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 (2022), 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 2022
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, 2022a) estimated that over 5 800 deaths involving one or more illicit drugs were reported in 2020 in the European Union. This estimate rises to more than 6 400 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 rarely reported and might be underestimated in some countries. Deaths related to stimulants such as cocaine and amphetamines have been reported in recent years in several countries. Most deaths involve polydrug use. .
(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. Enhancing the monitoring and responses to drug-related deaths are also a priority of the European Union Drugs Action Plan 2020-25. These pages pull together the most recent epidemiological data and highlight the gaps in the information available in this area across Europe.
We are publishing this page to mark International Overdose Awareness Day on 31 August 2022, 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
Pick a question below to jump straight to its answer.
Overdose situation
- What is a drug-induced death?
- How many people die every year in Europe?
- What is the most recent data available on overdose?
- Are the numbers of drug-induced deaths similar across different countries?
- Is the drug-induced deaths rate (deaths/population) similar across countries?
- Are there differences between the genders across countries?
- How has the distribution of drug-induced deaths among age groups changed in recent years?
- Is the age distribution of drug-induced deaths similar across different countries?
- What substances are involved in drug-induced deaths?
- Where have numbers of drug-induced deaths increased over the last 10 years?
Risk factors for overdose
Preventing overdose deaths
Methodology
- Where do the data come from?
- What cases are included?
- What sources of information are used in different countries?
- What is the preferred source of data chosen by the countries to show the details of the cases in EMCDDA publications?
- Are the data comparable among countries?
- How do we measure the overall and the cause-specific mortality rates related to drug use?
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.
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 5 800 overdose deaths occurred in the European Union in 2020. This rises to an estimated 6 400 deaths if Norway and Turkey are included, representing a slight increase compared with the 2019 figure of about 6 200. These overall numbers must be understood as underestimations, as there are limitations to drug-induced deaths data, particularly to European cumulative totals. Data for 2020 are not available for all countries, and for those cases (9 of the 29 countries in the EU, Norway and Turkey), the most recent available data may be used to estimate the overall European figures.
What is the most recent data available on overdose?
In 20 of the 29 countries (EU, Norway and Turkey) the 2020 data from the preferred source is available. The year of the most recent data available for the other countries is 2019 in Denmark, Spain, Poland and Portugal; 2018 in Greece and Malta; 2017 in Belgium and Ireland and 2016 in France.
The data for this graphic are available in this table in the source data section.
Are the numbers of drug-induced deaths similar across different countries?
Germany, Sweden, Spain and France together account for half (48 %) of the European total number of drug-related deaths in 2020. 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, Spain, Sweden and France, the next highest numbers of deaths were reported by Turkey, Italy and Norway (see figure below).
There are also differences within countries, with some regions and cities much more affected than others.
(1) No age breakdown was available in 2020 for Germany, 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 2020 was estimated to be 15 deaths per million in the population aged 15-64 years, but this varied across countries, with higher rates observed in countries in the north and east 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).
The data for this graphic are available in Table 2 in the source data section.
Note: For Germany, the mortality rate was computed based on the most recent data (2018) 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 (79 %). 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).
Note: The total number of cases is low in some countries (fewer than 20 cases reported in Cyprus, Luxembourg and Malta). For Germany, the proportion was computed based on the most recent data with gender breakdown (2017).
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 20.8 cases per million males compared with 5.4 cases per million women. Among men, those aged 35-39 were the most affected, with a mortality rate of 36 deaths per million. Among women, those aged 35-39 were the most affected, with a mortality rate of 7.5 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 82 % increase among the 50-64 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 2020, the overall mean age at death due to overdose was 41 years, compared with 36 years in 2012.
The data for this graphic are available in Table 5 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.
The data for this graphic are available in Table 6 in the source data section.
The data for this graphic are available in Table 7 in the source data section.
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 74 % 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, Finland and Sweden), as well as in Austria, Croatia 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. The proportion of cases with opioids involved shown here is a minimum estimate.
In Belgium, Bulgaria, Hungary, Lithuania, Malta 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.Note: Although information on toxicology is not available for data reported through the general mortality registers (preferred source) in France, 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 overdose deaths in Europe, although their significance varies by country. More information is available for some countries in the latest European Drug Report (EMCDDA, 2022a), 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 decrease in the number of deaths after the peak reached in 2017. 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).The data for this graphic are available in Table 15 in the source data section.
The southeast of Europe
Compared with 2011, the number of drug-related deaths has increased in seven out of eight countries in the southeast of Europe (see figure below). Only in Bulgaria, the number of drug-related deaths has slightly decreased. This trend needs to be analysed with caution as Bulgaria reports that there is some underestimation of the number of the drug-related deaths. In Turkey, the peak of drug-related deaths 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.
2011 = 100
Note: Other countries in the southeast of Europe, with fewer than 15 cases reported in 2020 or the last year with available data, are not represented (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 10 in the source data section.
North of Europe
The largest increases in 2020 – or the last year with available data – compared to 2011 are reported in the Netherlands, Latvia, Sweden and Finland (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 Norway, there was an increase in the number of overdose deaths compared with 2011. Most of the deaths involve opioids. In Denmark, the most recently reported number of deaths (for 2020) was smaller than in 2011. 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 3 years, to levels well below those reported 10 years ago. The Netherlands reported the largest increase compared to 2011. Most deaths where related to opioids, although limited information is available on the drugs identified.
2011 = 100.
Note: 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, see the health and social responses to opioid-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 2020 in 20 countries, 2019 in four countries, 2018 in two countries, 2017 in two countries and 2016 in one country (see Table 1).
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.
Eighteen countries indicated that the general mortality register was their preferred source, while 11 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 definition for the general mortality registers and those extracted from the special mortality registers are shown under the category EMCDDA definition for the special mortality registers.
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 the 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. More information is also available from the previous review of cohorts published by the EMCDDA (2015).
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 2022 – 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 2021 meeting (meeting report) 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 (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 (2022a), European drug report 2022: 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
| Country | Country code | Year |
|---|---|---|
| Austria | AT | 2020 |
| Belgium | BE | 2017 or ealier |
| Bulgaria | BG | 2020 |
| Croatia | HR | 2020 |
| Cyprus | CY | 2020 |
| Czechia | CZ | 2020 |
| Denmark | DK | 2019 |
| Estonia | EE | 2020 |
| Finland | FI | 2020 |
| France | FR | 2017 or ealier |
| Germany | DE | 2020 |
| Greece | EL | 2018 |
| Hungary | HU | 2020 |
| Ireland | IE | 2017 or ealier |
| Italy | IT | 2020 |
| Latvia | LV | 2020 |
| Lithuania | LT | 2020 |
| Luxembourg | LU | 2020 |
| Malta | MT | 2018 |
| Netherlands | NL | 2020 |
| Norway | NO | 2020 |
| Poland | PL | 2019 |
| Portugal | PT | 2019 |
| Romania | RO | 2020 |
| Slovakia | SK | 2020 |
| Slovenia | SI | 2020 |
| Spain | ES | 2019 |
| Sweden | SE | 2020 |
| Turkey | TR | 2020 |
| Country | Year | Number |
|---|---|---|
| Germany (1) | 2020 | 1581 |
| Spain | 2019 | 545 |
| Sweden | 2020 | 470 |
| France | 2016 | 391 |
| Turkey | 2020 | 309 |
| Italy | 2020 | 305 |
| Norway | 2020 | 297 |
| Greece | 2018 | 263 |
| Netherlands | 2020 | 261 |
| Finland | 2020 | 248 |
| Ireland | 2017 | 227 |
| Austria | 2020 | 190 |
| Poland | 2019 | 168 |
| Denmark | 2019 | 162 |
| Belgium | 2017 | 139 |
| Croatia | 2020 | 98 |
| Portugal | 2019 | 68 |
| Slovenia | 2020 | 62 |
| Czechia | 2020 | 54 |
| Hungary | 2020 | 48 |
| Lithuania | 2020 | 47 |
| Slovakia | 2020 | 34 |
| Romania | 2020 | 33 |
| Estonia | 2020 | 32 |
| Bulgaria | 2020 | 23 |
| Latvia | 2020 | 21 |
| Cyprus | 2020 | 6 |
| Luxembourg | 2020 | 6 |
| Malta | 2018 | 3 |
(1) No age breakdown was available in 2019 for Germany, therefore all cases are counted instead of only those aged 15-64 years.
| Country | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Austria | 33 | 35 | 28 | 24 | 21 | 26 | 28 | 26 | 31 | 33 | 32 |
| Croatia | 25 | 21 | 16 | 17 | 21 | 19 | 20 | 23 | 30 | 37 | 37 |
| Denmark | 64 | 76 | 61 | 58 | 63 | 50 | 62 | 53 | 43 | 44 | |
| Estonia | 112 | 138 | 192 | 127 | 113 | 102 | 132 | 130 | 43 | 30 | 38 |
| Finland | 42 | 53 | 58 | 54 | 47 | 43 | 53 | 55 | 72 | 65 | 72 |
| Norway | 74 | 77 | 70 | 68 | 76 | 82 | 75 | 66 | 77 | 73 | 85 |
| Slovenia | 18 | 17 | 18 | 20 | 20 | 22 | 29 | 32 | 41 | 51 | 46 |
| Sweden | 56 | 57 | 65 | 72 | 96 | 103 | 90 | 94 | 84 | 77 | 73 |
| EU27+2 | 14 | 13 | 13 | 14 | 15 | 16 | 17 | 18 | 16 | 15 | 15 |
(1) No age breakdown was available for Germany.
| Country | Year | Mortality rate - Females | Mortality rate - Males | Mortality rate - Total |
|---|---|---|---|---|
| Austria | 2020 | 10-40 | >40 | 10-40 |
| Belgium | 2017 | 10-40 | 10-40 | 10-40 |
| Bulgaria | 2020 | <10 | <10 | <10 |
| Croatia | 2020 | 10-40 | >40 | 10-40 |
| Cyprus | 2020 | <10 | 10-40 | 10-40 |
| Czechia | 2020 | <10 | 10-40 | <10 |
| Denmark | 2019 | 10-40 | >40 | >40 |
| Estonia | 2020 | 10-40 | >40 | 10-40 |
| Finland | 2020 | 10-40 | >40 | >40 |
| France | 2016 | <10 | 10-40 | <10 |
| Germany | 2017 | <10 | 10-40 | 10-40 |
| Greece | 2018 | <10 | >40 | 10-40 |
| Hungary | 2020 | <10 | 10-40 | <10 |
| Ireland | 2017 | >40 | >40 | >40 |
| Italy | 2020 | <10 | 10-40 | <10 |
| Latvia | 2020 | <10 | 10-40 | 10-40 |
| Lithuania | 2020 | <10 | >40 | 10-40 |
| Luxembourg | 2020 | <10 | 10-40 | 10-40 |
| Malta | 2018 | <10 | 10-40 | <10 |
| Netherlands | 2020 | 10-40 | 10-40 | 10-40 |
| Norway | 2020 | >40 | >40 | >40 |
| Poland | 2019 | <10 | <10 | <10 |
| Portugal | 2019 | <10 | 10-40 | 10-40 |
| Romania | 2020 | <10 | <10 | <10 |
| Slovakia | 2020 | <10 | 10-40 | <10 |
| Slovenia | 2020 | 10-40 | >40 | >40 |
| Spain | 2019 | <10 | 10-40 | 10-40 |
| Sweden | 2020 | 10-40 | >40 | >40 |
| Turkey | 2020 | <10 | 10-40 | <10 |
Note: No age break down available in Germany.
| Country | Year | Proportion | Proportion (categories) | Total cases |
|---|---|---|---|---|
| Austria | 2020 | 75 | 75-85 | 191 |
| Belgium | 2017 | 68 | <75 | 148 |
| Bulgaria | 2020 | 88 | >85 | 24 |
| Croatia | 2020 | 79 | 75-85 | 99 |
| Cyprus | 2020 | 83 | 75-85 | 6 |
| Czechia | 2020 | 78 | 75-85 | 58 |
| Denmark | 2019 | 68 | <75 | 202 |
| Estonia | 2020 | 85 | 75-85 | 33 |
| Finland | 2020 | 78 | 75-85 | 258 |
| France | 2016 | 78 | 75-85 | 465 |
| Germany | 2017 | 85 | 75-85 | 1125 |
| Greece | 2018 | 86 | >85 | 274 |
| Hungary | 2020 | 98 | >85 | 48 |
| Ireland | 2017 | 70 | <75 | 235 |
| Italy | 2020 | 87 | >85 | 308 |
| Latvia | 2020 | 95 | >85 | 21 |
| Lithuania | 2020 | 91 | >85 | 47 |
| Luxembourg | 2020 | 67 | <75 | 6 |
| Malta | 2018 | 100 | >85 | 3 |
| Netherlands | 2020 | 76 | 75-85 | 295 |
| Norway | 2020 | 69 | <75 | 324 |
| Poland | 2019 | 63 | <75 | 212 |
| Portugal | 2019 | 81 | 75-85 | 72 |
| Romania | 2020 | 85 | 75-85 | 33 |
| Slovakia | 2020 | 84 | 75-85 | 37 |
| Slovenia | 2020 | 84 | 75-85 | 70 |
| Spain | 2019 | 82 | 75-85 | 546 |
| Sweden | 2020 | 71 | <75 | 524 |
| Turkey | 2020 | 93 | >85 | 314 |
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 in 2019.
| Age | 2012 | 2020 |
|---|---|---|
| 15-19 | 87 | 145 |
| 20-24 | 346 | 341 |
| 25-29 | 614 | 490 |
| 30-34 | 775 | 735 |
| 35-39 | 699 | 863 |
| 40-44 | 594 | 712 |
| 45-49 | 516 | 676 |
| 50-54 | 288 | 522 |
| 55-59 | 192 | 305 |
| 60-64 | 89 | 213 |
| 65+ | 147 | 311 |
| Country | Year | Females <30 | Females 30-39 | Females 40+ | Males <30 | Males 30-39 | Males 40+ | Total <30 | Total 30-39 | Total 40+ |
|---|---|---|---|---|---|---|---|---|---|---|
| Austria | 2020 | 19 | 17 | 11 | 52 | 52 | 40 | 71 | 69 | 51 |
| Belgium | 2017 | 7 | 13 | 27 | 16 | 24 | 61 | 23 | 37 | 88 |
| Bulgaria | 2020 | 2 | 1 | 0 | 4 | 13 | 4 | 6 | 14 | 4 |
| Croatia | 2020 | 2 | 4 | 15 | 5 | 35 | 38 | 7 | 39 | 53 |
| Cyprus | 2020 | 0 | 0 | 1 | 3 | 1 | 1 | 3 | 1 | 2 |
| Czechia | 2020 | 2 | 4 | 7 | 9 | 17 | 19 | 11 | 21 | 26 |
| Denmark | 2019 | 4 | 6 | 55 | 17 | 21 | 99 | 21 | 27 | 154 |
| Estonia | 2020 | 2 | 2 | 1 | 3 | 19 | 6 | 5 | 21 | 7 |
| Finland | 2020 | 19 | 9 | 28 | 98 | 41 | 63 | 117 | 50 | 91 |
| France | 2016 | 7 | 16 | 81 | 42 | 111 | 208 | 49 | 127 | 289 |
| Germany | 2017 | 206 | 423 | 496 | ||||||
| Greece | 2018 | 1 | 13 | 24 | 23 | 107 | 106 | 24 | 120 | 130 |
| Hungary | 2020 | 1 | 0 | 0 | 25 | 15 | 7 | 26 | 15 | 7 |
| Ireland | 2017 | 6 | 24 | 40 | 31 | 56 | 78 | 37 | 80 | 118 |
| Italy | 2020 | 15 | 9 | 17 | 44 | 71 | 152 | 59 | 80 | 169 |
| Latvia | 2020 | 0 | 1 | 0 | 4 | 11 | 5 | 4 | 12 | 5 |
| Lithuania | 2020 | 2 | 2 | 0 | 8 | 20 | 15 | 10 | 22 | 15 |
| Luxembourg | 2020 | 0 | 1 | 1 | 1 | 1 | 2 | 1 | 2 | 3 |
| Malta | 2018 | 0 | 0 | 0 | 0 | 3 | 0 | 0 | 3 | 0 |
| Netherlands | 2020 | 5 | 10 | 56 | 34 | 42 | 148 | 39 | 52 | 204 |
| Norway | 2020 | 17 | 14 | 69 | 44 | 46 | 134 | 61 | 60 | 203 |
| Poland | 2019 | 17 | 15 | 47 | 38 | 49 | 46 | 55 | 64 | 93 |
| Portugal | 2019 | 0 | 2 | 12 | 4 | 15 | 39 | 4 | 17 | 51 |
| Romania | 2020 | 1 | 4 | 0 | 6 | 15 | 7 | 7 | 19 | 7 |
| Slovakia | 2020 | 0 | 2 | 4 | 9 | 14 | 8 | 9 | 16 | 12 |
| Slovenia | 2020 | 0 | 2 | 9 | 10 | 21 | 28 | 10 | 23 | 37 |
| Spain | 2019 | 10 | 12 | 77 | 47 | 113 | 287 | 57 | 125 | 364 |
| Sweden | 2020 | 29 | 32 | 93 | 98 | 105 | 167 | 127 | 137 | 260 |
| Turkey | 2020 | 10 | 8 | 3 | 118 | 98 | 73 | 128 | 106 | 76 |
| Country | Proportion |
|---|---|
| Austria | <30% |
| Belgium | >50-60% |
| Bulgaria | <30% |
| Croatia | >50-60% |
| Cyprus | 30-50% |
| Czechia | 30-50% |
| Denmark | >60% |
| Estonia | <30% |
| Finland | 30-50% |
| France | >60% |
| Germany | 30-50% |
| Greece | 30-50% |
| Hungary | <30% |
| Ireland | 30-50% |
| Italy | >50-60% |
| Latvia | <30% |
| Lithuania | 30-50% |
| Luxembourg | 30-50% |
| Malta | <30% |
| Netherlands | >60% |
| Norway | >60% |
| Poland | 30-50% |
| Portugal | >60% |
| Romania | <30% |
| Slovakia | 30-50% |
| Slovenia | >50-60% |
| Spain | >60% |
| Sweden | 30-50% |
| Turkey | <30% |
| Country | Proportion (categories) |
|---|---|
| Austria | >30% |
| Belgium | 15-25% |
| Bulgaria | 15-25% |
| Croatia | <15% |
| Cyprus | >30% |
| Czechia | 15-25% |
| Denmark | <15% |
| Estonia | 15-25% |
| Finland | >30% |
| France | <15% |
| Germany | 15-25% |
| Greece | <15% |
| Hungary | >30% |
| Ireland | 15-25% |
| Italy | 15-25% |
| Latvia | 15-25% |
| Lithuania | 15-25% |
| Luxembourg | 15-25% |
| Malta | <15% |
| Netherlands | <15% |
| Norway | 15-25% |
| Poland | >25-30% |
| Portugal | <15% |
| Romania | 15-25% |
| Slovakia | 15-25% |
| Slovenia | <15% |
| Spain | <15% |
| Sweden | 15-25% |
| Turkey | >30% |
| Country | Year | Proportion | Proportion (categories) | Type of register |
|---|---|---|---|---|
| Austria | 2020 | 91 | >80% | Special register |
| Belgium | 2017 | 49 | <50 | General register |
| Bulgaria | 2020 | 20 | <50 | General register |
| Croatia | 2020 | 87 | >80% | General register |
| Cyprus | 2020 | 67 | 50-80% | Special register |
| Czechia | 2020 | 51 | 50-80% | Special register |
| Denmark | 2019 | 100 | >80% | General register |
| Estonia | 2020 | 58 | 50-80% | General register |
| Finland | 2020 | 85 | >80% | General register |
| Germany | 2020 | 66 | 50-80% | Special register |
| Greece | 2018 | 75 | 50-80% | General register |
| Hungary | 2020 | 10 | <50 | Special register |
| Ireland | 2017 | 87 | >80% | Special register |
| Italy | 2020 | 70 | 50-80% | Special register |
| Latvia | 2020 | 80 | 50-80% | General register |
| Lithuania | 2020 | 47 | <50 | General register |
| Luxembourg | 2020 | 100 | >80% | Special register |
| Malta | 2018 | 33 | <50 | General register |
| Netherlands | 2020 | 56 | 50-80% | General register |
| Norway | 2020 | 84 | >80% | General register |
| Romania | 2020 | 91 | >80% | Special register |
| Slovakia | 2020 | 57 | 50-80% | Special register |
| Slovenia | 2020 | 71 | 50-80% | General register |
| Sweden | 2020 | 88 | >80% | General register |
| Turkey | 2020 | 41 | <50 | Special register |
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.
| Country | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 |
|---|---|---|---|---|---|---|---|---|---|---|
| Bulgaria | 100 | 103 | 72 | 52 | 59 | 76 | 62 | 83 | 38 | 83 |
| Croatia | 100 | 83 | 81 | 100 | 92 | 95 | 110 | 144 | 164 | 168 |
| Greece | 100 | 97 | 79 | 74 | 120 | 95 | 108 | 116 | ||
| Hungary | 100 | 171 | 221 | 164 | 179 | 207 | 236 | 236 | 307 | 343 |
| Romania | 100 | 187 | 200 | 220 | 140 | 127 | 213 | 173 | 300 | 220 |
| Slovakia | 100 | 162 | 169 | 81 | 169 | 125 | 119 | 200 | 212 | 231 |
| Slovenia | 100 | 108 | 117 | 117 | 133 | 167 | 196 | 246 | 308 | 292 |
| Turkey | 100 | 154 | 221 | 473 | 562 | 876 | 896 | 626 | 326 | 299 |
| EU27+2 | 100 | 100 | 103 | 114 | 123 | 134 | 135 | 129 | 128 | 133 |
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.
| Country | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 |
|---|---|---|---|---|---|---|---|---|---|---|
| Denmark | 100 | 82 | 77 | 86 | 66 | 86 | 80 | 61 | 68 | |
| Estonia | 100 | 138 | 90 | 80 | 72 | 93 | 89 | 32 | 22 | 27 |
| Finland | 100 | 108 | 102 | 89 | 84 | 98 | 102 | 132 | 119 | 131 |
| Ireland | 100 | 81 | 99 | 99 | 104 | 97 | 104 | |||
| Latvia | 100 | 155 | 100 | 136 | 164 | 164 | 200 | 182 | 109 | 191 |
| Lithuania | 100 | 156 | 120 | 193 | 256 | 242 | 184 | 131 | 116 | 104 |
| Luxembourg | 100 | 133 | 183 | 133 | 200 | 83 | 133 | 67 | 133 | 100 |
| Netherlands | 100 | 115 | 140 | 119 | 191 | 228 | 254 | 217 | 245 | 286 |
| Norway | 100 | 94 | 89 | 102 | 110 | 108 | 94 | 109 | 105 | 124 |
| Sweden | 100 | 115 | 129 | 169 | 181 | 162 | 172 | 156 | 146 | 140 |
| EU27+2 | 100 | 100 | 103 | 114 | 123 | 134 | 135 | 129 | 128 | 133 |
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.
| Country | Year | Available sources |
|---|---|---|
| Austria | 2020 | Both |
| Belgium | 2017 | General register |
| Bulgaria | 2020 | General register |
| Croatia | 2020 | General register |
| Cyprus | 2020 | Special register |
| Czechia | 2020 | Both |
| Denmark | 2019/2020 | Both |
| Estonia | 2020 | General register |
| Finland | 2020 | Both |
| France | 2016/2019 | Both |
| Germany | 2020 | Special register |
| Greece | 2018/2020 | Both |
| Hungary | 2020 | Both |
| Ireland | 2017 | Special register |
| Italy | 2020 | Special register |
| Latvia | 2020 | Both |
| Lithuania | 2020 | General register |
| Luxembourg | 2020 | Special register |
| Malta | 2018 | General register |
| Netherlands | 2020 | General register |
| Norway | 2020 | General register |
| Poland | 2019 | General register |
| Portugal | 2019/2020 | Both |
| Romania | 2020 | Special register |
| Slovakia | 2020 | Special register |
| Slovenia | 2020 | General register |
| Spain | 2019 | Both |
| Sweden | 2020 | General register |
| Turkey | 2020 | Special register |
| Country | Year | Preferred source |
|---|---|---|
| Austria | 2020 | Special register |
| Bulgaria | 2020 | General register |
| Croatia | 2020 | General register |
| Cyprus | 2020 | Special register |
| Czechia | 2020 | Special register |
| Belgium | 2017 | General register |
| Denmark | 2019/2020 | General register |
| Estonia | 2020 | General register |
| Finland | 2020 | General register |
| France | 2016/2019 | General register |
| Germany | 2020 | Special register |
| Greece | 2018/2020 | General register |
| Hungary | 2020 | Special register |
| Italy | 2020 | Special register |
| Latvia | 2020 | General register |
| Lithuania | 2020 | General register |
| Luxembourg | 2020 | Special register |
| Netherlands | 2020 | General register |
| Norway | 2020 | General register |
| Poland | 2019 | General register |
| Malta | 2018 | General register |
| Ireland | 2017 | Special register |
| Portugal | 2019/2020 | General register |
| Romania | 2020 | Special register |
| Slovakia | 2020 | Special register |
| Slovenia | 2020 | General register |
| Sweden | 2020 | General register |
| Turkey | 2020 | Special register |
| Spain | 2019 | General register |
| 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 |
| Country | Region |
|---|---|
| Bulgaria | Southeast |
| Croatia | Southeast |
| Cyprus | Southeast |
| Denmark | North |
| Estonia | North |
| Finland | North |
| Greece | Southeast |
| Hungary | Southeast |
| Ireland | North |
| Latvia | North |
| Lithuania | North |
| Luxembourg | North |
| Malta | Southeast |
| Netherlands | North |
| Norway | North |
| Romania | Southeast |
| Slovakia | Southeast |
| Slovenia | Southeast |
| Sweden | North |
| Turkey | Southeast |