Journal of Urban Health

, Volume 80, Issue 2, pp 274–287 | Cite as

Drug-related mortality and fatal overdose risk: Pilot cohort study of heroin users recruited from specialist drug treatment sites in London

  • Matthew Hickman
  • Zenobia Carnwath
  • Peter Madden
  • Michael Farrell
  • Cleone Rooney
  • Richard Ashcroft
  • Ali Judd
  • Gerry Stimson


Fatal overdose and drug-related mortality are key harms associated with heroin use, especially injecting drug use (IDU), and are a significant contribution to premature mortality among young adults. Routine mortality statistics tend to underreport the number of overdose deaths and do not reflect the wider causes of death associated with heroin use. Cohort studies could provide evidence for interpreting trends in routine mortality statistics and monitoring the effectiveness of strategies that aim to reduce drug-related deaths. We aimed to conduct a retrospective mortality cohort study of heroin users recruited from an anonymous reporting system from specialist drug clinics. Our focus was to test whether (1) specialist agencies would agree to participate with a mortality cohort study, (2) a sample could be recruited to achieve credible estimates of the mortality rate, and (3) ethical considerations could be met. In total, 881 heroin users were recruited from 15 specialist drug agencies. The overall mortality rate of the cohort of heroin users was 1.6 (95% confidence interval [CI], 1.1 to 2.2.) per 100 person-years. Mortality was higher among males, heroin users older than 30 years, and injectors, but not significantly higher after adjustment in a Cox proportional hazard model. Among the 33 deaths, 17 (52%) were certified from a heroin/methadone or opiate overdose, 4 (12%) from drug misuse, 4 (12%) unascertained, and 8 (24%) unrelated to acute toxic effects of drug use. Overall, the overdose mortality rate was estimated to be at least 1.0 per 100 person-years. The standardized mortality ratio (SMR) was 17 times higher for female and male heroin users in the cohort compared to mortality in the non-heroin-using London population aged 15–59 years. The pilot study showed that these studies are feasible and ethical, and that specialist drug agencies could have a vital role to play in the monitoring of drug-related mortality.


Heroin Standardize Mortality Ratio Heroin User Overdose Death Fatal Overdose 
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  1. 1.
    Darke S, Zador D, Fatal heroin overdose: a review. Addiction. 1996;91:1765–1772.CrossRefPubMedGoogle Scholar
  2. 2.
    Law M, Lynskey M, Ross J, Hall W. Back-projection estimates of the number of dependent heroin users in Australia. Addiction. 2001;96:433–443.CrossRefPubMedGoogle Scholar
  3. 3.
    President of the Council, Tackling Drugs to Build a Better Britain: the Government’s 10 Year Strategy for Tackling Drug Misuse. London, England: Her Majesty’s Stationery Office; 1998.Google Scholar
  4. 4.
    Hulse GK, English DR, Milne E, Holman DJ. The quantification of mortality resulting from the regular use of illicit opiates. Addiction. 1999;94:221–229.CrossRefPubMedGoogle Scholar
  5. 5.
    Advisory Council on Misuse of Drugs. Reducing Drug Related Deaths. London, England: Home Office; 2000.Google Scholar
  6. 6.
    Hickman M, Madden P, Henry J, et al. Trends in drug overdose deaths in England and Wales 1993–98: does methadone kill more drug users than heroin? Addiction. 2003; 98:419–426.CrossRefPubMedGoogle Scholar
  7. 7.
    Griffiths C, Brock A, Mickleburgh M. Deaths related to drug poisoning: results for England and Wales, 1993 to 2000. Natl Stat Q. 2002;13:76–81.Google Scholar
  8. 8.
    Hickman M, Shuying S, De Angelis D. Estimating long-term trends in the incidence and prevalence of injecting drug use (IDU) and the number of ex-IDU: the use of opiate overdose deaths and back-calculation methods [abstract]. International Harm Reduction Conference; April 6–10, 2003; Chiang Mai, Northern Thailand.Google Scholar
  9. 9.
    Neeleman J, Farrell M. Fatal methadone and heroin overdoses: time trends in England and Wales. J Epidemiol Community Health. 1997;51:435–437PubMedCrossRefGoogle Scholar
  10. 10.
    Uren Z. Geographical variations in deaths related to drug misuse in England and Wales, 1993–99. Natl Stat. 2001;January:25–35.Google Scholar
  11. 11.
    Joe G, Simpson D. Mortality rates among opioid addicts in a longitudinal study. Am J Public Health. 1987;77:347–348.PubMedGoogle Scholar
  12. 12.
    Frischer M, Goldberg D, Rahman M, Berney L. Mortality and survival among a cohort of drug injectors in Glasgow, 1982–1994. Addiction. 1997;92:419–427.CrossRefPubMedGoogle Scholar
  13. 13.
    Perucci CA, Davoli M, Rapiti E, Abeni DD, Forastiere F. Mortality of intrayenous drug users in Rome: a cohort study. Am J Public Health. 1991;81:1307–1310.PubMedCrossRefGoogle Scholar
  14. 14.
    Oppenheimer E, Tobutt C, Taylor C, Andrew T. Death and survival in a cohort of heroin addicts from London clinics: a 22 year follow-up study. Addiction. 1994;89:1299–1308.CrossRefPubMedGoogle Scholar
  15. 15.
    Orti RM, Domingo-Salvany A, Munoz A, Macfarlane D, Suelves JM, Anto JM. Mortality trends in a cohort of opiate addicts, Catalonia, Spain. Int J Epidemiol. 1996;25:545–553.PubMedGoogle Scholar
  16. 16.
    Davoli M, Perucci CA, Rapiti E, et al. A persistent rise in mortality among injection drug users in Rome, 1980 through 1992. Am J Public Health. 1997;87:851–853.PubMedGoogle Scholar
  17. 17.
    Quaglio G, Talamini G, Lechi A, Venturini L, Lugoboni F, Mezzelani P. Study of 2,708 heroin-related deaths in North Eastern Italy 1985–98 to establish the main causes of death. Addiction. 2001;96:1127–1137.CrossRefPubMedGoogle Scholar
  18. 18.
    McGinnis JM, Foege WH. Mortality and morbidity attributable to use of addictive substances in the United States. Proc. Assoc Am Phys. 1999;3:109–118.CrossRefGoogle Scholar
  19. 19.
    Ghodse AH, Sheehan M, Taylor C, Edwards G. Deaths of drug addicts in the United Kingdom 1967–81. BMJ. 1985;290:425–428.PubMedCrossRefGoogle Scholar
  20. 20.
    Ghodse H, Oyefeso A, Kilpatrick B. Mortality of drug addicts in the United Kingdom, 1967–1993. Int J Epidemiol. 1998;27:473–478.CrossRefPubMedGoogle Scholar
  21. 21.
    Hickman M, Griffin M, Mott J, et al. Can the epidemiological function of the Addicts Index be continued-evidence from matching the Home Office Addicts Index with the Drug Misuse Database (DMD). Drugs Educ Prev Policy. In press.Google Scholar
  22. 22.
    Hickman M, Sutcliffe A, Sondhi A, Stimson G. Surveillance of problem drug use in the UK: a review of a regional drug misuse database. J Public Health. 1999;21:271–277.Google Scholar
  23. 23.
    Devis T, Rooney C. The time taken to register a death. Popul Trends. Summer 1997: 48–55.Google Scholar
  24. 24.
    Bland M. An Introduction to Medical Statistics, 2nd ed. Oxford, UK: Oxford University Press; 1995.Google Scholar
  25. 25.
    Baker A. ONS drug-related deaths database: first results for England and Wales, 1993–97. Health Stat Q. 2000;5:57–60.Google Scholar
  26. 26.
    Stimson GV, Oppenheimer E. Heroin Addiction: Treatment and Control. London, England: Tavistock; 1982.Google Scholar
  27. 27.
    Griffiths P, Gossop M, Powis B, Strang J. Transitions in patterns of heroin administration: a study of heroin chasers and heroin injectors. Addiction. 1994;89:301–309.CrossRefPubMedGoogle Scholar
  28. 28.
    Caplehorn JR, Dalton MS, Cluff MC, Petrenas AM. Retention in methadone maintenance and heroin addicts’ risk of death. Addiction. 1994;89:203–209.CrossRefPubMedGoogle Scholar
  29. 29.
    Caplehorn JR, Dalton MS, Haldar F, Petrenas AM, Nisber JG. Methadone maintenance and addicts’ risk of fatal heroin overdose. Subst Use Misuse. 1996;31:177–196.PubMedGoogle Scholar
  30. 30.
    White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. 1999;94:961–972.CrossRefPubMedGoogle Scholar
  31. 31.
    Warner-Smith M, Darke S, Lynskey M, Hall W. Heroin overdose: causes and consequences. Addiction. 2001;96:1113–1125.CrossRefPubMedGoogle Scholar
  32. 32.
    Gossop M, Stewart D, Treacy S, Marsden J. A prospective study of mortality among drug misusers during a 4-year period after seeking treatment. Addiction. 2002;97:39–47.CrossRefPubMedGoogle Scholar
  33. 33.
    Office of the Information Commissioner. Draft Guidance: Use and Disclosure of Medical Data. Wilmslow, UK: Office of the Information Commissioner; 2001.Google Scholar
  34. 34.
    Gostin LO. Public Health Law: Power, Duty, Restraint. Berkeley, CA: University of California Press; 2001.Google Scholar
  35. 35.
    Medical Research Council. Personal Information in Medical Research. London, England: Medical Research Council; 2000.Google Scholar

Copyright information

© The New York Academy of Medicine 2003

Authors and Affiliations

  • Matthew Hickman
    • 1
  • Zenobia Carnwath
    • 1
  • Peter Madden
    • 1
  • Michael Farrell
    • 2
  • Cleone Rooney
    • 3
  • Richard Ashcroft
    • 4
  • Ali Judd
    • 1
  • Gerry Stimson
    • 1
  1. 1.Centre for Research on Drugs and Health Behaviour, Social Science and MedicineImperial CollegeLondonEngland
  2. 2.National Addiction CentreLondon
  3. 3.Office for National StatisticsLondon
  4. 4.Medical Ethics Unit, Department of Primary Care and Social MedicineImperial CollegeLondon

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