Differences between injectors and non-injectors, and a high prevalence of benzodiazepines among drug related deaths in Scotland 2003

Drug related deaths (DRDs) have been increasing in Scotland over at least the past decade. This study aimed to describe the characteristics ( gender, age, ICD10 cause of death), toxicology and circumstances of all Scotland's DRDs in 2003 to help inform a national overdose prevention strategy. Coronial files for 300/317 (95%) DRDs registered with the General Register Office for Scotland (GROS) in 2003 were examined retrospectively ( in 2004). Characteristics: 241/300 (80%) were male. Mean age at death was 32.8 years ( SE 0.63, range 16-82). Route of administration was injecting for 137/268 (51%) who were classifiable. Classified injectors were more likely to be male (91%: 124/137) and younger (mean age of 32 years) than those whose death was by a non-injecting route (male: 87/131 (66%) and mean age of 35 years). Twenty-five to forty-four year olds made up 108/137 DRDs by injecting (79%), but only 62/131 (47%) by non-injecting routes. Cases of intentional self-poisoning (injectors 1; non-injecting 34) and undetermined intent ( injectors 14; non-injecting 26) were infrequent among injectors. Of those who died by the injecting route, 108/137 were known intravenous drug users, but so too were 29/131 DRDs by non-injecting routes. Toxicology: overall 38/300 cases of DRD (13%) were negative for opioid drugs - only 2/137 DRDs by injecting (1%) were negative for opioids compared with 33/131 (25%) by non-injecting route. Methadone was present for 15/137 DRDs by injecting route (11%) and for 57/131 DRDs by non-injecting routes (44%, p < 0.001). Presence of dihydrocodeine, and anti-depressants was about three times and six times respectively, more likely in DRDs by non-injecting routes. Irrespective of route, two-thirds of DRDs tested positive for benzodiazepines (202/300 DRDs). Circumstances: time between overdose and death was within the hour for 61/137 DRDs (45%) by injecting, but rarely by non-injecting routes (3%: 4/131). Three out of four DRDs occurred in a house or flat: 98/137 DRDs (72%) by the injecting route and 101/131 (77%) by non-injecting routes. Interpretation: A relatively high proportion of cases died by non-injecting routes. National mortality databases should separate out cases of injecting-related DRD from non-injecting cases, and public health strategies to reduce DRDs should distinguish between these groups. Widespread availability in Scotland of prescribed and illicit benzodiazepines needs attention.