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Background: Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death. Aims: This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations. Methods: Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed. Results: From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected ( n = 110 deaths per year), rising to 18% in 2020 ( n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L). Conclusions: Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

Background People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied. Methods We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge. Results We identified 121 coroners’ reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34–46); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression. Conclusion Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care.

Background The UK, as the ‘cocaine capital of Europe’, currently accounts for ~75% of all cocaine-related hospital admissions in Europe. This study aims to analyse trends in cocaine-related deaths in England, Wales, and Northern Ireland over 20 years (2000-2019). Methods Cases reported to the National Programme on Substance Abuse Deaths (NPSAD) occurring between 2000-2019 where cocaine was detected at post-mortem were extracted for analysis. Results 5,339 cases were retrieved, with an increase in the rate of reporting over time. Cocaine was deemed a cause of death and quantified in post-mortem blood samples along with its major metabolite benzoylecgonine in 685 cases. Of these 685 cases, 25% (n=170/685) occurred following acute use, 22% (n=154/685) following chronic/binge use, 40% (n=271/685) in combination with morphine, 4% (n=29/685) in drug packer/swallower circumstances, and 9% (n=61/685) in a suicide context. Cardiac complications were evident in 22% of cases (n=154/685). The average concentration of cocaine detected in cardiac cases (900ng/ml) was considerably lower than that detected in cases where acute (19,100ng/ml) or chronic/binge (6,200ng/ml) dosing was evident. Conclusions This is the first cocaine-related mortality study in this geographical area. Deaths following cocaine use continue to rise despite its Class A drug listing in the UK. Whilst underlying and external risk factors including polydrug use, cardiac complications and mental health can all contribute to incidences of fatal drug toxicity following cocaine use, this study demonstrates that the risk of a cocaine overdose cannot be attributed to a specific blood concentration range.

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Barium is an alkaline earth metal whose toxicity is dictated by its compounded salt form: barium sulphate is insoluble and safe to ingest, but other barium salts (chloride, carbonate, sulphide, oxide, acetate) are bioavailable and therefore toxic when ingested. There have been 49 previous reports of fatal intoxications following barium consumption: 38 deemed accidental in nature, 8 suicidal, 1 homicidal and 2 of undetermined intent. In this report we detail the first intentional fatal self-poisoning with barium chloride to be reported in the UK, along with a review of the surrounding literature. This is the first case to report quantified levels of barium in blood and vitreous humour, and by providing details of sample collection, storage and processing this case will aid in future interpretations.

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