Deceased
Samuel Jack Morrison
Demographics
24y, male
Coroner
Coroner Audrey Jamieson
Date of death
2016-06-17
Finding date
2018-08-06
Cause of death
Combined drug toxicity (heroin, benzodiazepine and others)
AI-generated summary
Samuel Morrison, 24, died from combined drug toxicity involving heroin, benzodiazepines and other substances. He had a long history of depression, anxiety and illicit drug use, and had recently been discharged from psychiatric hospital where he received electroconvulsive therapy. Within days of discharge, he resumed using drugs (heroin, ice, marijuana). His GP prescribed escitalopram but declined a benzodiazepine request, advising psychiatrist referral. Despite scheduled psychiatric appointments, Morrison failed to attend. He died at home. The coroner noted that clinical systems failed to prevent him accessing drugs while hospitalised, and highlighted gaps in coordinated aftercare following discharge. This case exemplifies broader systemic issues in drug harm reduction and the critical importance of integrated mental health and addiction services.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
AT MELBOURNE Court Reference: COR 2016 2730
Form 38 Rule 60(2)
Section 67 of the Coroners Act 2008
I, AUDREY JAMIESON, Coroner having investigated the death of SAMUEL JACK MORRISON
without holding an inquest:
find that the identity of the deceased was SAMUEL JACK MORRISON born 21 November 1991
and the death occurred on 17 June 2016
at 9 Gildan Court, Hoppers Crossing Victoria 3029
from: 1(a) COMBINED DRUG TOXICITY (HEROIN, BENZODIAZEPINE AND OTHERS)
Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:
and depression.
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attendance.
INVESTIGATIONS Forensic pathology investigation
oedematous lungs with mixed inflammatory infiltrate.
4, Toxicological analysis of post mortem substances detected the presence of 6monoacetylmorphine, morphine, codeine,! citalopram,’ diazepam and its metabolites nordiazepam, temazepam and oxazepam,* and methylamphetamine.* These results were consistent with the recent use of heroin. Dr Almazrooei noted that heroin and morphine are depressants of the central nervous system (CNS), causing a reduced rate and depth of breathing and may cause cessation of the breathing reflex. In addition, there is an additive CNS depressive effect with concurrent use of other CNS depressant drugs, such as
benzodiazepines and antidepressants, which may increase the risk of death.
1 Heroin is an illegal drug produced from morphine obtained from the opium poppy. Within minutes of injection into a person, heroin is converted to morphine via the intermediate compound 6-acetyl morphine (6-AM). Morphine is the principal form detected in blood, although 6-AM may be detected in urine for about six hours of an injection and in blood only for a short time. 6-AM is not always present in the urine of recent heroin users. Heroin and morphine are depressants of the CNS, causing reduced rate and depth of breathing and eventually cessation of the breathing reflex.
Multiple use of drugs that also depress the CNS, such as alcohol, benzodiazepines and morphine-like drugs (opiates/opioids) wil] increase the risk of death. The presence of a small amount of codeine in blood, urine or other tissues of morphine positive cases is consistent with its presence from the use of heroin, in which it is a contaminant.
However, the use of codeine cannot be excluded.
? Citalopram is a selective serotonin reuptake inhibitor with antidepressant activity.
3 Diazepam is a sedative/hypnotic drug of the benzodiazepines class.
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heroin, benzodiazepine and others.
Police investigation
out of 28 tablets remained.
Detective Senior Constable Daniel Blake, the nominated coroner’s investigator,” conducted an investigation of the circumstances surrounding Mr Morrison’s death, at my direction, including the preparation of the coronial brief. The coronial brief contained, inter alia, statements made by Mr Morrison’s father Jeffrey Morrison, brother Luke Morrison, General Practitioner at Westgate Medical Centre Dr Firas Al-Jabbari, Senior Consultant Psychiatrist Dr Samir Ibrahim and Clinical Psychologist Dr Matthew Berry.
In the course of the investigation, police learned that Mr Morrison had a long history of illicit drug use and mental ill-health. Jeffrey Morrison stated that his son was a long term drug user,
and was known to use ‘ice’ and heroin.
General Practitioner Dr Firas Al-Jabbari stated that Mr Morrison was a patient at Westgate Medical Centre from 2006. Mr Morrison was revicwed several times at the clinic for issues relating to mental illness and drug use. Since 2014, he had attended 14 appointments. Dr AlJabbari stated that 11 of these consultations related to mental health and drug use issues. Mr Morrison was under the care of a drug clinic in Altona Meadows, and was on their suboxone program. Dr Al-Jabbari said he was referred to multiple psychiatrists and psychologists during the last two years of his life.
Jeffrey Morrison noted that his son had struggled following the death of a close friend from a drug overdose in mid-2015. At around this time, Mr Morrison was referred to Clinical Psychologist Dr Matthew Berry. The first of their five appointments took place on 27 June
Dr Berry reported that Mr Morrison presented with some suicidal ideation, however there were no signs or symptoms of impending risks. He was highly anxious, ambivalent
about his substance use and quiet depressed. Dr Berry opined that Mr Morrison’s depression
5 A coroner’s investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the coroner to assist the coroner with his/her investigation into a reportable death. The coroner’s investigator takes instructions direction from a coroner and carries out the role subject to the direction of a corner.
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and anxiety were primarily psychological in origin, relating to the death of his friend and his
sexuality. Mr Morrison’s fourth appointment with Dr Berry was on 23 July 2015.
Senior Consultant Psychiatrist Dr Samir Ibrahim stated that Mr Morrison was admitted to the Wyndham Clinic on 9 November 2015 for drug dependence issues. He underwent four weeks of drug detoxification and was subsequently transferred to the general psychiatric ward for
assessment and management of his depression.
Dr Ibrahim first met Mr Morrison on 9 December 2015. Dr Ibrahim noted that Mr Morrison had. a long history of chronic depression and substance abuse. He had undergone numcrous detoxification attempts and rehabilitation inpatient admissions, but invariably relapsed. Mr Morrison reported to Dr Ibrahim that he had been depressed and anxious since the age of 12 or
the years.
On 14 January 2016, Mr Morrison was discharged from hospital, into the care of his mother, after conceding he had used heroin on the premises. Mr Morrison was referred to a Crisis
Assessment and Treatment (CAT) Team and a private psychiatrist.
Dr Berry stated that Mr Morrison made contact with him in early 2016. Mr Morrison was hoping to talk about his grief regarding the death of his close friend, as his inpatient admissions had focused primarily on physical rather than psychological treatments. Their fifth and final appointment took place on 11 March 2016. Dr Berry stated that Mr Morrison spoke more openly at this appointment about his grief. He said Mr Morrison appeared quite relieved
to recognise that relapsing into substance use was strongly influenced by psychological issues.
Dr Ibrahim noted that he saw Mr Morrison on 7 April 2016, at his rooms in Sydenham. Mr Morrison attended this appointment with his father, and expressed a desire for readmission to
a detoxification program and subsequent rehabilitation.
On 27 April 2016, Mr Morrison was again admitted to the Wyndham Clinic for drug detoxification, and subsequently transferred to the general ward on 25 May 2016. Dr Ibrahim reported that Mr Morrison expressed sadness relating to a number of matters. After signing an informed consent form, Mr Morrison began an electroconvulsive therapy (ECT) course. At an appointment on 7 June 2016, after receiving a second ECT treatment, he reported feeling better. Dr Ibrahim described Mr Morrison as optimistic about the future at this time. Nursing notes over different shifts reported he had a good mood and ‘nil’ suicidal thoughts. Dr Ibrahim
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noted that Mr Morrison’s behaviour on the ward was changing and becoming more clevated
and active; some of the co-patients were concerned he was using illicit substances.
On 13 June 2016, Mr Morrison was asked about whether he was using drugs. Dr Ibrahim stated that Mr Morrison admitted using ‘ice’ which was provided by friends ‘over the fence’.
Mr Morrison’s mother was called and he was discharged pursuant to an agreement he had signed upon admission. Dr Ibrahim noted that Mr Morrison was provided escitalopram
medication upon discharge, and advised to call his rooms for an urgent appointment.
On 14 June 2016, Mr Morrison telephoned Dr Ibrahim to request an appointment. Dr Ibrahim understood he was using drugs. Mr Morrison was provided an appointment on the afternoon
of 16 June 2016.
Dr Al-Jabbari stated that he last saw Mr Morrison on 14 June 2016. He attended the appointment with his mother and advised that he was craving alcohol and drugs, and wanted a diazepam prescription to assist his withdrawal symptoms. Dr Al-Jabbari said that Mr Morrison conceded he had started using ‘ice’, heroin and marijuana again. He also wanted a prescription for his regular anti-depressants. Dr Al-Jabbari stated that he issued the prescription for escitalopram 20mg, and rejected his request for diazepam. He also advised Mr Morrison to book an appointment with his psychiatrist as soon as possible, and return for a review if needed.
Jeffrey Morrison stated that he was concerned for his son’s health on 15 June 2016, and he was taken to hospital by ambulance for observation. Mr Morrison was discharged the next day.
On 16 June 2016, Dr Ibrahim received a phone call from Jeffrey Morrison, apologising that his son had left the house half an hour prior to the scheduled appointment time, and refused to attend. They agreed to try for another appointment when he returned.
At approximately 1.30am on Friday 17 June 2016, Jeffrey Morrison went to Mr Morrison’s room to say goodnight. Mr Morrison was seated at the end of his bed, watching television.
Jeffrey Morrison reported that he seemed alright at this time.
Further correspondence
By way of correspondence dated 17 December 2016, Mr Morrison’s mother Sally-Ann Morrison provided further information to the Court. Ms Morrison stated that her son had initially suffered from mental ill-health and that he used alcohol and drugs to numb his pain.
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Ms Morrison reported that her son had variously been treated by facilities including Sober
Living House in Carmegie, Essendon Private Hospital, Malvern Private Hospital and the Royal Melbourne Hospital, in addition to the Wyndham Clinic. She noted that Mr Morrison was able to access drugs in these environments, by friends who visited. Ms Morrison lamented that her son would invariably be discharged when he was found to be using drugs, but that the
facilities’ systems had allowed the drugs to enter in the first place.
Ms Morrison stated that after every discharge, her son would ‘go on a binge’ due to his disappointment and shame. She added that he was at significant risk of overdosing during these periods, and on a number of occasions his family had called an ambulance. Ms Morrison also expressed concern that her son was often released too early from hospital following drug overdoses, and would return within 24 hours, following another overdose. She added that she
believed that if safe injection rooms were available, Mr Morrison would still be alive.
Ms Morrison suggested that the conditions in rehabilitation centres should be more restrictive, with regard to intemet access and visitors. She expressed concern in relation to Mr Morrison’s ECT treatment in the weeks leading up to his death, and the lack of consultation with family.
Ms Morrison also noted. dissatisfaction with waiting times and lengthy processes to access rehabilitation centres. While Mr Morrison was covered by private health insurance, she noted
that he often had to wait up to six weeks to obtain a place.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with
the death:
Recent Coronial engagement with heroin-related harms in Victoria
In October 2016, Her Honour Coroner Jacqui Hawkins announced that she would hold an inquest into the death of Ms A,® whose death was ascribed to global cerebral ischaemia secondary to mixed drug toxicity including a substance consistent with heroin. Ms A attended the City of Yarra regularly, particularly the North Richmond area, to purchase and use heroin;
and her fatal hcroin-involved overdose occurred in this area.
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occurred in the City of Yarra.
response to heroin-related harms in the area.
the Legislative Council’s Legal and Social Issues Committee (‘the Issues Committee’).
a position to intervene and reverse opioid drug overdoses in the City of Yarra.
Yarra remained the LGA with the highest frequency of heroin-involved overdose deaths, and
7 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations, as well as assisting in monitoring and evaluating the effectiveness of the recommendations, The CPU comprises a team with training in medicine, nursing, law, public health and the social sciences.
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also demonstrated that, as distinct from any other LGA, a significant majority of fatal heroin overdoses in the City of Yarra involving people who travelled from other areas to consume heroin. Additionally, a much greater proportion occurred in non-residential locations such as
parks, carparks, public toilets, restaurant toilets, cars, and on streets.
without Inquest, delivered 7 July 2017.
harm reduction potential of supervised injecting facilities.
address the steady increase of fatal and non-fatal drug harms in Victoria.
Substances Amendment Medically Supervised Injecting Centre) Bill 2017 was passed in
10 Legal and Social Issues Committee, Parliament of Victoria, Inquiry into the Drugs, Poisons and Controlled Substances Amendment (Pilot Medically Supervised Injecting Centre) Bill 2017, (2017).
“2 Law Reform, Road and Community Safety Committee, Parliament of Victoria, Inquiry into Drug Law Reform, (2018).
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December 2017. The North Richmond Community Health MSIC was opened to the public and
commenced a two year trial period in June 2018.
Future directions in heroin harm reduction
Advocating for establishment of the North Richmond Community Health MSIC has been the central focus of Coroners’ heroin harm reduction efforts over the past two years. However, if this MSIC had been operating when Mr Morrison was still alive, I suspect it would not have had an impact on the risk of his dying from heroin-involved overdose. The reason is, there is no evidence before me that Mr Morrison ever attended the City of Yarra to purchase and/or use heroin. The City of Yarra is not mentioned in any witness statements, and a Victoria Police Law Enforcement Assistance Program (LEAP) search did not reveal any contacts between
Victoria Police members and Mr Morrison in the City of Yarra.
This observation led me to consider what other prevention opportunities might exist to address heroin-related harms and prevent the deaths of people like Mr Morrison. To assist in considering this question, I directed that the CPU prepare updated data on overdose deaths generally and heroin-involved deaths in particular. The updated data, including. 2017 statistics
on fatal overdoses in Victoria, is Attachment B to this finding and shows:
a. The frequency of heroin-involved overdose deaths continued to rise in 2017, reaching 220 deaths (table 6). Between 2012 and 2017, the annual frequency of Victorian heroin-
involved overdose deaths more than doubled.
b. A substantial number of heroin-involved overdose deaths continued to occur in the City of Yarra in 2017, confirming that it remains an area of elevated heroin-related mortality.
However, there were several other LGAs with notably high levels of heroin overdose
deaths, including the City of Melbourne and Brimbank (table 9a).
c. The City of Yarra remained the only LGA where the majority of heroin-involved overdose deaths were of people who did not live in that LGA (table 10a). This provides further support for the rationale for locating the first MSIC in North Richmond: the City of Yarra attracts people from other areas to use heroin to an extent that does not occur anywhere
else.
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who inject drugs.
Mr Morrison had a significant history of mental ill-health and illicit drug use. However, there is no
evidence that he intended to take his own life on 17 June 2016.
I accept and adopt the medical cause of death as oped by Dr Khamis Almazrooei and find that Samuel Jack Morrison died from combined drug toxicity involving heroin, benzodiazepine and
others, in circumstances where he did not intend to end his own life.
I acknowledge the immense distress and grief endured by Mr Morrison’s family in the wake of his death. I note Ms Morrison’s frustration that her son was able to access illicit substances while seeking treatment for drug dependence. In doing so, J note that Mr Morrison died at home, and was
not an inpatient at this time.
Mr Morrison’s death is, tragically, only one of hundreds of heroin-involved overdose. deaths that have occurred in Victoria over the past.few years. Each ycar since 2012 the number of heroininvolved overdose deaths has risen in Victoria, and over time several local government areas in
Metropolitan Melbourne have been the location of particularly high numbers of deaths.
1 commend the Victorian Department of Health and Human Services for implementing Victoria’s first Medically Supervised Injecting Centre at North Richmond Community Health in the City of Yarra. This initiative hopefully marks the commencement of renewed engagement in prevention of
harms among people who inject drugs.
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Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations:
tisk reducing strategies for people who inject drugs.
Pursuant to section 73(1A) of the Coroners Act 2008, I order that this Finding be published on the
internet.
I direct that a copy of this finding be provided to the following:
Mr Jeffrey Morrison
Ms Sally-Anne Morrison
Mrs Jan Moffatt, Grindal & Patrick Lawyers on behalf of North Western Mental Health Service Secretary of the Department of Health and Human Services
Detective Senior Constable Daniel Blake
Signature:
AUDREY JAMIESON / CORONER Date: 6 August 2018
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Coroners Court of Victoria
Coroners Court of Victoria 65 Kavanagh Street, Southbank Tel: (03) 8688 0700 ail: courtadmin@:coronerscourt.vic.2ov.au
Coroners Court of Victoria
Table 1. Frequency of overdose deaths by local government area of fatal overdose, and type of location where the fatal overdose occurred, Victoria 2012-2016.
Local Type of location at which the deceased fatally overdosed government
area of fatal Ownhome Another'shome Non-residential Total overdose N % N % N % N % Yarra ‘18 28.1 15 23.4 31 48.4 64 100.0 Melbourne 34 58.6 5 8.6 19 32.8 38 100.0 Port Phillip 35. 72.9 9 18.8 4 8.3 48 100.0 Brimbank 28 63.6 8 18,2 8 18.2 44 100.0 Greater Dandenong 32 80.0 4 10.0 4 10.0 40 100.0 Greater Geelong 20 60.6 9 27.3 4 121 33 100.0 Darebin 25 80.6 4 12.9 2 6.5 3L 100.0 Maribyrmong 18 643 3 10.7 7 25.0 28 100.0 Whitehorse 18 75.0 2 8.3 4 16.7 24 100.0 Frankston 14 60.9 7 30.4 2 8.7 23 100.0
Table 2. Frequency of overdose deaths by local government area of fatal overdose, and local
government area of deceased’s usual residence, Victoria 2012-2016.
Local government area of usual residence
Local government SameasLGAof Different to LGA of area of fatal fatal overdose fatal overdose fond overdose N % N % N % Yarra 20 31.3 44 68.8 64 700.0 Melbourne 40 69.0 18 31.0 58 100.0 Port Phillip 36 75.0 12 25.0 48 = 100.0 Brimbank 36 81.8 8 18.2 44 700.0 Greater Dandenong 33 82.5 7 17.5 40 100.0 Greater Geelong 32 97.0 | 3.0 33 100.0 Darebin 28 90.3 3 97 31 100.0 Maribyrnong 19 67.9 9 32.1 28 100.0 Whitehorse 19 79.2 5 20.8 24 100.0 6 26.1 23 100.0
Frankston 17 73.9
Coroners Court of Victoria
Coroners Court of Victoria 65 Kavanagh Street, Southbank Tel: (03) 8688 0700 Email: courtadmin(@coronerscourt.vic.2ov.au
Date:
To:
From:
pe
Coroners Court of Victoria
Overdose deaths, Victoria 2009-2017
6 August 2018 Coroner Audrey Jamieson
Coroners Prevention Unit
Executive summary
(a)
(b)
This data summary examines overdose deaths investigated by Victorian coroners.during the period 2009-2017, and includes two sections specifically focusing on heroin-involved overdose deaths.
The annual frequency of fatal overdoses generally followed an upward trend between 2009 and 2017, reaching 523 deaths in 2017 (page 3).
Approximately 70% of deaths were caused by the acute toxic effects of multiple contributing drugs rather than a single drug (page 3).
Benzodiazepines were consistently the most frequent contributing drug group in overdose deaths across the period (page 6). The proportion of Victorian overdose deaths involving pharmaceutical opioids declined somewhat between 2009 and 2017, while the proportion involving illegal drugs rose (page 6).
Steadily increasing heroin involvement in Victorian overdose deaths was a highly notable finding. Between 2012 and 2017 the annual frequency of Victorian heroin-involvéd overdose deaths more than doubled, reaching 220 in 2017 (page 12). A substantial majority occurred in Metropolitan Melbourne rather than Regional Victoria (page 14).
Among local government areas where heroin-involved overdose deaths occurred, the City of Yarra was distinctive for two reasons. First, it was where the highest frequency of heroin-involved overdose deaths occurred.
Second, it was the only local government area examined where the majority of people who fatally overdosed on heroin did not reside there (page 16).
Overdose Deaths Summary Page 1 of 16
Coroner Audrey Jamieson directed that the Coroners Prevention Unit (CPU) prepare this data summary of overdose deaths investigated by Victorian coroners during the period 2009-2017, including a particular focus on heroin-involved overdose deaths, to contextualise individual deaths currently under investigation.
2, Method This section describes how data was sourced, extracted and analysed to prepare the summary.
2.1 Data source
In Victoria, all deaths from suspected non-natural causes (including suspected overdose deaths) must be reported to the CCOV for investigation. If the investigation establishes the death was an overdose, it is entered into the Victorian Overdose Deaths Register (‘the Register’).
The Register definition of an overdose death is consistent with the definition of “drug poisoning death” in the Substance Abuse and Mental Health Services Administration (SAMHSA) Consensus Panel recommendations: a death where the expert death investigators (the coroner, forensic pathologist and forensic toxicologist) established that the acute toxic effects of a drug or drugs played a contributory role.’ Overdose deaths include deaths where acute toxic effects of drugs were the only cause, and deaths where acute drug toxicity contributed in combination with other non-drug causes such as cardiovascular or respiratory disease. Deaths associated with the behavioural effects of drug taking (for example a fatal motor vehicle collision while affected by drugs and alcohol) or its chronic effects (for example haemorrhage of a gastrointestinal ulcer caused by chronic ibuprofen consumption) are excluded from the Register. Likewise, deaths resulting from allergic reactions to drugs are excluded, and deaths from drug administration-related injury and disease.
The Register definition of the term ‘drug’ is largely consistent with the SAMHSA definition:
Any chemical compound that may be used by or administered to humans or animals as an aid in the diagnosis, treatment, or prevention of disease or injury; for the relief of pain or suffering; to control or improve any physiologic or pathologic condition; or for the feeling it causes.”
However the Register includes alcohol as a drug whereas it is excluded under the SAMHSA definition.
Coded information is stored in the Register for each overdose death, including the deceased.
age, sex, reported date of death, and the location where the fatal overdose occurred. In line with the SAMHSA Consensus Panel recommendations for documenting causality in drug-
1 Goldberger BA, Maxweli JC, Campbell A, Wilford BB, “Uniform Standards and Case Definitions for Classifying Opioid-Related Deaths: Recommendations by a SAMHSA Consensus Panel”, Journal of Addictive Diseases, 32(3), 2013: 231-243.
2 Goldberger BA, Maxwell JC, Campbell A, Wilford BB, “Uniform Standards and Case Definitions for Classifying Opioid-Related Deaths: Recommendations by a SAMHSA Consensus Panel”, Journal of Addictive Diseases, 32(3), 2013: 235.
CCOV Overdose Deaths Summary — August 2018 Page 2 of 16
caused deaths, the Register records each individual drug that the expert death investigators determined was contributory in’ the fatal overdose. Where more than one drug was contributory, each was deemed to be equally contributory. Information regarding drugs that were detected but not determined to be contributory is not recorded.
2.2 Data extraction and analysis
To prepare the summary, on 3 August 2018 the Register was used to identify all Victorian overdose deaths reported to the CCOV between 2009 and 2017, and to extract data on the individual drugs that contributed to each death. This data was collated into a series of tables showing the annual frequency of Victorian overdose deaths by contributing drugs groups, drug types and individual drugs.
2.3 Considerations for interpreting Register data
The contents of the Register are regularly revised and updated as coronial investigations progress. Through the coroner’s investigation, an overdose death initially characterised as involving one drug might be determined to have involved two other drugs; or a death initially thought to be unrelated to drug consumption might be found to be a fatal overdose. This means that data reported from the Register about Victorian overdose deaths occurring in any given period, can change over time.
The contents of the Register are also revised as a result of coding practices being refined in line with current evidence. For example, this data extract was prepared following a detailed review of how the CPU ascertains codeine contribution to heroin- and morphine-involved overdose deaths; this review in turn was sparked by the publication of a new evidence-based model for classifying and reporting heroin-related deaths? The result is that codeine contribution to Victorian overdose deaths in this data summary is lower than the CPU has previously reported.*
A death is only included in the Register when the individual drugs that played a contributory role are known. In some circumstances, overdose can be established as the medical cause of death but the drugs are not known, because suitable blood and urine samples were not able to be obtained for toxicological testing; these are excluded from the Register. Some deaths occur in circumstances strongly suggestive of a fatal overdose, but the forensic pathologist and coroner are unable to ascertain the cause of death. These deaths too are excluded from the Register. Consequently the Register data slightly under-estimates the true number of overdose deaths that occur in Victoria each year.
3 Stam NC, Gerostamoulos D, Dietze PM, Parsons 8, Smith K, Lloyd B, Pilgrim JL, “The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths”, Forensic Science International, 281, 2017: 18-28.
4 For example, in the Victorian overdose deaths summary for 2009-2016 which the CPU provided to the Inquiry into Drug Law Reform, the annual frequency of codeine-involved overdose deaths peaked at 93 in
CCOV Overdose Deaths Summary — August 2018 Page 3 of 16
The 3 August 2018 data extract included 3685 overdose deaths investigated by Victorian coroners between 2009 and 2017. The following tables provide a basic overview of patterns of drug contribution over time in the deaths.
Table | shows the overall annual frequency of overdose deaths in Victoria for the period 2009-2017, and the frequency and proportion of overdose deaths each year which were due to the toxic effects of a single drug versus multiple drugs.
Table 1: Annual frequency and proportion of single- and multiple-drug overdose deaths, Victoria 2009-2017.
Overdose deaths 2009 «892010 2011 2012 2013 2014 2015 2016 2017 Overall frequency 379 341 362 367 3380 387 454 492 523 Single drug 131 123 134 116 119 101 131 137 123 Multiple drug 248 218 228 251 261 286 323 355 400 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1000 100.0 Single drug 34.6 36.1 37.0 31.6 31.3 26.1 28.9 27.8 23.5 Multiple drug 65.4 63.9 63.0 68.4 68.7 3.9 7A 72.2 76.5
Between 2016 and 2017 the annual frequency of Victorian overdose deaths increased by 6.3%. This was the seventh straight year that such an increase occurred; since 2010 the annual frequency of Victorian overdose deaths has increased by 53.4%. The proportion of Victorian overdose deaths involving multiple drugs increased across this period, from 65.4% of deaths (248 of 379) in 2009 to 76.5% of deaths (400 of 523) in 2017.
Contributing drugs across all Victorian overdose deaths were classified into three main types: pharmaceutical drugs, illegal drugs, and alcohol. Table 2 shows the annual frequency of Victorian overdose deaths involving each of these three contributing drug types. Most overdose deaths were from combined (multiple) drug toxicity, which is why the annual frequencies for each drug type in Table 2 sum to greater than the overall annual frequency.
Table 2: Annual frequency and proportion of overdose deaths by contributing drug types, Victoria 2009-2017
Drug types 2009-2010) = 2011) = 2012) 2013, «2014 «=. 2015S 2016 =. 2017 Overall frequency 379 341 362 367 380 387 454 492 523 Pharmaceutical 287 263 274 +303 312 316 356 381 414 Illegal 147 146 150 130 163 164 227 263 271 Alcohol 94 85 89 80 95 94 106 124 151 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Pharmaceutical 75.7 7A 75.7 82.6 82.1 81.7 78.4 77.4 79.2 Tegal 38.8 42.8 41.4 35.4 42.9 42.4 50.0 53.5 51.8 Alcohol 24.8 24.9 24.6 21.8 25.0 243 23.3 25,2 28.9
The proportion of annual Victorian overdose deaths involving pharmaceutical drugs was relatively steady during the period, ranging between 75.7% (2009 and 2011) and 82.6%
CCOV Overdose Deaths Summary — August 2018 Page 4 of 16
(2012); pharmaceutical drugs contributed in an average 78.9% of all overdose deaths across the period. Alcohol contribution was also relatively steady as a proportion of annual Victorian overdose deaths, ranging between 21.8% (2012) and 28.29% (2017) with an annual average 24.9%.
Greater variation occurred in illegal drug contribution. Between 2009 and 2014, the annual proportion of Victorian overdose deaths involving illegal drugs ranged from 35.4% (2012) and 42.9% (2013), but then increased to 50.0% of overdose deaths in 2015, and 53.5% of overdose deaths in 2016, and 51.8% of overdose deaths in 2017.
To explore further how pharmaceutical drugs, illegal drugs and alcohol interacted with one another, each death was classified according to the combination of drug types that contributed to the fatal overdose. The seven mutually exclusive combinations were:
Pharmaceutical drugs only (no contributing illegal drugs or alcohol).
Pharmaceutical and illegal drugs (no alcohol).
Iegal drugs only (no pharmaceutical drugs or alcohol).
Pharmaceutical drugs and alcohol (no illegal drugs).
Pharmaceutical and illegal drugs and alcohol.
Alcohol only (no contributing pharmaceutical or illegal drugs).
THlegal drugs and alcohol (no contributing pharmaceutical or illegal drugs).
Table 3 shows the annual frequency and proportion of Victorian overdose deaths for each combination of contributing drugs.
Table 3: Annual frequency and proportion of overdose deaths by combinations of contributing drug types, Victoria 2009-2017
ae 2009 2010 2011 2012 2013 2014 2015 2016 2017 Overall frequency 379 341 362 367 380 387 454 492 523 Pharma only 163 141 148 I71 148 160 153 153 165 Pharma + illegal 66 64 63 74 82 91 125 «144189 Illegal only 56 31 62 42 35 42 70 71 68 Pharma + alc 45 33 45 4] 57 45 52 47 61 Pharma + ill + ale 13 25 18 isl 25 20 26 37 49 Alcohol only 24 21 19 19 12 18 22 29 26 Illegal + alcohol 12 6 7 3 1 li 6 11 15
Table 3 continued over page
CCOV Overdose Deaths Summary — August 2018 Page 5 of 16
Table 3 continued from previous page
Pee 2009 2010 2011 2012 2013 2014 2015 2016 2017 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Pharma only 4.0 413 409 466 389 413 337 311 315 Pharma + illegal 17.4 18.8 17.4 20.2 21.6 23.5 27.5 29,3 26.6 Illegal only 14.8 15.0 17.1 11.4 14.5 10.9 15.4 14.4 13.0 Pharma + alc 19 987 124 28 1.0 %N6 WS 96 117 Pharma + ili + alc 3.4 7.3 5.0 3.0 6.6 5.2 5.7 75 9.4 Alcohol only 63 62 52 52 32 47 48 59 50 Illegal + alcohol 3.2 1.8 1.9 0.8 0.3 2.8 1.3 2.2 2.9
Pharmaceutical drug only overdose deaths were consistently the most frequent type of Victorian overdose death between 2009 and 2017. However, over time there was a decline in the proportion of pharmaceutical drug only overdose deaths, and a shift towards overdose deaths involving pharmaceutical drugs in combination with illegal drugs (both with and without alcohol).
Pharmaceutical drugs were disaggregated into drug groups for more detailed analysis. Table 4a shows the annual frequency of Victorian overdose deaths 2009-2017 involving cach of the major contributing pharmaceutical drug groups, with illegal drugs and alcohol included for context. Most overdose deaths were from combined drug toxicity, which is why the annual frequencies for each drug group in Table 4 sum to greater than the overall annual frequency.
Table 4a: Annual frequency and proportion of contribution to overdose deaths, among major contributing pharmaceutical drag groups plus alcohol and illegal drugs, Victoria 2009-2017. (* Non-benzodiazepine
anxiolytics; * Non-opioid analgesics.)
Drug groups 2009-2010 2011) = 2012) 2013) «20142015 2016) 2017 Overall frequency 379 341 362 367 380 387 454 492 523 Benzodiazepines 160 168 180 199 212 215 238 263 303 Ulegal drugs 147 146 150 130 163 164 227 263 271 Opioids 156 127 165 188 175 182 185 183 198 Antidepressants 122 105 101 142 134 144 161 164 196 Alcohol 94 85 89 80 95 94 106 124 151 Antipsychotics 63 64 65 78 75 81 91 107 136 Non-benzo anx.* 35 28 33 38 56 48 60 39 56 Non-opioid anlg.* 26 25 30 44 39 49 46 35 38 Anticonvulsants 18 14 13 10 37... 45 51 54 75 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Benzodiazepines 42.2 49.3 49.7 542 558 556 524 53.5 57.9 Illegal drugs 38.8 42.8 41.4 35.4 42.9 42.4 50.0 53.5 51.8 Opioids 41.2 37.2 45.6 51.2 46.1 47.0 40.7 37.2 37.9
Table 4a continued over page
CCOV Overdose Deaths Summary — August 2018 Page 6 of 16
Table 4a continued from previous page.
Dmg groups 2009-2010 «2011. 2012) 2013) 2014 2015 2016)=— 2017 Antidepressants 32.2 308 27.9 387 35.3 37.2 35.5 33.3 37.5 Alcohol 24.8 249 246 218 250 243 23.30 25.2 289 Antipsychotics 16.6 18.8 18.0 21.3 19.7 20.9 20.0 21.7 260 Non-benzo anx.* 9.2 8.2 9.1 10.4 14.7 12.4 13.2 19 10.7 Non-opioid anlg.* 69 73 8.3 12.0 10.3 12.7 10.1 7d 73 Anticonvulsants AT 4.1 3.6 2.7 9.7 11.6 11.2 11.0 14.3
Benzodiazepines were the most frequent contributing pharmaceutical drug group, playing a role in an average 52.6% of overdose deaths annually across the period. The next most frequent pharmaceutical drug groups were opioids (an average 42.3% of overdose deaths each year), antidepressants (annual average 34.4%) and antipsychotics (annual average 20.6%).
Notable trends in the data included the proportional increase over time in benzodiazepine, antipsychotic and anticonvulsant involvement in overdose deaths; and the recent decrease in the proportion of annual overdose deaths mvolving pharmaceutical opioids.
In Table 4b, the overall frequency of overdose deaths for each of the major contributing drug groups was analysed to establish the proportion of single versus multiple drug overdose deaths associated with each contributing drug group. .
Table 4b: Proportion of single and multiple drug overdoses involving drugs from major contributing drug groups, Victoria 2009-2017
Drug group Nive sindaent <TSdngdeais Benzodiazepines 1938 1.7 98.3 Illegal drugs 1661 27.0 73.0 Opioids 1559 9.4 90.6 Antidepressants 1269 3.7 94.3 Alcohol 918 20.7 79.3 Antipsychotics 760 3.4 96.6 Non-benzodiazepine anxiolytics 393 15.0 85.0 Non-opioid analgesics 332 13,9 86.1 Anticonvulsants 317 3.8 96.2
At one end of the spectrum, 27.0% of the 1661 Victorian overdose deaths that occurred between 2009-2017 and involved illegal drugs, were single-drug deaths. At the other end of the spectrum, only 1.7% of the 1938 overdose deaths involving benzodiazepines were singledrug deaths.
3.5. Overdose deaths by individual contributing drugs Table 5a shows the annual frequency of overdose deaths, Victoria 2009-2017, involving the
most frequent contributing individual drugs. The individual drugs are tabulated by the major drug groups to which they belong.
CccoV Overdose Deaths Summary — August 2018 Page 7 of 16
Table Sa: Most frequent contributing individual drugs in overdose deaths, Victoria 2009-2017.
Individual drugs 2009 2010 «2011 2012 2013 2014 2015 2016 2017 Benzodiazepines 160 168 180 199 212 215 238 263 303 Diazepam 104 109 124 133 164 169 192 204 242 Alprazolam 62 56 43 57 45 28 23 23 27 Temazepam 28 22 48 34 22 20 25 26 32 Oxazepam 18 19 44 40 17 19 34 27 23 Clonazepam 7 8 14 18 19 25 33 31 48 Nitrazepam 17 15 11 24 26 13 17 22 11 Lorazepam 0 0 3 1 4 6 2 7 7 Opioids 156 127 165 188 175 182 185 183 198 Methadone 50 55 72 75 70 67 67 73 71 Oxycodone 41 38 46 46 60 46 58 54 66 Codeine 48 32 38 55 46 47 48 46 37 ‘Tramadol 22 9 15 18 23 23 32 26 32 Morphine 22 12 12 13 9 12 9 13 18 Fentanyl 1 2 5 17 ll 11 23 13 14 Buprenorphine 3 4 14 4 3 7 4 2 8 Tilegal drugs 147 146 150 130 163 164 227 263 271 Heroin 127 136 125 107 128 136 171 190 220 Methamphetamine 23 14 29 34 51 53 72 119 93 Amphetamine 4 4 19 10 10 8 9 I 3 Cocaine 7 1 2 4 5 7 15 11 10 MDMA 5 i 1 1 3 4 5 12 7 Antidepressants 122 105 101 142 134 144 161 164 196 Mirtazapine 24 26 22 32 25 41 28 34 47 Amitriptyline 23 21 23 26 30 29 50 25 42 Citalopram 17 22 21 25 24 25 26 28 35 Venlafaxine 25 12 16 15 20 19 10 22 27 Fluoxetine 8 9 8 13 10 7 12 16 10 Duloxetine 3 5 7 15 lL 12 12 15 12 Sertraline 6 6 4 12 13 9 12 11 18 Desvenlafaxine 0 1 3 6 8 lk 15 19 15 Alcohol 94 85 89 80 95 94 106 124 151 Antipsychotics 63 64 65 78 7 81 1 107 136 Quetiapine 28 36 34 41 41 48 49 57 74 Olanzapine 19 18 17 22 15 21 30 36 4] Risperidone 6 3 11 8 10 7 9 14 9 Zuclopenthixol 5 4 4 6 3 3 5 14 Chlorpromazine 5 2 10 6 3 5 5 Clozapine 5 6 0 4 6 2 4 5 3
Table 5a continued over page
ccov Overdose Deaths Summary — August 2018 Page 8 of 16
Table 5a continued from previous page
Individual drugs 2009 2010 2011 «2012 «2013 «2014:«2015-—« 2016 ~—«2017 Non-benzo anx. 35 28 33 38 56 48 60 39 56 Doxylamine 13 16 li 21 23 13 14 12 18 Zopiclone 6 3 6 13 14 11 17 13 17 Pentobarbitone * 4 5 11 1 8 15 18 9 10 Zolpidem 11 3 5 4 6 11 6 8 Diphenhydramine 5 1 4 7 5 3 4 6 Non-opioid anlg. 26 25 30 44 39 49 46 35 38 Paracetamol 23 21 24 42 37 37 42 30 32 Ibuprofen 5 5 4 5 2 7 5 4 1 Anticonvulsants 18 14 13 10 37 45 51 54 75 Pregabalin ° 0 0 0 0 17 27 34 34 52 Sodium valproate 9 9 5 6 13 9 6 7 Carbamazepine 7 3 6 1 3 8 3 Lamotrigine 1 2 1 2 2 3 6
For Table 5b, the most frequent contributing individual drugs were collated by the proportion.
of single-drug and multiple-drug deaths in which each was involved across the period 2009-
Table 5b: Most frequent contributing drugs in overdose deaths, and the proportion of single and multiple drug overdoses to which each drug contributed, Victoria 2009-2017
% single % raultiple Drug Group N ine ane Diazepam Benzodiazepine 1441 0.1 99.9 Heroin Illegal 1340 26.4 73.4 Alcohol Alcohol 918 20.7 79,3 Methadone Opioid 600 8.3 917 Methamphetamine Illegal 488 14.8 85.2 Oxycodone Opioid 455 8.6 91.4 Quetiapine Antipsychotic 408 2.7 97.3 Codeine Opioid 397 2.5 97.5 Alprazolam Benzodiazepine 364 0.5 99.5 Paracetamol Non-opioid analgesic 288 15.6 84.4 Amitriptyline Antidepressant 279 8.6 914 Mirtazapine Antidepressant 269 ll 98.9 Temazepam Benzodiazepine 257 5.4 94.6 Oxazepam Benzodiazepine 241 1.2 98.8
Table 5b continued over page
5 Pentobarbitone prescribing to humans is not permitted in Australia, and the drug could be alternatively
classified as illegal.
6 Routine post-mortem testing for pregabalin did not commence in Victoria until 2013, which may account for the lack of recorded pregabalin-involved overdose deaths in 2009-2012.
Overdose Deaths Summary — August 2018
Table 5b continued from previous page.
% single % multiple
Drug Group N ala, crag Citalopram Antidepressant 223 2.2 97.8 Olanzapine Antipsychotic 219 0.9 99.1 Clonazepam Benzodiazepine 203 1.0 99.0 Tramadol Opioid 200 1.5 98.5 Venlafaxine Antidepressant 166 5.4 94.6 Pregabalin Anticonvulsant 164 0.0 100.0 Nitrazepam Benzodiazepine 156 3.8 96.2 Doxylamine Non-benzodiazepine anxiolytic 141 1.4 98.6 Morphine Drug Opioid 120 17.5 82.5 Zopiclone Non-benzodiazepine anxiolytic 100 0.0 100.0 Fentanyl Opioid 97 17.5 82.5 Fluoxetine Antidepressant 93 2.2 97.8 Duloxetine Antidepressant 92 33 96.7 Sertraline Antidepressant 91 5.5 94.5 Promethazine Antihistamine 88 0.0 100.0 Pentobarbitone Non-benzodiazepine anxiolytic 81 64.2 35.8 Desvenlafaxine Antidepressant 78 0.0 100.0 Risperidone Antipsychotic TT 1.3 98.7
Notably, only one drug (pentobarbitone) was involved in a greater proportion of single-drug than multiple-drug overdose deaths.
The majority of Victorian fatal overdoses occurred as a result of combined or multiple drug toxicity. This underscores the importance of educating people in how drugs interact with one another, to reduce overdose-related harms.
The continuing ubiquity of benzodiazepines in Victorian overdose deaths reflects a prevention opportunity lost. Acting on concerns about benzodiazepine contribution to Victorian overdose deaths, in 2012 Victorian Coroners commenced a campaign for the Therapeutic Goods Administration (TGA) to move all benzodiazepines from Schedule 4 to Schedule 8 of the Standard for the Uniform Scheduling, so that doctors would need to provide stronger clinical justification when prescribing them. The TGA ultimately determined to move only alprazolam to Schedule 8, leaving all others in their previous schedules. The results of this are now clear: alprazolam involvement in Victorian overdose deaths has declined, but the harms have simply shifted to other benzodiazepines such as diazepam and clonazepam, and overall fatal harms associated with benzodiazepines have remained unchanged.’
The increase in illegal drug contribution to Victorian overdose deaths that was observed in 2015 and 2016, has continued in 2017. Methamphetamine contribution in the deaths
7 For an earlier background and commentary on this issue see Lloyd B, Dwyer J, Bugeja L, Jamieson J, “Alprazolam in fatal overdose following regulatory rescheduling: A response to Deacon et al”, International Journal of Drug Policy, 39, 2017, 138-139.
CCOV Overdose Deaths Summary — August 2018 Page 10 of 16
decreased from 2016 to 2017 after six years of steady year-on-year increases (which included a 65% jump between 2015 and 2016, from 76 to 119 deaths). However this was compensated by yet another year-on-year rise in heroin-involved overdose deaths. Between 2012 and 2017 the annual frequency of heroin-involved overdose deaths more than doubled.
The increasing contribution of quetiapine and pregabalin in the deaths, may be at least in part be driven by the increasing number of heroin-involved overdose deaths; both quetiapine and ~ pregabalin are known to be widely used to enhance the effects of opioids including heroin, and to manage side effects of drug use. While the Victorian Department of Health and Human Services has recognised the seriousness of quetiapine misuse and have determined to include quetiapine among monitored drugs in its real-time prescription monitoring system, pregabalin has not been included as yet; this data suggests they should reconsider this decision.®
The 3 August 2018 data extract included 1340 overdose deaths investigated by Victorian coroners between 2009 and 2017 where heroin was determined to be a contributory drug. This section examines the heroin deaths in more detail.
By way of background, the CPU notes that determining heroin contribution to an overdose is not always straightforward. When heroin-specific metabolite 6-monoacetylmorphine (6MAM) is detected in toxicological analysis, this is generally regarded as sufficient evidence that heroin was used by a deceased person. However 6-MAM is rapidly converted to morphine and therefore can be cleared from the body before death. Morphine, as well as being a heroin metabolite, is also a drug in its own right, and is a metabolite of the drug codeine.
And to further confuse matters, codeine is often present as an adulterant in heroin purchased on the street.
Techniques for interpreting the presence of 6-MAM, morphine and codeine in forensic toxicology results, to determine whether the deceased had used heroin, morphine and/or codeine, have recently been described in the literature.” The CPU has used similar techniques for some time when coding possible heroin-involved overdose deaths into the Register, taking into account the circumstances of the death and the deceased’s history of drug use. Recently, in line with the literature, the CPU revised its coding approach to also consider the ratio of morphine to codeine detected in toxicological analysis.
The CPU acknowledges that despite its best efforts, uncertainty in the available evidence could lead to some overdose deaths being inappropriately attributed to heroin, and likewise heroin being inappropriately excluded as a contributing drug in other deaths. However the number of wrongly coded overdose deaths is likely to be low; each year on average around 78% of Victorian overdose deaths coded as heroin-involved are on the basis of 6-MAM being detected, and 22% are coded as heroin-involved on the basis of circumstantial evidence and codeine-morphine ratios in the absence of 6-MAM.
8 For a more detailed discussion of this issue see Coroner Rosemary Carlin, Finding without Inquest in the Death of NJ [name suppressed], COR 2015 2127, delivered on 4 July 2017.
9 Roxburgh A, Pilgrim JL, Hall WD, Burns L, Degenhardt L, “Accurate identification of opioid overdose deaths using coronial data”, Forensic Science International, 287, 2018: 40-46.
CCOV Overdose Deaths Summary — August 2018 Page 11 of 16
Table 6 shows the annual frequency of heroin-involved overdose deaths in Victoria for the period 2009-2017, and the frequency and proportion of overdose deaths each year which were due to the toxic effects of heroin only versus multiple drugs including heroin.
Table 6: Annual frequency and proportion of heroin-only and multiple-drug (including heroin) overdose deaths, Victoria 2009-2017.
Overdose deaths 2009 «2010. «2011. «2012. 2013) 2014) = 20152016 )=— 2017 Overall frequency 127 136 125 107 128 136 171 190 220 Heroin only 47 46 53 32 38 27 38 36 39 Multiple drug 80 90 72 75 90 109 133 154 181 Overall proportion 100.0 100.0 100.0 100.0 1000 1000 100.0 100.0 100.0 Heroin only 37.0 33.8 42.4 29.9 29.7 19.9 22.2 18.9 17.7 Multiple drug 63.0 66.2 57.6 70.1 70.3 80.1 778 81.1 82.3
The majority of deaths involved other contributing drugs in combination with heroin.
Additionally, the proportion of multiple drug heroin-involved overdose deaths appears to have increased over time.
4.3 Co-contributing drugs in heroin-involved overdose deaths
Table 7 shows the main co-contributing drug groups in heroin-involved overdose deaths, with individual drugs arranged under the groups to which they belong.
Table 7: Most frequent co-contributing drug groups and individual drugs in heroin-involved overdose deaths, Victoria 2009-2017.
Co-contributors 2009 2010 2011 2012 2013 2014 2015 2016 2017 Benzodiazepines 46 73 55 58 71 78 89 109 132 Diazepam 27 46 39 43 61 71 81 91 115 Alprazolam 24 26 14 23 23 14 8 13 16 Oxazepam 4 8 17 8 6 8 9 12 8 Clonazepam 2 7 3 3 6 12 10 9 16 Temazepam 4 4 22 6 5 0 6 5 Nitrazepam 2 6 2 2 9 3 4 ll 2 Antidepressants 18 25 25 32 31 33 42 47 56 Mirtazapine 5 8 5 9 8 10 23 11 11 Citalopram 2 3 & 4 4 9 7 10 13 Amitriptyline 2 5 4 3 7 8 5 7 12 Venlafaxine 0 3 3 4 3 2 0 7 5 Opioids 22 21 28 28 36 35 46 45 38 Methadone 12 12 15 18 24 21 24 25 27 Oxycodone 3 2 7 5 10 5 11 7 7 Tramadol 3 3 1 5 6 7 7 9 5 Codeine 3 3 3 0 2 2 3 8 ]
Table 7 continued over page
ccoVv Overdose Deaths Summary — August 2018 Page 12 of 16
Table Sa continued from previous page
Co-contributors 2009 «2010 «2011 «2012 2013 2014 2015 2016 2017 Hlegal drugs 17 8 15 20 27 43 39 61 57 Methamphetamine ll 6 13 17 24 34 32 37 52 Cocaine 4 0 0 0 4 5 7 8 7 Amphetamine 1 3 7 6 4 4 6 0 0 Alcohol 23 29 22 14 22 27 25 41 60 Antipsychotics 14 18 11 22 24 21 27 33 46 Quetiapine 4 8 3 12 13 10 13 15 20 Olanzapine 7 6 4 7 5 8 11 12 16 Risperidone 2 1 3 3 5 1 4 7 4 Zuclopenthixol 2 2 1 2 1 2 3 2 10 Non-benzo anx. 6 7 2 5 1 8 9 6 13 Diphenhydramine 3 1 2 2 4 5 4 2 5 Doxylamine 2 6 0 2 6 1 2 2 5 Anticonvulsants 2 3 2 1 4 4 7 9 19 Pregabalin 0 0 0 0 2 2 4 5 14
The most frequent co-contributing drug group was benzodiazepines; they played a role overall in 53.1% (711) of the 1340 heroin-involved overdose deaths. Antidepressants were the next most frequent co-contributing drug group (309 deaths, 23.1%) followed by opioids (299 deaths, 22.3%), illegal drugs other than heroin (287 deaths, 21.4%) and alcohol (263 deaths, 19.6%). The highest co-contributing individual drugs were diazepam (574 deaths, 42.8%), methamphetamine (246 deaths, 18.4%) and methadone (178 deaths, 13.3%).
Alcohol, methamphetamine, and a broad range of central nervous system depressant pharmaceutical drugs contribute to heroin-involved overdose death in Victoria. As was noted.
more generally with respect to overdose death in section 3.6 of this data summary, strategies to prevent heroin-involved overdose deaths will likely need to address also the drugs that are taken together with heroin.
On 8 May 2017, Coroner Audrey Jamieson delivered her finding in the death of David Leslie Chapman (case 2722 of 2016), who died from a fatal heroin-involved overdose at a nonresidential location in Richmond. The finding included an attachment with location data on selected heroin-involved overdose deaths for the period 2012-2016. The following tables expand this location data and update it to include deaths from 2017.
§.1. Regions where heroin-involved overdose deaths occurred
Table 8 shows the annual frequency and proportion of heroin-involved overdose deaths that occurred in Metropolitan Melbourne or Regional Victoria.
CCOV Overdose Deaths Summary — August 2018 Page 13 of 16
Table 8: Annual frequency and proportion of heroin-involved overdose deaths where fatal incident occurred in Metropolitan Mefbourne and Regional Victoria, 2009-2017,
Race RUE 2012 «2013S s«a2014. 2015S 2016 ~=—S 2017 -~—Ss‘ Total overdose occurred
Overall frequency 107 128 136 171 190 220 952 Metropolitan Melbourne 90 109 119 150 157 184 809 Regional Victoria 15 18 17 21 32 35 138 Unknown 2 1 0 0 1 1 5
Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Metropolitan Melbourne 84.1 85.2 87.5 87.7 82.6 83.6 85.0 Regional Victoria 14.0 14.1 12.5 12.3 16.8 15.9 14.5 Unknown 1.9 0.8 0.0 0.0 0.5 0.5 0.5
The majority (85%) of heroin-involved overdose deaths occurred in Metropolitan Melbourne; this proportion was relatively steady from year to year.
5.2. Local government areas (LGAs) where heroin-involved overdose deaths occurred
The CPU further disaggregated the location of fatal drug-taking incident to LGA level. Table 9a shows the annual frequency of heroin-involved overdose deaths for the 15 Metropolitan Melbourne LGAs where a total of 20 or more such deaths occurred during the period 20122017. Table 9b shows similar data for the seven Regional Victorian LGAs where a total of eight or more deaths occurred across the period being examined.
Table 9a: Annual frequency and proportion of heroin-involved overdose deaths by LGA where fatal incident occurred, Metropolitan Melbourne 2012-2017.
heap 2012 2013.-=S« «2014S 2015S 2016. ~—2017~—S‘ Total
Metropolitan Melbourne 90 109 119 150 157 184 809 Yarra 5 11 11 19 18 16 80 Melbourne 10 12 17 12 6 15 72 Brimbank 7 12 7 5 12 19 62 Port Phillip 8 7 10 9 13 9 56 Greater Dandenong 7 6 4 ll 11 10 49.
Darebin 3 4 6 8 9 9 39 Maribyrmong 6 1 7 9 5 9 37 Frankston 1 4 8 8 3 6 30 Whitehorse 3 3 4 8 6 6 30 Moreland 4 2 3 5 4 8 26 Knox 0 7 1 7 4 6 25 Moonee Valley 2 2 5 2 6 6 23 Monash 1 4 2 1 10 4 22 Wyndham 2 1 3 5 5 6 22 Boroondara 1 6 1 5 2 5 20 All other LGAs 30 27 30 36 43 50 216
ccoVv Overdose Deaths Summary — August 2018 Page 14 of 16
Table 9b: Annual frequency and proportion of heroin-involved overdose deaths by local government area where fatal incident occurred, Regional Victoria 2012-2017.
Tee eal 2012 2013-2014. 2015-2016 = 2017_~—SCs‘ Total overdose occurred
Regional Victoria 15 18 17 21 32 35 138 Greater Geelong 4 6 6 4 12 6 38 Greater Bendigo 0 1 1 2 3 9 16 Ballarat 1 1 2 1 1 4 10 Latrobe 0 2 2 1 2 2 Wangaratta 1 1 0 0 2 2 Wellington 0 0 1 3 2 0 Mitchell 2 1 1 0 0 1 5 All other LGAs 7 6 4 10 10 il 48
In both Metropolitan Melbourne and Regional Victoria, there were a large number of LGAs each with a comparatively low number of heroin-involved overdose deaths, which is why the ‘all other LGAs’ rows in Table 9a and Table 9b are so high.
For the 15 Metropolitan Melbourne LGAs shown in Table 9a with the highest frequencies of heroin-involved overdose deaths during 2012-2017, the CPU compared the LGA where the fatal overdose occurred with the LGA where the deceased usually resided. Each death was categorised into one of four groups:
Same, if the LGA where the deceased usually resided was the same as the LGA where the fatal overdose occurred.
Different, if the LGA where the deceased usually resided was different to the LGA where the fatal overdose occurred.
Unknown, if the LGA where the. deceased usually resided was not able to be established, or if the deceased had no fixed address proximal to the death.
Interstate / overseas, if the deceased usually resided interstate or overseas and had been in Victoria for less than seven days when the death occurred.
The same categorisation was also applied to the seven Regional Victorian LGAs shown in Table 9b. The results of the categorisation process are shown in Tables 10a and 10b, for Metropolitan Melbourne and Regional Victoria respectively.
Tables 10a and 10b show that overall, the majority of heroin-involved overdose deaths in Metropolitan Melbourne (74.5%, 603 of 809) and Regional Victoria (89.1%, 123 of 138) occurred in the LGA where the deceased usually resided. The only specific LGA examined where this finding did not hold true was the City of Yarra; only 30% of overdose deceased also resided there.
ccov Overdose Deaths Summary — August 2018 Page 15 of 16
Table 10a: Overall frequency of heroin-involved overdose deaths by LGA where fatal incident occurred, Metropolitan Melbourne 2012-2017.
LGA of deceased's usual residence
LGA where fatal overdose occurred Same Different Unknown —_‘Mlerstate/ Total overseas
Metropolitan Melbourne 603 184 13 9 809 Yarra 24 52 2 2 80 Melbourne 48 22 1 1 72 Brimbank 48 11 1 2 62 Port Phillip 40 12 3 1 56 Greater Dandenong 40 8 0 1 49 Darebin 36 3 0 0 39 Maribyrnong 27 10 0 0 37 Frankston 22 7 1 0 30 Whitehorse 24 3 2 1 30 Moreland 22 4 0 0 26 Knox 22 3 (0) 0 25 Moonee Valley 15 8 0 0 23 Monash 18 4 0 0 22 Wyndham 19 3 0 0 22 Boroondara 16 4 0 0 20 All other LGAs 182 30 3 I 216
Table 10b: Overall frequency of heroin-involved overdose deaths by LGA where fatal incident occurred, Metropolitan Melbourne 2012-2017.
LGA of deceased’s usual residence
LGA where fatal overdose occurred Same Different Unknown _—‘lerState/ Total overseas
Regional Victoria 123 11 2 2 138 Greater Geelong 37 0 0 1 38 Greater Bendigo 14 2 0 0 16 Ballarat 9 1 0 0 10 Latrobe 8 0 1 0 9 Wangaratta 4 2 0 0 6 Wellington 5 1 0 0 6 Mitchell 3 0 1 1 5 All other LGAs 43 5 0 0 48
For further information or clarification regarding the Victorian overdose deaths summary presented here, please contact Coroners Prevention Unit Senior Case Investigator Dr Jeremy
Dwyer.
CCOV Overdose Deaths Summary — August 2018 Page 16 of 16
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