Around 2013-14, like many in the sector we began to see a rise in deaths within our services. As with other providers we were beginning to see a rise in all-cause mortality deaths, so we decided to take a closer look. Our task was to investigate the complexity of risk factors for premature all-cause mortality within the treatment population, and the impact of current clinical management.
There were 316 deaths of people engaged with Derbyshire Healthcare NHS Foundation Trust’s (DHCFT) substance misuse services – or up to one year post-discharge – between 1 January 2012 and 20 August 2020. The data cut-off point meant we only had a partial year for 2020 so it wasn’t included, but deaths in 2020 and 2021 exceeded those for 2019.
Overdose (predominantly opiate) was by far the most common cause of death at 115 cases, constituting 40 per cent of deaths for which the cause was known. The cause of death was unascertainable or not yet known in 21 cases (7 per cent). After heroin or opiate toxicity, drugs such as diazepam, temazepam, gabapentin, mirtazapine and increasingly pregabalin were frequently highlighted under section 1b (‘underlying cause’ of the main cause of death) on the death certificate. All other deaths were physical health-related with the exception of suicides, of which there were 20 (6.3 per cent). The most common causes of physical health deaths were predominantly liver disease, COPD, bacterial infections and cancers.
The highest number of deaths occurred in the 35-39 age group, followed closely by the 40-44 age group. The age profile of overdose deaths followed the same pattern, but with a more pronounced peak in the 35-39 age group. The data suggests that those aged 50 and over are more likely to die from a physical health condition than an overdose – in the 50-plus age group 19 per cent of deaths were due to overdose, compared to 39 per cent of deaths in those aged 35-49.
When only chronic causes of deaths are analysed (brain-related illnesses, cancer, cardiovascular illness, diabetes, liver disease, lung conditions and kidney disease), the age profile becomes slightly older, with a peak in the 45-49-year age bracket. However, the data shows many deaths at a young age from these causes, with 58 per cent of deaths occurring in those aged under 50 and 22 per cent in those under 40.
The data shows that most individuals (161, or 52 per cent) were found alone, while 37 per cent (115) died in a hospital, hospice or care home. Most deaths in hospital were caused by physical health conditions – only 11 were due to overdose. Twenty-six of the people that died in hospital were receiving end of life care. Only 11 per cent of all decedents were known to have died in the presence of friends – of those people who were found alone, 80 per cent were male. Of the 115 people who died by overdose, an even greater proportion (72 per cent) were found alone. Ten per cent of overdose deaths occurred in hospital and 18 per cent in the presence of friends.
Physical health conditions
Physical health conditions were highly prevalent in the cohort that died, with 81 per cent of people (251) having at least one such condition – 60 per cent (186) had two or more. The most commonly occurring conditions were chronic obstructive pulmonary disease (COPD) at the time of death. In this study 243 decedents were under the age of 50. Of these 191 had at least one long-term health condition such as COPD, liver disease, or a heart condition, and 155 had an identifiable mental health condition, such as anxiety and depression disorders, personality disorder, PTSD or psychotic illness. Poor physical health and life-limiting conditions will continue to be a challenge to the sector. Three quarters of the people who died had also had at least one hospital admission in the previous 12 months – a significant red flag and a clear indicator of risk regardless of reason for hospital admission.
In addressing overdoses we started rolling out naloxone in 2015, and it’s likely that deaths both locally and nationally would have seen a greater increase without it. However, the prerequisite for naloxone effectiveness is that another person is present and available to administer it at the time of an overdose. With the number of people using drugs alone, living in isolation, and dying alone it is becoming clear that further interventions will be required, and it is highly likely that technology will play a key role.
A partnership between Derbyshire Healthcare NHS Foundation Trust and ImpACT+, the specialist respiratory/COPD team based at the Royal Derby Hospital, was created to address a recognised need for access to specialist respiratory care for those using our services. This service is now delivered from within two of our treatment bases. More people have been diagnosed and commenced on treatment regimes, with one case of TB identified and treated. Many with symptoms but undiagnosed have been identified and received appropriate investigations for symptoms they had previously not addressed or been unable to access their GP to discuss. One client was identified to be suffering from a range of conditions including a DVT and heart failure and is only alive today because the health improvement nurse had access to the specialist team who were able to act accordingly on her concerns.
We continue to work in collaboration with several hepatitis C ODNs and peers alongside our nurses to eliminate hepatitis C – in the last two years only one person had hepatitis C referenced on their death certificate. We also introduced on-site ECG testing in Derby, with tests uploaded and results received within 30 minutes. A recent audit showed 33 per cent needed a follow-up referral, and the system is fully integrated with GPs, hospitals and our own data system. We will soon be rolling this out across the county. Future research should also examine the impact of opioid substitution treatment on mortality.
Engage and re-engage
In order to keep people engaged in treatment we employed an outreach worker to re-engage those who had dropped off their prescription and stopped attending appointments, and optimisation of medication is encouraged to allow people to find a dose that’s comfortable for them. More outreach workers were employed in the city and county to work specifically within the homeless community, and in the city we have an outreach worker to work specifically with females who are at risk.
One of the challenges the sector faces is not just deaths through overdose but deaths through physical health conditions. It sometimes appears that it is acceptable to talk about deaths in general but it’s still unusual to see services openly discuss all-cause mortality within their services. As we move into 2022 the full impact of COVID-19 on this client group is currently unknown, but it is reasonable to assume that the isolation and inequalities that they experienced pre-COVID would have intensified throughout 2020-22. As we all see a rise in the cost of living as always it is those with the least that will be most affected.