EMCDDA logo Annual report on the state of the drugs problem in the European Union 2001

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Introduction to the annual report
Chapter 1: Drug demand and drug supply
Drug use
Health consequences
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Drug-market indicators
Chapter 2: Responses to drug use
Chapter 3: Selected issues
Chapter 4: The drugs problem in central and eastern European countries
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Health consequences of drug use

Health consequences: Demand for treatment | Drug-related infectious diseases | Drug-related deaths and mortality of drug users

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

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.

(1) Box 1 OL: Definitions of 'acute drug-related death' in EU Member States, as used in the EMCDDA annual report, and reported in national reports. Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland and Italy, Luxembourg, the Netherlands, Portugal, Sweden, Spain, United Kingdom.

(2) Box 2 OL: Proposed EMCDDA standard to count acute drug-related deaths - the DRD standard, Version 1.0.

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'.

Figure 10 OL Proportion of abuse of opiate and non-opiate drugs among the cases of drug-related deaths, valid percentages based on cases with known toxicology

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.

Figure 11 OL Proportion of people over 30 among drug-related deaths in some EU countries, 1986 and 1999

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.

  • 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.

  • 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.

  • 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.

Figure 10


These trends can be calculated for all EU countries. A few are presented as examples. Proportional variations over 1985 figures are presented. For Greece, the series begins in 1986 to avoid distortion.
In some countries with an increasing trend, improved reporting may account for part of the increase.
Not all countries provided data for all years, but this situation has been controlled in the analysis.

Reitox national reports 2000, taken from national mortality registries or special registries (forensic or police). See also standard epidemiological tables on drug-related deaths.

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.

Figure 11, Mortality from all causes in cohorts of opiate users recruited in treatment centres in several EU countries or cities standardised mortality rates(males and females)

Health consequences: Demand for treatment | Drug-related infectious diseases | Drug-related deaths and mortality of drug users

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