Review of Deaths Related to Analgesic- and Cough Suppressant-opioids; England and Wales 1996-2002

Objective: The data on England and Wales voluntarily supplied by Coroners to the National Programme on Substance Abuse Deaths for the August 1996-December 2002 time frame were analyzed. Methods: All cases in which at least one analgesic- and cough suppressant-opioid other than heroin/morphine, methadone or buprenorphine was identified were extracted from the database. We hypothesized that: a) populations of addicts and non-addicts presented differences in patterns of drugs involved; and b) within the population of addicts and non-addicts, intentional and non-intentional deaths presented different patterns of substance consumption. Results: A total of 2024 deaths related to selected opioids, either alone or in combination, were included in the analysis. Typically, non-addicts were older than 45 and died as a result of intentional poisoning whilst majority of addicts were young, males and victims of accidental deaths. In about 93% of cases the selected opioids were reported in combination with another substance. Most frequently identified narcotics were propoxyphene, codeine and dihydrocodeine. Co-proxamol, Co-codamol and Co-dydramol were typically prescribed for non-addicts, whilst dihydrocodeine was mostly given to addicts. In non-addicts, alcohol was mostly represented in accidental deaths and antidepressants were typically represented in intentional deaths. Conversely, illicit drugs and hypnotics/sedatives were typically reported in addicts' accidental deaths. Conclusions: The present report constitutes the largest available collection of analgesic- and cough suppressant-opioid mortality data in the UK. Users should be educated about risks associated with polydrug misuse.

References

• 1 Breckenridge J, Clark JD. Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain.  J Pain. 2003;  4 344-350
• 2 Cassano P, Fava M. Depression and public health. An overview.  J Psychosom Res. 2000;  53 849-857
• 3 Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000.  Pain. 2004;  109 514-519
• 4 Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: Concerns and strategies.  Drug Alcohol Depend. 2006;  81 103-107
• 5 Cone EJ, Fant RV, Rohay JM, Caplan YH, Ballina M, Reder RF, Haddox JD. Oxycodone involvement in drug abuse deaths. II. Evidence for toxic multiple drug-drug interactions.  J Anal Toxicol. 2004;  28 217-225
• 6 Corkery J, Schifano F, Ghodse AH, Oyefeso A. Methadone effects and its role in fatalities.  Hum Psychopharmacol Clin Exp. 2004;  19 565-576
• 7 Darke S, Ross J. The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia.  Addiction. 2001;  96 1443-1453
• 8 Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly.  Drugs Aging. 2003;  20 23-57
• 9 Department of Health, Scottish Office Department of Health, Welsh Office, Department of Health and Social Security Northern Ireland .Drug Misuse and Dependence, Guidelines in Clinical Management (Orange Guidelines). HMSO, London (1999). Available at: http:www:dh:gov:uk=assetRoot=04=07=81=98=04078198:pdf (accessed on July 24th, 2005)
• 10 Edwin T, Nammalvar N, Ramanujam V. Dextropropoxyphene dependence: a cautionary note.  J Assoc Physicians India. 2001;  49 571-573
• 11 Fleming GF, McElnay JC, Hughes CM. The separation of codeine from nonprescription combination analgesic products.  Subst Use Misuse. 2003;  38 1217-1226
• 12 Fleming GF, McElnay JC, Hughes CM. Development of a community pharmacy-based model to identify and treat OTC drug abuse/misuse: a pilot study.  Pharm World Sci. 2004;  26 282-288
• 13 Fugelstad A, Ahlner J, Brandt L, Ceder G, Eksborg S, Rajs J, Beck O. Use of morphine and 6-monoacetylmorphine in blood for the evaluation of possible risk factors for sudden death in 192 heroin users.  Addiction. 2003;  98 463-470
• 14 Ghodse AH, Corkery J, Schifano F, Oyefeso A, Bannister D, Annan J. Drug related deaths in the UK, January-December 2004. London; International Centre for Drug Policy, St George's, University of London 2005
• 15 Ghodse AH, Schifano F, Oyefeso A, Jambert-Gray R, Cobain K, Corkery J. Drug-related deaths as reported by coroners in England, Wales, Scotland, N Ireland and Channel Islands. Annual review 2002 and np-SAD Report no. 11. London; European Centre for Addiction Studies, St George's Hospital Medical School 2003
• 16 Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity.  Br J Anaesth. 2005;  95 434-441
• 17 Hawton K, Simkin S, Deeks J. Co-proxamol and suicide: a study of national mortality statistics and local non-fatal self poisonings.  BMJ. 2003;  326 1006-1008
• 18 Hawton K, Simkin S, Gunnell D, Sutton L, Bennewith O, Turnbull P, Kapur N. A multicentre study of coproxamol poisoning suicides based on coroners' records in England.  Br J Clin Pharmacol. 2005;  59 207-212
• 19 Henricson K, Carlsten A, Ranstam J, Rametsteiner G, Stenberg P, Wessling A, Melander A. Utilisation of codeine and propoxyphene: geographic and demographic variations in prescribing, prescriber and recipient categories.  Eur J Clin Pharmacol. 1999;  55 605-611
• 20 Hickman M, Carnwath Z, Madden P, Farrell M, Rooney C, Ashcroft R, Judd A, Stimson G. Drug-related mortality and fatal overdose risk: pilot cohort study of heroin users recruited from specialist drug treatment sites in London.  J Urban Health. 2003;  80 274-287
• 21 Hughes GF, McElnay JC, Hughes CM, McKenna P. Abuse/misuse of non-prescription drugs.  Pharm World Sci. 1999;  2 251-255
• 22 Jonasson U, Jonasson B, Saldeen T. Correlation between prescription of various dextropropoxyphene preparations and their involvement in fatal poisonings.  Forensic Sci Int. 1999;  103 125-132
• 23 Medicines and Healthcare products Regulatory Agency (MHRA), 2005 .Available at: http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4102347&chk=muLo27 (accessed on March 17th, 2005)
• 24 Nicholas MK, Molloy AR, Brooker C. Using opioids with persisting noncancer pain: a biopsychosocial perspective.  Clin J Pain. 2006;  22 137-146
• 25 Office of Applied Statistics. Mortality data Drug Abuse Warning Network, 2002. MD, US; Department of Health and Human Services 2004
• 26 Olsen Y, Daumit GL. Opioid prescribing for chronic nonmalignant pain in primary care: challenges and solutions.  Adv Psychosom Med. 2004;  25 138-150
• 27 Penning R, Fromm E, Betz P, Kauert G, Drasch G, von Meyer L. Drug death autopsies at the Munich Institute of Forensic Medicine (1981-1992).  Forensic Sci Int. 1993;  62 135-139
• 28 Schifano F, Corkery J, Gilvarry E, Deluca P, Oyefeso A, Ghodse AH. Buprenorphine mortality, seizures and prescription data in the UK (1980-2002).  Hum Psychopharmacol Clin Exp. 2005;  20 343-348
• 29 Schifano F, Oyefeso A, Webb L, Pollard M, Oyefeso A, Ghodse AH. Review of deaths related to taking ecstasy, England and Wales, 1997-2000.  BMJ. 2003;  326 80-81
• 30 Seymour A, Black M, Jay J, Oliver JS. The role of dihydrocodeine in causing death among drug users in the west of Scotland.  Scott Med J. 2001;  46 143-146
• 31 Simkin S, Hawton K, Sutton L, Gunnell D, Bennewith O, Kapur N. Co-proxamol and suicide: preventing the continuing toll of overdose deaths.  QJM. 2005;  98 159-170
• 32 World Health Organization .International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), version for 2003. Available from: http://www3.who.int/icd/vol1htm2003/fr-icd.htm (accessed on August 2nd, 2005)

1 Conflict of interest
None declared

2 Individual contributions
FS wrote the manuscript and coordinated the study. GZ and FZ collected the data. PD and DL carried out the statistical analysis. All Authors participated in interpreting the results. FS is guarantor. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication

Correspondence