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The enemy within: The rise of prescription drug-related deaths

The stark headline from the most recent report from the National Drug-related Deaths Index (NDRDI) is that 73 per cent of poisoning deaths involved prescribed drugs in 2014, the latest year for which data is available.

The data will always be two years old on publication because of the way in which it is compiled by researchers led by Dr Suzi Lyons and her colleague Ena Lynn from the Health Research Board, who painstakingly extract the data from all coroners’ files nationwide.

The report divides the deaths into those by poisoning, of which there were 354 in 2014 compared to 397 in 2013 and deaths due to non-poisonings, which increased from 301 in 2013 to 343 in 2014. Non-poisoning deaths are those that occurred in people with a history of drug dependency or non-dependent drug use who died due to either trauma (hanging, drowning, falls, shooting or stabbing) or to medical causes (cardiovascular, liver disease, cancer or respiratory infections), whether or not drug use was directly implicated in the death. The main causes of non-poisoning deaths in 2014 were hanging (27 per cent) and cardiac (15 per cent). Most hangings were in males with a history of mental illness and cannabis and cocaine were the most common drugs used by such individuals.

Most poisoning deaths involved polydrug use, according to the 2014 data. In 2004, 44 per cent of deaths involved more than one drug, but 10 years later the figure was 66 per cent. An average of four different drugs were detected, compared to an average of two in 2004. The concern I mentioned in an article in Irish Pharmacist on pregabalin misuse, is justified by the 86 per cent increase in pregabalin-related deaths between 2013 (14) and 2014 (26).  It is not possible to determine how much of this rise is linked to increased prescribing for ‘off-label’ indications and how much is due to recreational abuse for its alcohol-like euphoric effects.

Deaths from ‘other opiates’ rose in 2014 due largely to an increase in fatalities where tramadol was detected postmortem (19). The number of deaths involving codeine and oxycodone do not appear to have increased and the small number where fentanyls were found are not believed to be due to street products (so-called ‘designer fentanyls’), but the HSE alert over a cluster of deaths involving either acetylfentanyl or acryloylfentanyl or furanylfentanyl suggests that these will feature in future NDRDI updates.

Over a quarter (27 per cent) of poisonings featured an antidepressant, often in combination with a benzodiazepines (benzos) and/or an opiate. Citalopram continues to be the main culprit and the death rate has increased to a notable extent in women (47 per cent of such deaths). In some respects, this is not surprising because the General  Population Study on Drug Use in Ireland for 2014/15 (but not published  by the NACDA until November 2016) showed that women were significantly more likely to report use of antidepressants than men (lifetime use in women was 14.5 per cent compared to 8.6 per cent in men).

One of the other notable features of the 2014 figures on poisoning deaths is that fatalities implicating benzos were at 115, the same as for alcohol, which surprisingly dropped from 140 the previous year. Of those benzo cases, only three involved benzos on their own. The remainder were polydrug deaths involving mainly methadone and/or heroin. It is hardly a surprise to learn that combinations of antidepressants and benzos are particularly risky, with 80 such deaths recorded, as were 37 cases involving alcohol and benzos. A major concern must be the finding that more than one benzo was implicated in 58 deaths. This might indicate inappropriate prescribing practices, but equally the victims might have sourced different benzos on the black market. Not only do we have to cope with such a market in pharmaceutical benzos, but there is also evidence of a market in ‘designer’ benzos such as phenazepam and in counterfeit hypnotics such as zopiclone, which media reports suggest has been manufactured in clandestine labs in some rural areas.

Deaths related to zopiclone, of whatever origin, increased by 41 per cent to 72 between 2013 and 2014. Deaths due to antipsychotics such as olanzapine, combined with either opiates or benzos, also feature, as do deaths linked to quetiapine. The EMA recently modified the latter’s SPC to advise that caution may be needed when prescribing to patients with a history of alcohol or drug abuse.

The other prescribed drug implicated in a large number of deaths is methadone. The vast majority (92 per cent) of these deaths involved other drugs, mainly benzos. Just over half of those who died were in treatment at the time of death, indicating yet again the existence of a significant black market in methadone.

Given the scale of the death-toll involving so many different classes of prescribed drugs, there is a professional obligation on all parties – including doctors and pharmacists – to do all in their power to reduce such deaths.

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