Drug-related Deaths – just the tip of the iceberg?

By Dr Louise Marryat, Baxter and ESRC Fellow, University of Dundee. 

Premature mortality in people affected by co-occurring homelessness, justice involvement, opioid dependence, and psychosis: a retrospective cohort study using linked administrative data

https://doi.org/10.1016/S2468-2667(22)00159-1

Last week, the National Records of Scotland published the latest drug-related death data, showing that Scotland continues to have the highest levels of drug-related deaths in the UK and Europe. In some ways, however, these deaths are just the tip of the iceberg. Many more people living with problematic substance use die early every year due to complex co-occurring health and socio-economic conditions (e.g., poverty, homelessness), which are not counted as ‘drug-related deaths’.

Emily Tweed, who previously sat on the DRNS Steering Committee, is a doctor, and researcher at the University of Glasgow, specialising in health inequalities, with a particular focus on the use of routine administrative data to understand the broader determinants of health. Emily has recently published a paper with colleagues, exploring early death in people affected by co-occurring homelessness, justice involvement, opioid dependence, and psychosis. With the recently published drug-related death statistics showing Scotland’s poor performance in this area, this research is particularly timely. The researchers note that these co-occurring experiences frequently overlap, and involve exclusionary processes such as stigma and discrimination; restrictions on basic freedoms or rights (e.g., voting, privacy, and liberty); or barriers to accessing public services (e.g., health care). In experiencing any one of these things, the evidence we have suggests that people are more likely to experience poor health and die early, compared with those who don’t have these experiences. We know less, however, about the impact of having more than one of these experiences on health outcomes.

Emily and colleagues decided to investigate early deaths among people who had experienced these co-occurring experiences, with a particular focus on deaths from potentially avoidable causes, non-communicable diseases (a disease that is not transmissible directly from one person to another e.g., most cancers and heart diseases), and years of potential life lost.

They did this using administrative data (e.g., hospital records, justice records, death registrations) recorded between April 2010 and March 2019 for all people aged 18-75 living in Glasgow City. Data from different sources were linked together.

A total of 536,653 adults were identified as residents of the Glasgow City Council area who were alive and younger than 75 years at the start of follow-up on April 1, 2014. Of these 5.2% of people had experienced at least one of homelessness (2.4%), justice involvement (1%), opioid dependence (1.4%), and psychosis (0.9%); and 1% of people had experienced more than one of these. People who had experienced any of these things were more likely to be male (64.8%), and to live in more deprived areas (75.2%).

When the Emily and her team looked at the impact of having one or more of these experiences on the likelihood of dying early, the results were very interesting. In general, people who had experienced more than one of homelessness, justice involvement, opioid dependence, or psychosis were more likely to have died early than their peers who had only one or none of these experiences. However, this was not the case for people with opioid dependence, who were more likely to die early, regardless of whether they had other co-occurring experiences.

These deaths are largely preventable. As a sociologist, I often tell my students about Julian Tudor-Hart’s Inverse Care Law, which describes how people in most need of medical care are the least likely to receive it. Although the Inverse care law was first proposed more than 50 years ago, it is sadly still very apparent today. People who use substances are a clear example of this law in action, whereby stigma, high threshold services (e.g. only treating those with the most severe needs or requiring abstinence prior to accessing services), as well as availability of services in different areas, make it difficult, if not impossible, for many people to receive the care that they need. We need services that are joined up and cater for groups that are currently underserved in our population, particularly those with multiple needs and complex lives, in order to enable all people in our society to lead long and healthy lives.