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Drug-related
deaths and mortality of drug users
The number of acute drug-related
deaths ('overdoses') is sometimes used as a simplistic
way of assessing a country's drug situation and to draw
comparisons. Drug deaths are a source of social and
political concern, especially acute deaths among young
people.
| Methodology
and definitions for drug-related deaths |
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In this report the focus is placed
on acute drug-related deaths (overdoses) unless
stated otherwise.
Direct comparisons between countries
can be misleading because the number of drug-related
deaths depends not only on the prevalence of problem
drug use and the risk patterns (such as injection)
but also on national definitions and recording
methods. For instance, Portugal has an inclusive
definition whereas Sweden has recently changed
from a broad to a more restrictive definition(1).
Drug-related deaths and mortality
among drug users is one of the EMCDDA's epidemiological
key indicators. A European standard protocol has
been developed to report cases from general mortality
registries (GMR) and special registries (SR) -
forensic or police. This standard protocol has
been tested in all Member States, and active collaboration
is maintained with Eurostat and the World Health
Organisation(2).
Where definitions, methods and
quality of reporting remain consistent within
a given country, the statistics can indicate trends
over time and, if correctly analysed and integrated
with other indicators, can be valuable in monitoring
the more extreme patterns of drug use.
Deaths indirectly associated
with drug use - deaths from AIDS, traffic accidents,
violence or suicide - should also be taken into
account when assessing the overall impact of drug
abuse, but they require different sources of information
and a more research-oriented methodology.
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Characteristics
of acute drug-related deaths
In the last five years
(1994 to 1999) based on the available information, the
overall number of cases reported by EU countries has
fluctuated between 7 000 and 8 000. In the EU, opiates
continue to be present in most cases of acute drug-related
deaths — 'overdoses' or 'poisonings
The presence of other substances,
such as alcohol, benzodiazepines or cocaine is common.
The presence of depressant substances such as alcohol
or benzodiazepines is considered a risk factor for opiate
overdose. Acute deaths with presence of cocaine, amphetamine
or ecstasy without opiates seem to be infrequent in
Europe.
Many opiate deaths occur up to three
hours after use, making medical intervention possible.
In addition many fatal and non-fatal overdoses are witnessed
by other users, which would make intervention possible
- in such cases, it is important that users know how
to seek effective assistance.
Most opiate deaths occur among injectors
in their late 20s or 30s, usually after several years
of use. The large majority of deaths occurred among
males. As with clients entering treatment, a clear ageing
trend is observed among deceased opiate users in many
EU countries.
Some cocaine-related deaths may pass
unnoticed because of the social background of victims
or because of a different clinical presentation of them
(such as ischemic heart diseases or arrhythmia). Emergency
services personnel should be aware of this possibility.
Acute deaths related only to ecstasy seem to be rare,
despite the public concern these caused during the mid-90s
in some European countries.
Methadone has been identified in a
number of drug deaths and its role has been discussed
in several European countries. Since methadone substitution
has become quite widespread in recent years, circumstantial
toxicological findings of methadone are more frequent
among drug users that die due to accidents, AIDS, etc.
A few local studies suggest that some acute deaths may
be caused by methadone diverted to the illegal market,
perhaps facilitated by poorly organised prescription
services. An improvement in the organisation of methadone
substitution programmes has been recommended in some
countries. Despite these problems, research shows that
substitution treatment reduces the risks of drug-related
death among programme participants.
Trends
in acute drug-related deaths
Many EU countries witnessed a marked increase
of acute drug-related deaths in the second half of the
1980s and the early 1990s. However, in recent years,
the number of acute deaths at EU level as a whole has
stabilised, between 7 000 to 8 000 per year, and in
some countries they have even decreased.
Multiple factors probably contribute
to the recent stabilisation of drug-related deaths.
The number of problem drug users may have stabilised
and treatment data suggest that risk practices, for
example injecting, have also decreased in some countries.
In addition, treatment interventions - including substitution
programmes - have expanded in many countries and medical
assistance for overdoses may have improved.
The stabilisation is consistent with
the decrease in overall mortality (in some cases also
in overdose deaths) among cohorts of problem drug users
as described below (mortality of
drug users section).
Within the overall EU trend, different
national trends are observed.
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Several countries present a general
downward trend, although with year-to-year fluctuations,
for example, Austria, France, Germany, Luxembourg,
Italy and Spain. Austria (1999), Germany (1999-2000)
and Luxembourg (1997-98) reported new increases
recently but they are not as high as previous values.
This development has to be closely monitored.
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Some countries have reported a
substantial upward trend until recently - for example,
Greece, Ireland (a decrease observed in 1999) and
Portugal. These increases are probably related to
a later expansion of heroin use in these countries
during the 1990s, which may be explained by their
sociological evolution. Recording practices may
also have improved. The broad case definition used
may influence in part the marked increase observed
recently in Portugal.
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The United Kingdom presents a
moderate but continuously increasing trend. Other
countries have a stable trend, or trends are difficult
to assess due to the recent switch in the International
Classification of Diseases (9th edition to 10th
edition), or changes in national definitions.
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Comparisons between estimates of drug-related
deaths for the EU and the United States should be made
and interpreted with extreme caution. Current European
definitions of drug-related death are heterogeneous
and the United States definition is somewhat broader
and includes psychoactive medicines. Even so, it is
worth noting that the number of cases recorded in the
EU countries (376 million inhabitants) amounts to roughly
half of those recorded in the United States (270 million
inhabitants). In recent years, the number of cases in
the EU has fluctuated between 7 000 and 8 000, whereas
the United States appears to present an upward trend
from about 13 000 to almost 16 000 in the same period
(ONDCP, the national drug control strategy, 2001 annual
report).
Mortality
among drug users
Problem drug users represent a very
small proportion of the population, but they concentrate
disproportional health problems and, in particular,
suffer very high mortality.
Follow-up studies that consist of
tracking groups of problem users (usually opiate users
recruited from treatment centres) over several years
have shown consistently that opiate users have an overall
mortality rate (for all causes) of up to 20 times higher
than that of the general population of the same age.
This is due not only to drug overdose but also to accidents,
suicides, AIDS and other infectious diseases. Further
risk factors have been identified: the mortality of
injectors is two to four times higher than that of non-injectors,
while that of users infected by HIV is two to six times
higher than of non-infected users. Combined use of opiates
with other depressant substances such as alcohol or
benzodiazepines may increase the risk of overdoses.
The mortality of problem drug users
that do not use opiates or do not inject their drugs
is visibly lower, although their health risks are more
difficult to assess with precision. In general, traditional
drug treatment centres record relatively few and selected
cases of heavy cocaine or amphetamine users and a substantial
proportion of them seem to be former or concomitant
opiate users, former injectors, or socially excluded
people. Different methodologies and/or sources may be
needed for these drug users other than for traditional
opiate users.
A multi-site
study (374KB) coordinated by the EMCDDA has established
cohorts in nine European sites (cities or countries)
following as far as possible a common protocol developed
as part of the key indicator -drug-related deaths and
mortality among drug users. The study shows substantial
differences in overall mortality and causes of death
between locations.
Trends
in mortality among drug users
The EMCDDA study mentioned
above reveals that in several locations mortality rates
reached their highest levels in the early or mid-1990s,
decreasing in more recent years (Barcelona, Hamburg,
Vienna and perhaps Denmark - with information only in
the last few years). In Barcelona, this phenomenon has
been particularly evident: mortality reached over 50
per 1 000 users per year from 1992 to 1996 before falling
markedly, reflecting mainly a drop in AIDS deaths and,
to a lesser extent, in overdose deaths.
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