**10. Results**

360 Pharmacology

Given the potentially large numbers of consumers involved in the use of mephedrone across both the EU and the UK (EMCDDA, 2011), the main aims of this study were to report and analyse information relating to the socio-demographics and clinical circumstances of all recorded mepherone-related deaths for the whole of the UK, both when the index drug was taken on its own and when in combination with other drugs. The rationale for doing this is to make accessible a corpus of material which will help inform treatments and interventions so as to reduce deaths associated with the use of this drug and other methcathinones.

In the UK and Islands all sudden, unexpected or violent deaths - as well as deaths in custody - are formally investigated by Coroners (or their equivalent in the Islands), or Procurators Fiscal in the case of Scotland. Most drug-related deaths are subject to these

Since its establishment in 1997, the National Programme on Substance Abuse Deaths (np-SAD) has been regularly receiving coroners' information on drug-related deaths amongst both addicts and non-addicts in the UK, the Channel Islands and the Isle of Man. The average annual response rate from coroners in England and Wales to np-SAD has been between 89% and 95% (Ghodse et al., 2010). Since 2004, information has also been received from the Scottish Crime &Drug Enforcement Agency and the General Register Office for Northern Ireland. To date, details of some 25,000 deaths have been received. The information reported here on deaths associated with mephedrone consumption are based on all relevant cases recorded in the Special Mortality Register of the np-SAD based at St

To be recorded in the np-SAD database as a drug-related death, at least one of the following criteria must be met: (a) presence of one or more psychoactive substances directly implicated in death; (b) history of dependence or abuse of drugs; and (c) presence of controlled drugs at post-mortem. Full details of the np-SAD data collection form and its surveillance work can be found in the Programme's annual report (Ghodse et al., 2010). Ethical approval is not required in the UK for studies whose subjects are deceased. However, confidentiality arrangements are in place with each of the respective data

A range of documents are contained in coronial inquest files, although the variety differs from case to case. Typically, the coroner has access to: statements from witnesses, family and friends; General Practitioner records (if the deceased is registered with one); reports from ambulance, police or other emergency services; hospital Emergency Department and clinical ward reports; psychiatric and substance abuse team reports; as well as post mortem and toxicology reports. Internet searches of toxicological as well as newspaper and other media websites revealed information on further cases. The media reports available for some cases were used to supplement the information provided on the np-SAD data collection form,

In addition to its routine surveillance activities, the Programme also provides real-time information on the emergence of novel substances or new ways of taking existing substances to the UK Early Warning System and the Advisory Council on the Misuse of

**9. Methodology for identifying potential mephedrone-related fatalities** 

processes, typically by way of a coronial inquest (Corkery, 2002).

George's Hospital Medical School, University of London.

especially where access to the full coronial files was not possible.

providers.

A total of 125 alleged or suspected mephedrone-associated fatalities have been identified by the np-SAD team (Fig. 1). However, in 25 cases (20.0%) mephedrone was not found at post mortem and for 13 cases (10.4%) the toxicology results are still pending. For those 87 cases (69.6%) where mephedrone was identified at post mortem, inquests have been concluded in 60 cases. These were considered as confirmed fatalities meeting the above inclusion criteria, and on which the present analysis will focus.

#### **10.1 Demographics**

The mean age of the sample was 28.7 years (SD 11.3), range 14-64 years old. The mean age for males was 28.9 years compared to 28.0 years for females; this difference was not statistically significant (t = 0.27 (two-tailed for equality of means) p = 0.79 (95% CI = -5.87 to +7.72). Where known, most victims were described as 'White' (Table 1). Where place of birth was given, 39 were born in the UK and Islands and 8 overseas. Many were in employment (n = 25), but one-quarter (n = 16) were unemployed, and 11 were students.

Mephedrone-Related Fatalities in the United Kingdom: Contextual, Clinical and Practical Issues 363

Just over half (33) died in their home or that of a friend and 12 in hospital (Table 2). The verdict/conclusion returned by the coroners or procurators fiscal in 35 instances was accidental death or misadventure; (non-dependent) abuse of drugs in 5 cases, suicide in 10 cases, homicide in one case, natural causes in one case, and an open verdict in 8 cases. Fortyfour of these deaths occurred in England; nine in Scotland, four in Northern Ireland, two on

Twenty-seven were known to be as 'addicts' (either dependent on or misusing drugs), and 10 were not addicts; for 23 cases the information was not known. Only 11 of the deceased were known to have been prescribed psychoactive drugs: these included diazepam, antidepressants, antipsychotics, antiepileptics, methadone, and opioid analgesics, often in

space/woodland/river = 7; other = 7; unknown = 1.

Sunday = 13; Monday = 12; Tuesday = 10; Wednesday = 8; Thursday

Feb 2010 = 7; Mar 2010 = 9; Apr 2010 = 6; May 2010 = 3; Jun 2010 = 1; Jul 2010 = 7; Aug 2010 = 2; Sep 2010 = 0; Oct 2010 = 2; Nov 2010 = 2; Dec 2010 = 0; Jan 2011 = 0; Feb 2011 = 2; Mar 2011 = 0; Apr 2011 = 2;

accident/misadventure = 35; (non-dependent) abuse of drugs = 5; open/undetermined = 8; suicide = 10; killed unlawfully = 1; other =

Characteristics

1.

undetermined = 6.

Place of death at home = 28; friend's home = 5; hospital = 12; open

= 2; Friday = 5; Saturday = 10.

Country of death England = 44; Wales = 1; Scotland = 9; Northern Ireland = 4; Guernsey = 2; Jersey = 0; Isle of Man = 0.

Month of death Sep 2009 = 1; Oct 2009 = 1; Nov 2009 = 1; Dec 2009 = 5; Jan 2010 = 7;

Table 2. Circumstances of 60 deaths associated with mephedrone reported to np-SAD

occurred several days later in hospital – in one case three weeks after the event.

The first known death in the UK occurred in September 2009. The number steadily rose to 7 both in January and February 2010, peaked at 9 in March, falling to 6 in April, and declining in the next couple of months to one in June. However, there was a further peak of 7 cases in July, followed by two deaths in August and another 2 in both October and November. There then followed a period of a few months without any reported fatalities, but the most recent deaths occurred in April and May 2011 (Fig. 2). There were twice as many deaths on Saturdays, Sundays, Mondays and Tuesdays (n = 45, average 11.2 per day) compared to the other days of the week (n = 15; average of 5.0 per day). It should be noted that the day of death was not necessarily the day that mephedrone was consumed, as in a few cases death

May 2011 = 2; Jun 2011 = 0; Jul 2011 = 0; Aug 2011 = 0.

natural = 1; accidental = 41; suicidal = 11; homicidal = 1;

Guernsey, and one in Wales.

combination.

Demographic variable

Day of week of death

(this is not necessarily day of consumption)

Verdict (legal conclusion)

Manner of death (intentionality)

Fig. 1. Flow-chart of UK deaths associated with mephedrone


Table 1. Socio-demographics of 60 UK deaths associated with mephedrone reported to np-SAD

mean = 28.9, median = 24.9, minimum = 17.1, maximum = 63.8, range

mean = 28.0, median = 24.9, minimum = 14.8, maximum = 55.1, range

mean = 28.7, median = 24.9, minimum = 14.8, maximum = 63.8, range

invalidity/sickness = 1; student = 11; housewife = 0; unknown = 7.

alone = 11; with parents = 20; with partner = 14; with partner and children = 2; with friends = 4; no fixed abode = 2; self & children = 1;

Age-group (years) < 15 = 1; 15-24 = 30; 25-34 = 16; 35-44 = 6; 45-54 = 5; 55-64 = 2; >64 = 0. Ethnicity White = 50; Black = 0; Asian = 1; Other (Filipina) = 1; Not known = 8. Country of birth England = 32, Wales = 2, Scotland = 1, Northern Ireland = 2, Guernsey = 2; overseas = 8; unknown/unavailable = 13. Employment status non-manual = 9; manual = 14; unemployed = 16; self-employed = 2;

Fig. 1. Flow-chart of UK deaths associated with mephedrone

Characteristics

= 46.8, SD = 11.1.

= 40.3, SD = 12.2.

= 49.0, SD = 11.3.

Other = 1; unknown = 5.

Addict status non-addict = 10; addict/drug abuser = 27; unknown = 23.

Table 1. Socio-demographics of 60 UK deaths associated with mephedrone reported to np-

Demographic variable

Age (years):

Living arrangements

SAD

male (n=45)

female (n=15)

all (n=60)

Just over half (33) died in their home or that of a friend and 12 in hospital (Table 2). The verdict/conclusion returned by the coroners or procurators fiscal in 35 instances was accidental death or misadventure; (non-dependent) abuse of drugs in 5 cases, suicide in 10 cases, homicide in one case, natural causes in one case, and an open verdict in 8 cases. Fortyfour of these deaths occurred in England; nine in Scotland, four in Northern Ireland, two on Guernsey, and one in Wales.

Twenty-seven were known to be as 'addicts' (either dependent on or misusing drugs), and 10 were not addicts; for 23 cases the information was not known. Only 11 of the deceased were known to have been prescribed psychoactive drugs: these included diazepam, antidepressants, antipsychotics, antiepileptics, methadone, and opioid analgesics, often in combination.


Table 2. Circumstances of 60 deaths associated with mephedrone reported to np-SAD

The first known death in the UK occurred in September 2009. The number steadily rose to 7 both in January and February 2010, peaked at 9 in March, falling to 6 in April, and declining in the next couple of months to one in June. However, there was a further peak of 7 cases in July, followed by two deaths in August and another 2 in both October and November. There then followed a period of a few months without any reported fatalities, but the most recent deaths occurred in April and May 2011 (Fig. 2). There were twice as many deaths on Saturdays, Sundays, Mondays and Tuesdays (n = 45, average 11.2 per day) compared to the other days of the week (n = 15; average of 5.0 per day). It should be noted that the day of death was not necessarily the day that mephedrone was consumed, as in a few cases death occurred several days later in hospital – in one case three weeks after the event.

Mephedrone-Related Fatalities in the United Kingdom: Contextual, Clinical and Practical Issues 365

cardiac arrest was caused by multiple drug toxicity (including mephedrone) and/or excited delirium. In two cases the ingestion of mephedrone with other drugs led to hypoxic brain injury (one with cerebral oedema). Health issues were present in a number of cases. These, along with mephedrone (and other substances) contributed to death; for example,

Found unresponsive/dead after taking mephedrone (and other substance) – 14

Suicide by gun-shot following consumption of mephedrone, other methcathinone(s) and

Had consumed mephedrone and other substances, jumped from bridge where relative had

Following family argument, took fatal levels of amitriptyline and methadone, consumed

Reported missing after argument with partner, found dead next day on running track with

Had taken mephedrone, but was stabbed and his large supply of mephedrone was stolen,

Took drugs (including mephedrone and cocaine), started behaving bizarrely, aggressively and abusively; police tried unsuccessfully to calm him down and had to arrest him;

Attended party, took mephedrone 'bomb', collapsed with very high temperature which prevented blood from clotting, causing abdominal haemorrhages, never regained

Took mephedrone and other methcathinones, together with cocaine, which caused fatal

cardiovascular conditions - 4, bronchopneumonia - 3.

Found hanging after paranoiac/suicidal behaviour - 6

Found dead after cutting own throat – 1

previously committed suicide – 1

cocaine – 1

mephedrone – 1

bled to death – 1

consciousness - 1

heart attack – 1

drowned - 1

accident – 3

Found hanging following depression relationship broke up – 1

Self-suspension when intoxicated with alcohol and cocaine – 1 Found hanging after no apparent untoward behaviour – 1

Committed suicide by drug overdose, including mephedrone – 2

collapsed whilst under restraint and suffered cardiac arrest - 1 Attended party, collapsed with cardiac arrest, died in hospital – 1

suicide note, had consumed prescribed medications and mephedrone - 1

Attended party, collapsed with breathing difficulties, died in hospital – 1

Took mephedrone and other substances, collapsed with chest pains – 2

Took cocaine and mephedrone at party, collapsed and died following day - 1 Had consumed mephedrone but died from heroin and alcohol toxicity – 1

Found dead after consuming Datura, dihydrocodeine, alcohol and mephedrone - 1 Had consumed mephedrone and other stimulants, attempted to swim across river but

Had taken mephedrone and other drugs, driving vehicle involved in fatal road traffic

Following consumption of alcohol and mephedrone, felt sick, collapsed, died in hospital – 1

Found hanging following row with girlfriend over his drug misuse - 1

Fig. 2. Evolution of suspected deaths (n = 125) and cases with confirmed positive toxicology for mephedrone submitted to np-SAD as at 31 August 2011 (n = 60)

#### **10.2 Events leading to death**

As might be expected given the typical purpose of using mephedrone to experience its psychoactive effects, many deaths occurred following recreational consumption of the drug (Table 3), often in the deceased's or another's home. However, some deaths (road traffic collisions, drowning, hypothermia, etc.) occurred as the result of accidents through impaired judgement due to mephedrone use. In two cases, the deceased had been engaged in sexual activity.

There was a significant number (n = 18) of deaths involving violent means, and especially hanging (13 cases). In several of these cases, mephedrone was considered by the pathologist/coroner/Procurator Fiscal to have played a role although it was not being specifically mentioned in the cause of death field. Mephedrone withdrawal was considered a contributory factor in one suicide by hanging. There were also three fatal road traffic accidents following consumption of mephedrone (and other drugs), and one homicide when the deceased was killed for his supply of mephedrone (about 500 g).

#### **10.3 Cause(s) of death**

The effects ('adverse', poisoning, intoxication, toxicity) of mephedrone, including other substances, were recorded in the cause of death for 24 cases (Table 4). Consumption of mephedrone led to a seizure in one case, and cardiac arrest in another. In a further case, cardiac arrest was caused by multiple drug toxicity (including mephedrone) and/or excited delirium. In two cases the ingestion of mephedrone with other drugs led to hypoxic brain injury (one with cerebral oedema). Health issues were present in a number of cases. These, along with mephedrone (and other substances) contributed to death; for example, cardiovascular conditions - 4, bronchopneumonia - 3.

Found unresponsive/dead after taking mephedrone (and other substance) – 14

Found hanging after paranoiac/suicidal behaviour - 6

Found hanging following depression relationship broke up – 1

Found hanging following row with girlfriend over his drug misuse - 1

Self-suspension when intoxicated with alcohol and cocaine – 1

Found hanging after no apparent untoward behaviour – 1

Found dead after cutting own throat – 1

364 Pharmacology

Fig. 2. Evolution of suspected deaths (n = 125) and cases with confirmed positive toxicology

As might be expected given the typical purpose of using mephedrone to experience its psychoactive effects, many deaths occurred following recreational consumption of the drug (Table 3), often in the deceased's or another's home. However, some deaths (road traffic collisions, drowning, hypothermia, etc.) occurred as the result of accidents through impaired judgement due to mephedrone use. In two cases, the deceased had been engaged

There was a significant number (n = 18) of deaths involving violent means, and especially hanging (13 cases). In several of these cases, mephedrone was considered by the pathologist/coroner/Procurator Fiscal to have played a role although it was not being specifically mentioned in the cause of death field. Mephedrone withdrawal was considered a contributory factor in one suicide by hanging. There were also three fatal road traffic accidents following consumption of mephedrone (and other drugs), and one homicide when

The effects ('adverse', poisoning, intoxication, toxicity) of mephedrone, including other substances, were recorded in the cause of death for 24 cases (Table 4). Consumption of mephedrone led to a seizure in one case, and cardiac arrest in another. In a further case,

for mephedrone submitted to np-SAD as at 31 August 2011 (n = 60)

the deceased was killed for his supply of mephedrone (about 500 g).

**10.2 Events leading to death** 

in sexual activity.

**10.3 Cause(s) of death** 

Suicide by gun-shot following consumption of mephedrone, other methcathinone(s) and cocaine – 1

Had consumed mephedrone and other substances, jumped from bridge where relative had previously committed suicide – 1

Committed suicide by drug overdose, including mephedrone – 2

Following family argument, took fatal levels of amitriptyline and methadone, consumed mephedrone – 1

Reported missing after argument with partner, found dead next day on running track with suicide note, had consumed prescribed medications and mephedrone - 1

Had taken mephedrone, but was stabbed and his large supply of mephedrone was stolen, bled to death – 1

Took drugs (including mephedrone and cocaine), started behaving bizarrely, aggressively and abusively; police tried unsuccessfully to calm him down and had to arrest him; collapsed whilst under restraint and suffered cardiac arrest - 1

Attended party, collapsed with cardiac arrest, died in hospital – 1

Attended party, collapsed with breathing difficulties, died in hospital – 1

Attended party, took mephedrone 'bomb', collapsed with very high temperature which prevented blood from clotting, causing abdominal haemorrhages, never regained consciousness - 1

Took mephedrone and other substances, collapsed with chest pains – 2

Took mephedrone and other methcathinones, together with cocaine, which caused fatal heart attack – 1

Took cocaine and mephedrone at party, collapsed and died following day - 1

Had consumed mephedrone but died from heroin and alcohol toxicity – 1

Found dead after consuming Datura, dihydrocodeine, alcohol and mephedrone - 1

Had consumed mephedrone and other stimulants, attempted to swim across river but drowned - 1

Had taken mephedrone and other drugs, driving vehicle involved in fatal road traffic accident – 3

Following consumption of alcohol and mephedrone, felt sick, collapsed, died in hospital – 1

Mephedrone-Related Fatalities in the United Kingdom: Contextual, Clinical and Practical Issues 367

1a Cardiac arrest, cause unascertained between multiple drug toxicity [mephedrone,

1a Overdosage of mephedrone (meow meow) compounded by cocaine; 2 Cocaine abuse - 1

1a Patchy bronchopneumonia & pulmonary oedema; 1b Cardiac ischaemia, contributed to

1a Hypoxic brain injury; 1b Cerebral oedema; 1c Ingestion of psychoactive drug [inc.

1a Combined toxic effects of alcohol, dihydrocodeine and atropine/hyoscine (from Datura

1a Systemic sepsis, resulting in cardiac arrest; 1b Bronchopneumonia; 1c Beta haemolytic

1a Medication toxicity; 2 Acute & chronic debilitating back pain, early stage

(Where cause of death sections of the death certificate specifically mentioned mephedrone or where it was included in verdict. Mephedrone was implicated on its own in 18 cases, with other substances in 18 cases. In many of the hanging causes, mephedrone was considered to have played a contributory role although not recorded in the cause of death.)

Table 4. Cause of deaths associated with mephedrone reported to np-SAD

1a Seizure; 1b Effect of mephedrone – 1

MDPV, fluoromethcathinone] and/or Excited Delirium – 1

1a Combined toxic effects of amphetamine and mephedrone – 1

1a Adverse effects of methadone and mephedrone – 1

1a Ischaemic heart disease; 1b Illicit use of cathinones - 1

1a Mixed MDMA and mephedrone toxicity – 1

by mephedrone, citalopram and diazepam - 1

1a Toxic effects of drugs [inc. mephedrone] – 1 1a Fatal drug intoxication [inc. mephedrone] – 1 1a Mixed drug toxicity [inc. mephedrone] – 1

1a Toxic effects of alcohol and cocaine – 1

1a Morphine toxicity (on balance of probability) – 1

Stramonium) together with postural asphyxia - 1

1a Combined methadone and alcohol overdose – 1

1a Amitriptyline/Methadone overdose - 1 1a Asphyxia [plastic bag suffocation] – 1

1a Combined effects of alcohol and GBL intoxication – 1

1a Heroin and alcohol toxicity - 1

1a Acute alcohol poisoning – 1 1a Morphine (heroin) toxicity - 1

1a BZP and TFMPP toxicity – 1 1a Illicit methadone misuse – 1

Streptococcal Group A infection – 1

bronchopneumonia - 1

1a GHB intoxication – 2

mephedrone] – 1

1a Aspiration of blood; 1b Mixed drug intoxication [inc. mephedrone] - 1

1a Hypoxic brain injury; 1b Mixed drug overdose [inc. mephedrone] - 1

Took alcohol and mephedrone, collapsed and unrouseable, died in hospital - 1 Collapsed after taking mephedrone, died in hospital 3 weeks later from acute liver failure – 1 Attended party where took mephedrone and heroin, collapsed died in hospital 3 weeks later – 1

Died in hospital after taking mephedrone – 1

Indulged in sexual activity, self-injected mephedrone, had seizure and collapsed – 1

Had taken large amounts of methcathinones, engaged in auto-erotic asphyxiation with plastic bag over head, but accidentally suffocated - 1

Consumed amphetamine & mephedrone, vomited, felt cold & sleepy; taken to hospital where, despite treatment, suffered liver problems & multi-organ failure – 1

Found unresponsive in bed, death certified at scene; had been feeling unwell, on medication for chronic abdominal & back pain – 1

Admitted to Emergency Department previous day with drug overdose, had been partying but later found hanging – 1

Aspirated blood following mixed drug (including mephedrone) intoxication - 1

Had consumed GHB and mephedrone; found dead beside bed at home by a friend – 1

Not known – 2

Table 3. Events leading to death

1a Hanging – 10

1a Hanging; 2 Mephedrone withdrawal – 1

1a Hanging; 2 alcohol and mephedrone use – 1

1a Hanging; 2 using mephedrone - 1

1a Shotgun wound to head; 2 Use of mephedrone, methylone and cocaine – 1

1a Blood loss following fatal stabbing to thigh [inflicted by third party] – 1

1a Exsanguination; 1b Neck laceration cutting left jugular vein [self-inflicted] – 1

1a Multiple injuries; 1b Blunt force trauma; 1c Vehicular collision (driver) – 1

1a Ruptured inferior vena cava with haemorrhage in abdominal cavity & cervical spine fracture; 1b Road traffic accident; 2 Cirrhosis of liver & misuse of drugs – 1

1a Multiple injuries [road traffic accident] – 1

1a Multiple injuries [fall from height] – 1

1a Drowning; 2 Multiple drug overdose – 1

1a Hypothermia; 1b Drug overdose [quetiapine, lorazepam, venlafaxine, mephedrone] - 1

1a Adverse effects of mephedrone - 1

1a Poisoning by mephedrone – 1

1a Mephedrone toxicity - 1

1a Mephedrone poisoning; 2 Coronary artery disease – 1

1a Adverse effects of mephedrone; 2 Atherosclerotic coronary artery disease; myocardial fibrosis – 1

1a Mephedrone intoxication – 2

1a Cardiac arrest following ingestion of mephedrone – 1

1a Seizure; 1b Effect of mephedrone – 1 1a Cardiac arrest, cause unascertained between multiple drug toxicity [mephedrone, MDPV, fluoromethcathinone] and/or Excited Delirium – 1

1a Aspiration of blood; 1b Mixed drug intoxication [inc. mephedrone] - 1

1a Adverse effects of methadone and mephedrone – 1

1a Overdosage of mephedrone (meow meow) compounded by cocaine; 2 Cocaine abuse - 1

1a Mixed MDMA and mephedrone toxicity – 1

1a Combined toxic effects of amphetamine and mephedrone – 1

1a Patchy bronchopneumonia & pulmonary oedema; 1b Cardiac ischaemia, contributed to by mephedrone, citalopram and diazepam - 1

1a Ischaemic heart disease; 1b Illicit use of cathinones - 1

1a Toxic effects of drugs [inc. mephedrone] – 1

1a Fatal drug intoxication [inc. mephedrone] – 1

1a Mixed drug toxicity [inc. mephedrone] – 1

1a Hypoxic brain injury; 1b Mixed drug overdose [inc. mephedrone] - 1

1a Hypoxic brain injury; 1b Cerebral oedema; 1c Ingestion of psychoactive drug [inc. mephedrone] – 1

1a Toxic effects of alcohol and cocaine – 1

1a Heroin and alcohol toxicity - 1

1a GHB intoxication – 2

366 Pharmacology

Collapsed after taking mephedrone, died in hospital 3 weeks later from acute liver failure – 1 Attended party where took mephedrone and heroin, collapsed died in hospital 3 weeks

Took alcohol and mephedrone, collapsed and unrouseable, died in hospital - 1

Indulged in sexual activity, self-injected mephedrone, had seizure and collapsed – 1 Had taken large amounts of methcathinones, engaged in auto-erotic asphyxiation with

Consumed amphetamine & mephedrone, vomited, felt cold & sleepy; taken to hospital

Admitted to Emergency Department previous day with drug overdose, had been partying

where, despite treatment, suffered liver problems & multi-organ failure – 1 Found unresponsive in bed, death certified at scene; had been feeling unwell, on

Aspirated blood following mixed drug (including mephedrone) intoxication - 1 Had consumed GHB and mephedrone; found dead beside bed at home by a friend – 1

1a Shotgun wound to head; 2 Use of mephedrone, methylone and cocaine – 1 1a Blood loss following fatal stabbing to thigh [inflicted by third party] – 1 1a Exsanguination; 1b Neck laceration cutting left jugular vein [self-inflicted] – 1 1a Multiple injuries; 1b Blunt force trauma; 1c Vehicular collision (driver) – 1

fracture; 1b Road traffic accident; 2 Cirrhosis of liver & misuse of drugs – 1

1a Ruptured inferior vena cava with haemorrhage in abdominal cavity & cervical spine

1a Hypothermia; 1b Drug overdose [quetiapine, lorazepam, venlafaxine, mephedrone] - 1

1a Adverse effects of mephedrone; 2 Atherosclerotic coronary artery disease; myocardial

later – 1

Died in hospital after taking mephedrone – 1

plastic bag over head, but accidentally suffocated - 1

medication for chronic abdominal & back pain – 1

but later found hanging – 1

Table 3. Events leading to death

1a Hanging; 2 Mephedrone withdrawal – 1 1a Hanging; 2 alcohol and mephedrone use – 1

1a Multiple injuries [road traffic accident] – 1 1a Multiple injuries [fall from height] – 1 1a Drowning; 2 Multiple drug overdose – 1

1a Mephedrone poisoning; 2 Coronary artery disease – 1

1a Cardiac arrest following ingestion of mephedrone – 1

1a Adverse effects of mephedrone - 1 1a Poisoning by mephedrone – 1 1a Mephedrone toxicity - 1

1a Mephedrone intoxication – 2

1a Hanging; 2 using mephedrone - 1

Not known – 2

1a Hanging – 10

fibrosis – 1

1a Acute alcohol poisoning – 1

1a Morphine (heroin) toxicity - 1

1a Morphine toxicity (on balance of probability) – 1

1a BZP and TFMPP toxicity – 1

1a Illicit methadone misuse – 1

1a Combined effects of alcohol and GBL intoxication – 1

1a Combined toxic effects of alcohol, dihydrocodeine and atropine/hyoscine (from Datura Stramonium) together with postural asphyxia - 1

1a Systemic sepsis, resulting in cardiac arrest; 1b Bronchopneumonia; 1c Beta haemolytic Streptococcal Group A infection – 1

1a Medication toxicity; 2 Acute & chronic debilitating back pain, early stage bronchopneumonia - 1

1a Combined methadone and alcohol overdose – 1

1a Amitriptyline/Methadone overdose - 1

1a Asphyxia [plastic bag suffocation] – 1

(Where cause of death sections of the death certificate specifically mentioned mephedrone or where it was included in verdict. Mephedrone was implicated on its own in 18 cases, with other substances in 18 cases. In many of the hanging causes, mephedrone was considered to have played a contributory role although not recorded in the cause of death.)

Table 4. Cause of deaths associated with mephedrone reported to np-SAD

Case No.

Mephedrone present

2 Yes bl <0.01mg/l

4 Yes bl 1.3mg/l

5 Yes bl 0.07mg/l,

6 Yes bl 0.41mg/l,

12 Yes bl 2.24mg/l,

14 Yes bl 0.32mg/l 15 Yes bl 0.88mg/l ,

17 Yes bl 0.04mg/l,

19 Yes bl 3.3mg/l,

21 Yes bl 9.01ug/ml,

ur 0.01ug/ml, stomach +

18 Yes bl

20 Yes bl >

ur +

ur +

0.15mg/l ur 16mg/l

0.42mg/l

8 Yes bl 16ug/l alcohol

10 Yes bl 2.1ug/ml alcohol 11 Yes bl 0.21ug/ml

ur +

ur +

ur +, stomach +

0.19mg/l, ur 64.8mg/l, stomach 2.65mg/l

0.108mg/l, 0.08mg/l

stomach +, hair 4.2ng/mg, 4.7ng/mg

2.0mg/ml

13 Yes bl 1.0mg/l MDMA

7 Yes bl + alcohol cocaine &

Mephedrone levels

Mephedrone-Related Fatalities in the United Kingdom: Contextual, Clinical and Practical Issues 369

Third drug present

Fourth drug present

metabolites

lignocaine

BZP TFMPP chlorpheni-

ramine

GBL TFMPP ketamine methylamph

Fifth drug present

zine

etamine

Sixth drug present

diazepam

Second drug present

3 Yes bl 0.76mg/l alcohol GBL diazepam &

1 Yes bl 0.04mg/l methadone diazepam olanzapine chlorproma-

alcohol diazepam

diazepam citalopram

TFMPP alcohol

alcohol diazepam

morphine cannabis

paracetamol

16 Yes bl 22mg/l alcohol amphetamine diazepam

amphetamine

metabolite

9 Yes bl detected alcohol cocaine cocaethylene levamisole lignocaine

#### **10.4 Drugs implicated**

Mephedrone was specifically mentioned as being present at post-mortem in 59 cases. The drug was formally included in the cause of death in 18 cases and implicitly (e.g. polydrug toxicity given in the cause of death without specifying particular drugs, but mephedrone was found in post-mortem analysis or mentioned by the pathologist as contributing to death) in 10 further cases. In a further case, the drug was not mentioned either as being present at post-mortem (death occurred 3 weeks after mephedrone consumption) or in the cause of death although stated by witnesses to have been consumed.

Where details of the drugs present at post-mortem (or ante-mortem) were given, mephedrone alone was used on eight occasions, solely with alcohol in four cases, and in combination with further substances in 18 cases (Table 5). In 15 cases mephedrone was ingested with stimulants, and with diazepam in 13 cases. It is noteworthy that other newly emerging psychoactive substances were also here identified, including: GBL/GHB, ketamine, and piperazines, as well as other methcathinones (n = 8), especially MDPV. Prescribed medications were also present: opioids including methadone; hypnotics/sedatives; antidepressants; antipsychotics; and antiepileptics.

(Mephedrone was present in 59 cases, including 2 ante-mortem. It had been consumed in all cases in the period leading up the incident causing death.)

Mephedrone sole mention – 8 Mephedrone with alcohol – 4 Mephedrone and alcohol and other drugs - 18 Mephedrone with cannabis – 4 Mephedrone with stimulants – 15 Mephedrone with diazepam - 13 Mephedrone with opiates – 12 Mephedrone with piperazines – 7 Mephedrone with GBL/GHB – 5 Mephedrone with ketamine – 2 Mephedrone with other methcathinones – 8 Mephedrone with antidepressants – 5 Mephedrone with antipsychotics - 2 Mephedrone with antiepileptics - 1 Mephedrone with hypnotics/sedatives (exc. Diazepam) – 3

Table 5. Summary of drug combinations and positive toxicological findings for deaths associated with mephedrone reported to np-SAD

#### **10.5 Toxicology**

Full details of mephedrone levels are given in Table 6; actual levels were quantified in 36 cases (Table 6). Overall: (n = 36) mean = 1.586mg/l, range = <0.01 – 22.0mg/l; mono-mephedrone cases (n = 10) mean = 1.996mg/l range = <0.01 – 12.15mg/l; combined mephedrone cases (n = 26): mean = 1.429mg/l; range = 0.03 – 22.0mg/l. These figures exclude one combined mephedrone case with a level of >2000mg/l.

Mephedrone was specifically mentioned as being present at post-mortem in 59 cases. The drug was formally included in the cause of death in 18 cases and implicitly (e.g. polydrug toxicity given in the cause of death without specifying particular drugs, but mephedrone was found in post-mortem analysis or mentioned by the pathologist as contributing to death) in 10 further cases. In a further case, the drug was not mentioned either as being present at post-mortem (death occurred 3 weeks after mephedrone consumption) or in the

Where details of the drugs present at post-mortem (or ante-mortem) were given, mephedrone alone was used on eight occasions, solely with alcohol in four cases, and in combination with further substances in 18 cases (Table 5). In 15 cases mephedrone was ingested with stimulants, and with diazepam in 13 cases. It is noteworthy that other newly emerging psychoactive substances were also here identified, including: GBL/GHB, ketamine, and piperazines, as well as other methcathinones (n = 8), especially MDPV. Prescribed medications were also present: opioids including methadone; hypnotics/sedatives; antidepressants; antipsychotics; and

(Mephedrone was present in 59 cases, including 2 ante-mortem. It had been consumed in

Table 5. Summary of drug combinations and positive toxicological findings for deaths

Full details of mephedrone levels are given in Table 6; actual levels were quantified in 36 cases (Table 6). Overall: (n = 36) mean = 1.586mg/l, range = <0.01 – 22.0mg/l; mono-mephedrone cases (n = 10) mean = 1.996mg/l range = <0.01 – 12.15mg/l; combined mephedrone cases (n = 26): mean = 1.429mg/l; range = 0.03 – 22.0mg/l. These figures exclude one combined

cause of death although stated by witnesses to have been consumed.

all cases in the period leading up the incident causing death.)

Mephedrone and alcohol and other drugs - 18

Mephedrone with other methcathinones – 8 Mephedrone with antidepressants – 5 Mephedrone with antipsychotics - 2 Mephedrone with antiepileptics - 1

associated with mephedrone reported to np-SAD

mephedrone case with a level of >2000mg/l.

Mephedrone with hypnotics/sedatives (exc. Diazepam) – 3

**10.4 Drugs implicated** 

antiepileptics.

**10.5 Toxicology** 

Mephedrone sole mention – 8 Mephedrone with alcohol – 4

Mephedrone with cannabis – 4 Mephedrone with stimulants – 15 Mephedrone with diazepam - 13 Mephedrone with opiates – 12 Mephedrone with piperazines – 7 Mephedrone with GBL/GHB – 5 Mephedrone with ketamine – 2


Case No.

Mephedrone present

54 Yes bl

57 Yes ur

reported to np-SAD

**11. Discussion** 

**11.1 User profile** 

53 Yes bl 0.04mg/l,

59 Yes bl 0.05mg/l,

with mephedrone in the literature.

involve other methcathinones such as MDPV.

Mephedrone levels

51 Yes ur + methylam-

ur +

<0.005mg/l

<0.005mg/l

ur 0.05mg/l

Mephedrone-Related Fatalities in the United Kingdom: Contextual, Clinical and Practical Issues 371

50 Yes bl 0.17mg/l MDPV MDMA MDA cocaine diazepam

Third drug present

morphine nitrazepam buprenor-

Fourth drug present

amphetamine GHB ketamine

phine

diazepam

flephedrone MDPV ibuprofen unidentified

atropine hyoscine

Fifth drug present

butylbromide

mirtazapine

compounds

metabolites

Sixth drug present

diazepam

Second drug present

phetamine

55 Yes bl 0.21mg/l cocaine levamisole alcohol 56 Yes n/k methadone amitriptyline nitrazepam

60 Yes bl 1.94mg/l BZP TFMPP diazepam

52 Yes n/k alcohol morphine cocaine fluoxetine

58 Yes n/k MDPV MDPBP pentylone cocaine

MDPV fluoromethcat hinone

Table 6. Combinations of post mortem drugs in deaths associated with mephedrone (levels)

The existence of the Special Mortality Register maintained by the National Programme on Substance Abuse Deaths fulfills several major roles: it provides a unique UK-wide historic repository of unparalleled detailed information on drug-related deaths and deaths of drug addicts since 1997; the provision of a nation-wide surveillance capability for monitoring substance-related deaths; and the provision of information on the epidemiology of such events. This paper contributes to the knowledge-base on mephedrone by providing supplementary/complementary information on the epidemiology of its use in the UK through the provision of centralised collation of post mortem toxicological results. Furthermore, this report has provided an analysis of the only UK-wide, mephedronespecific mortality dataset. Although not all cases have yet been fully investigated, to the best of our knowledge this is the most comprehensive and detailed study of deaths associated

One in five of 'mephedrone fatalities' turned out here not to be actually related to mephedrone, since the drug was actually not identified at post mortem. This might be understood in the context of the high levels of both media attention and public concerns surrounding the unprecedented rapidity of the appearance of mephedrone in the UK recreational drug market (Davey et al., 2010). However, some of these cases turned out to

Typical mephedrone victims in this study were young (78% under 35 years of age); male (75%); White (96% where ethnicity was known); either in full time employment,

alcohol dihydrocodeine



Table 6. Combinations of post mortem drugs in deaths associated with mephedrone (levels) reported to np-SAD
