An authentic yet lighthearted take on the world of medicines and healthcare in the UK
Sept. 24, 2026

9.1 Learning from the Dead, with Dr Caroline Copeland

9.1 Learning from the Dead, with Dr Caroline Copeland
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Season 9

A chance lunchtime conversation changed Dr Caroline Copeland’s career. Newly arrived at St George’s as a pharmacologist, she discovered an old file. Two decades of coroners’ reports were sitting in paper files. Caroline saw what could be learned from them and changed direction to help keep the programme alive. The rest, as they say, is history.

Today Caroline is Senior Lecturer in Pharmacology and Toxicology at King’s College London and Director of the National Programme on Substance Use Mortality. We talk about the people behind the statistics, the role of coroners and toxicology, deprivation and stigma, and why the details recorded after a death matter for preventing the next one. The conversation takes us from naloxone delivered by drone to the changing illicit drug supply and the difficulty of detecting Nitazenes after death.

Our micro discussion continues the theme and explores Caroline’s research suggesting that opioid-related deaths in England and Wales have been substantially underestimated. Why does this matter and what can we do about it? https://www.sciencedirect.com/science/article/pii/S0955395925002725?via%3Dihub

As ever, Caroline shares a memory-evoking medicine, a career anthem and a book. As ever, it is the stories behind the choices that we love. In the Final Ingredient, Gimmo tells the story of Bixonimania: a fictional illness that found its way into confident AI answers. A reminder to check the source, however convincing the wording.

Mentioned in this episode

Follow The Aural Apothecary on LinkedIn and find more episodes at theauralapothecary.com. We are on Instagram @auralapothecary.

From Prescription to Ocean — A TEDx Talk by Jamie HayesWe’re incredibly proud to share that Aural Apothecary co-host Jamie Hayes has taken to the TEDx stage with a thought-provoking talk: Prescription to Ocean: The Hidden Impact of Medicines https://www.youtube.com/watch?v=swCLNaAG5qY

Jamie explores a fascinating and urgent question: What happens to our medicines once they leave the prescription pad — and how do they impact the world beyond the patient? It’s a journey that connects healthcare, the environment, and our shared responsibility for the future. You’ll never think about prescribing (or taking) medicines in quite the same way again. Please take a few minutes to watch, reflect, and share — this is a conversation worth having.

WEBVTT

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Welcome to the Oral Apothecary Podcast, authentic chat about medicines,

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pharmacy and healthcare in the UK.

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Pharmacists Jamie, Gimo and STC take on topical and controversial

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stories but keep it edgy yet light-hearted.

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Podcasts share their career-defining drug, song and book and also

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share their joyful patient stories.

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Welcome to the Oral Apothecary Podcast. It's Series 9. My

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name is Jamie Hayes. For this episode, we're joined by Dr.

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Caroline Copeland. Caroline is a senior lecturer in pharmacology at

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King's College London. Her work focuses on drug-related deaths across

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the UK. We'll welcome Caroline in a moment as she

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shares a drug for our formerie, her career anthem, and

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recommends a book for the Oral Apothecary Library. Our micro-discussion

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this week will be informed by a paper from the

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International Journal of Drug Policy looking at the data on

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opiate-related deaths in England and Wales. But first, let me

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welcome my two fellow apothecaries. STC is in Bournemouth and

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Gimmo is in Cardiff.

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Welcome both. Welcome, evening.

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Yep.

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Series 9.

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Here we are. Very happy to be back for Series 9, yeah.

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We're never quite sure when we finish the previous series

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whether we're going to make it to another one, but

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we have, so well done us.

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Great series lined up.

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It is.

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Lots of guests already pre-booked. The listener might be interested

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to know, but we're not going to tell you who

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they are.

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It's a surprise.

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Wait and see. What have you been up to over

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the summer?

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It's been warm, hasn't it?

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Super hot, yeah.

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So for context, if some people are listening in the future,

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it was a hot summer, record breaker, it's a heat wave,

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and the world's going to end because of AI. So

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AI was a little baby when we started this podcast,

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and we've charted this journey, and we may well find

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ourselves doing the last series when the world's ended because

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of it. But I suppose my main news, Harry, my son,

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graduated with a first in law, so that's That's big

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news for us. So congratulations, Harry.

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Congratulations, Harry.

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Very good. I don't have any students anymore in my family.

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But going back to your AI point, Gimo. Yes, I've

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been trying to be my curious pragmatist self. And I've

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been trying to follow and use some large language models

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where I can. But can't help but being dragged back to, hmm,

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we do need to use the guardrails here, don't we?

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And what came out this week, which was the National

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Commission into AI Regulation in Healthcare. And in fact, one

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of the authors, Professor Henrietta Hughes, who's also the Commissioner

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for Patient Safety, is one of the guests at the

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Royal College of Pharmacy conference, which we are attending, are

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we not? So that will be good. And I thought

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that it's good. And what I really liked, actually, was

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that the new president of the Royal College of Pharmacy

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actually had a good quote. And it said, for pharmacy

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and medicines, it is essential that AI supports rather than

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replaces professional judgment with patients at the center of how

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it is used. We look forward to working with our

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members and partners to ensure AI is adopted safely, effectively,

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responsibly across pharmacy and healthcare. And I obviously agree with that,

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but it was slightly contrary to the overall commission's vision on,

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I think it's page eight of the document, and it

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looks at safe, fast, and trusted, but fast comes at

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the top, And therefore, to my mind, looks like it's

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saying that it's more important than safe and trusted. But

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that might just be the way I'm reading it. But anyway,

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keeping my watch on AI anyway. James?

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Public workshops continue through the summer, which was great. As

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Gimo said, it was a scorcher. And so I think

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some of the workshops went ahead when they perhaps shouldn't, actually.

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It was probably a patient safety incident. asking a load

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of over 50s and over 60s to congregate in a

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local village hall or a rugby club, but they went well.

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And just as we finished Series 8, I gave the

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keynote at the 10-year celebration of realistic medicine in Glasgow.

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So that was a great conference. And the first half

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of the conference in particular was all about culture and

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the arts and the role that they have in improving healthcare.

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And it was a great day.

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And so that was.

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That was that. Okay, let's move on. Our great pleasure

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to welcome Dr. Caroline Copeland to the Oral Apothecary. Caroline

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is a senior lecturer in pharmacology and toxicology at King's

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College London and director of the National Programme on Substance

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Use Mortality. Her research sits at the intersection of pharmacology,

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toxicology and public health, exploring what real-world patterns of drug

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use can tell us about medicine safety and emerging harms.

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Using mortality and toxicological data, she investigates everything from prescription

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and over-the-counter medicines, to novel psychoactive substances and illicit drugs,

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including the often overlooked interactions between them. She also works

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closely with national and international drug policy and surveillance organisations

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to help translate evidence from drug-related deaths into practice and policy.

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Welcome to the podcast, Caroline.

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Thanks very much.

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So.

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If we bumped into you in a pub, a coffee

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shop or indeed a conference in Oxford, what would that

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conversation look like? Tell us about what was the title

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of your session at Oxford? First of all, Caroline, can

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you remember?

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Oh, goodness.

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No.

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Now you're asking me. I submitted something that I hoped

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would be picked. And it was.

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It was eye-catching. I think it was something along the

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lines of learning from death.

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I think, yes, it definitely mentioned death because I think

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we started calling.

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You the death cop.

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It was learning from the dead.

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Learning from the dead. There we are. You're absolutely right.

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We've just got our title.

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Yeah.

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Learning from the dead. So Steve and I bumped into you.

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We were fascinated by, this was before you did your

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talk as well, Caroline, I think we just bumped into you.

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And so tell us about your work, the National Programme

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on Substance Use Mortality and what you get involved in.

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Yeah, so, uh, it's, well, it's been a bit of

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an interesting story to ending up at that conference in Oxford, really. So, uh,

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I'm actually originally a basic pharmacologist, laboratory scientist who did, um,

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all sorts of different experimental techniques. And, uh, it was

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during my first lectureship at St George's medical school that

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I had a new job. It was my first lecture,

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lecturing position. I was very excited. And this woman came

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into my office and said, you're not Colin. To which

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I had to say, no, I'm not Colin.

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Not from accounts either. You weren't from accounts either.

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No, I had to tell her that I had Colin's

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job from Colin's office because he'd left quite quickly for

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another university. And she said, oh, sometimes I have lunch

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with him. And then she went, well, you knew, so

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you won't have anyone to have lunch with. So let's

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have lunch. I couldn't really argue with this chain of thoughts.

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So I said, right, yeah, cool. Let's have lunch. And

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she told me in this conversation that she was the

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point two FT admin assistant essentially left working on this

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drug deaths database. The chap who had founded it died

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suddenly five or six years prior and nobody had taken

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it on and it was going to close. And the

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more I learned about it and heard her speak, I

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was like, this can't shut. Like this is too much

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of a shame. And so I pivoted entirely from neuronal

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network sensory pharmacology to the pharmaco-epidemiology of drug deaths. And

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here we are, however many years it is later, I

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started doing this in, I think that was 2018. So yeah,

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so coming up for eight years now, rescuing this database,

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promoting it, using the data and learning.

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From the dead.

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So what was it about the database that struck you

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as important?

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So the database was started in 1997. So even by 2017,

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there was 20 years worth of drug death data that

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was being routinely reported by coroners. And it wasn't digitised.

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It was all paper-based records in a filing cabinet. And

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I just thought that it would be a massive shame

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for all this data that could be used to evidence

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better drug policy and prevent future deaths from happening and

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I just thought it was a massive shame that it

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would otherwise just go to waste and drugs are interesting

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you know drugs are cool as well so you know

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you have that aspect of it that I was interested

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in getting into and yeah it's such an amazing resource

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and I think another aspect of it is that if

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you meet me at a conference in Oxford dressed quite nicely,

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you'll see a fairly well-spoken white woman who I like

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to think of myself as well-dressed, but it really depends

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upon the day, I suppose. But actually, both of my

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parents grew up on council estates. Neither of them went

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to university. And they worked really, really hard to make

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sure that me and my brother weren't exposed to the

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childhoods that they had, essentially. And I know that I

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am just one generation away from living in a deprived

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area of the UK and exposed to social housing and

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all the problems that come with that. And reading about

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all these people that did live those lives and weren't

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offered the opportunities that me and my brother were, that's

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part of my motivation for working on this as well,

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is to try and afford better opportunities to those that

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weren't as lucky.

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As I was.

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Thanks Grant.

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Just for the listener, it sounds as though, what is

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the name of your two-year-old who's making his debut on podcast?

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Oh, sorry. Yes, it's little Eugene, just Gene we call him.

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He is in the room next door having a bath.

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So if you can hear some splashing like a washing machine.

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I apologise for that.

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I can hear laughing, he's loving it by the sounds

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of it.

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Yeah, bath time with Daddy, so yeah, always chaos.

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So Carly, you mentioned the database. For the lay listener,

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very simply, what is the database? How does it work

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and what's it involved in?

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So any death... uh, due to psychoactive drug use. So

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that's drugs that act on the brain, uh, gets reported

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to us by the coroner that presided over the inquest of,

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of that person's life and death. Uh, so that the

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deaths that happen can be due to illicit drug use.

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So things like heroin or MDMA or ecstasy, uh, but

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also licensed medicines. So things like fentanyl and, uh, pregabalin

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people might have heard of, diazepam, which is marketed as Valium.

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So any deaths due to those substances. And so there's

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a huge range of things that we can do with

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that data. So broadly, the aim of the work that

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we do is to try and evaluate current drug policy

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and suggest how we can make it better and propose

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new drug policy. We can... survey the illicit drug market

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for emerging substances and new substances that haven't appeared yet,

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usually quite dangerous substances as well. So that's one of

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the things that we do and we report those new

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notifications to national and international agencies that might not have

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come across them before. We also work with public health

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teams about potentially new innovative things that could be done.

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We're currently working on a project of delivering naloxone, which

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is an antidote for opioid overdose by drone, because the

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modelling suggests that the drone will get to a lot

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of these overdoses much more quickly than an ambulance would. So, yeah,

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so some interesting public health interventions. And then the policy

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thing as well. And, yeah, drug policy is a difficult

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fish to fry.

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Caroline, in preparation for the podcast, we I think we've

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all listened to the BBC Inside Health, Can We Reverse

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Rising Drug Deaths? And really going back to your original

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point about your motivation to get involved, it was a

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fascinating conversation, including a GP who had previously been an

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addict on that Inside Health document. And so as you

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kind of alluded to in talking about the social and

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economic deprivation and the stigma attached to addicts, And maybe

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we'll come on to this. But like you say, if

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we don't shine a light on the numbers and the severity,

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then that potentially stops further investment, doesn't it, in relation

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to public health and things. And it was just such

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a fascinating episode, I think, in relation to, and I

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remember this, the GP, who previously was an addict, saying that,

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you know, it's hard for health professionals to sometimes to

242
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show compassion to addicts, but that actually on a human level,

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you know, each death needs to be considered, doesn't it?

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And so I suppose, again, that partly drives on what

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you're trying to do there is shining a light on

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these things.

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I think for a lot of people who haven't ever

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used drugs themselves or know someone close to them who

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uses drugs, that for those people who are using drugs dependently,

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they have to use those drugs. It's not a choice.

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It's not A recreational, oh, let's have fun tonight, you know,

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pop a tab whilst we're dancing in Ministry of Sound

253
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or whatever. And it's that dependent drug use, which is

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the problematic drug use. And those are the people that

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need the most help. Often they've started using drugs to

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escape some horrible reality or traumatic experience. And it's then

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just become more entrenched since then. And in terms of

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stopping drug use in the UK and anywhere, I think

259
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we have to realise that there are some people that

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will take drugs because they like them and that's just

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going to happen anyway. I am an absolute lover of coffee.

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That's a drug that's psychoactive. It keeps me awake. It

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just happens to be a legal one. But it's the

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drug use that affects people negatively. their relationships, their ability

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to work, their ability to function that need the most help.

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And unfortunately, that population of people aren't a particularly attractive

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bunch for taxpayers to see their money being spent on.

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Yeah.

269
00:14:58.409 --> 00:15:00.600
I mean, the other thing that I did was I

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decided to read Matthew Perry's autobiography that was recommended by

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a previous guest, Sally Neith, episode 6.3, if you're catching up.

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And like you said, his story is incredible. If you've

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never read a story about somebody who openly says that

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they're an addict, it is incredible. Like it's totally, you know,

275
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I've been a health professional for 35 years. Of course,

276
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I've dealt with addicts. But actually, I've never in any

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great depth listened to or read, in this case, just

278
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all the things that he did to feed his addiction.

279
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And going back to the GP who was on the

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inside health He said that they are addicts, they are

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at dis-ease. And he was saying you need to treat

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it like a disease because they are at dis-ease. And

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it was incredible, the Matthew Perry story about how you

284
00:15:51.250 --> 00:15:53.700
might know this, that he ended up after a jet

285
00:15:54.200 --> 00:15:57.419
ski accident, he ended up on Vicodin, which is an

286
00:15:57.679 --> 00:16:02.879
American version of essentially paracetamol and a type of opiate

287
00:16:02.899 --> 00:16:05.870
that we don't have in this country called hydrocodone. but

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00:16:05.909 --> 00:16:09.070
he constantly talks about that. At times he was taking, well,

289
00:16:09.289 --> 00:16:13.149
he says he was taking 55 tablets a day. Well,

290
00:16:13.539 --> 00:16:16.419
I worked that out and that's 16 and a half

291
00:16:16.480 --> 00:16:18.879
grams of paracetamol a day. So I'm not sure whether

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he really was on 55, but maybe he lost count

293
00:16:21.860 --> 00:16:24.340
after a certain time. But the point was, and he

294
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was also on at times 14 milligrams of lorazepam, otherwise

295
00:16:28.289 --> 00:16:31.289
known as Ativan, which is equivalent to 140 milligrams of diazepam.

296
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And he was making Friends, you know, the episodes of Friends.

297
00:16:38.259 --> 00:16:41.120
It was incredible that he was still going and all

298
00:16:41.159 --> 00:16:45.809
the things that he did to hoodwink genuine health professionals,

299
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not people he had on speed dial who were dodgy

300
00:16:48.970 --> 00:16:51.990
and could get him things, but actual genuine health professionals

301
00:16:52.049 --> 00:16:54.190
and how he hoodwinked them into saying he was in

302
00:16:54.490 --> 00:16:56.960
much more pain. That was a real, real window for

303
00:16:57.000 --> 00:16:58.700
me in relation to the life of an addict.

304
00:16:58.879 --> 00:17:02.149
Well, I mean, the doses that you're describing there, I

305
00:17:02.169 --> 00:17:05.130
would agree with you that I would question his liver

306
00:17:05.150 --> 00:17:08.029
function at that point with that much paracetamol on a

307
00:17:08.049 --> 00:17:11.269
daily basis. But in terms of things like that level

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00:17:11.329 --> 00:17:15.069
of diazepam, oh gosh, I can hear the bath has

309
00:17:15.089 --> 00:17:22.450
just ended. In terms of that much diazepam, there are

310
00:17:22.470 --> 00:17:26.269
certain drugs that when you take them regularly, what he

311
00:17:26.309 --> 00:17:28.470
gets used to them a bit like alcohol for some

312
00:17:28.490 --> 00:17:31.869
people and so in order to achieve the same effect

313
00:17:32.150 --> 00:17:34.380
you have to take more and more and more and

314
00:17:34.410 --> 00:17:37.390
next time it's then even more that you're taking so

315
00:17:37.410 --> 00:17:40.119
you know i'm not surprised that he was able to

316
00:17:40.140 --> 00:17:42.920
you know tolerate and function at that such high levels

317
00:17:43.039 --> 00:17:44.680
of flurazepam.

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00:17:44.240 --> 00:17:46.920
Thing is is you hear about matthew perry don't you

319
00:17:46.960 --> 00:17:49.799
because he's he's famous and and was it was it

320
00:17:49.839 --> 00:17:52.740
ketamine he he overdosed on in the end and and

321
00:17:52.779 --> 00:17:55.359
i think So you hear those stories, don't you? But

322
00:17:55.400 --> 00:18:00.460
looking at your research, Caroline, it's a common cause of death,

323
00:18:00.539 --> 00:18:03.660
isn't it? You know, once you strip out natural causes,

324
00:18:03.700 --> 00:18:05.519
it must be up there with one of the sort

325
00:18:05.539 --> 00:18:07.200
of highest sort of.

326
00:18:07.259 --> 00:18:11.410
Yeah, so I don't think we've quite got there in

327
00:18:11.430 --> 00:18:13.150
the UK. I don't think we particularly want to get there.

328
00:18:13.490 --> 00:18:17.210
But I believe that drug overdose a few years ago

329
00:18:17.569 --> 00:18:21.470
surpassed suicide as the biggest killer of under 40s in

330
00:18:21.490 --> 00:18:25.670
the USA. the number of accidental drug overdoses that are happening.

331
00:18:25.910 --> 00:18:30.299
When you're defining drug overdose, you're meaning taking too much

332
00:18:30.339 --> 00:18:32.700
of a drug as opposed to deliberately taking a drug

333
00:18:33.059 --> 00:18:36.299
to take your own life, isn't it? That's what happens.

334
00:18:36.660 --> 00:18:38.880
So we do, so the database that I work on,

335
00:18:38.920 --> 00:18:43.940
we do take any death following drug use, irrespective of intent.

336
00:18:44.480 --> 00:18:47.420
So we do and have done and are doing some

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work in terms of suicide prevention, but we treat, you know,

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00:18:51.269 --> 00:18:53.660
accidental overdoses as unintentional deaths.

339
00:18:54.190 --> 00:18:58.690
Can you join some dots for me then, Caroline? Somebody dies,

340
00:18:58.710 --> 00:19:03.730
where does the corona preventing future death reports fit into that?

341
00:19:04.150 --> 00:19:06.190
And then I think it's a colleague of yours and

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00:19:06.990 --> 00:19:10.250
it's the preventable deaths tracker. Where does all that sort

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00:19:10.289 --> 00:19:11.769
of fit together in our world?

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00:19:12.809 --> 00:19:17.410
So when somebody dies, if their death is deemed to

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be unnatural or unexpected, that's when they're referred to a coroner.

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00:19:23.170 --> 00:19:26.450
So I think if you've seen a healthcare professional within

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00:19:26.710 --> 00:19:29.430
two weeks of your death and you've been fairly unwell,

348
00:19:29.490 --> 00:19:31.740
your death can be treated as expected and you're not

349
00:19:31.779 --> 00:19:35.380
going to be referred up. Then a coroner, if you

350
00:19:35.400 --> 00:19:37.619
get to the coroner's desk, will make an assessment as

351
00:19:37.660 --> 00:19:40.700
to whether or not they will need to proceed with

352
00:19:40.720 --> 00:19:44.930
an inquest. A post-mortem will be ordered depending upon the

353
00:19:44.970 --> 00:19:48.890
circumstances of the death. Toxicology will be taken, but not

354
00:19:49.029 --> 00:19:55.049
all deaths have toxicology. taken. And then the toxicology is

355
00:19:55.190 --> 00:19:59.750
tested for. In terms of which drugs are tested for,

356
00:19:59.789 --> 00:20:03.650
there's a common library of drugs which deaths are screened for,

357
00:20:04.309 --> 00:20:07.880
but the the novel drugs, I think you've mentioned some

358
00:20:07.900 --> 00:20:12.660
of the nitizines, which are these synthetic opioids, synthetic cannabinoids

359
00:20:12.700 --> 00:20:15.640
we have as well, now you're finding counterfeit vapes. And

360
00:20:15.680 --> 00:20:19.720
they aren't tested for in every death. They're only tested

361
00:20:19.740 --> 00:20:22.160
for usually if they're suspected that the person might have

362
00:20:22.180 --> 00:20:25.200
been using those drugs. And it's at that point that

363
00:20:25.259 --> 00:20:29.960
then the toxicologist feeds back any detections and interpretations to

364
00:20:29.980 --> 00:20:32.900
the pathologist who did the post-mortem. And then the pathologist

365
00:20:32.980 --> 00:20:37.920
sends their diagnosis anatomical findings report together with the tox

366
00:20:37.960 --> 00:20:41.240
report to the coroner. The coroner then, depending again upon

367
00:20:41.279 --> 00:20:44.599
the circumstance of death, will have things like a police report,

368
00:20:44.779 --> 00:20:51.099
maybe recent contact with healthcare, maybe some social care support

369
00:20:51.140 --> 00:20:54.180
if that was involved. And they will hold an inquest

370
00:20:54.339 --> 00:20:57.680
and determine the cause of death that happened. And it's

371
00:20:57.700 --> 00:21:00.509
at that point that if a drug was involved, a

372
00:21:00.630 --> 00:21:05.900
psychoactive drug, they will report to us a bundle of

373
00:21:06.319 --> 00:21:09.460
notes about that death, which we then collate and analyse

374
00:21:09.599 --> 00:21:12.420
together with all the others that we receive. But the

375
00:21:12.500 --> 00:21:16.759
deaths only have what's known as a prevention of future

376
00:21:16.819 --> 00:21:23.130
deaths report written if the coroner feels that that death

377
00:21:23.190 --> 00:21:25.809
could have been prevented if certain action had been taken.

378
00:21:26.390 --> 00:21:29.230
And the idea of a PFD, is there no prevention

379
00:21:29.250 --> 00:21:33.029
of future death report, is for the coroner to write

380
00:21:33.069 --> 00:21:38.089
specifically to the organisations that they feel need to action

381
00:21:38.690 --> 00:21:41.970
in order for those such deaths to be prevented from

382
00:21:41.990 --> 00:21:45.769
happening in the future and what my colleague Georgia does

383
00:21:45.809 --> 00:21:49.670
is she collects all these PFDs together so I think

384
00:21:49.950 --> 00:21:53.769
PFDs about a third of them are related to drug

385
00:21:53.869 --> 00:21:56.410
use but a good two-thirds are due to other things

386
00:21:56.470 --> 00:22:00.930
such as the um One famous case, which you probably

387
00:22:00.950 --> 00:22:03.579
will remember, is there was a young girl who ate

388
00:22:03.680 --> 00:22:07.480
a baguette at Pret that was freshly prepared on site.

389
00:22:07.960 --> 00:22:09.619
And there was a rule at the time that freshly

390
00:22:09.660 --> 00:22:12.299
prepared food, you didn't have to list the ingredients on them.

391
00:22:12.799 --> 00:22:15.150
And she had a nut allergy or a sesame allergy,

392
00:22:15.269 --> 00:22:18.490
and she had an anaphylactic reaction and died. So PFD

393
00:22:18.509 --> 00:22:22.109
was written about that anaphylaxis case, you know, maternal death cases,

394
00:22:22.150 --> 00:22:24.190
things like that, all had PFDs written as well.

395
00:22:24.490 --> 00:22:26.619
I guess we might come back to the coroner's bit

396
00:22:26.650 --> 00:22:29.509
when we do the micro discussion, but I don't think

397
00:22:29.529 --> 00:22:31.250
we can let you go before we move on to

398
00:22:31.369 --> 00:22:34.970
ask you to explain to our listeners about nitazines. And again,

399
00:22:35.089 --> 00:22:37.710
we'll put the link in the show notes, the other

400
00:22:37.809 --> 00:22:41.609
podcast that we listen to called The Drug Detectives. But again, fascinating.

401
00:22:41.650 --> 00:22:44.869
Would you want to just explain to the listener nitazines,

402
00:22:44.930 --> 00:22:47.630
what they are and why they're such a problem?

403
00:22:48.170 --> 00:22:51.380
I will try and give you a quick rundown of them.

404
00:22:51.440 --> 00:22:57.559
So nitazines are a type of synthetic opioid that appeared.

405
00:22:59.069 --> 00:23:03.259
More widely on the illicit drug market particularly as adulterants

406
00:23:03.279 --> 00:23:07.299
to heroin and also counterfeit valium tablets in large numbers

407
00:23:07.339 --> 00:23:12.539
in summer 2023 and this was in response we think

408
00:23:13.079 --> 00:23:17.930
to the drug gangs in europe not being quite sure

409
00:23:17.970 --> 00:23:20.509
where they were going to get their heroin from so

410
00:23:20.809 --> 00:23:22.430
in 2021.

411
00:23:22.190 --> 00:23:24.509
This was after the afghanistan war yeah is that right

412
00:23:24.549 --> 00:23:25.230
sorry so.

413
00:23:25.109 --> 00:23:28.920
When yeah so when um the Taliban returned to power

414
00:23:28.960 --> 00:23:32.160
in Afghanistan. One of the first things that they did

415
00:23:32.240 --> 00:23:39.420
was to ban opium poppy planting and harvesting. And Europe

416
00:23:39.500 --> 00:23:43.509
and the UK got most of its heroin from Afghanistan.

417
00:23:44.069 --> 00:23:45.950
And some listeners might be thinking, well, hang on a

418
00:23:46.029 --> 00:23:49.789
second for the previous 20 years, who was in charge

419
00:23:49.829 --> 00:23:52.869
in Afghanistan and let poppy planting happen? Anyway, that's a

420
00:23:52.890 --> 00:23:56.059
different topic for a different time. But when the Taliban

421
00:23:56.539 --> 00:24:00.059
came back, they said no more poppy. And the drug

422
00:24:00.079 --> 00:24:02.440
gangs in Europe were probably going, Christ, what are we

423
00:24:02.460 --> 00:24:04.259
going to do? We've got lots of customer base and

424
00:24:04.279 --> 00:24:07.259
we like making money. And you might think, well, why

425
00:24:07.279 --> 00:24:10.279
haven't we got fentanyl then? And they probably thought the

426
00:24:10.319 --> 00:24:14.269
same thing. But a lot of the illicitly produced fentanyl

427
00:24:14.309 --> 00:24:18.950
and fentanyl precursors go to the US via Mexico. And

428
00:24:19.150 --> 00:24:23.049
the Mexican cartels essentially have a monopoly on fentanyl. fentanyl

429
00:24:23.089 --> 00:24:25.650
and its precursors. And I think the European drug gangs

430
00:24:25.910 --> 00:24:29.420
realized that going into business competition with the Sinaloa cartel

431
00:24:29.859 --> 00:24:32.019
was probably a very good way of not being alive

432
00:24:32.039 --> 00:24:35.460
for very long. So they looked for some alternatives. And

433
00:24:35.519 --> 00:24:38.619
the nitizines were actually synthesized in the late 50s and

434
00:24:38.660 --> 00:24:45.509
early 60s alongside fentanyl and its analogs for potential use

435
00:24:45.569 --> 00:24:49.700
in humans clinically. But it became quite apparent very quickly

436
00:24:49.839 --> 00:24:52.690
that they were far too potent to be useful. Their

437
00:24:53.049 --> 00:24:57.950
therapeutic range massively overlapped with their fatal range and so

438
00:24:58.029 --> 00:25:01.109
being able to titrate a safe dose is just not possible.

439
00:25:01.690 --> 00:25:05.700
So clinical development stopped and they were essentially forgotten about

440
00:25:05.859 --> 00:25:09.819
until 2021 when there were some drug gangs looking for

441
00:25:09.859 --> 00:25:14.319
some alternatives and I think that's probably how we've ended

442
00:25:14.380 --> 00:25:17.089
up with them on our streets and they're incredibly potent.

443
00:25:17.109 --> 00:25:21.019
They are as potent as fentanyl, some of them, and

444
00:25:21.299 --> 00:25:25.180
they're like the weakest ones. And I say weakest there,

445
00:25:25.220 --> 00:25:28.799
but very, very strong still. And then some of them

446
00:25:29.140 --> 00:25:33.009
are 50, 100 times more potent than fentanyl. And so

447
00:25:33.029 --> 00:25:36.769
these are not safe for human use. I think some

448
00:25:36.789 --> 00:25:39.769
of the reported potential uses for them have been the

449
00:25:41.150 --> 00:25:45.650
inclusion in darts for wild animals like rhinos and hippos.

450
00:25:46.349 --> 00:25:50.099
And I think a colleague recently found a proposed use

451
00:25:50.140 --> 00:25:55.289
for them to euthanise beached whales. So they are incredibly

452
00:25:55.329 --> 00:25:58.769
potent and they're incredibly dangerous as a result. I think

453
00:25:58.950 --> 00:26:04.990
for the BBC documentary I prepared three vials of just

454
00:26:05.009 --> 00:26:08.119
table salt for them and in one vial I had

455
00:26:08.460 --> 00:26:11.859
what is a pretty standard accepted lethal dose of heroin

456
00:26:12.480 --> 00:26:15.140
which is half a teaspoon or something in the bottom

457
00:26:15.160 --> 00:26:19.119
of the vial. The amount that a fatal dose of fentanyl,

458
00:26:19.180 --> 00:26:21.859
which is a tenth of a teaspoon, and then a

459
00:26:22.220 --> 00:26:25.019
fatal dose of one of these nitosines. And to do that,

460
00:26:25.299 --> 00:26:29.180
my PhD student at the time was going through some

461
00:26:29.220 --> 00:26:31.720
grains of table salt and he was picking out the

462
00:26:31.769 --> 00:26:35.670
smallest one and putting it on the scale and going, no,

463
00:26:35.710 --> 00:26:38.390
that one's too heavy. I need to find a smaller

464
00:26:38.509 --> 00:26:42.990
one to then plonk it in this vial. That's how

465
00:26:43.029 --> 00:26:45.549
potent these things are. If they were to aerosolize me,

466
00:26:45.589 --> 00:26:48.529
you could overdose just breathing them in which is why

467
00:26:48.670 --> 00:26:53.970
when police and emergency services come across a scene which

468
00:26:54.049 --> 00:26:57.390
involves potential synthetic opioids they have to put on PPE

469
00:26:57.430 --> 00:27:00.809
because they have to be trying to protect themselves in

470
00:27:00.869 --> 00:27:01.930
that scenario as well.

471
00:27:02.109 --> 00:27:06.750
Wow that's a great visual for the listener that's a

472
00:27:06.789 --> 00:27:09.289
great way of describing just how potent they are and

473
00:27:09.670 --> 00:27:12.829
again in that podcast the sad cases of people who

474
00:27:13.309 --> 00:27:17.210
You know, we're forever telling people don't buy drugs online

475
00:27:17.609 --> 00:27:19.589
from somewhere that you don't know where it's come from.

476
00:27:19.630 --> 00:27:22.950
And there were cases, weren't there, where people have bought oxycodone,

477
00:27:22.990 --> 00:27:26.329
for example, because they couldn't get it. And even these

478
00:27:26.349 --> 00:27:29.109
are people who weren't necessarily addicts. They were saying they

479
00:27:29.130 --> 00:27:30.849
couldn't get hold of their, they were short over a

480
00:27:30.869 --> 00:27:33.710
weekend or something, bought it online and it was laced

481
00:27:33.759 --> 00:27:34.880
with nitrazine and they died.

482
00:27:35.710 --> 00:27:39.279
Well, if you've got any listeners out there with some

483
00:27:39.299 --> 00:27:40.740
kids that they want to learn how to say no

484
00:27:40.759 --> 00:27:42.119
to drugs, just send them to me for a week

485
00:27:42.240 --> 00:27:45.329
or two and to redo some of the deaths and

486
00:27:45.910 --> 00:27:49.930
it acts as a pretty good contraceptive in that regard.

487
00:27:49.950 --> 00:27:52.930
And it makes you think that those drug gangs must

488
00:27:52.950 --> 00:27:57.289
have had some pharmacy input or pharmacology input, mustn't it?

489
00:27:57.299 --> 00:27:59.599
There's a couple of pharmacologists waiting for those drug gangs,

490
00:27:59.640 --> 00:28:00.039
isn't there?

491
00:28:00.740 --> 00:28:07.240
Oh, completely. So prior to the Psychoactive Substances Act, there

492
00:28:07.259 --> 00:28:09.000
were things that were called, you might have heard the

493
00:28:09.019 --> 00:28:12.950
term legal highs or designer drugs and And the term

494
00:28:12.990 --> 00:28:14.890
legal high came from because they were at that point

495
00:28:15.150 --> 00:28:17.049
technically legal because they weren't.

496
00:28:17.089 --> 00:28:18.630
Controlled by our drug laws.

497
00:28:19.069 --> 00:28:21.630
That was one of them. But the other term that

498
00:28:21.670 --> 00:28:24.519
was used was design a drug. And that's not because

499
00:28:24.559 --> 00:28:27.299
they had, I don't know, the Louis Vuitton logo on

500
00:28:27.339 --> 00:28:30.380
the pill or something. It was because they were specifically

501
00:28:30.420 --> 00:28:34.819
being designed chemically to circumvent the drug laws. So the

502
00:28:34.839 --> 00:28:37.339
way drug laws are written in banning or controlling a

503
00:28:37.400 --> 00:28:43.519
substance is that the actual structure is described. And these

504
00:28:43.559 --> 00:28:47.440
gangs have medicinal chemists that can interpret this and say, aha, well,

505
00:28:47.480 --> 00:28:53.400
if we do an alkyl substitution instead of a carbonyl substitution,

506
00:28:53.490 --> 00:28:55.589
that will circumvent the law.

507
00:28:55.630 --> 00:28:56.829
Gimmo loves a bit of chemistry.

508
00:28:57.690 --> 00:29:01.150
And we can design our way out of control.

509
00:29:02.309 --> 00:29:05.579
We mentioned at the beginning... and you know it, don't you,

510
00:29:05.640 --> 00:29:08.380
is Dr. Amira Ghegheiros, who we had on, I think,

511
00:29:08.420 --> 00:29:12.839
our second guest, second episode. And the book she recommended

512
00:29:12.880 --> 00:29:16.759
was Narconomics. And just a reminder, if anyone hasn't read it,

513
00:29:16.779 --> 00:29:18.619
it's a really good book, but it's essentially about how

514
00:29:19.339 --> 00:29:22.339
the drug business, the illegal drug business, is a business

515
00:29:22.380 --> 00:29:25.880
like any other big business. And you've just described it

516
00:29:25.920 --> 00:29:29.279
perfectly there. Their supply lines have run up, they've run out,

517
00:29:29.299 --> 00:29:31.900
they've come up with an alternative, they've created a new

518
00:29:31.960 --> 00:29:35.349
product for the market. um you know they've tested it

519
00:29:35.369 --> 00:29:37.450
and they put it put it out to market it's

520
00:29:37.700 --> 00:29:41.980
it's it's frighteningly business like what you're describing isn't.

521
00:29:41.759 --> 00:29:43.740
It i give you breaking bad.

522
00:29:45.940 --> 00:29:51.140
Completely and um before um the so the netizens were

523
00:29:51.160 --> 00:29:55.490
brought under control in the uk beginning of last year

524
00:29:55.509 --> 00:29:58.589
and they were controlled in china in summer last year

525
00:29:59.630 --> 00:30:05.009
And prior to a lot of these novel psychoactives come

526
00:30:05.089 --> 00:30:09.509
out of illicit labs in China. And prior to their

527
00:30:09.569 --> 00:30:14.450
control in those two jurisdictions, the nitizines we were seeing

528
00:30:15.089 --> 00:30:17.250
most of were the ones that were actually the lesser

529
00:30:17.309 --> 00:30:20.359
potent ones. And that's because we think the market sort

530
00:30:20.410 --> 00:30:23.460
of settled on the users not wanting to take something

531
00:30:23.500 --> 00:30:25.930
that would kill them. and the dealers not wanting to

532
00:30:25.970 --> 00:30:28.529
deal something that was killing their customers, because that's bad

533
00:30:28.569 --> 00:30:30.730
for business. If you're shrinking your pool, you're not going

534
00:30:30.750 --> 00:30:36.529
to make money. But post-control, what we've seen is those

535
00:30:36.569 --> 00:30:38.789
principles have now gone out the window, and the drug

536
00:30:38.809 --> 00:30:42.950
gangs are now prioritising not being caught. And so we're

537
00:30:43.019 --> 00:30:46.279
now seeing the more potent nitizines that we didn't actually

538
00:30:46.319 --> 00:30:50.079
see before appearing. And that's because if you need to

539
00:30:50.500 --> 00:30:52.670
smuggle drugs and you don't want to get caught, If

540
00:30:52.690 --> 00:30:55.069
you can smuggle the smallest amount, it's probably not going

541
00:30:55.109 --> 00:30:58.569
to get intercepted. And it can be diluted at destination

542
00:30:58.609 --> 00:31:02.170
into many, many, many more doses. And so they've moved

543
00:31:02.230 --> 00:31:05.650
away from let's not kill our customers to a, well,

544
00:31:05.670 --> 00:31:07.849
we still want to make money. And so we're now

545
00:31:08.650 --> 00:31:12.289
being pushed towards a more potent product, which is even

546
00:31:12.329 --> 00:31:16.569
more dangerous. And this isn't, unfortunately, a new phenomenon either.

547
00:31:16.609 --> 00:31:20.210
There was something coined as the potency paradox, I think,

548
00:31:20.259 --> 00:31:27.079
in the late 90s, by some drug policy experts that

549
00:31:27.150 --> 00:31:30.720
had noticed then that you control something and what next

550
00:31:30.779 --> 00:31:33.559
appears is this even more potent hydro.

551
00:31:34.339 --> 00:31:36.799
Well, let's try and lighten the mood slightly and move

552
00:31:36.819 --> 00:31:38.380
on to your... No, no, no, no, it's fine. We

553
00:31:38.500 --> 00:31:40.799
asked you and you told us, and I think our

554
00:31:40.839 --> 00:31:43.740
listeners will find it very interesting, which is why when

555
00:31:43.769 --> 00:31:46.430
we heard you at Oxford, Jamie and I looked at

556
00:31:46.450 --> 00:31:48.069
each other and said, we've got to get her on

557
00:31:48.109 --> 00:31:50.759
the podcast. So one of the pleasures of coming on

558
00:31:50.799 --> 00:31:53.220
the podcast, and I know that you know this, is

559
00:31:53.259 --> 00:31:56.420
to give us your three prescription item for the oral

560
00:31:56.440 --> 00:31:59.740
apothecary prescription. And the first one always starts with a

561
00:32:00.009 --> 00:32:03.450
desert island drug. So this is a drug or medicine

562
00:32:04.369 --> 00:32:08.450
that evokes a powerful memory for you. So what would

563
00:32:08.470 --> 00:32:10.150
you like to choose and why?

564
00:32:10.170 --> 00:32:15.160
So I am going to choose the very recent and

565
00:32:15.200 --> 00:32:17.819
much talked about GLP-1 agonists.

566
00:32:18.279 --> 00:32:18.599
Okay.

567
00:32:18.950 --> 00:32:19.890
Any one in particular?

568
00:32:20.690 --> 00:32:24.210
Well, I'm not actually going to name one because the

569
00:32:24.250 --> 00:32:28.230
memory that evokes is at the time, I don't think

570
00:32:28.269 --> 00:32:30.750
I knew the name of any of the drugs. So

571
00:32:30.990 --> 00:32:38.119
back when I was an undergraduate in 2000, mid-2000s, I

572
00:32:38.160 --> 00:32:43.700
can't remember if I was in second or third year,

573
00:32:44.000 --> 00:32:49.569
I did pharmacology undergraduate at UCL. And we had a

574
00:32:50.049 --> 00:32:53.170
chap from pharmaceutical industry come and give us a talk.

575
00:32:54.009 --> 00:32:56.190
And it was at a time when we were likely

576
00:32:56.230 --> 00:32:59.190
to be going to industry, you know, big pharma startup,

577
00:32:59.210 --> 00:33:01.619
to be staying in academia. And it was meant to

578
00:33:01.630 --> 00:33:05.880
be a careers talk for us. And what he was

579
00:33:05.920 --> 00:33:10.359
talking about was trying to show us the process of

580
00:33:10.920 --> 00:33:14.339
big pharma. And he asked us, what is the best drug?

581
00:33:14.730 --> 00:33:16.390
that you can think of, you know, chat to your

582
00:33:16.410 --> 00:33:18.470
partner for five minutes and see what you can come

583
00:33:18.529 --> 00:33:21.710
up with. And when he brought everyone back, you know,

584
00:33:21.750 --> 00:33:24.160
we had things like, you know, a cure for HIV,

585
00:33:24.220 --> 00:33:27.720
a cure for tuberculosis. And he sort of went, yeah,

586
00:33:27.799 --> 00:33:31.859
that all seems very good. But in terms of a

587
00:33:31.960 --> 00:33:35.700
large market of wealthy people that can make a profit,

588
00:33:36.569 --> 00:33:41.019
not really the best one. And he then proposed to us,

589
00:33:42.140 --> 00:33:44.519
anti-obesity drugs. He said, you know, it's a problem of

590
00:33:44.559 --> 00:33:47.859
the West. The West has lots of money. And these

591
00:33:47.900 --> 00:33:50.240
are people that have a problem that can be solved

592
00:33:50.339 --> 00:33:54.000
by purchasing these drugs. And that's what a pharmaceutical company

593
00:33:54.099 --> 00:33:58.160
is interested in, is the revenue. And I remember, and

594
00:33:58.220 --> 00:34:00.660
it's a crystallising moment for me in my career, I

595
00:34:00.660 --> 00:34:04.079
remember sitting in that lecture theatre and just thinking, I

596
00:34:05.380 --> 00:34:08.880
don't want to be doing science just to make money.

597
00:34:09.659 --> 00:34:12.630
I want to be doing my science to make a

598
00:34:12.659 --> 00:34:16.489
difference and it was at that point that I decided

599
00:34:16.570 --> 00:34:19.309
I did not ever want to go into industry and

600
00:34:19.349 --> 00:34:23.349
wanted to stay within the academic research field which is

601
00:34:23.369 --> 00:34:26.070
why I can't tell you a particular one because okay

602
00:34:26.420 --> 00:34:28.980
back in the mid-2000s they were more of a concept

603
00:34:29.000 --> 00:34:32.500
than a Zenpig or a Wee Govie or whatever the

604
00:34:32.539 --> 00:34:33.599
newest one is at the moment.

605
00:34:33.659 --> 00:34:36.079
But there is a link though isn't there because basically

606
00:34:36.239 --> 00:34:38.139
a lot of these people are addicted to sugar right?

607
00:34:39.039 --> 00:34:43.159
Um oh gosh goodness me maybe we shouldn't get on

608
00:34:43.260 --> 00:34:47.920
to i am a career fat person here and so

609
00:34:48.059 --> 00:34:51.320
um yeah i i'm um yeah i just have to

610
00:34:51.360 --> 00:34:53.679
look at a jelly baby and i put on three

611
00:34:53.719 --> 00:34:57.659
kilos um whereas my darling husband can drink three liters

612
00:34:57.719 --> 00:35:00.320
of full fat coke an entire packet of haribo and

613
00:35:00.340 --> 00:35:02.500
still have room for a chocolate orange and be shaped

614
00:35:02.519 --> 00:35:07.119
like a triangle and run triathlons so um I don't

615
00:35:07.280 --> 00:35:09.460
think it's just down to how much you eat, unfortunately.

616
00:35:09.519 --> 00:35:11.360
And the sad thing is there's probably going to be

617
00:35:11.389 --> 00:35:13.269
a connection in the future with your current work, because

618
00:35:13.309 --> 00:35:17.130
I wouldn't be surprised if they start appearing on PFDs

619
00:35:17.289 --> 00:35:20.130
or coroner's reports at some point in the future, given

620
00:35:20.510 --> 00:35:21.429
how much they used.

621
00:35:22.389 --> 00:35:25.380
So I had a call from a coroner. Gosh, I

622
00:35:25.400 --> 00:35:27.480
think it was a couple of years ago now. They

623
00:35:27.519 --> 00:35:30.199
had a lady who had died of an overdose of

624
00:35:30.500 --> 00:35:34.530
the antidepressant medication she was prescribed. And the coroner's question

625
00:35:34.590 --> 00:35:38.010
to me was that she had had a few years

626
00:35:38.070 --> 00:35:42.809
prior bariatric surgery. I can't remember if it was a

627
00:35:43.889 --> 00:35:48.110
sleeve or a staple or a bypass. I can't remember exactly.

628
00:35:48.550 --> 00:35:51.929
But his question was that if you have changed how

629
00:35:51.969 --> 00:35:54.389
a drug is absorbed and how much of that drug

630
00:35:54.409 --> 00:35:57.989
can be absorbed, is it possible that she was taking

631
00:35:58.030 --> 00:36:03.750
her drug as prescribed, but actually the altered physiology anatomy

632
00:36:03.809 --> 00:36:08.150
had led to the overdose and we published a paper

633
00:36:08.170 --> 00:36:10.710
about a year ago I think we found it was

634
00:36:10.730 --> 00:36:13.170
only a handful I think it was about 15 people

635
00:36:13.670 --> 00:36:17.010
who had a history of bariatric surgery and then had

636
00:36:17.070 --> 00:36:20.710
died of a drug overdose but I think all of

637
00:36:20.769 --> 00:36:26.150
them had died following use of their prescribed medicines and

638
00:36:26.170 --> 00:36:30.030
it wasn't clear from them if they had been not

639
00:36:30.190 --> 00:36:33.510
using them as directed or using them as they should have,

640
00:36:33.559 --> 00:36:37.639
but then their altered physiology had caused the problems. And

641
00:36:37.719 --> 00:36:41.960
the same goes for these GLP-1 agonists. Part of their

642
00:36:42.019 --> 00:36:47.159
design is that they slow down stomach transit time. So

643
00:36:47.199 --> 00:36:50.550
the food stays in your stomach for longer to make

644
00:36:50.590 --> 00:36:53.849
you feel fuller for longer and more quickly. But if

645
00:36:53.869 --> 00:36:58.170
that happens with your oral medication, and your oral medication

646
00:36:58.230 --> 00:37:00.309
stays in your stomach for longer than it should do,

647
00:37:00.889 --> 00:37:03.969
and doesn't get transited into your intestine, which has a

648
00:37:03.989 --> 00:37:06.289
different pH, which means that it's not going to be

649
00:37:06.309 --> 00:37:08.670
absorbed as well, are we going to end up with

650
00:37:08.750 --> 00:37:13.110
either overall under-absorption, so overdose or lack of therapy in

651
00:37:13.150 --> 00:37:15.449
people taking these GLP-1s? And I don't think we know

652
00:37:15.469 --> 00:37:16.329
the answer to that yet.

653
00:37:16.449 --> 00:37:19.329
Very good. Well, I don't think anybody's had a GLP-1 before,

654
00:37:19.369 --> 00:37:22.360
so I think that's the first into the oral apothecary formulary.

655
00:37:22.840 --> 00:37:25.599
So well done on that. Okay, the second thing then,

656
00:37:26.429 --> 00:37:29.889
is a life or career anthem, a piece of music

657
00:37:29.949 --> 00:37:33.460
to go into the Oral Apothecary Spotify playlist. And yes,

658
00:37:33.559 --> 00:37:35.880
it really is on Spotify. So what would you like

659
00:37:35.900 --> 00:37:36.679
to give us and why?

660
00:37:37.159 --> 00:37:41.400
This was actually really, really tough for me. And not

661
00:37:41.440 --> 00:37:43.019
for the reasons that you'll think of, like, oh, I

662
00:37:43.039 --> 00:37:47.199
don't know which one to choose. But I genuinely don't

663
00:37:47.300 --> 00:37:51.389
listen to music. Oh, wow. I'm one of those people

664
00:37:51.409 --> 00:37:56.010
that can drive for two hours in pure silence. because

665
00:37:56.030 --> 00:37:58.150
I think it's just that I have such a busy

666
00:37:58.230 --> 00:38:01.340
brain that is going 100 miles an hour all the time.

667
00:38:01.760 --> 00:38:05.480
I think I am my own entertainment. And I just

668
00:38:05.599 --> 00:38:07.880
don't listen to music. So what I'm going to suggest

669
00:38:07.900 --> 00:38:11.719
to you instead is I do actually play music in

670
00:38:12.110 --> 00:38:15.829
a brass band. And so I'm going to suggest a

671
00:38:15.909 --> 00:38:24.150
classic brass banding tune for you, which is Knights Templar. uh,

672
00:38:24.230 --> 00:38:30.369
by George Allen. And, uh, this particular brass banding piece, uh,

673
00:38:30.510 --> 00:38:35.360
holds the particular, um, part of my heart because there's

674
00:38:35.380 --> 00:38:37.340
something called, I don't know if you ever heard of

675
00:38:37.400 --> 00:38:41.280
the whip Friday marches at all up in Saddleworth.

676
00:38:42.139 --> 00:38:42.579
Ah, right.

677
00:38:42.960 --> 00:38:47.590
This is right up your street. So, um, every whip Friday.

678
00:38:47.610 --> 00:38:51.219
So however many weeks after Easter that is, um, around

679
00:38:51.219 --> 00:38:54.130
100 bands mostly from the uk but we get people

680
00:38:54.170 --> 00:38:56.889
from canada and norway new zealand all over the show

681
00:38:57.429 --> 00:39:01.409
descend on the villages of saddleworth and they all pile

682
00:39:01.510 --> 00:39:04.269
on to coaches and they drive around and you have

683
00:39:04.289 --> 00:39:08.170
to each the villages as a competition and you have

684
00:39:08.210 --> 00:39:12.510
to announce your arrival by marching down the road playing

685
00:39:12.530 --> 00:39:15.809
a particular tune we in recent years have gone for

686
00:39:16.440 --> 00:39:19.500
pop songs like Backstreet Boys or I think we did

687
00:39:19.559 --> 00:39:22.090
Under the Sea by Little Mermaid one year. And then

688
00:39:22.110 --> 00:39:25.269
you get to the, I'll say arena, but it tends

689
00:39:25.289 --> 00:39:27.369
to just be a patch of grass, where you then

690
00:39:27.429 --> 00:39:30.420
have to play your contest piece and be marked. by

691
00:39:30.440 --> 00:39:34.159
an adjudicator. But a lot of these brass bands have

692
00:39:34.400 --> 00:39:38.230
very fancy uniforms. And if the adjudicator could see them,

693
00:39:38.289 --> 00:39:41.269
they would know which band it was just from the

694
00:39:41.289 --> 00:39:43.130
colour of the jacket or the lapels or something. We

695
00:39:43.190 --> 00:39:45.329
all look like sea captains when we're wearing these things.

696
00:39:46.570 --> 00:39:49.460
And so they have to be hidden from view. So

697
00:39:49.500 --> 00:39:54.480
in some villages, the adjudicator is in a caravan with

698
00:39:54.500 --> 00:39:57.460
the window open. There's one village where they're in the

699
00:39:57.500 --> 00:40:00.460
first floor of a pub, just over the way from

700
00:40:00.480 --> 00:40:02.599
where we play, with the window open. I think my

701
00:40:02.639 --> 00:40:04.980
favourite one, there was a chap one year who was

702
00:40:05.019 --> 00:40:07.889
in the back of a lorry that just had the

703
00:40:07.929 --> 00:40:10.510
back of it just cracked open at the bottom. And

704
00:40:10.829 --> 00:40:12.869
I could see his shoes, and he was very well

705
00:40:12.909 --> 00:40:14.769
dressed back there, from what I could tell from the

706
00:40:14.809 --> 00:40:18.269
shoes and the trousers. But it's this absolutely crazy, mad...

707
00:40:19.429 --> 00:40:24.349
of all these brass bands playing to adjudicators that can't

708
00:40:24.389 --> 00:40:28.050
see them. And it goes on until 11 o'clock midnight.

709
00:40:28.170 --> 00:40:32.849
So Knights Templar, I have probably played as much as

710
00:40:32.929 --> 00:40:35.329
I have drunkenly sung with a beer in one hand

711
00:40:35.389 --> 00:40:38.730
and a pork pie in the other, whilst the band

712
00:40:38.789 --> 00:40:40.510
before us have done it.

713
00:40:40.809 --> 00:40:42.550
How have I never heard of that? That's fantastic.

714
00:40:42.610 --> 00:40:43.659
Oh, it's brilliant.

715
00:40:44.070 --> 00:40:46.239
Let's go. Let's all have an AAA trip.

716
00:40:46.260 --> 00:40:48.519
Didn't that feature in the film Brassed Off?

717
00:40:48.969 --> 00:40:50.400
Oh, I think so, probably.

718
00:40:50.579 --> 00:40:51.760
Oh, I've seen that.

719
00:40:52.000 --> 00:40:53.699
Yeah, similar. That's what I thought.

720
00:40:53.820 --> 00:40:57.019
Yeah, we call it band Christmas. It's our favourite day

721
00:40:57.039 --> 00:40:57.519
of the year.

722
00:40:57.900 --> 00:41:00.300
Very good. I think that's also a first. I don't

723
00:41:00.360 --> 00:41:04.210
think we've had any brass band music. So you're doing

724
00:41:04.269 --> 00:41:06.849
very well. So you've got two. And may I just

725
00:41:06.889 --> 00:41:10.989
say that you are the 94th guest on the Oral

726
00:41:11.030 --> 00:41:14.929
Apothecary and you've had two firsts. So why don't you

727
00:41:14.969 --> 00:41:17.699
fill your boots and go for your third of a

728
00:41:17.840 --> 00:41:20.210
book for the Oral Apothecary Library?

729
00:41:20.469 --> 00:41:25.130
So, I was torn with this one because being an

730
00:41:25.250 --> 00:41:28.719
academic new mum who moved house earlier this year, I

731
00:41:28.760 --> 00:41:32.480
surprisingly find that when I need to be reading something,

732
00:41:32.539 --> 00:41:34.840
unless it's a paper or a bit of my student's work,

733
00:41:34.900 --> 00:41:39.519
I just have extreme guilt. So, I'd either have to

734
00:41:39.579 --> 00:41:43.070
pick an adult book that I have read from quite

735
00:41:43.090 --> 00:41:45.389
a long time ago or I'd One of the books,

736
00:41:45.429 --> 00:41:47.989
which I've probably read about 100 times just in the

737
00:41:48.010 --> 00:41:52.730
past month. So you've either got a choice, and I'll

738
00:41:52.750 --> 00:41:54.010
leave it up to you because one of these might

739
00:41:54.030 --> 00:41:58.940
be a duplication. It's my absolute favourite book as a

740
00:41:58.960 --> 00:42:01.420
young adult and even now is The Count of Monte Cristo.

741
00:42:01.440 --> 00:42:06.139
And it's a huge adventure story, Alexander Dumas. It's got

742
00:42:06.719 --> 00:42:09.969
a bit of everything in it. It's got injustice, escape,

743
00:42:10.809 --> 00:42:15.820
this ridiculously elaborate revenge plot. And it's very exciting. And

744
00:42:15.880 --> 00:42:19.000
so it really grabs my attention whenever I read it.

745
00:42:20.400 --> 00:42:23.320
You've either got that or you've got Where's Spot?

746
00:42:23.980 --> 00:42:24.480
The dog?

747
00:42:25.019 --> 00:42:27.739
The Lift the Flat book. That's one of my son's

748
00:42:27.960 --> 00:42:32.159
absolute favourite books. And one of the things that I've

749
00:42:32.239 --> 00:42:35.440
come to realise when reading this with him is that

750
00:42:36.400 --> 00:42:38.880
Spot has a lot of apex predators living in his house.

751
00:42:39.800 --> 00:42:44.039
You know, a lion, a bear, Crocodile.

752
00:42:44.739 --> 00:42:46.579
What was I doing there?

753
00:42:48.219 --> 00:42:50.449
I think actually either of them would be a first.

754
00:42:51.349 --> 00:42:58.170
I've read both of them. Any parent can sort of

755
00:42:58.210 --> 00:43:01.289
align with the idea of a spot or the Gruffalo.

756
00:43:01.409 --> 00:43:03.369
I like the Count of Monte Cristo. That's a fab book.

757
00:43:03.510 --> 00:43:05.730
Because I knew we were going down the children's book,

758
00:43:06.690 --> 00:43:08.730
I thought, wouldn't it be great if you picked a

759
00:43:08.750 --> 00:43:09.630
squash and a squeeze?

760
00:43:09.650 --> 00:43:09.719
Yes.

761
00:43:10.429 --> 00:43:11.110
Oh, yeah.

762
00:43:11.250 --> 00:43:14.349
And took us all the way back to our polypharmacy

763
00:43:14.389 --> 00:43:16.170
pain patient of series one.

764
00:43:16.190 --> 00:43:18.190
I would think Caroline's too young for that.

765
00:43:18.469 --> 00:43:18.869
Yeah.

766
00:43:18.889 --> 00:43:21.510
Well, I think we'll go for The Count of Monte Cristo.

767
00:43:21.639 --> 00:43:23.679
That is a classic. I haven't read it, but my

768
00:43:23.739 --> 00:43:27.480
dad is 87, and he's always told me that it

769
00:43:27.519 --> 00:43:30.019
was his favourite book when he was growing up. And

770
00:43:30.059 --> 00:43:32.480
I recently watched the BBC. No, it wasn't the BBC.

771
00:43:32.519 --> 00:43:35.500
It was on the BBC, but it was a French dramatisation,

772
00:43:35.980 --> 00:43:38.880
four parts. Absolutely loved it. Watched it with my wife.

773
00:43:39.389 --> 00:43:41.599
And did start reading it recently, but I haven't got

774
00:43:41.619 --> 00:43:42.039
very far.

775
00:43:42.320 --> 00:43:44.059
So I think it's got to be the Count de

776
00:43:44.099 --> 00:43:44.699
Monte Cristo.

777
00:43:44.800 --> 00:43:45.380
Yes.

778
00:43:45.579 --> 00:43:49.460
Because there is poison in it, isn't it? And opiates

779
00:43:49.519 --> 00:43:52.099
appear in it and strychnine and things like that.

780
00:43:52.599 --> 00:43:58.119
A massive poisoning plot. I think that's one of the poisons.

781
00:43:58.199 --> 00:43:59.420
I don't think.

782
00:44:01.659 --> 00:44:04.440
This does actually give anything away. But depending upon how

783
00:44:04.500 --> 00:44:08.119
much you take, it can either be an elixir or

784
00:44:08.139 --> 00:44:08.980
a deadly poison.

785
00:44:10.260 --> 00:44:11.840
Oh, the dose maketh the poison.

786
00:44:11.860 --> 00:44:18.690
Exactly. Paracelvis. It's not the joke for how much you take.

787
00:44:19.070 --> 00:44:21.530
Exactly. Okay, so we'll go for The Count of Monte

788
00:44:21.570 --> 00:44:27.210
Cristo by Alexandra Dumas. Excellent. So three firsts, which is

789
00:44:27.269 --> 00:44:29.130
very impressive as the 94th guest.

790
00:44:29.349 --> 00:44:33.719
Quick quiz question for you and the listeners. What superhero

791
00:44:33.860 --> 00:44:35.739
had a dog named Spot?

792
00:44:36.539 --> 00:44:38.659
Is it a proper superhero or a cartoon?

793
00:44:38.699 --> 00:44:39.159
Superman.

794
00:44:39.809 --> 00:44:44.389
Hong Kong phooey. And he actually had stripes, didn't he?

795
00:44:44.429 --> 00:44:47.130
That was the other thing. Anyway, let's move on. Our

796
00:44:47.170 --> 00:44:50.949
micro discussion next. We've got the International Journal of Drug Policy.

797
00:44:50.989 --> 00:44:54.320
It's one of Caroline's that we've gone with. And they've

798
00:44:54.340 --> 00:44:56.739
done a clever thing here because the title of the

799
00:44:56.780 --> 00:44:59.480
paper is actually the message of the paper as well,

800
00:44:59.519 --> 00:45:02.900
isn't it? So comparison of Office for National Statistics and

801
00:45:02.940 --> 00:45:07.699
National Programme on Substance Use Mortality Data suggests that opioid-related

802
00:45:07.719 --> 00:45:13.889
deaths in England and Wales have been systemically underestimated discuss caroline.

803
00:45:13.989 --> 00:45:22.139
Yeah um yeah this is a recent paper and um

804
00:45:23.039 --> 00:45:29.099
i've started actually not writing long papers um so there's

805
00:45:29.119 --> 00:45:32.760
a full journal report three and a half four thousand

806
00:45:32.800 --> 00:45:36.039
words but I've just decided that you can say most

807
00:45:36.079 --> 00:45:37.719
of what you want within 2,000 words.

808
00:45:38.559 --> 00:45:42.219
Well, harder to write a short paper than a long paper, Caroline.

809
00:45:42.340 --> 00:45:44.659
Yes, but who's got time to write and read the

810
00:45:44.699 --> 00:45:50.210
long ones anyway? So, yes, this was a short report

811
00:45:50.309 --> 00:45:57.849
that had a really important message to it. And interestingly,

812
00:45:58.030 --> 00:46:02.239
it started– when we had a conversation with the Office

813
00:46:02.260 --> 00:46:05.659
for National Statistics themselves, and they said, look, we realise

814
00:46:06.039 --> 00:46:08.909
that this is a big problem, but we just don't

815
00:46:09.090 --> 00:46:12.909
know how big a problem it is. And, you know,

816
00:46:12.989 --> 00:46:16.590
can we work together to try and see.

817
00:46:16.929 --> 00:46:19.809
So what is the problem? Just explain the problem for us.

818
00:46:20.250 --> 00:46:25.300
So the problem is that if a coroner, when they

819
00:46:25.360 --> 00:46:28.460
are writing the cause of death of how somebody has

820
00:46:28.519 --> 00:46:34.039
died down, If they use an ambiguous cause term that

821
00:46:34.480 --> 00:46:37.579
the ONS, the Office for National Statistics, can't tell what

822
00:46:37.619 --> 00:46:42.280
the drug is, they can't count it in their deaths

823
00:46:42.320 --> 00:46:44.780
due to opioid use or deaths due to cocaine use

824
00:46:44.949 --> 00:46:46.929
because they don't know what they are. And so those

825
00:46:47.030 --> 00:46:49.550
ambiguous terms, some examples of things like, you know, they

826
00:46:49.570 --> 00:46:54.929
could just write multidrug toxicity or polydrug overdose. And a

827
00:46:55.090 --> 00:46:58.429
poly drug, it just means more than one, right? So

828
00:46:58.449 --> 00:47:04.650
that could be a codeine paracetamol overdose, which could have

829
00:47:04.690 --> 00:47:10.130
happened due to purchase of over-the-counter cocodamol. Or it could

830
00:47:10.170 --> 00:47:13.070
have been a death due to heroin and cocaine use.

831
00:47:13.159 --> 00:47:17.039
They're both poly drug deaths, but very different types of

832
00:47:17.099 --> 00:47:20.280
deaths in terms of how those drugs were probably purchased

833
00:47:20.360 --> 00:47:22.920
and used and their motivation and so on and so forth.

834
00:47:23.710 --> 00:47:28.340
And so what we, so the database that I run,

835
00:47:29.059 --> 00:47:31.780
in addition to getting the records of inquest, which is

836
00:47:31.800 --> 00:47:34.679
where the coroner lists their causes of death, we get

837
00:47:34.739 --> 00:47:38.639
the full toxicology report that ONS don't get. And we

838
00:47:38.679 --> 00:47:41.570
can see therefore on these deaths that are described as

839
00:47:41.699 --> 00:47:44.309
poly drug or multi drug, we can actually see which

840
00:47:44.829 --> 00:47:48.070
of the substances were involved. And so what we did

841
00:47:48.150 --> 00:47:52.869
was we say, just for ease of interpretation, hopefully, Say

842
00:47:52.909 --> 00:47:56.929
you had 100 deaths due to tramadol reported to the

843
00:47:56.969 --> 00:48:01.190
database and 60 of them had tramadol named on the

844
00:48:01.230 --> 00:48:07.250
death certificate, but then 40 had it ambiguously implicated. We

845
00:48:07.289 --> 00:48:11.030
would be able to say that 60% of tramadol deaths

846
00:48:11.429 --> 00:48:13.969
ONS would be getting, but they'd be missing 40% of them.

847
00:48:13.989 --> 00:48:17.480
So I should probably point out at this point, we

848
00:48:17.559 --> 00:48:21.099
don't have 100% of coroners reporting to the NPSUN. We've

849
00:48:21.139 --> 00:48:23.840
got just over 90% now, but it's not full coverage.

850
00:48:23.920 --> 00:48:27.539
So ONS get all deaths reported to them, but then

851
00:48:27.559 --> 00:48:30.760
they're missing the detail. Whereas we get the majority or

852
00:48:30.800 --> 00:48:34.420
quite a lot of deaths reported to us, but in

853
00:48:34.539 --> 00:48:36.559
high detail, but we don't get all of them. So

854
00:48:37.800 --> 00:48:42.300
by triangulating them together, we were able to estimate the

855
00:48:42.469 --> 00:48:47.809
likely true number of opioid deaths that have happened.

856
00:48:47.570 --> 00:48:47.989
In the UK.

857
00:48:48.010 --> 00:48:50.610
I think we did it over a 10 year period

858
00:48:51.329 --> 00:48:55.860
and it was around I think between 35 and 40

859
00:48:55.860 --> 00:49:00.159
percent of opioid related deaths have been missed by ONS

860
00:49:00.739 --> 00:49:03.019
and that's a huge number to be missing.

861
00:49:03.219 --> 00:49:05.659
And so that matters doesn't it because that's you know

862
00:49:05.980 --> 00:49:09.960
how much money spent on drug misuse policy you know

863
00:49:09.960 --> 00:49:14.159
it just means we've massively underestimated the scale of the problem.

864
00:49:14.159 --> 00:49:16.400
Yeah so if you have a shop that only has

865
00:49:16.400 --> 00:49:19.860
enough product for 60 of your customers, you're going to

866
00:49:19.880 --> 00:49:22.820
have to shut early. And for people who use drugs,

867
00:49:22.860 --> 00:49:24.280
that just means that they aren't going to be able

868
00:49:24.300 --> 00:49:28.409
to access treatment. But it's not just a scale problem.

869
00:49:28.449 --> 00:49:31.510
It's not just saying, well, now you need to fund

870
00:49:31.550 --> 00:49:38.199
drug treatment centres 40% more. Because... scaling is not the

871
00:49:38.300 --> 00:49:41.639
only solution here. And if I'm teaching a classroom of

872
00:49:41.639 --> 00:49:44.800
10 students, what I deliver in terms of how that

873
00:49:44.840 --> 00:49:47.739
teaching is done is very different from how I teach

874
00:49:47.739 --> 00:49:51.059
50 students. I deliver that in an entirely different way

875
00:49:51.619 --> 00:49:54.280
and drug services will have to be the same. And

876
00:49:54.340 --> 00:49:58.030
also we can't assume that the people that ONS aren't

877
00:49:58.150 --> 00:50:02.050
counting and capturing are demographically the same as the ones

878
00:50:02.090 --> 00:50:06.769
that they are counting. So, you know, for example, deaths

879
00:50:07.730 --> 00:50:11.070
by suicide tend to only involve a couple of substances.

880
00:50:11.130 --> 00:50:13.570
Most people just take a lot of one or maybe

881
00:50:13.610 --> 00:50:16.730
two things. And so if you've got fewer drugs present

882
00:50:17.369 --> 00:50:19.309
in a death, the coroner is more likely to write

883
00:50:19.329 --> 00:50:22.130
them out than they are if there's seven or eight

884
00:50:22.150 --> 00:50:26.469
different ones that have to be written out. So demographically,

885
00:50:26.570 --> 00:50:28.949
the deaths that are being missed are also going to

886
00:50:28.989 --> 00:50:32.489
be different. And so it's not just a scaling issue,

887
00:50:32.550 --> 00:50:35.909
but a orientation issue as well.

888
00:50:36.309 --> 00:50:38.369
So just because we mentioned it earlier in the podcast,

889
00:50:38.409 --> 00:50:42.480
but didn't give numbers. So the ONS data for 2023

890
00:50:42.480 --> 00:50:47.239
says five and a half thousand deaths due to drug poisoning. Granted,

891
00:50:47.420 --> 00:50:49.940
you're saying that that's not necessarily the full picture. And

892
00:50:49.980 --> 00:50:53.539
that's about just under 1% of all deaths. That's in

893
00:50:53.599 --> 00:50:57.119
England and Wales, isn't it? And half of those involved opioids.

894
00:50:57.360 --> 00:51:02.030
Yeah, so the overall drug death number reported to ONS

895
00:51:02.179 --> 00:51:06.480
is probably near enough accurate. But it's the proportion of

896
00:51:06.519 --> 00:51:09.719
those that they're able to attribute to opioids is where

897
00:51:09.739 --> 00:51:10.760
the problem comes from.

898
00:51:11.440 --> 00:51:14.059
And I suppose then the final thing, we have on

899
00:51:14.099 --> 00:51:18.360
this podcast discussed things to do with coroners before. So

900
00:51:18.730 --> 00:51:20.989
I think it's fair to say that although your paper

901
00:51:21.070 --> 00:51:25.909
points out politely that sometimes perhaps coroners try to simplify

902
00:51:25.969 --> 00:51:29.530
for their audience, so particularly for members of the family

903
00:51:29.590 --> 00:51:31.929
of the deceased, particularly if they took their own life,

904
00:51:32.739 --> 00:51:35.369
that they had very serious mental health issues, that they

905
00:51:35.409 --> 00:51:38.469
might not want to go into too much detail. However,

906
00:51:38.530 --> 00:51:42.409
your conclusion I completely concur with, which is why on

907
00:51:42.510 --> 00:51:46.449
earth do the coroners not get mandated to use agreed

908
00:51:46.510 --> 00:51:48.699
criteria and then we would solve the problem, right?

909
00:51:48.949 --> 00:51:51.619
Indeed, and one of the things that was actioned after

910
00:51:51.659 --> 00:51:57.179
this paper was that the Office for Health Inequality and Disparity, OBID,

911
00:51:57.219 --> 00:52:01.880
did write a letter to the chief coroner recommending that

912
00:52:03.780 --> 00:52:06.260
a letter is written to all coroners in England and

913
00:52:06.300 --> 00:52:11.059
Wales to better use cause terms that are more transparent.

914
00:52:11.840 --> 00:52:16.030
I think in the most recent statistics, it's something like

915
00:52:16.030 --> 00:52:20.710
25% of drug deaths they aren't able to attribute to substances.

916
00:52:21.230 --> 00:52:24.710
But the coroners in Northern Ireland are actually very good

917
00:52:24.769 --> 00:52:27.690
at using specific cause terms and only 6% of deaths

918
00:52:29.230 --> 00:52:34.809
In Northern Ireland, they couldn't attribute to particular substances. But

919
00:52:34.829 --> 00:52:37.210
that number is even lower in Scotland. Scotland have a

920
00:52:37.230 --> 00:52:39.610
slightly different system to England, Wales and Northern Ireland. I

921
00:52:39.630 --> 00:52:42.789
think they were only able to not identify which drugs

922
00:52:42.809 --> 00:52:45.469
are involved in something like 1% of cases. So it

923
00:52:45.530 --> 00:52:46.429
is obviously possible.

924
00:52:46.699 --> 00:52:50.639
Yeah. And unfortunately, Scotland is top of the tables, unfortunately,

925
00:52:50.679 --> 00:52:53.099
isn't it, in relation to drug deaths?

926
00:52:54.019 --> 00:52:58.500
Yes, it has the highest number of deaths per capita.

927
00:52:59.309 --> 00:53:00.590
In Europe, is that?

928
00:53:00.699 --> 00:53:04.840
In the world, I believe. I think they surpass even

929
00:53:04.880 --> 00:53:08.639
the US. But it is a proportions and numbers game.

930
00:53:09.019 --> 00:53:13.719
So Scotland has fewer drug deaths than England and Wales,

931
00:53:14.199 --> 00:53:16.469
but they have a much smaller population. But if you

932
00:53:16.489 --> 00:53:21.630
do death per... capita of population, then the number is

933
00:53:21.650 --> 00:53:22.050
very high.

934
00:53:22.289 --> 00:53:24.150
So Caroline, two things from me and then I think

935
00:53:24.170 --> 00:53:26.719
we'll wrap up. We could have gone with your safety

936
00:53:26.860 --> 00:53:31.340
concerns on fentanyl patches paper, which when I read that,

937
00:53:32.039 --> 00:53:34.760
so that was safety concern reported by coroners following fentanyl

938
00:53:34.800 --> 00:53:38.960
patch fatalities in England, Wales, Northern Ireland between 1997 and 2024.

939
00:53:39.800 --> 00:53:43.960
And that almost mirrors our careers, really, because fentanyl patches

940
00:53:44.400 --> 00:53:47.019
came about in 94, 95, I think you said, or

941
00:53:47.059 --> 00:53:48.800
something like that, which was just at the start of

942
00:53:49.860 --> 00:53:53.849
our careers. And then that safety profile, and then all

943
00:53:53.869 --> 00:53:55.929
of a sudden you can see that they're starting to

944
00:53:55.969 --> 00:53:59.469
be implicated. But you mentioned nitizines earlier, just on the

945
00:53:59.530 --> 00:54:03.269
cause of death bit. We didn't touch on the fact that,

946
00:54:03.530 --> 00:54:06.460
and so be brief if you can, but that the nitizines,

947
00:54:07.219 --> 00:54:10.400
has this story changed? That they weren't as detectable as they,

948
00:54:10.840 --> 00:54:12.579
and that detectability was changing?

949
00:54:13.260 --> 00:54:14.800
Yeah, yeah, yeah.

950
00:54:14.840 --> 00:54:19.269
So again, we did a report, I think it was

951
00:54:19.289 --> 00:54:21.809
published earlier this year. So this was, so I go

952
00:54:21.829 --> 00:54:24.630
to lots of different conferences and chat to anyone who'll

953
00:54:24.670 --> 00:54:26.269
have a chat with me. Now I've ended up here.

954
00:54:26.769 --> 00:54:30.110
And quite a few of the, I think it was

955
00:54:30.130 --> 00:54:33.210
about three or four different toxicologists that work in the

956
00:54:33.320 --> 00:54:35.539
UK came to me and were like, Caroline, I'm seeing

957
00:54:35.619 --> 00:54:39.519
something weird. And there was one chap who was detecting

958
00:54:39.539 --> 00:54:42.500
mitosine in urine, but not in blood. There was another

959
00:54:42.539 --> 00:54:45.780
person who detected it in a syringe that was found

960
00:54:45.840 --> 00:54:48.989
in the deceased person's arm, but couldn't find it in

961
00:54:49.030 --> 00:54:52.369
the blood. And then there was one person who had

962
00:54:52.650 --> 00:54:55.369
detected mitosine in a blood sample that was taken on

963
00:54:55.409 --> 00:54:58.050
the day that the person had died. But then when

964
00:54:58.070 --> 00:54:59.829
they'd been in the morgue for a week and the

965
00:54:59.869 --> 00:55:02.550
full post-mortem was done and that blood sample was taken,

966
00:55:02.650 --> 00:55:05.710
it couldn't be detected then. So we did a controlled

967
00:55:05.769 --> 00:55:09.889
experiment with some rat studies to see if the nitazines

968
00:55:09.929 --> 00:55:12.920
were disappearing from the post-mortem blood. And we were able

969
00:55:12.960 --> 00:55:17.559
to demonstrate that compared to the nitazine present at death

970
00:55:17.679 --> 00:55:22.000
versus after the body had been stored in the fridge

971
00:55:22.019 --> 00:55:24.309
for a week, which is often how long it takes

972
00:55:24.329 --> 00:55:26.929
for a pathologist to get around to doing a post-mortem,

973
00:55:27.699 --> 00:55:30.070
Not that they're sitting just around doing nothing, they've got other,

974
00:55:30.329 --> 00:55:32.750
you know, a backlog of cases to get through. And

975
00:55:32.789 --> 00:55:36.130
then similarly, when they send that sample to the tox labs,

976
00:55:36.150 --> 00:55:39.570
they've got a backlog of samples to go through. And

977
00:55:40.230 --> 00:55:42.349
it's not unreasonable, it takes them sometimes a month to

978
00:55:42.369 --> 00:55:44.909
get to that sample. So after being in the body

979
00:55:45.250 --> 00:55:47.250
for a week and in the fridge for a month,

980
00:55:47.869 --> 00:55:52.630
only 14, 1.4% of the nitosine that was detected at

981
00:55:52.690 --> 00:55:56.340
point of death was left at point of analysis. And

982
00:55:56.360 --> 00:55:59.159
I've already said how potent these substances are. You don't

983
00:55:59.219 --> 00:56:03.619
need very much to prove fatal. And now if you

984
00:56:03.659 --> 00:56:06.510
only have 14% of not very much, that's going to

985
00:56:06.530 --> 00:56:09.409
be falling below the limits of detection of these toxicology

986
00:56:09.449 --> 00:56:15.389
machines and come back as a negative result for these nitrosines.

987
00:56:15.750 --> 00:56:19.320
Once again, don't buy drugs offline.

988
00:56:19.400 --> 00:56:21.900
That's the message of the show.

989
00:56:21.940 --> 00:56:25.380
So we're almost... You'll see the headlines. I think we're

990
00:56:25.420 --> 00:56:28.440
up to over a thousand people have been registered now

991
00:56:28.480 --> 00:56:35.269
as having died following nitazine use. Vast majority accidentally because

992
00:56:35.289 --> 00:56:38.590
they didn't know what they were taking. But the modelling

993
00:56:38.610 --> 00:56:41.489
that we've done suggests that figure might be an underestimate

994
00:56:41.550 --> 00:56:50.519
by about a third. And on that note... Yeah, essentially

995
00:56:50.639 --> 00:56:54.610
it's just drugs are really bad and awful and don't

996
00:56:54.650 --> 00:56:55.070
take them.

997
00:56:55.369 --> 00:56:58.550
Thank God you didn't throw that book away 15 years ago,

998
00:56:58.570 --> 00:57:00.889
whatever it was, eh? That's the message here.

999
00:57:01.409 --> 00:57:04.110
Oh, the file in drug deaths when you took over

1000
00:57:04.150 --> 00:57:07.309
from Colin from accounts. Oh, yeah, well, yeah.

1001
00:57:07.329 --> 00:57:11.719
Yeah, it was, yeah, Christine coming to find me and saying,

1002
00:57:11.760 --> 00:57:14.960
you're not Colin. Yeah, I wouldn't be here if it

1003
00:57:15.000 --> 00:57:17.039
wasn't for her looking for him and.

1004
00:57:17.590 --> 00:57:19.010
And you've recessed the service.

1005
00:57:19.389 --> 00:57:20.190
There we go.

1006
00:57:20.530 --> 00:57:21.550
Yeah, indeed.

1007
00:57:21.730 --> 00:57:24.219
Okay. Thanks all. A big thank you to Caroline for

1008
00:57:24.239 --> 00:57:26.579
joining us on the Oral Apothecary, for sharing her stories,

1009
00:57:26.619 --> 00:57:29.099
her Desert Island drug, her career anthem, and her book

1010
00:57:29.159 --> 00:57:32.599
for the Oral Apothecary Library. Coming up next time, we'll

1011
00:57:32.619 --> 00:57:37.139
be joined by the writer, broadcaster, and Guardian columnist, Adrian Childs.

1012
00:57:37.920 --> 00:57:39.619
Join us next time on the Oral Apothecary. You can

1013
00:57:39.679 --> 00:57:42.360
contact us via X at Oral Apothecary. You can follow

1014
00:57:42.389 --> 00:57:47.610
us on LinkedIn. You can email us at oralapothecarypod at gmail.com.

1015
00:57:47.829 --> 00:57:51.489
The website is there also. Gimo now with a final ingredient.

1016
00:57:51.710 --> 00:57:52.050
Brilliant.

1017
00:57:52.530 --> 00:57:55.269
So on social media, we are trying to make a

1018
00:57:55.289 --> 00:57:57.070
bit more of an effort with LinkedIn. And I think

1019
00:57:57.090 --> 00:58:00.090
we're even going to start posting on Instagram this year.

1020
00:58:00.130 --> 00:58:02.489
So please have a look and make an effort to

1021
00:58:02.530 --> 00:58:05.030
talk to us because we love it when people talk

1022
00:58:05.050 --> 00:58:07.070
to us we might not reply straight away but but

1023
00:58:07.090 --> 00:58:08.949
we do we do like it when people talk so

1024
00:58:09.150 --> 00:58:12.909
um thanks caroline that that was fabulous um steve as

1025
00:58:12.949 --> 00:58:16.289
a clinician can you help me out um so i've

1026
00:58:16.349 --> 00:58:21.230
got sore itchy eyes um it happens after spending too

1027
00:58:21.289 --> 00:58:24.389
long staring at a screen and when i rub them

1028
00:58:24.449 --> 00:58:27.280
they've they've started to turn slightly pink have you got

1029
00:58:27.300 --> 00:58:30.940
any any idea what what i've got conjunctivitis no i

1030
00:58:30.960 --> 00:58:35.800
think i think i've got something called bix bix onomania Bixonomania.

1031
00:58:36.239 --> 00:58:40.320
So it's a condition that's out there, but the problem

1032
00:58:40.380 --> 00:58:45.780
is Bixonomania doesn't exist. And in fact, researchers invented the

1033
00:58:45.820 --> 00:58:50.960
condition and then they planted two deliberately ridiculous papers online.

1034
00:58:52.239 --> 00:58:56.340
In the papers, they mentioned fictional universities, thanked Starfleet Academy

1035
00:58:56.400 --> 00:58:59.000
for their support, and they even admitted in one of

1036
00:58:59.039 --> 00:59:02.880
the papers that the entire study was made up. But actually,

1037
00:59:02.900 --> 00:59:07.590
as reported in a recent Nature feature, major AI chatbots

1038
00:59:07.889 --> 00:59:12.210
began describing Bixonomania as a real illness, complete with symptoms,

1039
00:59:12.389 --> 00:59:16.429
prevalence figures, and medical advice. The fake research was even

1040
00:59:16.510 --> 00:59:20.719
cited in a genuine peer-reviewed paper, which has since been retracted.

1041
00:59:21.880 --> 00:59:24.460
So it's a good reminder on our ongoing theme that

1042
00:59:24.559 --> 00:59:29.309
AI can make mistakes, convincing language for reliable evidence. And

1043
00:59:29.349 --> 00:59:33.690
the polished nonsense is still nonsense. It's a powerful reminder

1044
00:59:33.710 --> 00:59:37.000
of the risks of trusting blindly the answers that AI

1045
00:59:37.059 --> 00:59:39.380
give us. I did do a little follow-up when I

1046
00:59:39.500 --> 00:59:44.039
asked ChatGPT about Bixonomania as a test. It did pass.

1047
00:59:44.400 --> 00:59:46.739
It told me it was a fake condition. But actually,

1048
00:59:46.760 --> 00:59:49.610
a little worryingly, it asked me who told me about it.

1049
00:59:49.860 --> 00:59:52.409
So it was interested, wanted to find out who told me.

1050
00:59:53.510 --> 00:59:55.690
So there we have it. Whether advice comes from a

1051
00:59:55.710 --> 00:59:59.539
chatbot or a peer-reviewed paper, always check. the source.

1052
01:00:00.119 --> 01:00:03.059
You have been listening to a Three Apothecaries production. Sound

1053
01:00:03.119 --> 01:00:07.570
engineer Jimbo Slough, original music Jamie Brewster, artwork by David

1054
01:00:07.619 --> 01:00:09.150
Baker and Jacob Howard.

1055
01:00:09.730 --> 01:00:13.489
Thanks for listening to the Oral Apothecary podcast. For maximum effect,

1056
01:00:14.010 --> 01:00:15.170
install weekly.

1057
01:00:15.730 --> 01:00:20.460
This episode of the Oral Apothecary is sponsored by onelesspill.com,

1058
01:00:20.960 --> 01:00:23.340
a medicines optimization consultancy.

1059
01:00:26.380 --> 01:00:27.280
Thank you.