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Please note that the information on this page is based on the EMCDDA Annual report 2011: the state of the drugs problem in Europe. Most statistical data relate to the year 2009 (or the last year available).


Annual report 2011: the state of the drugs problem in Europe
Drug-related infectious diseases and drug-related deaths

Published: 15 November 2011

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 have 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

The most recent estimates suggest that there were about 7 630 drug-induced deaths in 2009 in the EU Member States and Norway, indicating a stable situation when compared with the 7 730 cases reported in 2008 (2). The numbers are likely to be conservative, as national data may be affected by under-reporting or under-ascertainment of drug-induced deaths. Few countries have assessed the magnitude of underestimation in their national data.

During the period 1995-2008, between 6 300 and 8 400 drug-induced deaths were reported each year by EU Member States and Norway. In 2008, the most recent year for which data are available for almost all countries, more than half of all reported drug-induced deaths were accounted for by two countries, Germany and the United Kingdom, who together with Spain and Italy, registered two-thirds of all reported cases (5 075).

For 2009, the average EU mortality rate due to overdoses is estimated at 21 deaths per million population aged 15-64 years, with most countries reporting rates of between 4 and 59 deaths per million (Figure 19). Rates of over 20 deaths per million are found in 13 out of 28 European countries, and rates of over 40 deaths per million in seven countries. Among Europeans aged 15-39 years, drug overdoses accounted for 4 % of all deaths (3).

The number of reported drug-induced deaths 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 by 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 endorsed by the EMCDDA (4). Nevertheless, caution must be exercised when comparing countries because there are still differences in reporting methodology and data sources.

Deaths related to opioids


Opioids, mainly heroin or its metabolites, are present in the majority of drug-induced deaths reported in Europe. In the 22 countries providing data for 2008 or 2009, opioids accounted for the large majority of all cases: over 90 % in five countries, and between 80 % and 90 % in a further 12. 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 occur in a context of polydrug use, as illustrated by a review of toxicology of drug-related deaths in Scotland in 2000-07. It showed that the presence of heroin and alcohol were positively associated, particularly among older males. Among men whose deaths were related to heroin, alcohol was present in 53 % of those aged 35 and more, compared to 36 % in cases under 35 years (Bird and Robertson, 2011; see also GROS, 2010).

Men account for most overdose deaths reported in Europe (81 %). Overall, there are around four males for each female case (with the ratio ranging from 1.4:1 in Poland to 31:1 in Romania) (5). In the Member States that joined the EU more recently, reported drug-induced deaths are more likely in males and in younger people compared to the pre-2004 Member States and Norway. Patterns differ across Europe, with higher proportions of males reported in southern countries (Greece, Italy, Romania, Cyprus, Hungary, Croatia), and in Estonia, Latvia and Lithuania. Denmark, the Netherlands, Sweden and Norway report higher proportions of older cases. In the majority of countries, the average age of those dying of heroin overdoses is in the mid-thirties, and in many countries 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, 12 % of overdose deaths reported in Europe occur among those aged under 25 years (6).

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. Other factors linked with overdoses are binge drug use, co-morbidity, homelessness, poor mental health (e.g. depression and intentional poisoning), not being in drug treatment, previous experience of overdose, and being alone at the time of overdose (Rome et al., 2008). The time immediately after release from prison (WHO, 2010) or discharge from drug treatment is a particularly risky period for overdoses, as illustrated by a number of longitudinal studies.

Other opioids

Besides heroin, a range of other opioids are found in toxicological reports, including methadone (7) and buprenorphine. Deaths due to buprenorphine poisoning are infrequent and mentioned by very few countries, despite its increasing use in substitution treatment in Europe. In Finland, however, buprenorphine remains the most common opioid detected in forensic autopsies, but usually in combination with other substances. This was illustrated by a recent Finnish report investigating drug findings in cases of accidental poisoning, which reported the presence of benzodiazepines in almost all (38/40) cases where buprenorphine was identified as the primary cause of death. Alcohol was also a significant contributory factor identified in 22 out of 40 cases (Salasuo et al., 2009). In Estonia, most drug-induced deaths reported in 2009 were, as in previous years, due to 3-methylfentanyl.

Deaths related to other drugs

Deaths caused by acute cocaine poisoning seem to be relatively uncommon (EMCDDA, 2010a). But, as cocaine overdoses are more difficult to define and identify than those related to opioids, they may be under-reported (see chapter 'Cocaine and crack cocaine').

In 2009, about 900 deaths related to cocaine were reported in 21 countries. Due to the lack of comparability in the available data, it is difficult to describe the European trend. The most recent data for Spain and the United Kingdom, the two countries with the highest levels of cocaine prevalence, indicate a decrease in deaths related to the drug: in Spain, from 25.1 % of the reported cases with cocaine (and no opiates) in 2007 to 19.3 % in 2008; and in the United Kingdom, from 12.7 % in 2008 to 9.6 % in 2009. Cocaine is very rarely identified as the only substance contributing to a drug-induced death.

A recent international review on mortality among cocaine users concluded that there are limited data on the extent of elevated mortality among problematic or dependent cocaine users (Degenhardt et al., 2011). The review included findings from three European follow-up studies: a French study following individuals arrested for cocaine offences; a Dutch study with cocaine injectors recruited via low-threshold services; and an Italian study with dependant cocaine users receiving treatment. Crude mortality rates in these studies ranged from 0.54 to 4.6 per 100 person-years. A recent Danish cohort study, with individuals in treatment for cocaine use, showed an excess mortality risk of 6.4 compared to same age and sex peers in the general population (Arendt et al., 2011).

Deaths in which ecstasy (MDMA) is present are infrequently reported and, in many of these cases, the drug has not been identified as the direct cause of death (8). In 2009, deaths possibly related to cathinones were reported in England (mephedrone) and Finland (MDPV) (see chapter 'New drugs and emerging trends').

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 (9). Between 2000 and 2003, most EU Member States reported a decrease, followed by a subsequent increase from 2003 until 2008. Preliminary data available for 2009 suggest an overall figure equal to or slightly below that for 2008. Where a comparison is possible, the numbers of deaths reported have decreased in some of the largest countries, including Germany, Italy and the United Kingdom.

The reasons for the sustained or increasing numbers of reported drug-induced deaths in some countries 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 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 more vulnerable drug users.

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. Deaths indirectly related to drug use are difficult to quantify, but their impact on public health can be considerable. Such 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, heroin 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 across populations, between countries and over time. Generally, though, the main cause of death among problem drug users in Europe 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, accidents and alcohol abuse.

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.

Other diseases that also account for a proportion of deaths among drug users include chronic conditions such as liver diseases, mainly due to infection with the hepatitis C virus (HCV) and often worsened by heavy alcohol use and HIV co-infection. Deaths caused by other infectious diseases are rarer. Causes of death among drug users such as suicide and trauma as well as homicide have received much less attention, despite indications of a considerable impact on mortality.


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

(2) The European estimate is based on 2009 data for 17 of the 27 Member States and Norway, 2008 data for nine countries and projected data for one country. Belgium is excluded as no data are available. For more information, see Table DRD-2 (part i) in the 2011 statistical bulletin.

(3) See Figure DRD-7 (part i) and Tables DRD-5 (part ii) and DRD-107 (part i) in the 2011 statistical bulletin.

(4) For detailed methodological information, see the 2011 statistical bulletin and drug-related death key indicator pages.

(5) 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 Figure DRD-1 in the 2011 statistical bulletin.

(6) See Figures DRD-2 and DRD-3 and Table DRD-1 (part i) in the 2011 statistical bulletin.

(7) See the box 'Methadone and mortality' on this page.

(8) For data on deaths related to drugs other than heroin, see Table DRD-108 in the 2011 statistical bulletin.

(9) See Figures DRD-8 and DRD-11 in the 2011 statistical bulletin.

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

(11) See Table DRD-5 (part iii) in the 2011 statistical bulletin.

Bibliographic references

Arendt, M., Munk-Jørgensen, P., Sher, L., and Jensen, S.O. (2011), 'Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: A nationwide follow-up study of Danish substance users in treatment', Drug and Alcohol Dependence 114, pp. 134-9.

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.

Bird, S.M. and Robertson, J.R. (2011), 'Toxicology of Scotland's drugs-related deaths in 2000-2007: Presence of heroin, methadone, diazepam and alcohol by sex, age-group and era', Addiction Research and Theory 19, pp. 170-8.

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, p. a478.

EMCDDA (2009), Polydrug use: patterns and responses, Selected issue, Publications Office of the European Union, Luxembourg.

EMCDDA (2010), Annual report 2010: the state of the drug problem in Europe, Publications Office of the European Union, Luxembourg.

Degenhardt, L., Singleton, J., Calabria, B., McLaren, J., Kerr, T., Mehta, S., Kirk, G. and Hall, W.D. (2011), 'Mortality among cocaine users: A systematic review of cohort studies', Drug and Alcohol Dependence 113, pp. 88-95.

GROS (General Register Office for Scotland) (2010), Drug-related deaths in Scotland in 2009, General Register Office for Scotland.

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

Salasuo, M., Vuori, E., Piispa, M. and Hakkarainen, P. (2009), Suomalainen huumekuolema 2007. Poikkitieteellinen tutkimus oikeuslääketieteellisistä kuolinsyyasiakirjoista [Finnish drug-related deaths in 2007. Cross-discipline study of forensic medical cause-of-death documents.], THL. Raportti 43/2009, Yliopistopaino, Helsinki.

WHO (2010), Global tuberculosis control: a short update to the 2010 Report, World Health Organization, Geneva.

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Page last updated: Friday, 28 October 2011