Scottish Blues- Benzodiazepines and Drug Related Deaths in Scotland
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1 Scottish Blues- Benzodiazepines and Drug Related Deaths in Scotland EMCDDA Sep. 25 th 2014 Dr Saket Priyadarshi Associate Medical Director NHS Greater Glasgow and Clyde Vice-Chair, National Forum on Drug Related Deaths
2 Scottish Blues:
3 Benzodiazepines and Drug Related Deaths: Introduction to Benzodiazepine pharmacology, use and misuse Benzodiazepines and drug related deaths Benzodiazepines and High Risk Drug Users Supply and availability Reducing benzodiazepine use in HRDUs
4 A class of psychoactive drugs which have a common structure (benzene and diazepine rings) and common effects. Chlordiazepoxide discovered 1955 Diazepam marketed since 1963.
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6 Effects Prescribing Indications Anxiolytic Grief/Bereavement/Insomnia Panic/Fear of Flying/etc etc Anxiety disorders/trauma Sedative Psychosis/Behavioural Problems Anticonvulsant Seizures Muscle relaxant Back Pain Hypnotic / Amnesic Anaesthesia Detoxification Short or Long-acting? 2-4 weeks maximum Max Dose 30mg Diazepam
7 Harms: Recreational Use/Abuse Risk Taking Behaviour/Accidents Paradoxical Stimulation Dependency Emotional Blunting Cognitive Impairment Anxiety and Agoraphobia Pregnancy Overdose?
8 Coma BARBITURATES CNS EFFECTS Depression Anesthesia Hypnosis BENZODIAZEPINES Sedation, Anti-Anxiety INCREASING DOSES Possible selective anticonvulsant & musclerelaxing activity Felice Nava
9 BZDPs and DRD: Implicated Synergistic/potentiating effects In combination with other depressants Present Found at toxicology but not directly involved in poisoning but Contributed to risk behaviour? Not an exact science!» Tox levels don t help» Forensic pathology decision- subjectivity and practice is variable
10 Likelihood of a drug that is present in post mortem toxicology being implicated in a drug death: (National Drug Related Deaths Database, ISD) 2012 Drugs Implicated/ Drugs Present % Implicated Alcohol 75/ Amphetamines 9/ Anti-Depressants 48/ Cannabis 0/ Cocaine 12/ Codeine 14/ Diazepam 136/ Dihydrocodeine 49/ Ecstasy 3/ Heroin/Morphine 168/ Methadone 186/ NPS 16/ Tramadol 18/
11 Drug Related Deaths in Scotland: (National Records Scotland) No. of BZDP drugs implicated in DRDs in Scotland (NRS) No. of DRDs All DRDs Any Benzo Diazepam Temazepam Year
12 National Drug Related Deaths Database: Information Services Division % of DRDs with BZDPs implicated / present and % Implicated %Present
13 NDRD Database : BZDPS drugs present in body at Post Mortem Diazepam Temazepam Oxazepam Phenazepam Zopiclone Nitrazepam Chlordiazepo... Alpazolam Etizolam Benzo - unspec...
14 Combination Drugs found in Toxicology with Diazepam present, % 50% 40% 30% 20% 10% 0% Heroin & Diazepam Methadone & Diazepam Diazepam & Alcohol Heroin, Diazepam & Alcohol Methadone, Diazepam & Alcohol
15 Gender for DRDs with BZDPs present % of BZDP DRD Male Female Years
16 Age Bands for DRD with BZDPs present % of DRDs with BZDPs present under and over Age Bands
17 Deprivation and DRDs with BZDPs present % of DRDs with BZDPs present SIMD1 SIMD2 SIMD3 SIMD4 SIMD5 Scottish Index of Multiple Deprivation (1=most deprived; 5= least deprived)
18 DRDs with BZDPs present known to have used drugs prior to death % of DRDs with BZDPs present yes no Year BZDPs are Class C Controlled Drugs, UK Misuse of Drugs Act 1971
19 % of DRDs with BZDPs present DRDs with BZDPs present who were prescribed ORT at time of death Year
20 Breakdown of Benzodiazepine presence in DRDs within NHS GG&C in 2012/ Implied Present but not implied Not present
21 BZDPs present and implied in DRDs in GG&C 2012 and % 80% 60% 40% 20% 0% 19.30% 26.10% 15.30% 10.90% 65.70% 63.00% Not present Implied Present but not implied
22 Breakdown of Benzodiazepines present in DRDs within NHS GG&C in 2012/ Temazepam Phenazepam Nitrazepam Midazolam Lorazepam Etizolam Diazepam Chlordiazepoxide Alprazolam Breakdown of Benzodiazepines Implied in DRDs within NHS GG&C in 2012/ Temazepam Phenazepam Nitrazepam Midazolam Lorazepam Etizolam Diazepam Chlordiazepoxide Alprazolam
23 In previous year
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25 BZDPS and High Risk Drug Users: General population: one in seven British adults take benzodiazepines at some time during the year and 1 in 40 take them throughout the year The proportion of women using prescribed psychotropics is double the proportion of men. HDRUs : Drugscope Almost 60,000 PDUs in Scotland (opiate and/or benzodiazepines) =Prevalence 1.71% of years. ISD 2011
26 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Benzodiazepines as an illicit drug by clients reporting to the SDMD, by gender and main and secondary drug; 1995/ /13 Male Main Drug Female Main Drug Male Secondary Drug Female Secondary Drug 1996/ / / / / / / / / / / / / / / / /13 Financial Year Scottish Drug Misuse Database, ISD 1995/96 % of those using Drugs at an Initial Assessment
27 Benzodiazepine use and ORT NHS GG&C: Site of Audit % Random Urines positive for benzodiazepines Comments Glasgow- Methadone and Suboxone 55% Women> Men Not age related Inverse relationship to dose Renfrewshire- Methadone and Suboxone 65% (non-prescribed bzdp) Women>Men Associated with antidepressant prescribing 25% of ORT patients prescribed bzdps at any time either through specialist addiction service or GPs. (PIS) But very variable practice: co-prescribing rates of 0-60% (GAS)
28 Sources and supply:
29 Prescribing Resources Team, Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde
30 Prescribing Resources Team, Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde
31 Street Blues: Macdougall-Heasman et al Abertay University Robert Gordon University Police Scotland
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36 Guidance but no consensus!
37 Acknowledgements Dr Tony Martin- GG&C Addiction Services Garry Hecht-NHS National Services Scotland, Information Services Division Andrew McAuley- NHS Health Scotland, Public Health Science Directorate Kenny Simpson- STOP Unit, Police Scotland Denise McKeown Forensic Medicine, Glasgow University National Fatalities Unit Dr Lee Middleton- Glasgow Addiction Services Dr Claire Duncan- Renfrewshire Drug Services Sean MacBride-Stewart- Medicines Management Resource Lead, GG&C Ben Tait and Lee Barnsdale- Information Services Devision Felice Nava, Vice-Preident Italian Society of Addiction Medicine
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