Frequently asked questions (FAQ): drug overdose deaths in Europe

Frequently asked questions (FAQ):
drug overdose deaths in Europe

Introduction

This page provides an update on drug-related deaths in Europe, presenting and analysing the latest data on and trends in drug-induced deaths in the European Union, Norway and Turkey. It draws on contributions from specialists from these countries, as well as on information provided by European countries in the annual reporting exercise to the agency.

The latest European Drug Report showed that over 8 200 deaths involving one or more illicit drugs were reported in 2017 in the European Union. This estimate exceeds 9 400 deaths when Norway and Turkey are included. Men account for four fifths of drug-induced deaths. Most of the deaths were premature, affecting people in their thirties and forties.

An update from the EMCDDA expert network, published in July 2019, also highlighted that opioids, often heroin, are involved in between 8 and 9 out of every 10 drug-induced deaths reported in Europe, although this is not true for all countries. Opioids used in substitution treatment can also be found in post-mortem analyses in some countries. Deaths related to medications, such as oxycodone and tramadol, are also reported. Deaths associated with fentanyl and its analogues are probably underestimated, and outbreaks of deaths related to these substances have been reported.

Aim and objectives

This page aims to raise awareness on the nature and scale of the drug overdose deaths problem in Europe. This topic does not receive sufficient attention, despite the high number of lives lost in Europe, the dramatic consequences for families and communities and the fact that all deaths are, in principle, preventable and avoidable.

This page provides an update on the current situation of drug overdose and highlights other analyses recently published in this field by the agency.

Finally, we are publishing this page to mark International Overdose Awareness Day on 31 August 2019, thereby contributing to the agency’s broader public health initiatives.

What this page contains

This page contains up-to-date information on where we are with overdose death in Europe (who is dying, where and how this has been changing over time). It also summarise the common situations that increase the risk of overdose (risk factors for overdose) and highlights current main concerns. Finally, background information is given on the methodology, the sources of information and their limitations, together with references and links to resources.

Questions

Pick a question below to jump straight to its answer.

Overdose situation

Overdose situation

What is a drug-related death?

The EMCDDA has defined a 'Drug-related deaths and mortality (DRD)' epidemiological indicator with two complementary components:

  • regular national, population-based statistics on deaths directly attributable to the use of drugs (drug-induced deaths, also known as poisonings or overdoses)
  • estimations of the overall and cause-specific mortality among high-risk drug users.

Case definition

For the purpose of the EMCDDA regular national statistics, the definition of drug-related deaths is ‘deaths happening shortly after consumption of one or more illicit psychoactive drugs and directly related to this consumption, although they may often happen when such substances are taken in combination with other substances, such as alcohol or psychoactive medicines’. These deaths are often referred to as ‘drug-induced deaths’ or also, poisonings or overdoses.

Exclusion criteria

Deaths for which a drug has been found in the toxicological analysis but in which this drug did not have a causal or determinant role in the death are not included in the EMCDDA statistics. This may happen when a toxicological analysis is undertaken in certain investigations (e.g. traffic accidents, suicides and violence). Deaths that are indirectly related to drugs are also excluded from the regular national statistics of ‘drug-induced’ or ‘overdose’ deaths (e.g. deaths related to HIV/AIDS acquired through injecting drugs).

The component of 'overall and cause-specific mortality among drug users' is based on follow up longitudinal ad-hoc studies. More information is presented in the methodology section at the end of this document, and also in the methods pages of the EMCDDA Statistical Bulletin, and in the EMCDDA European DRD protocol. The protocol establishes harmonised criteria to collect data and report figures, based on the information available in different mortality registries, at the end point of the chain of certification/ascertainment procedures.

How many people die every year in Europe?

It is estimated that at least 8 238 overdose deaths occurred in the European Union in 2017. This rises to an estimated 9 461 deaths if Norway and Turkey are included, representing a stable figure (an increase of 0.7 %) compared with the revised 2016 figure of 9 397. These overall numbers must be understood as underestimations, as there are limitations to drug-induced deaths data, particularly to European cumulative totals.

According to the latest available data, it is estimated that there were at least 8 799 deaths in 2017 among those aged 15-64 years old in Europe.

Drug-induced deaths in the European Union, Norway and Turkey: total number among adults aged 15-64 years, 2017

Are the numbers of drug-related deaths similar across different countries?

As in previous years, the United Kingdom (34 %) and Germany (13 %) together account for around half of the EU total number of drug-related deaths in 2017. This relates partly to the size of the at-risk populations in these countries, but also to under-reporting in certain other countries. Following the United Kingdom and Germany, Turkey, Sweden, Spain, France, Italy and Norway report the largest numbers of deaths.

There are also differences within countries, with some regions and cities much more affected than others.

Is the drug-related deaths rate (deaths/population) similar across countries?

The mortality rate due to drug overdoses in Europe in 2017 was estimated to be 22.6 deaths per million in the population aged 15-64 years, but this varied across countries, with higher rates observed in countries in the north of Europe.

Comparisons should be made with caution though because of under-reporting in some countries (see more below in the section on methods).

drug induced mortality rates among adults

Are women and men equally affected? What are the trends in the gender distribution of deaths? 

Men represent the majority of drug-related deaths in Europe (78 %).

Compared with 2007, the number of women dying in relation to drugs has increased by more than one third (41 %), while the number of men dying has increased by 14 %. Since 2012, there has been a large increase which was mainly driven by deaths among males.

Are there differences between the genders across countries?

The current distribution of drug-related deaths between men and women varies between countries, with the proportion of male deaths higher in the south and east of Europe, compared with the north and west of Europe.

Proportion of males among drug-related deaths in the European Union, Norway and Turkey, 2017

Note: it is important to note that the number of cases is low in some countries (less than 20 cases reported in Bulgaria, Cyprus, Luxembourg, Malta and Slovakia). No age and gender break down was reported from Greece.

Who are the people most at risk?

Drug-related deaths predominantly affect men: there are 35.8 deaths per million men aged 15-64 years, which is almost four times the number of drug-related deaths among women (9.3 deaths per million women aged 15-64 years).

In 2017, the highest overdose mortality rate was seen in men, with 57 deaths per million men aged 35-39 years.

How has the distribution of drug-related deaths among age groups changed in the last 5 years?

The reported number of overdose deaths is continually increasing among older age groups. While users aged over 40 years represented around one third of the deaths 10 years ago, they represented around half in 2017. Older people (over 50 years) represent a small proportion of all drug-induced deaths, but the number doubled between 2007 and 2017.

This reflects the ageing nature of Europe’s opioid-using population in most countries. It is important because older high-risk drug users may be at the greatest risk of drug overdose death.

In 2017, the overall mean age at death due to overdose was 39 years, compared with 36 years in 2012. Between 2012 and 2017, overdose deaths in the European Union increased in all age categories above 30 years.

Number of drug-induced deaths reported in the European Union in 2012 and 2017, or most recent year, by age band

Is the age distribution of drug-related deaths similar across different countries?

There are differences in the age distribution of the drug-induced cases (see bar chart). Drug-related deaths in most countries in the west of Europe are among older people than in eastern countries (see map). This mirrors, in part, the ageing populations of opioid users in western countries.

Distribution of drug-induced deaths reported in 2017, or most recent year, by 10-year age band

Proportion of drug-induced deaths among people aged 40 years or older in the European Union, Norway and Turkey, 2017 (or most recent data available)

Are there differences between men and women in the distribution of intentional and accidental drug-related deaths?

Most drug-related deaths are classified as accidental deaths, particularly those among men, for which accidental deaths represent 86 % of cases, compared with 71 % among women.

The remaining cases are classified as intentional deaths (suicidal) or as deaths with an undetermined intent, both of which are more common among women (18 % of deaths are suicidal among women, compared with 7 % among men, and 11 % of deaths have an undetermined intent among women, compared with 7 % among men).

Some cases classified as having an undetermined intent might be suspected but unconfirmed suicides. Please note, there may also be differences across countries in the recording and coding of the intentionality of the death.

Proportion of drug-related deaths classified as accidental, suicidal or having an undetermined intent in men and women in the 21 countries with available information, 2017 (or most recent data available

Note: ‘21 countries reporting ICD breakdown based on General mortality register, for a total of 5531 cases (67.1%)’.

What substances are involved in drug-related deaths?

Opioids, mainly heroin or its metabolites, often in combination with other substances, are present in the majority of fatal overdoses reported in Europe. In most drug-related deaths, more than one substance is detected, indicating polydrug use.

Overall, opioids are involved in 77.8 % of cases, with large differences across countries (see more country-level data in the Statistical Bulletin).

In some countries, no or limited data are reported on the post mortem toxicology findings.

For example, in Poland only Warsaw provided data and these show a large majority of cases with opioid involvement. In Spain, six cities provided more detailed data and these suggest a predominance of opioids and cocaine in drug-related deaths.

In Turkey (which principally reported synthetic cannabinoids, MDMA and amphetamines) and Hungary (which principally reported new psychoactive substances), less than one quarter and less than one third, respectively, of cases involved opioids.

Stimulants such as cocaine, MDMA, amphetamines and cathinones are implicated in a smaller number of overdose deaths in Europe, although their significance varies by country. More information is available for some countries in this European Drug Report and a recent update on cocaine-related deaths is available here, pointing to an increase in the number of deaths where this drug is involved.

Where have numbers of drug-related deaths increased or decreased most over the last 10 years?

Overdose data, especially the European cumulative total, must be interpreted with caution. Among the reasons for this are systematic under-reporting in some countries, differences in the ways toxicological examinations are conducted and registration processes that can result in reporting delays. Annual estimates therefore represent a provisional minimum value.

Country numbers and trends vary across Europe, but they should also be interpreted with caution.

Indexed trends in the number of deaths in countries with the most relevant increases in Europe, 2007-2017

Indexed trends in the number of deaths in countries with the most relevant decreases in Europe, 2007-2017

Note: Countries with less than 25 cases reported in 2017 (or the last years available) have been excluded. from On the top graph: Turkey was omitted as part of the important increase observed in the country over the last years might be due to improved reporting; Portugal was omitted because there was discrepancy between sources in the first years. Greece is excluded from the bottom graph due to reporting delays.

Risk factors for overdose

Risk factors for overdose

What are the common situations that increase the risk of overdose?

There are individual, situational and organisational risk factors for overdoses and they can be modified to reduce fatal outcomes (Frisher et al., EMCDDA, 2012).

Individual and situational factors include the type of drugs used, the route of administration, the use of several drugs together, age and decreased tolerance to opioids and other drugs. See more in the topic overview on Preventing drug-related deaths. ADD LINK

The type of substance used, the route of administration and the health of the user all have an impact on the risk of overdose. Most overdose deaths are linked to the use of opioids, primarily the injection of heroin or synthetic opioids, while polydrug use is also very common, including the combination of heroin or other opioids with other central nervous system depressants, such as alcohol or benzodiazepines, which bears particularly high risks. Using/injecting alone is also a risk factor for overdose death.

A number of environmental factors increase the risk of drug overdose death, including, in the case of opioid users, disruption of treatment provision or discontinuity of treatment and care. In certain situations, for example following detoxification or discharge from drug-free treatment, the tolerance of drug users to opioids is greatly reduced and, as a result, they are at a particularly high risk of overdosing if they resume use. For these same reasons, an inadequate continuity of care between prison and community life has also been identified as an important environmental risk factor (WHO, 2014; Zlodre and Fazel, 2012). In a cohort study in England, differences in the risk of fatal opioid poisoning were identified, which were dependent on the type of treatment received: opioid users who received only psychological support appeared to be at a greater risk than those who received opioid-agonist pharmacotherapy (Pierce et al., 2016). This adds to the body of evidence that supports enrolling and retaining problem opioid users in OST and continuity between treatment in prisons and the community and at other transition points.

Points of concern

Points of concern

These two focuses are selected because Scotland has the highest overdose mortality rates in Europe, and because fentanyls and its analogues have been involved in large numbers of deaths in some countries, and in outbreaks recently. Their possible penetration in national drug markets have the potential to result in large increases in deaths and non-fatal intoxications.

Scotland

In Scotland, most recent data available show that 1 187 drug-related deaths were reported in 2018, with an increase of 27% over 2017. This figure is the largest number ever recorded, after an overall increasing trend of over 20 years. Since 2012/13 a dramatic increase has been observed.

Scotland’s drug-death rate among adults (15–64 years) is higher than those reported for all the EU countries (although there are issues of coding, coverage and under-reporting in some countries).  To illustrate the scale of the problem, Scotland with a population of 5.5 million reports a similar number of overdose deaths as Germany does that has a population of 83 million. Most cases in Scotland are associated with opioids (9 in 10) and benzodiazepines (7 in 10) but almost all 85% involve more than one drug. Recent increases are primarily seen in the 35–44 and 45–54 age groups.

It is important to follow up and understand the factors driving this phenomenon in Scotland, in order to further develop and implement appropriate interventions.

Trend in drug-related deaths, 1996-2018 (Scotland)

Source: Statistics of drug-related deaths in 2018 and earlier, broken down by cause of death, selected drugs reported, age and sex

Deaths related to fentanyl and fentanyl analogues

llicitly manufactured fentanyl and its analogues are involved in large numbers of deaths in some countries, such as Estonia, and Sweden which saw a peak in 2017. In England, in the spring of 2017, intelligence from post-mortem results and drug seizures suggested that fentanyl and its analogues had been introduced into the heroin supply in the north of the country. Public Health England issued an alert at the end of April 2017 advising (1) on the availability of, and harms from, heroin that had been mixed with fentanyl or carfentanil, (2) that warnings be cascaded and (3) of the naloxone dosing regime in the event of an overdose (see the figure above). Read more in the report.

It is very important to follow closely any signal and alert about harms related to fentanyl and fentanyl analogues, because these substances have a very high toxicity, compared to other opioids, namely heroin. They have therefore the potential to create large clusters of incidents and of deaths if they enter the drug markets in Europe.

Fentanyl-related incidents in England (UK) in 2017: locations of the deaths

Source. Martin White, for the DRD Rapid Communication report, July 2019. Note: large urban centres are shown in green.

Methodology

Methodology

The national focal points and their experts in the 28 EU Member States, Norway and Turkey report data annually to the EMCDDA through standard tables and workbooks. Country-specific information is available in the Country Drug Reports. The annual Statistical Bulletin contains the most recent available data on the drug situation in Europe provided by the Member States, Norway and Turkey. These data sets underpin the analysis presented in the European Drug Report.

Where do the data come from?

There are two kinds of mortality registers from which cases of drug-related deaths can be retrieved and reported: the general mortality register and special mortality registers.

  • General mortality registers: These are usually maintained by national statistical offices or health departments. They are based on the mandatory death certificates issued for all deaths by a certifying doctor. In cases of deaths with legal intervention, the certifying person is usually a forensic doctor or a coroner.  
  • Special mortality registers: These are ideally developed specifically for drug mortality monitoring through a combination of different sources (e.g. forensic, police and other sources), which allows a high degree of detection of drug-related deaths in a country. Alternatively, these registers are included in and maintained by existing information systems of police or medico-legal institutions (e.g. forensics institutes, coroners) for all unnatural deaths that required investigation.

What cases are included?

The European definition of drug-related deaths is translated into a set of codes and criteria to allow the extraction of the relevant cases from mortality registers.

For the extraction of cases from general mortality registers, the deaths classified with the following International Classification of Disease (ICD)-10 codes are eligible (see the eligible codes in the methods page).

For the extraction of cases from special mortality registers, a set of criteria are also defined in the EMCDDA European protocol.

What sources of information are used in different countries?

Most countries report data from both sources (general and special registers), which allows triangulation and validation of the data.

While the trends are usually consistent between both sources (as can be seen in the Statistical Bulletin), there can be discrepancies between the general mortality register and the special mortality register data in some countries. This can be because the coding of the causes of deaths in the general mortality register is not sufficiently sensitive, or because the data reported from the special register do not cover the whole country.

Depending on the certification and coding procedures in the registries and also on the flux of information between the special and the general mortality registries, there are reporting delays in some countries. The most recent data are from 2017 in 20 countries, 2016 in six countries, 2015 in one country and 2014 in one country.

Sources used by the countries to report drug-related deaths to the EMCDDA, 2017 (or most recent data available)

What is the preferred source of data chosen by the countries to show the details of the cases in EMCDDA publications?

When both sources are available, the countries are asked to choose which is more valid and which should be taken as the reference for the EMCDDA Statistical Bulletin. The data from the selected source are then used to compute the European figures and European trends.

Meanwhile, at national level, figures from both sources (the selected source or ‘national definition’ and the other source) are given in the Statistical Bulletin.

Eighteen countries indicated that the general mortality register was their preferred source, while 12 preferred the special register. In the Statistical Bulletin, when,the EMCDDA definition is fully applied the cases extracted from the general mortality register are showed under the category ‘Selection B’) and those extracted from the special mortality registers are showed under the category ‘Selection D’.

Sources preferred by the countries to report drug-related deaths to the EMCDDA, 2017 (or most recent data available)

Are the data comparable among countries?

There are differences between (and within) countries with regard to the identification and certification of the cause of death, and the classification and reporting of the number of drug-induced deaths.

This relates to:

  • the quality and frequency of post mortem investigations,
  • the availability of this information for the determination of the cause of death,
  • the classification system used,
  • the quality of classification,
  • the coverage and quality of the overall reporting system.

Countries also have different levels of forensic laboratory capacity and different standard procedures for post mortem toxicological investigations of suspected drug-induced deaths (EMCDDA, 2019; Leifman, 2017 and Millar, 2017). These factors have an impact on the sensitivity of analyses and hence on the comparability of the data within and across countries. Caution is thus advised when interpreting and comparing data on drug-induced deaths over time and between countries.

Insights into the differences in post mortem toxicology investigations have been published in 2019.

Contextual information is also available for the 30 countries through the Country Drug Reports.

Are there cohort or longitudinal studies among drug users to measure the overall and the cause-specific mortality rates? 

Monitoring overall mortality among high-risk drug users is the second component of the DRD epidemiological indicator. The overall or ‘all-cause’ mortality among high-risk drug users is investigated by means of cohort studies, which link records from death registers with records of individuals — typically from treatment registers — who are or have been using drugs (see the EMCDDA protocol here). In this way, it is possible to check the vital status of the individuals who enrolled in treatment at some point. Follow-up cohort studies also allow measurements of behaviour over time, for example the duration of treatment and interruptions, if any.

Mortality cohort studies can be used to cross-validate national statistics on overdose.

While 12 countries still have no recent findings available, there are, for the majority of countries, some recent data based on cohort studies.

Such data are instrumental in measuring the overdose mortality risk among drug users. This risk can, in turn, be applied in the estimated population of high-risk drug users in countries. These data also allow an estimation of the expected number of deaths in countries and can help cross-validate the reported number of overdoses.

Availability of cohorts and reports from cohort studies. More information is available from the 2019 Rapid Communication Report on DRD and on the previous review of cohorts published by the EMCDDA.

Availability of cohorts and reports of information from cohort studies listed in the present paper and in the 2015 EMCDDA study

Resources

Resources

For further methodological information and EMCDDA most recent publications in this area please consult the Statistical Bulletin 2019 — methods and definitions for overdose deaths.

Loading