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

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

Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2021), Frequently asked questions (FAQ): drug overdose deaths in Europe,
https://www.emcdda.europa.eu/publications/topic-overviews/content/faq-drug-overdose-deaths-in-europe.

Page last updated: 31 August 2021

Introduction

This page provides answers to the questions most often asked about drug overdose deaths in Europe. Also known as drug-induced deaths, they are deaths directly attributable to the use of illicit drugs. The information presented here is based on the latest data from the Member States of the European Union (1) and the EMCDDA affiliates 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 (EMCDDA, 2021a) estimated that over 5 100 deaths involving one or more illicit drugs were reported in 2019 in the European Union. This estimate rises to more than 5 700 deaths when Norway and Turkey are included. Men accounted for three quarters of drug-induced deaths. All of these deaths were premature, predominantly affecting people in their thirties and forties.

Opioids, often heroin, were involved in more than three quarters of the 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 in recent years in several countries.

(1) The United Kingdom left the European Union on 31 January 2020 and is not included in the overall analysis presented here.

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, the dramatic consequences for families and communities and the fact that all of these deaths are, in principle, preventable and avoidable.

We are publishing this page to mark International Overdose Awareness Day on 31 August 2021, thereby contributing to the EMCDDA’s broader public health initiatives.

What this page contains

This page contains up-to-date information on overdose deaths in Europe, focusing on the demographics (who is dying) and the time trends. It also summarises 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

Overdose situation

Overdose situation

What is a drug-induced death?

Overdose or drug-induced deaths are monitored by the EMCDDA under the ‘Drug-related deaths and mortality (DRD)’ epidemiological indicator. This has two complementary components:

  • drug-induced deaths: regular national, population-based statistics on deaths directly attributable to the use of drugs (also known as poisonings or overdoses). In many publications and documents, the term ‘drug-related deaths’ is used, although strictly speaking this term is more inclusive);
  • drug-related mortality: estimations of the overall and cause-specific mortality among high-risk drug users, based on follow-up longitudinal ad-hoc studies.

Case definition

For the purpose of the EMCDDA regular national statistics, drug-induced deaths are those ‘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’.

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).

More information

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 (EMCDDA, 2010). 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 5 141 overdose deaths occurred in the European Union in 2019. This rises to an estimated 5 769 deaths if Norway and Turkey are included, representing a slight decrease compared with the 2018 figure of 5 920. These overall numbers must be understood as underestimations, as there are limitations to drug-induced deaths data, particularly to European cumulative totals. Data for 2019 are not available for all countries, and for those cases the most recent available data may be used to estimate the overall European figures.

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

Germany, Sweden, Spain and France together account for half (49 %) of the European total number of drug-related deaths in 2019. This relates partly to the size of the at-risk populations in these countries, but also to under-reporting in certain other countries. Following Germany, Sweden, France and Spain, the next highest numbers of deaths were reported by Italy, Turkey and Norway (see figure below).

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

Drug-induced deaths in the European Union, Norway and Turkey: total number among adults aged 15-64 years, 2019

(1) No age breakdown was available in 2019 for Germany and Greece, therefore all cases are counted instead of only those aged 15-64 years.

The data for this graphic are available in Table 1 in the source data section.

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

The mortality rate due to drug overdoses in Europe in 2019 was estimated to be 14 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 (see map and trend chart below).

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

Drug-induced mortality rates among adults (15-64): selected trends and most recent data

The data for this graphic are available in Table 2 in the source data section.

Drug-induced mortality rates among adults (15-64): mortality rates

Note: For Germany and Greece, the mortality rate was computed based on the most recent data (respectively 2018 and 2017) for which a breakdown by age was available.

The data for this graphic are available in Table 3 in the source data section.

Are there differences between the genders across countries? 

Men represent overall the majority of drug-induced deaths in Europe (76 %). The current distribution of drug-induced 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 (see figure below). This difference might relate to a range of factors including the proportion of men among people who are using drugs, and varying drug use patterns by gender across regions. Besides differences in gender distribution, there are different age-distributions of the cases of drug-induced deaths across Europe; with some countries in the north of Europe reporting deaths among older women (including those who have died from use of prescription pills), while some countries in the south of Europe report high numbers of deaths among younger men using illicit drugs (see the section below on age differences).

Proportion of males among drug-related deaths in the European Union, Norway and Turkey, 2019

Note: The total number of cases is low in some countries (fewer than 20 cases reported in Bulgaria, Cyprus, Latvia, Luxembourg and Malta). For Germany, the proportion was computed based on the most recent data with gender breakdown (2017). No gender breakdown was reported for Greece over the last 6 years.

The data for this graphic are available in Table 4 in the source data section.

Drug-induced deaths predominantly affect men: a mortality rate of 23.7 cases per million males compared with 6.3 cases per million women. Among men, those aged 35-39 were the most affected, with a mortality rate of 37.7 deaths per million. Among women, those aged 45-49 were the most affected, with a mortality rate of 8.5 deaths per million.

How has the distribution of drug-induced deaths among age groups changed in recent years?

Comparing the number of deaths over a longer time period, overdose deaths in the European Union have been increasing since 2012, overall and among teenagers and all age categories above 35 (see figure below), with the 74 % increase among the 50-plus age group particularly high. 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 2019, the overall mean age at death due to overdose was 42 years, compared with 36 years in 2012.

Number of drug-induced deaths reported in the European Union in 2012 and 2019, or most recent year, by age band

graphic drug induced deaths by age band

The data for this graphic are available in Table 6 in the source data section.

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

There are differences between countries in the age distribution of drug-induced deaths (see bar chart below). Countries in the west of Europe tend to have an older age profile among overdose deaths than countries in the east (see maps below). This mirrors, in part, the ageing populations of opioid users (including ageing users of illicit opioids, typically heroin; and also in some countries, people using prescription opioids, such as oxycodone) in western countries.

Distribution of drug-induced deaths reported in 2019, or most recent year, by age group

The data for this graphic are available in Table 5 in the source data section.

Proportion of drug-induced deaths among older (40+ years) people in the European Union, Norway and Turkey, 2019 (or most recent data available)

The data for this graphic are available in Table 7 in the source data section.

Proportion of drug-induced deaths among younger (under 30 years) people in the European Union, Norway and Turkey, 2019 (or most recent data available)

The data for this graphic are available in Table 8 in the source data section.

What substances are involved in drug-induced 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-induced deaths, more than one substance is detected, indicating polydrug use (2).

Overall, opioids are involved in 76 % of cases reported in the European Union, with large differences across countries (see map below). More than 8 in 10 overdose deaths involved opioids in countries in the north of Europe (Ireland, Norway and Sweden), as well as in Austria and Romania.

In some countries, no or limited data are reported on the post mortem toxicology findings. Furthermore, in several countries, some cases are reported with ‘unknown or unspecified’ toxicology, in particular when there are several drugs involved. Most of these cases involve at least an opioid. Therefore the proportion of cases with opioids involved shown here is a minimum estimate.

In Belgium, Bulgaria, Czechia, Hungary, Malta, the Netherlands and Turkey, less than half of cases involved opioids. Although limited information is reported in some countries, most cases appear to involve polydrug drug use. Detailed information on toxicology findings is available in few countries: in Turkey, the substances most often involved in overdose deaths are mainly synthetic cannabinoids, MDMA and amphetamines; in Hungary, the substances most often involved in overdose deaths are new psychoactive substances; and in Czechia, most cases involve amphetamines
Proportion of drug-induced deaths with opioids involved in the European Union, Norway and Turkey, 2019 (or most recent data available)

Note: Although information on toxicology is not available for data reported through the general mortality registers (preferred source) in France, Greece, Spain, Portugal and Poland, data from the alternative source (forensic special mortality registers) suggest that most drug-induced deaths in these countries involved opioids.

The data for this graphic are available in Table 9 in the source data section.

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 the latest European Drug Report (EMCDDA, 2021a), and a recent report points to an increase in the number of deaths related to cocaine (EMCDDA, 2018).

A recent review of MDMA-related deaths in Australia and Europe showed an increase of the numbers of these deaths in Australia and all the three European countries (Finland, Portugal and Turkey) participating in the study (Roxburgh et al., 2021).

Deaths associated with new psychoactive substances are a cause of concern. A review published in 2021, and based on the reports to the EMCDDA of drug-induced deaths from the EU countries as well as Norway, Turkey and the United Kingdom, found that in 2017, one in six drug-related deaths in these countries involved new psychoactive substances, and the proportion and numbers increased from 2016 levels (López-Pelayo et al., 2021). However, three quarters of the cases were concentrated in only two countries and involved a small number of substances. In 2016 and 2017, 73 % and 77 % of the cases were concentrated in the United Kingdom and Turkey, related mainly to etizolam – a ‘new benzodiazepine’ – generally together with opioids and synthetic cannabinoids respectively. In Turkey, there has been a marked decrease in the number of deaths in 2018 and 2019. To fully understand the public health implications of new psychoactive substances, further monitoring of drug-induced deaths linked to these substances and their distribution in Europe is needed.

(2) ‘Polydrug use’ is a term to describe the use of more than one drug or type of drug by an individual, either at the same time or sequentially. It encompasses use of both illicit drugs and legal substances, such as alcohol and medicines (EMCDDA, 2017).

Where have numbers of drug-induced deaths increased over the last 10 years?

Data on fatal overdoses, 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 value.

Country numbers and trends vary across Europe, but they should also be interpreted with caution. The section below presents selected countries. Countries from the southeast and from the north of Europe are presented separately (as indicated in the map below).
Countries included in the ‘southeast’ and ‘north’ of Europe for this trend analysis

The data for this graphic are available in Table 15 in the source data section.

The southeast of Europe

Compared with 2010, the number of drug-related deaths has increased in six out of seven countries in the southeast of Europe (see figure below). In Turkey, the peak observed in 2016-17 was mainly related to deaths involving synthetic cannabinoids. These drugs were often found together with stimulants (MDMA, amphetamines, cocaine) and other drugs including heroin. Most deaths during this outbreak occurred among young males in their twenties and early thirties.

The recent increase observed in Slovenia relates to deaths involving opioids and cocaine mainly. The increase in Hungary relates largely to deaths involving new psychoactive substances and non-cocaine stimulants. An outbreak of deaths related to synthetic cannabinoids was reported in the summer of 2020. In the remaining four represented countries, the number of reported overdose deaths have remained similar to the numbers reported in 2010.

Indexed trends in the number of deaths in selected countries in the south east of Europe, 2010-2019

2010 = 100

Note: Other countries in the southeast of Europe, with fewer than 15 cases reported in 2019 or the last year with available data, are not represented (Bulgaria, Cyprus and Malta). When a national data point was missing for the computation of the European index trend, it was replaced by the value of the preceding year.

The data for this graphic are available in Table 11 in the source data section.

North of Europe

The largest increases in 2019 – or the last year with available data – compared to 2010 are reported in the Netherlands, Finland and Sweden (see figure below). In these countries, overdose deaths are mostly related to opioids and polydrug use. In Sweden, part of the peak in the number of deaths reported in 2015-2017 was due to an increase in the number of deaths associated with fentanyl. In Lithuania, most of the increase observed in the same period was due to deaths associated with opioids.

In Ireland and Norway, there was small increase in the number of overdose deaths compared with 2010. In both countries, most of the deaths involve opioids. In Denmark, the most recently reported number of deaths (for 2018) was smaller than in 2010. In Estonia, an outbreak of overdose deaths, which peaked in 2011-12, was associated with fentanyl and fentanyl derivatives. After years of police intervention, along with the implementation of treatment and new harm reduction measures (namely take-home naloxone programmes), the country observed a marked reduction in overdose deaths in the last 2 years, to levels well below those reported 10 years ago.

Indexed trends in the number of deaths in selected countries in the north of Europe, 2010-2019 (2010 = 100)

2010 = 100.

Note: Latvia, which had fewer than 15 cases reported in 2019, is not represented. When a national data point was missing for the computation of the European index trend, it was replaced by the value of the preceding year.

The data for this graphic are available in Table 11 in the source data section.

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., 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.

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, lack of access to and 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 access to treatment while in prison and, thereafter, an inadequate continuity of care between prison and community life has also been identified as an important environmental risk factor (Degenhardt et al., 2014; WHO Regional Office for Europe, 2010; 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 (opioid substitution treatment) (Pierce et al., 2016). This adds to the body of evidence that supports enrolling and retaining high-risk opioid users in opioid substitution treatment (see the EMCDDA Best practice portal), access to harm reduction interventions and continuity between treatment in prisons and the community and at other transition points (see also in the recently published EMCDDA Insights on prison and drugs (EMCDDA, 2021b)).

Preventing overdose deaths

Preventing overdose deaths

How can overdose deaths be prevented?

A multifaceted response is needed to prevent overdose deaths, as there is no single or simple intervention that will make a large impact alone. This section briefly lists the most important interventions, and provides links to more detailed resources in this area.

Strategies to reduce drug-related deaths can include in particular the following:

  • provision of large-scale opioid substitution treatment;
  • promotion of quality in the care in treatment and implementation of interventions supported by evidence;
  • provision of harm-reduction interventions;
  • provision of drug treatment, including opioid substitution treatment, in prisons;
  • development of a national overdose prevention policy, supported by long-term commitment from policymakers and funding for treatment services;
  • reinforcement of the collaboration between different stakeholders in the treatment services for substance use disorders;
  • interventions to reduce demand/use for drugs, particularly opioids;
  • promotion of safer drug taking, such as switching from injection to inhaling opioids, not taking drugs alone, and not combining drugs, as well as taking lower doses, if tolerance may be lost;
  • beyond the prevention of overdose, provision of integrated health care services, including hepatitis C treatment to people who are using drugs.

For more information on measures to reduce the risk of overdose and prevent deaths, including take-home naloxone programmes, see the online topic overview on Preventing drug-related deaths and the EMCDDA Best practice portal.

Methodology

Methodology

The national focal points and their experts in the 27 EU Member States, Norway and Turkey report data annually to the EMCDDA through standard tables and workbooks. 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: general mortality registers 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. These registers are limited, as often they do not have specific information on which drugs were consumed. Limitations are also due to the use of broad categories such as ‘other synthetic opioids’ and ‘other opioids’ in the coding of the cause of death in these registers. 
  • 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-induced 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-induced deaths is translated into a set of codes and criteria to allow the extraction of the relevant cases from mortality registers.

The extraction of cases from general mortality registers is explained in detail in the DRD methods page of the Statistical Bulletin. Cases are counted when their underlying cause of death is mental and behavioural disorders due to psychoactive substance use or poisoning (accidental, intentional or by undetermined intent) (EMCDDA, 2010).

What sources of information are used in different countries?

Most countries report data from both sources (general and special registers – see map below), 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 2019 in 20 countries, 2018 in six countries, 2017 in one country, 2016 in one country and 2014 in one country.

Sources used by the countries to report drug-induced deaths to the EMCDDA, 2019 (or most recent data available)

The data for this graphic are available in Table 12 in the source data section.

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.

Seventeen countries indicated that the general mortality register was their preferred source, while 12 preferred the special register (see map below).

In the Statistical Bulletin, when the EMCDDA definition is fully applied, the cases extracted from the general mortality register are shown under the category EMCDDA ‘Selection B’ and those extracted from the special mortality registers are shown under the category EMCDDA ‘Selection D’.

Sources preferred by the countries to report drug-induced deaths to the EMCDDA, 2019 (or most recent data available)

The data for this graphic are available in Table 13 in the source data section.

Are the data comparable among countries?

The differences in drug-induced death rates across regions may be explained by several factors including the different size of the population at risk, different drug taking and risk taking patterns – including injecting drugs – different practices among drug users, and also different age-distribution and health status among drug users. There are also differences in access to health care, drug treatment and harm-reduction interventions.

Besides these, there are varying rates of post mortem examinations, varying quality in the data available about toxicology and mortality, and varying practices in coding of cause of death, including the use of ‘unknown cause of death’. These are some known influential factors that might impact on the comparability of the data.

In particular, 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 and codification 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, 2019a, 2019b; Leifman, 2017; 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 recently (EMCDDA, 2019a).

How do we measure overall and the cause-specific mortality rates related to drug use?

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 guidelines for carrying out, analysing and reporting key figures (EMCDDA, 2012)). 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 measure 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, in combination with the reported number of drug-induced deaths. Overdose mortality rates from cohorts can allow researchers to estimate the ‘expected’ number of overdose deaths in countries and can help cross-validate the reported number of overdoses in the national statistics (3).

The provisional findings of a mapping conducted in 2021 suggest that, for the majority of countries, there are some recent data based on cohort studies (see map below). More detailed information and results of this mapping will be available soon. More information is also available from the previous review of cohorts published by the EMCDDA (2015).
Mortality cohort studies among people using drugs in Europe: countries with studies conducted within the last 10 years or earlier. July 2021 – provisional findings

The data for this graphic are available in Table 14 in the source data section.

(3) More information on the methods was presented during the annual DRD expert meeting in 2019 (Vicente and Giraudon, 2019).

Resources

Resources

For further methodological information and the most recent EMCDDA data in this area consult the Statistical Bulletin 2021 – methods and definitions for overdose deaths.

The European network of drug-related deaths experts supports the EMCDDA’s work on the DRD key epidemiological indicator. The network meets each year to share and discuss new data, studies and experiences at regional, national and European level.

Details of the 2020 meeting are available on the EMCDDA website.

The findings of the 2019 meeting were published recently (EMCDDA, 2021c).

All EMCDDA publications are available online at https://www.emcdda.europa.eu/publications.

References

Degenhardt, L., Larney, S., Kimber, J., Gisev, N., Farrell, M., Dobbins, T., Weatherburn, D. J., Gibson, A., et al. (2014), ‘The impact of opioid substitution therapy on mortality post-release from prison: Retrospective data linkage study’, Addiction 109(8), pp. 1306-1317.

EMCDDA (2010), Drug-related deaths (DRD) standard protocol, version 3.2, EMCDDA, Lisbon.

EMCDDA (2012), Mortality among drug users: guidelines for carrying out, analysing and reporting key figures, EMCDDA, Lisbon.

EMCDDA (2015), Mortality among drug users in Europe: new and old challenges for public health, Publications Office of the European Union, Luxembourg.

EMCDDA (2017), Responding to polydrug use, https://www.emcdda.europa.eu/best-practice/briefings/responding-polydrug....

EMCDDA (2018), Recent changes in Europe’s cocaine market: results from an EMCDDA trendspotter study, Publications Office of the European Union, Luxembourg.

EMCDDA (2019a), An analysis of post-mortem toxicology practices in drug-related death cases in Europe, Technical report, Publications Office of the European Union, Luxembourg.

EMCDDA (2019b), Drug-related deaths and mortality in Europe: update from the EMCDDA expert network, Rapid Communication, Publications Office of the European Union, Luxembourg.

EMCDDA (2021a), European drug report 2021: trends and developments, Publications Office of the European Union, Luxembourg.

EMCDDA (2021b), Prison and drugs in Europe: current and future challenges, Insights, Publications Office of the European Union, Luxembourg.

EMCDDA (2021c), Drug-related deaths and mortality in Europe: update from the EMCDDA expert network, Technical Report, Publications Office of the European Union, Luxembourg.

Frisher, M. Baldacchino, A., Crome, I. and Bloor, R. (2012), Preventing opioid overdoses in Europe: a critical assessment of known risk factors and preventative measures, EMCDDA, Lisbon.

Leifman, H. (2017), Drug-related deaths in Sweden: estimations of trends, effects of changes in recording practices and studies of drug patterns, Centralförbundet för alkohol- och narkotikaupplysning, Stockholm.

López-Pelayo, H., Vicente, V., Gallegos, A., McAuley, A., Büyük, Y., White, M. and Giraudon, I. (2021), ‘Mortality involving new psychoactive substances across Europe, 2016-2017’, Emerging Trends in Drugs, Addictions and Health 1, 100016.

Millar, T. and McAuley, A. (2017), EMCDDA assessment of drug-induced death data and contextual information in selected countries, EMCDDA, Lisbon.

Pierce, M., Bird, S. M., Hickman, M., Marsden, J., Dunn, G., Jones, A. and Millar, T. (2016), ‘Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England’, Addiction 111(2), pp. 298-308.

Roxburgh, A., Sam, B., Kriikku, P., Mounteney, J., Castanera, A., Dias, M. and Giraudon, I. (2021), ‘Trends in MDMA-related mortality across four countries’, Addiction, doi:10.1111/add.15493.

Vicente, J. and Giraudon, I. (2019), ‘Improving DRD information: multi-indicator coherence analysis (multi-country analysis)’, presentation in Session 5 of the 2019 EMCDDA annual meeting on drug-related deaths, EMCDDA, Lisbon 21-22 October 2019 (available at https://www.emcdda.europa.eu/meetings/2019/drd#section2).

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

Zlodre, J. and Fazel, S. (2012), ‘All-cause and external mortality in released prisoners: systematic review and meta-analysis’, American Journal of Public Health 102(12), pp. e67-e75.

 

Source data for figures

Table 1. Drug-induced deaths in the European Union, Norway and Turkey: total number among adults aged 15-64 years, 2019
Country Number
Germany (1) 1398
Sweden 490
Spain 450
France 391
Italy 369
Turkey 333
Norway 267
Ireland 227
Netherlands 224
Finland 224
Austria 193
Poland 153
Denmark 146
Croatia 97
Greece (1) 72
Slovenia 69
Other countries 380

(1) No age breakdown was available in 2019 for Germany and Greece, therefore all cases are counted instead of only those aged 15-64 years.

Table 2. Untitled table showing trends in mortality
Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Sweden 32.87 34.96 34.57 42.45 36.16 38.31 35.46 47.31 49.07 53.22 56.06 56.43 65.1 71.62 95.49 102.07 89.06 93.01 81.49 76.87
Norway 124.11 135.17 97.89 83.89 99.58 75.84 80.96 86.1 82.26 87.99 73.96 76.77 70.43 68.4 76.39 81.77 75.39 66.46 77.16  
Ireland 48.32 42.69 47.39 38.28 45.63 57.42 64.48 67.85 69.71 66.9 55.09 72.59 59.19 72.07 73.28 73.91 69.09 72.54    
Finland 37.56 29.42 25.89 25.86 36.43 31.8 35.64 39.92 47.3 46.85 41.66 53.29 58.03 54.31 47.43 43.06 53.05 54.64 72.02 65.29
Slovenia 20.83 22.22 25.74 14.27 17.8 24.92 18.48 29.79 25.66 19.8 17.59 16.9 18.36 19.88 20 21.6 29.03 32.19 40.59 50.95
Denmark 69.41 72.13       55.3 57.68 62.53 68.37 68.91 63.63 75.45 61.5 60.69 60.3 51.02 55 51.73 39.41  
Croatia 17.71 21.53 18.06 19.48 30.26 29.2 25.03 39.94 30.26 46.61 45.92 36.88 33.15 37.51 39.84 39.16 43.25 52.62 65.9 36.61
Austria 30.94 25.63 25.42 29.58 32.78 34.11 35.28 30.77 35.67 36.45 33.2 35.49 28.13 24.19 21.11 26.32 27.87 25.66 31.17 32.65
EU+2             13.82 15.24 15.64 16.92 14.98 14.2 14.04 14.72 15.81 17.11 18.04 18.13 15.08 13.84

(1) No age breakdown was available for Germany. For Greece, the mortality rate was computed based on the most recent data (2017) for which a breakdown by age was available.

Table 3. Drug-induced mortality rates among adults (15-64): mortality rates
Country Mortality rate
Austria 10-40
Belgium <10
Bulgaria <10
Croatia 10-40
Cyprus <10
Czechia <10
Denmark 10-40
Estonia 10-40
Finland >40
France <10
Germany 10-40
Greece <10
Hungary <10
Ireland >40
Italy <10
Latvia <10
Lithuania 10-40
Luxembourg 10-40
Malta <10
Netherlands 10-40
Norway >40
Poland <10
Portugal <10
Romania <10
Slovakia <10
Slovenia >40
Spain 10-40
Sweden >40
Turkey <10

Note: No age break down available in Germany. No age breakdown available in 2019 in Greece, there 2017 data was used for the computation of the mortality rate among the population aged 15-64.

Table 4. Proportion of males among drug-related deaths in the European Union, Norway and Turkey, 2019
Country Percentage of males
Austria 75-85%
Belgium 75-85%
Bulgaria >85%
Croatia >85%
Cyprus 75-85%
Czechia <75%
Denmark <75%
Estonia <75%
Finland 75-85%
France 75-85%
Germany <75%
Greece Not available
Hungary 75-85%
Ireland <75%
Italy >85%
Latvia <75%
Lithuania 75-85%
Luxembourg >85%
Malta >85%
Netherlands <75%
Norway <75%
Poland <75%
Portugal <75%
Romania 75-85%
Slovakia >85%
Slovenia >85%
Spain 75-85%
Sweden <75%
Turkey >85%

Note: The total number of cases is low in some countries (fewer than 20 cases reported in Bulgaria, Cyprus, Latvia, Luxembourg and Malta). No age and gender breakdown was reported for Germany and Greece in 2019.

Table 5. Distribution of drug-induced deaths reported in 2019, or most recent year, by age group
Country 40+ 30-39 <30
Portugal 43 7 5
Spain 297 118 35
Denmark 114 30 29
Netherlands 165 50 37
France 289 127 49
Croatia 59 29 9
Italy 222 87 64
Norway 166 79 41
Poland 106 41 52
Czechia 22 10 10
Sweden 275 136 129
Ireland 118 80 37
Belgium 30 18 13
Slovenia 33 26 15
Slovakia 15 12 7
Lithuania 22 16 14
Greece 19 26 7
Austria 62 71 63
Finland 73 70 91
Hungary 13 15 15
Estonia 7 13 7
Latvia 3 6 3
Luxembourg 2 4 2
Turkey 70 87 178
Romania 8 27 9
Bulgaria 0 7 4
Cyprus 0 4 1
Malta 0 3 0
Table 6. Distribution of drug-induced deaths reported in 2019, or most recent year, by  age group
Country <30 30-39 40+
Turkey 178 87 70
Finland 91 70 73
Bulgaria 4 7 0
Hungary 15 15 13
Austria 63 71 62
Lithuania 14 16 22
Poland 52 41 106
Estonia 7 13 7
Latvia 3 6 3
Luxembourg 2 4 2
Sweden 129 136 275
Czechia 10 10 22
Belgium 13 18 30
Slovakia 7 12 15
Romania 9 27 8
Slovenia 15 26 33
Cyprus 1 4 0
Italy 64 87 222
Denmark 29 30 114
Ireland 37 80 118
Netherlands 37 50 165
Norway 41 79 166
Greece 7 26 19
France 49 127 289
Croatia 9 29 59
Portugal 5 7 43
Spain 35 118 297
Malta 0 3 0
Table 7. Proportion of drug-induced deaths among older (40+ years) people in the European Union, Norway and Turkey, 2019 (or most recent data available)
Country Proportion
Austria 30-50%
Belgium 30-50%
Bulgaria <30%
Croatia >60%
Cyprus <30%
Czechia >50-60%
Denmark >60%
Estonia <30%
Finland 30-50%
France >60%
Germany 30-50%
Greece 30-50%
Hungary 30-50%
Ireland >50-60%
Italy >50-60%
Latvia <30%
Lithuania 30-50%
Luxembourg <30%
Malta <30%
Netherlands >60%
Poland >50-60%
Portugal >60%
Romania <30%
Slovakia 30-50%
Slovenia 30-50%
Spain >60%
Sweden >50-60%
Turkey <30%
Norway >50-60%
Table 8. Proportion of drug-induced deaths among younger (under 30 years) people in the European Union, Norway and Turkey, 2019 (or most recent data available)
Country
Austria >30%
Belgium 15-25%
Bulgaria >30%
Croatia <15%
Cyprus 15-25%
Czechia 15-25%
Denmark 15-25%
Estonia >25-30%
Finland >30%
France <15%
Germany 15-25%
Greece <15%
Hungary >30%
Ireland 15-25%
Italy 15-25%
Latvia 15-25%
Lithuania >25-30%
Luxembourg 15-25%
Malta <15%
Netherlands <15%
Poland >25-30%
Portugal <15%
Romania 15-25%
Slovakia 15-25%
Slovenia 15-25%
Spain <15%
Sweden 15-25%
Turkey >30%
Norway <15%
Table 9. Proportion of drug-related deaths with report of opioids present, 2017 (or most recent year available), from preferred source
Country Proportion
Hungary <50%
Bulgaria <50%
Malta <50%
Belgium <50%
Czechia <50%
Turkey <50%
Netherlands <50%
Slovakia 50-80%
Lithuania 50-80%
Latvia 50-80%
Slovenia 50-80%
Germany 50-80%
Finland 50-80%
Italy 50-80%
Croatia 50-80%
Estonia 50-80%
Denmark 50-80%
Cyprus >=80%
Norway >=80%
United Kingdom >=80%
Ireland >=80%
Sweden >=80%
Romania >=80%
Austria >=80%
Luxembourg >=80%
France Not available
Greece Not available
Poland Not available
Portugal Not available
Spain Not available

Although toxicology data are not available for France, Spain, Portugal and Poland through the general mortality registers, data from the forensic special mortality registers suggest that most drug-induced deaths in these countries involved opioids.

Table 10. Indexed trends in the number of deaths in selected countries in the south east of Europe, 2010-2019 (2010 = 100)
Country 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Slovenia 100 96 104 112 112 128 160 188 236 296
Turkey 100 83 129 184 394 468 730 747 521 271
Hungary 100 82 141 182 135 147 171 194 194 253
Slovakia 100 80 130 135 65 135 100 95 160 170
Croatia 100 81 67 66 81 74 77 89 116 133
Romania 100 44 82 88 97 62 56 94 76 132
Greece 100 71 48 46 42 51 44 38 54 48
EUROPE 100 94 93 96 106 114 125 125 119 116

Note: Other countries in the southeast Europe, with fewer than 15 cases reported in 2019 or last year with available data, are not represented (Bulgaria, Cyprus and Malta). When a national data point was missing for the computation of the European index trend, it was replaced by the value of the preceding year.

Table 11. Indexed trends in the number of deaths in selected countries in the north of Europe, 2010-2019 (2010 = 100)
Country 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Denmark 100 119 98 98 98 80 93 94 68  
Ireland 100 130 106 129 129 136 127 135    
Norway 100 106 99 94 107 117 114 100 115  
Netherlands 100 110 126 153 131 210 250 279 238 268
Finland 100 126 137 129 113 106 124 128 167 150
Sweden 100 101 116 129 170 182 163 172 153 146
Lithuania 100 88 137 106 171 225 214 163 116 102
Estonia 100 122 168 110 97 87 113 109 39 27
EUROPE 100 94 93 96 106 114 125 125 119 116

Note: other countries in the north of Europe, with fewer than 15 cases reported in 2019 or last year with available data are not represented (Luxembourg and Latvia). When a national data point was missing for the computation of the European index trend, it was replaced by the value of the preceding year.

Table 12. Sources used by the countries to report drug-induced deaths to the EMCDDA, 2019 (or most recent data available)
Country Source
Cyprus Special register
Greece Special register
Ireland Special register
Romania Special register
Slovakia Special register
Turkey Special register
Belgium General register
Croatia General register
Estonia General register
Lithuania Both
Luxembourg Special register
Malta General register
Netherlands General register
Norway General register
Slovenia General register
Sweden General register
United Kingdom General register
Austria Both
Bulgaria General register
Czechia Both
Denmark Both
Finland Both
France Both
Germany Both
Hungary Both
Italy Both
Latvia Both
Poland Both
Portugal Both
Spain Both
Table 13. Sources preferred by the countries to report drug-induced deaths to the EMCDDA, 2019 (or most recent data available)
Country Source
Austria Special register
Belgium General register
Bulgaria General register
Croatia General register
Cyprus Special register
Czechia Special register
Denmark General register
Estonia General register
Finland General register
France General register
Germany Special register
Greece Special register
Hungary Special register
Ireland Special register
Italy Special register
Latvia General register
Lithuania General register
Luxembourg Special register
Malta General register
Netherlands General register
Norway General register
Poland General register
Portugal General register
Romania Special register
Slovakia Special register
Slovenia General register
Spain General register
Sweden General register
Turkey Special register
Table 14. Mortality cohort studies among people using drugs in Europe: countries with studies conducted within the last 10 years or earlier. June 2021 – provisional findings
Country Last study
Belgium Within the last 10 years
Bulgaria Within the last 10 years
Croatia Within the last 10 years
Cyprus None
Czechia Within the last 10 years
Denmark Within the last 10 years
Estonia None
Finland Within the last 10 years
France Within the last 10 years
Germany Within the last 10 years
Greece None
Hungary None
Ireland Within the last 10 years
Italy Within the last 10 years
Latvia Within the last 10 years
Lithuania Within the last 10 years
Luxembourg Within the last 10 years
Malta None
Netherlands Within the last 10 years
Poland Within the last 10 years
Portugal Within the last 10 years
Romania More than 10 years
Slovakia Within the last 10 years
Slovenia Within the last 10 years
Spain Within the last 10 years
Sweden Within the last 10 years
Turkey None
Norway Within the last 10 years
Table 15. Countries included in the ‘southeast’ and ‘north’ of Europe for this trend analysis
Country Region
Bulgaria SE
Croatia SE
Cyprus SE
Denmark N
Estonia N
Finland N
Greece SE
Hungary SE
Ireland N
Latvia N
Lithuania N
Malta SE
Netherlands N
Norway N
Romania SE
Slovakia SE
Slovenia SE
Sweden N
Turkey SE
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