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Please note that the information on this page is based on the EMCDDA Annual report 2010: the state of the drugs problem in Europe. Most statistical data relate to the year 2008 (or the last year available).

 
 

Annual report 2010: the state of the drugs problem in Europe
Drug-related infectious diseases and drug-related deaths

Published: 10 November 2010

Drug-related deaths and mortality

Drug use is one of the major causes of health problems and mortality among young people in Europe and can account for a considerable proportion of all deaths among adults. Studies found that between 10% and 23% of mortality among those aged 15 to 49 could be attributed to opioid use (Bargagli et al., 2006; Bloor et al., 2008).

Mortality related to drug use comprises the deaths caused directly or indirectly by the use of drugs. This includes deaths from drug overdoses (drug-induced deaths), HIV/AIDS, traffic accidents — in particular when combined with alcohol — violence, suicide and chronic health problems caused by repeated use of drugs (e.g. cardiovascular problems in cocaine users) (1).

Drug-induced deaths

During the period 1995–2007, between 6 400 and 8 500 drug-induced deaths were reported each year by EU Member States, Croatia, Turkey and Norway. The United Kingdom and Germany reported almost half of all drug-induced deaths in 2007. Population mortality rates due to overdoses vary between countries, ranging from 2 to just under 85 deaths per million population aged 15–64 years (average of 21 deaths per million). Rates of over 20 deaths per million are found in 14 out of 28 European countries, and rates of over 40 deaths per million in six countries. Among Europeans aged 15–39 years, drug overdoses accounted for 4% of all deaths (2). Areas with higher prevalence of problem drug use can be disproportionally affected. For example, in 2008, the number of drug-induced deaths in Scotland was 112.5 per million inhabitants, which is much higher than the rate for the United Kingdom as a whole (38.7 per million).

The number of drug-induced deaths reported can be influenced by the prevalence and patterns of drug use (injection, polydrug use), the age and the co-morbidities of drug users, and the availability of treatment and emergency services, as well as the quality of data collection and reporting. Improvements in the reliability of European data have allowed better descriptions of trends, and most countries have now adopted a case definition in line with that of the EMCDDA (3). Nevertheless, caution must be exercised when comparing countries, as national differences exist in the quality of case ascertainment and reporting practices.

Deaths related to opioids

Heroin

Opioids, mainly heroin or its metabolites, are present in the majority of drug-induced deaths reported in Europe. In the 20 countries providing data in 2008, opioids accounted for more than three quarters of all cases (77–100%), with 11 countries reporting proportions of over 85% (4). Substances often found in addition to heroin include alcohol, benzodiazepines, other opioids and, in some countries, cocaine. This suggests that a substantial proportion of all drug-induced fatalities may occur in a context of polydrug use.

Men account for most overdose deaths occurring in Europe (81%). In the majority of countries, the mean age of those dying is in the mid-thirties, and in many instances it is increasing. This suggests a possible stabilisation or decrease in the number of young heroin users, and an ageing cohort of problem opioid users. Overall, 13% of overdose deaths reported in Europe occur among those aged under 25 years, though Austria, Romania and Malta (small numbers) report percentages of 40% or more. This may indicate a younger population of heroin users or injectors in these countries (5).

A number of factors are associated with fatal and non-fatal heroin overdoses. These include injection and simultaneous use of other substances, in particular alcohol, benzodiazepines and some antidepressants. Also related to overdoses are binge drug use, co-morbidity, homelessness, poor mental health (e.g. depression), not being in drug treatment, having experienced previous overdoses, and being alone at the time of overdose (Rome et al., 2008). The time immediately after release from prison or discharge from drug treatment is a particularly risky period for overdoses, as illustrated by a number of longitudinal studies (WHO, 2010).

Other opioids

Opioid substitution treatment reduces substantially the risk of fatal overdose, as illustrated by a Norwegian study on 3 800 persons with up to seven years follow-up, which showed a reduction in mortality during treatment compared with pre-treatment. The risk reduction was significant for both overdose deaths (relative risk 0.2) and all-cause mortality (relative risk 0.5) (Clausen et al., 2008).

Deaths showing the presence of substances used in opioid substitution treatment are also reported each year. This reflects the large number of drug users undergoing this type of treatment and does not imply that these substances were the cause of death. Overdose deaths among clients in substitution treatment can be the result of combining drugs, as some treatment clients still use street opioids, engage in heavy drinking and use prescribed psychoactive substances. However, most deaths due to substitution substances (often in combination with other substances) happen among people who are not in substitution treatment (Heinemann et al., 2000).

Deaths due to buprenorphine poisoning are infrequent, despite its increasing use in substitution treatment in Europe (see 'Opioid use and drug injection'). In Finland, however, buprenorphine remains the most common opioid detected in forensic autopsies, but usually in combination with other substances such as alcohol, amphetamine, cannabis and medicines, or taken by injection.

In Estonia, most drug-induced deaths reported in 2007 and 2008 were associated with the use of 3-methylfentanyl. In Finland, opioids such as oxycodone, tramadol or fentanyl were reported, though the role of these drugs in deaths was not specified.

Deaths related to other drugs

Deaths caused by acute cocaine poisoning seem to be relatively uncommon (6). But, as cocaine overdoses are more difficult to define and identify than those related to opioids, they might be underreported.

In 2008, about 1 000 deaths related to cocaine were reported in 15 countries. There are signs of cocaine being detected in increasing numbers of drug-induced deaths reported in European countries, but due to the lack of comparability in the available data, it is not possible to describe the European trend. A marked increase in the number of deaths related to cocaine in recent years has been observed in the two countries with the highest prevalence of cocaine use in the general population. In Spain, deaths in which cocaine was present in the absence of opioids showed a marked increase between 2002 and 2007. In the United Kingdom, the number of death certificates mentioning cocaine doubled between 2003 (161) and 2008 (325).

Deaths in which ecstasy is present are infrequently reported and, in many of these cases, the drug has not been identified as the direct cause of death (7). The EMCDDA’s 2010 Selected issue on problem amphetamine and methamphetamine use reviews the data on deaths related to these two substances.

Trends in drug-induced deaths

Drug-induced deaths increased sharply in Europe during the 1980s and early 1990s, paralleling the increase in heroin use and drug injection, and thereafter remained at high levels (8).

Between 2000 and 2003, most EU Member States reported a decrease (23%), followed by a subsequent increase (11%) in deaths between 2003 and 2007. Preliminary data available for 2008 suggest an overall figure at least equal to that for the previous year, with increases reported by 11 out of 18 countries where a comparison is possible. The United Kingdom and Germany, accounting for the bulk of reported cases in Europe, show a progressive year-on-year increase since 2003 and 2006, respectively. Other countries (e.g. France, Finland, Norway), also report an increase.

The reasons for the sustained numbers of reported drug-induced deaths are difficult to explain, especially given the indications of decreases in injecting drug use and increases in the numbers of opioid users in contact with treatment and harm-reduction services. Possible explanations that require further investigation include: increased levels of polydrug use (EMCDDA, 2009) or high-risk behaviour; increases in the numbers of relapsing opioid users leaving prison or treatment; and an ageing cohort of drug users, possibly with a more vulnerable population of chronic drug users. For instance, several countries (e.g. Germany, Spain, United Kingdom) report an increased proportion of cases aged over 35 years, which reflects the upward trend in the mean age of drug-induced deaths ('Figure 15: Trends in mean age of drug-induced deaths in some European countries').

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Overall mortality related to drug use

Overall mortality related to drug use comprises drug-induced deaths and those caused indirectly through the use of drugs, such as through the transmission of infectious diseases, cardiovascular problems and accidents. The number of deaths indirectly related to drug use is difficult to quantify, but its impact on public health can be considerable. Drug-related deaths are mainly concentrated among problem drug users, although some (e.g. traffic accidents) occur among occasional users.

Estimates of overall drug-related mortality can be derived in various ways, for example by combining information from mortality cohort studies with estimates of drug use prevalence. Another approach is to use existing general mortality statistics and estimate the proportion related to drug use.

Mortality cohort studies

Mortality cohort studies track the same groups of problem drug users over time and, through linkage with mortality registries, try to identify the causes of all deaths occurring in the group. This type of study can determine overall and cause-specific mortality rates for the cohort, and can estimate the group’s excess mortality compared to the general population (9).

Depending on recruitment settings (e.g. drug treatment facilities) and enrolment criteria (e.g. injecting drug users), most cohort studies show mortality rates in the range of 1–2% per year among problem drug users. These mortality rates are roughly 10 to 20 times higher than those of the same age group in the general population. The relative importance of the different causes of death varies between countries and over time. Generally, though, the main cause of death among problem drug users is drug overdose, accounting for up to 50–60% of deaths among injectors in countries with low prevalence of HIV/AIDS. In addition to HIV/AIDS and other diseases, frequently reported causes of deaths include suicide and alcohol abuse, as illustrated by a recent study in Stockholm, which found that 17% of the deaths among a cohort of mainly opioid users were from suicide and 15% were accidental. Alcohol was involved in 30% of the deaths (Stenbacka et al., 2010).

Deaths indirectly related to drug use

By combining existing data from Eurostat and HIV/AIDS surveillance, the EMCDDA has estimated that about 2 100 people died of HIV/AIDS attributable to drug use in the European Union in 2007 (10), with 90% of these deaths occurring in Spain, France, Italy and Portugal. Following the introduction of highly active antiretroviral therapy in 1996, HIV/AIDS mortality decreased markedly in most EU Member States, but it has been increasing in Estonia and Latvia since 2003. The highest HIV/AIDS mortality rates among drug users are reported for Portugal, followed by Estonia, Spain, Latvia and Italy; in most other countries the rates are low (11).

Other diseases that also account for a proportion of deaths among drug users include chronic conditions such as liver diseases, mainly due to hepatitis C (HCV) infection and often worsened by heavy alcohol use and HIV co-infection. Deaths caused by other infectious diseases are rarer. Non-infectious causes of death mainly include cancer and cardiovascular problems (12).

Other causes of death among drug users have received much less attention, despite indications of a considerable impact on mortality. A recent WHO study (Degenhardt et al., 2009) estimated that, in Europe, suicides and trauma could account for about one-third of the mortality attributable to problem drug use, which would imply several thousand deaths every year. Regarding specifically suicide, a literature review (Darke and Ross, 2002) found that heroin users had a 14 times higher risk of suicide death than the general population.

Information on the number of deaths related to drug driving remains scarce. Some studies suggest increased risks of accidents associated with illicit drug use, and that the combined use of drugs and alcohol cause additional impairment (EMCDDA, 2008).

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Footnotes

(1) See ‘Drug-related mortality: a complex concept’ in the 2008 annual report.

(2) See Figure DRD-7 (part i) and Tables DRD-5 (part ii) and DRD-107 (part i) in the 2010 statistical bulletin.

(3) For detailed methodological information, see the 2010 statistical bulletin.

(4) As most of the drug-induced deaths reported to the EMCDDA are opioid overdoses (mainly heroin), the general characteristics of the reported deaths are presented here to describe and analyse deaths related to heroin use.
See Table DRD-1 in the 2010 statistical bulletin.

(5) See Figures DRD-2 and DRD-3 and Table DRD-1 (part i) in the 2010 statistical bulletin.

(6) See the box ‘Deaths caused by cocaine’.

(7) For data on deaths related to drugs other than heroin, see Table DRD-108 in the 2010 statistical bulletin.

(8) See Figures DRD-8 and DRD-11 in the 2010 statistical bulletin.

(9) For information on mortality cohort studies, see the Key indicators on the EMCDDA website.

(10) See Table DRD-5 (part iii) in the 2010 statistical bulletin.

(11) See Figure DRD-7 (part ii) in the 2010 statistical bulletin.

(12) In particular related to cocaine, see ‘Health consequences of cocaine use’ in Cocaine and crack cocaine'.

(13) See Table HSR-8 in the 2009 statistical bulletin.

Bibliographic references

Bargagli, A.M., Hickman, M., Davoli, M., Perucci, C.A., Schifano, P. et al. (2006), ‘Drug-related mortality and its impact on adult mortality in eight European countries’, European Journal of Public Health 16, pp. 198–202.

Bloor, M., Gannon, M., Hay, G., Jackson, G., Leyland, A.H. and McKeganey, N. (2008), ‘Contribution of problem drug users' deaths to excess mortality in Scotland: secondary analysis of cohort study. BMJ 337:a478.

Clausen, T., Anchersen, K. and Waal, H. (2008), ‘Mortality prior to, during and after opioid maintenance treatment (OMT): a national prospective cross-registry study’, Drug and Alcohol Dependence 94, pp. 151–7.

Darke, S. and Ross, J. (2002), ‘Suicide among heroin users: rates, risk factors and methods’, Addiction 97, pp. 1383–94.

Degenhardt, L., Hall, W., Warner-Smith, M. and Linskey, M. (2009), ‘Illicit drug use’, in: Comparative quantification of health risks. Global and regional burden of disease attributable to major risk factors. Volume 1, Majid Ezzati et al. (editors), World Health Organization, Geneva (available online).

EMCDDA (2008), Towards a better understanding of drug-related public expenditure in Europe, EMCDDA Selected issue, Publications Office of the European Union, Luxembourg.

EMCDDA (2009), Internet-based drug treatment interventions: best practice and applications in EU Member States, EMCDDA Insights, Publications Office of the European Union, Luxembourg.

Heinemann, A., Iwersen-Bergmann, S., Stein, S., Schmoldt, A. and Puschel, K. (2000), ‘Methadone-related fatalities in Hamburg 1990–1999: implications for quality standards in maintenance treatment?’, Forensic Science International 113, pp. 449–55.

Rome, A., Shaw, A. and Boyle, K. (2008), Reducing drug users’ risk of overdose, Scottish Government Social Research, Edinburgh.

Stenbacka, M., Leifman, A. and Romelsjo, A. (2010), ‘Mortality and cause of death among 1705 illicit drug users: a 37 year follow up’, Drug and Alcohol Review 29, pp. 21–7.

WHO (2010), Prevention of acute drug-related mortality in prison populations during the immediate post-release period, World Health Organization Europe, Copenhagen.

 

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The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU’s decentralised agencies. Read more >>

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Page last updated: Tuesday, 26 October 2010