

22. Conclusions If death has been caused by a pathology e.g.cardiac disease or infection which has resulted from illicit drug use the drug use should be identified on the death certificate If death has been caused by a pathology e.g.cardiac disease or infection which has resulted from illicit drug use the drug use should be identified on the death certificate These deaths are also directly attributable to drug misuse These deaths are also directly attributable to drug misuse Information should be available to target risk groups Information should be available to target risk groups