buprenorphine, meprobamate, methaqualone etc.). Group IV All other drugs and poisons, including ethanol and carbon monoxide. Deaths were recorded ...
Forensic Science International
ELSEVIER
78 (1996) 29-37
Forensic Science lnternidii
Fatal poisonings in young drug addicts in the Nordic countries: a comparison between 1984-1985 and 1991 A. Steentoft”, B. Teigeb, P. Holmgrenc, E. Vuorid, J. Kristinssone, E. Kaaf, G. Wetheg, G. Ceder”, J. Pikkarainenh, K.W. Simonsen’ aInstitute of Forensic Medicine,
University of Copenhagen, Frederik V’s Vej II, DK-2100 Copenhagen, Denmark bInstitute of Forensic Medicine, University of Oslo, Oslo, Norway ‘Department of Forensic Chemistry, National Board of Forensic Medicine, LinkGping, Sweden ‘Department of Forensic Medicine, University of Helsinki, Helsinki, Finland eDepartment of Pharmacology, University of Iceland, Reykjavik, Iceland ‘Department of Forensic Medicine, University of Aarhus, Aarhus, Denmark gNational Institute of Forensic Toxicology, Oslo, Norway “National Public Health Institute, Helsinki Finland ‘Institute of Forensic Medicine, University of Odense, Odense, Denmark
Received 12 May 1995; revision received 24 July 1995; accepted 29 August 1995
Abstract Fatal poisonings among young drug addicts (15-34 years) in the five Nordic countries, Denmark, Finland, Iceland, Norway and Sweden in 1991 were investigated and compared to a similar investigation for 1984-1985 (Sweden for 1984 only). A common definition of ‘drug addict’ has been applied by the participating countries. In both investigations, the greatest number of drug addict deaths was seen in Denmark calculated per lo5 inhabitants, followed in descending order by Norway, Sweden, Finland and Iceland. An increased number of deaths was observed from 1984-1985 to 1991 in all five countries. The increase in Denmark and Sweden was small while the number of deaths was more than doubled in Norway and Finland. The increased number of cases in Norway and Sweden in 1991 is mainly due to a greater number of deaths in the age group 25-34 years. In Finland, the increased number was seen mainly in the age group 15-24 years. In the two investigations heroin/morphine
* Corresponding author. 0379-0738/96/$15.00Q 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0379-0738(95)01850-t
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caused most of the fatal poisonings in Norway and Sweden. In Denmark, heroin/morphine caused about half of the fatal poisonings only, and strong analgesics other than heroimmorphine caused about one third of the deaths. In 1984-1985 it was methadone, propoxyphene and ketobemidone and in 1991 mostly methadone. The number of heroin/morphine related deaths in Finland increased from 1984-1985 to 1991, but other drugs and poisons caused a much higher proportion of the deaths. Pentobarbital caused the only fatal poisoning in Iceland in 1991. Keywords:
Drug addicts; Nordic countries; Fatal poisonings; Number; Age distribution
1. Introduction Surveys of deaths among drug addicts are a useful indicator of trends in drug abuse. Several studies on drug addict deaths in Europe have been published [l-8] but the data presented are difficult to compare due to the lack of standardized definitions of the terms ‘drug addict’ and ‘drug-related death’. In 1984-1985 a study was carried out in the five Nordic countries, Denmark, Finland, Iceland, Norway and Sweden (Sweden for 1984 only), concerning fatal poisonings in young people (15-34 years) [8]. Drug addiction was an area of special interest, and the participating countries applied a common definition of a drug addict [S]. Standardization of the definition and the protocol for collection of data enabled a valid comparison of drug abuse in the Nordic countries measured by the number of deaths, of drugs detected and the cause of death. This first Nordic study showed large differences between the five countries. Judging from the parameters included, the drug problem was quite extensive in Denmark, less so in Norway and Sweden and much less in Finland. No drug addict deaths were seen in Iceland in 1984-1985. In Finland, ethanol, carbon monoxide and barbiturates were the most frequently encountered substances; whereas, in Denmark, Norway and Sweden heroin/morphine was the most frequently encountered drug. In Denmark, strong analgesics other than heroin/morphine were seen more frequently than in the other countries. The drug problem in Europe has increased since 1984-1985 [9]. With the purpose of examining to what extent this has affected the Nordic countries, a follow-up study was initiated in 1991. The 1991 investigation, which included all age groups of drug addicts and all causes of death, not only fatal poisonings, is presented in a separate paper. In the present paper, the situation in 198441985 will be compared to that of 1991. Only the part of the 1991 material which is comparable to the 1984-1985 investigation is included.
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2. Material
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and methods
The two surveys consist of cases of fatal poisoning among drug addicts, 15-34 years of age, which were submitted to medicolegal autopsy and toxicological investigation in Denmark, Finland, Iceland, Norway and Sweden in 1991 and 1984-1985 (in Sweden in 1984 only). Medicolegal practice, and the frequency with which autopsies are requested, differ somewhat between the five Nordic countries. In all five countries, however, most of the deaths caused by poisoning among drug addicts are subjected to medicolegal autopsy and toxicological investigation [8]. The following definition of drug addicts was applied: Persons, who according to information from the police and/or autopsy reports were known to have abused drugs intravenously and/or abusers of drugs listed in the Single Convention on Narcotic Drugs 1961, schedule I and/or the International Convention on Psychotropic Substances 1971, schedules I and II. Drugs and poisons were divided into four groups: Group I
Drugs listed in the Single Convention on Narcotic Drugs 1961 schedule I (cocaine, dextromoramide, heroin/morphine ketobemidone, methadone, etc.) and schedule II (codeine ethylmorphine, pholcodine, propoxyphene, etc.). Group II Drugs listed in the International Convention on Psychotropic Substances 197 1, schedules I and II (amphetamine tetrahydrocannabinol, etc.). Group III Drugs listed in the International Convention on Psychotropic Substances 197 1, schedules III and IV (most barbiturates benzodiazepines, buprenorphine, meprobamate, methaqualone etc.). Group IV All other drugs and poisons, including ethanol and carbon monoxide. Deaths were recorded according to the drug evaluated to be the primary cause of death. Cases involving multiple drugs, in which the cause of death could not be ascribed to a single substance, were recorded according to the drug with the lowest group number with reference to the classification above. Cases involving two or more drugs in the same group were recorded according to the drug judged to be the primary cause of death. A continuous, interlaboratory quality control has been practised during this period. Fatal poisoning rates for each country were calculated per lo5 inhabitants in the given age group. 3. Results Fig. 1 shows the recorded number of fatal poisonings in drug addicts (15-34 years) in 1984-1985 and 1991 and the death rates per lo5 inhabitants. In both surveys the greatest number of drug addict deaths was seen in Denmark. Denmark also registered the greatest number of deaths per lo5 inhabitants, followed in descending order by Norway, Sweden, Finland and Iceland. In all five countries an increase was noted from 1984- 1985 to 1991.
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Denmark
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Finland
Sweden
Norway
Iceland
T
T $ N
104
N=194/2
-
:.
!984-85 2
1991
1984-85 2
1991
1984
1991
1964-85 2
1991
1984-85 2
1991
Fig 1. Fatal poisoning (per 105 inhabitants) in drug addicts (15-34 years) submitted to medicolegal autopsy and toxicological analyses in the five Nordic countries 198441985 (Sweden 1984 only) and 1991. Annual average number of cases stated on top of bars. Two times the standard deviation (assuming that the number of deaths are Poisson distributed) are given in vertical lines.
The increase in Denmark and Sweden was small, while the number of deaths was more than doubled in Norway and Finland. In the Norwegian material, the increased number of deaths in 1991 included an increased proportion of women (Table 1). The opposite trend was observed in Finland where the ratio of women decreased from 1984-1985 to 1991. Fig. 2 shows the age distribution. The increased number of cases observed in 1991 is mainly due to an increased number of deaths in the two highest age groups in Norway and Sweden. In Finland, however, the increase was seen mainly in the two lowest age groups. Table 1 Percent women in fatal poisonings among drug addicts (15534 years) Year/country
Denmark
Norway
Sweden”
Finland
Iceland
1984- 1985
24% 24%
19’Y” 33%
22% 18%
36% 9%
0% 100%
1991
“Sweden 1984 only
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Denmark
Norway
15-19 25-29 20-24 30-34
15-19 25-29 20-24 3034
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Sweden
33
Finland
12 10
g6 6 !i
4
32 n 15-19 25-29 20-24 30-34
15-19 25-29 20-24 3034
Age groups Fig. 2. Age distribution of drug addicts (15-34 years) submitted to medicolegal autopsy and toxicological analyses in the five Nordic countries 1984- 1985 (Sweden 1984 only) and 1991, Stated as number per 10’ inhabitants in each age group.
Table 2 shows the fatal poisonings according to the cause of death. Drugs in group I caused most of the deaths in Denmark Norway and Sweden in the two periods investigated. Heroin/morphine caused most of the fatal poisonings in Norway and Sweden. In Denmark, about half of the deaths only was caused by heroin/morphine and about one third by other drugs in group I; in 1984-1985 methadone, propoxyphene and ketobemidone and in 1991 mostly methadone. In Finland, a higher proportion of deaths was caused by drugs/poisons in groups III and IV, but an increase in heroin/morphine related deaths was seen from 19841985 to 1991. Pentobarbital caused the only fatal poisoning in Iceland in 1991, and none was seen in 1984-1985. 4. Discussion The regulations and practice concerning medicolegal autopsies and toxicological investigations in cases of known drug addict deaths remained unchanged in the fi\e Nordic countries from 1984-1985 to 1991. The selection criteria for the two survey?; therefore, were assumed to be the same. The comparability of the toxicological results was ensured by an interlaboratory quality control. In both Denmark and Sweden, the drug addict situation investigated in this survey, which only included persons between 15 and 34 years, was very similar in 1984- 1985 and in 1991. In Norway, the increased number of fatal poisonings
97
0 2.5 5.5
Group II drugs Group 111drugs Group IV drugs and poisons
Total
53.5 89
Group I Heroin/morphine Total group 1 drugs
104
1 0 5
60 98
27.5
3
1
0
19 23.5
(1984 + 1985)/2
(1984 + 1985)/2
1991
Norway
Denmark
63
0 3 4
51 56
1991
32
2 0 5
23 25
1984
Sweden
44
3 0 3
34 38
1991
9.5
0 3 5
0.5 1.5
(1984+ 1985)/2
Finland
Table 2 Annual average number of fatal poisonings in drug addicts (15-34 years), grouped according to cause of death
22
1 2 8
5 11
1991
0
0 0 0
0 0
(1984 + 1985)/2
Iceland
1
0 1 0
0 0
1991
Y
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among drug addicts observed from 1984- 1985 to 1991 included a greater proportion of ‘older’ addicts. Since heroin was first introduced on the illicit market in Norway in the 1970s few ‘old’ drug addicts existed in 1984-1985 [lo]. Both in Denmark [l l] and Sweden [12,13], the drug problem started earlier than in Norway. This could explain why the age distribution in Norway in the 1984-1985 survey is markedly different from that in Denmark and Sweden at the same timepoint and also different from the distribution in Norway in 1991. In Finland, widespread abuse of drugs is a relatively new problem, especially the abuse of heroin/morphine. The increased number of deaths among young drug addicts in Finland indicates a recent recruitment among young people to the abuse of heroin/morphine [14]. Heroin/morphine has been the preferred drug among drug addicts in Norway [15]. The size of the drug addict population has probably been fairly constant from 1985 to 1991, but the population has grown older. An older and more worn-out population may be the explanation for a part of the observed increase in heroin/ morphine related deaths in Norway, but the main explanation probably is cheaper heroin and increased availability (information from the Norwegian police) leading to more frequent use and larger doses [7]. Data from the National Institute of Forensic Toxicology also show that the number of drivers in the age group 15-34 years suspected for drugged driving in Norway was nearly doubled from 1985 to 1991. The drug problem in Sweden and Finland appears to be less extensive than in Norway and Denmark according to this survey at least in the age group investigated, but where the number of drug addict deaths increased only slightly from 1984 to 1991 in Sweden, it was more than doubled in Finland. In Sweden, drug addicts have traditionally preferred amphetamine to heroin, and the abuse of central stimulants started already in the 1950s (mainly amphetamine and phenmetrazine) and increased substantially together with the abuse of cannabis in the 1960s [12,13]. According to official statistics, the amount of heroin versus amphetamine seized during 1977- 1982 by the police was 3-35% and by customs 12-50%. Previous studies [12,13] have reported the number of heroin addicts as being less than 30% of the total number of intravenous addicts in Sweden. This misuse pattern is likely to have caused fewer cases of accidental fatal overdose. By 1991, prescription rules concerning propoxyphene were strict in all the Nordic countries, except in Finland. These regulations, however, were introduced at different times. In Denmark, regulations were tightened in 1988, and a marked reduction in the number of deaths caused by this drug was noted in the Danish material from 1984- 1985 to 1991. In Finland, Iceland and Sweden, no changes in the regulations have taken place during this period. In Norway, strict regulations were introduced in 1982 and deaths caused by propoxyphene have not been a major problem since then. The number of methadone deaths in Denmark increased from 1984- 1985 to 1991 probably reflecting the increasing number of drug addicts in methadone treatment. According to the Danish National Board of Health, this number doubled from 1985 to 1989. Controlling measures about the dispensing of methadone are often insufficient, and according to the Annual Report from the Danish police methadone
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is traded illicitly. Methadone is also used in the treatment of drug addicts in Sweden, but to a much lesser extent and under stricter control than in Denmark. In Finland and Iceland, methadone has not been used in treatment programmes in the period from 1984 to 1991. In Norway, a methadone treatment programme was initiated for a limited number of persons in June 1991. In Iceland, drug abuse has mostly been confined to prescription drugs and alcohol, which has been documented by surveys on emergency room admission and fatal poisonings. Drugs in group I and II were involved in only few of the cases, but the abuse of strong analgesics and illicit drugs has in recent years been an increasing problem [8,16,17]. By using a standardized definition of the term ‘drug addict’ and a common protocol for collection of data in this survey, we have been able to compare the situation in the five Nordic countries regarding fatal poisonings among drug addicts. Changes in age distribution, as well as changes in the frequency of certain drugs, have been demonstrated from 1984-1985 to 1991. In that way, forensic toxicological data can be a useful indicator, among others, in the efforts to describe the extent of the drug abuse in different countries as well as changing trends in the drug scene. Acknowledgements Supported by the Nordic Council for Alcohol and Drug Research (NAD). The authors want to thank their colleagues for their assistance in providing the data on which this survey is based. References [I] F.R. Ingold, Study of deaths related to drug abuse in France and Europe. Bull. Nurc., 38 (1986) 81-89. [2] H. Ghodse, M. Sheehan, C. Taylor, G. Edwards, Deaths of drug addicts in the United Kingdom 196771981. Br. Med. J., 290 (1985) 425-428. [3] H.B. Spear, Drug abuser deaths. Br. J. Addict., 78 (1983) 173-178. [4] W. Janssen, K. Triibner, K. Ptischel, Deaths caused by drug addiction: A review of the experiences in Hamburg and the situation in the Federal Republic of Germany in comparison with the literature. Forensic Sci. In?., 43 (1989) 223-237. [5] J.G. Harvey, Drug related mortality in an inner city area. Drug Alcohol Depend., 7 (1981) 239-247. [6] E. Kaa and B. Teige, Drug-related deaths during the 1980s. A comparative study of drug addict deaths examined at the Institutes of Forensic Medicine in Aarhus, Denmark and Oslo Norway. Znt. /. Leg. Med., 106 (1993) 5-9. [7] B. Teige and G. Wethe, Fatal heroin/morphine related deaths in Norwegian drug addicts, l977- 1992. Advances in Forensic Sciences. Proceedings 13th Meeting International Association of Forensic Sciences, Diisseldorfi August 22-28, 1993, (1995) 180- 186. [8] A. Steentoft, B. Teige, E. Vuori, G. Ceder, P. Holmgren, E. Kaa, J. Kristinsson, P.T. Normann, J. Pikkarainen Fatal intoxications in the Nordic countries. A forensic toxicological study with special reference to young drug addicts. 2. Rechtsmed., 102 (1989) 3555365. [9] H. Klingemann, C. Goos, R. Hartnoll, A. Jablensky and J. Rehm, European Summary on Drug Abuse. First Report 1985-1990 WHO, 1992.
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[IO], O.J. Skog, The Development of Intravenous Drug Abuse in Norway. National Institute for Alcohol and Drug Research Report l/90, 1990 (in Norwegian with summary in English). [1 l] J. Voigt, J.B. Dalgaard, J. Simonsen, Fatalities among drug users in Denmark in the period 1968-1972. Med. Sci. Law, 15, 4 (1975) 265-269. [12] R. Hartnoll, U. Avico, F.R. Ingold, K. Lange, L. Lenke, A. O’Hara, A. de Roij-Moishagen, A multi-city study of drug misuse in Europe. Bull. Narc., 41 (1989) 3-27. [13] M.B. Olsson and L. Lenke, Stockholm City Report: Multi-city Study of Drug Misuse, Section 1. Council of Europe, Strasbourg, 1987, pp. 265-298. [14] J. Partanen, Wet high. Alkoholipolitiikka, 59 (1994) 397-411 (in Finnish with summary in English). [15] A. Skretting, Arrested i.o. Drug Abusers. National Institute for Alcohol and Drug Research, Report l/89 1989, (in Norwegian with summary in English). [16] G. Oddsson, J. Kristinsson and F. Sigurbergsson, One year survey of illicit drugs in self-poisonings in Reykjavik 1987-1988. Pharmacol. Toxicol., 65 (1989) 20. [17] J. Kristinsson and H. Hlidar, Fatal poisonings by drugs and ethanol in Iceland 1974-1993. Proceedings XII Nordiske mote i rettsmedisin, IO- 13 August 1994 LiNehammer, Norway, 1995, pp. 191-195, (in English).
