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EMCDDA Meeting on the Key Indicator Drug-related Deaths and Mortality among drug users

16-18 October 2013 - Lisbon

Compilation of National Abstracts

Recent developments concerning the Key Indicator in the Member States, Candidate Countries and Norway

Recent developments concerning the DRD Key Indicator in Austria

New information

1. Brief overall situation on DRD

Overdoses

In 2012, a total of 161 fatal overdoses were verified in the context of autopsies (including 22 deaths – for which no autopsies were performed). It is reasonable to assume that, after a noticeable rise between 2004 and 2006, the number of fatal poisonings has not gone down again in recent years.

Mortality among drug users

No data.

2. Recent specific analysis / studies on drug-related mortality

No new analysis

3. Recent trends and emerging concerns: new substances, characteristics of victims…

New substance still a rather small issue in Austria regarding DRD Decrease in the number of drug induced deaths

Recent developments concerning the DRD Key Indicator in Belgium


Overdoses




4. Your suggestion(s) for presentations

Recent developments concerning the DRD Key Indicator in Bulgaria

New information


In Bulgaria GMR is National Statistical Institute (NSI).

The mortality rate of DRD according the NSI is 0,41 per 100 000 of the general population for 2012 in Bulgaria. The males аre 76,70% of the all deaths caused by drug use in 2011. The mortality rates for males and females are 0,65 per 100 000 and 0,19 per 100 000 respectively.

The largest number of drug related deaths is in the 25-29 age group, such as the late years tendency is. 66,6% of all drug related deaths are in the 20-39 age group.

The average age of the deceased by drug use is 35,8 and it is a bit lower for males 29,8 compared to this one for females – 55.5 On the other side the median mortality age is considerably lower – 29 years for all dead. In 2012, no significant changes in the structure of deaths by cause. There are two cases of deaths due classified in Class V of ICD-10, "Mental and behavioral disorders."

The largest proportion of people who died due to "Accidental poisoning by and exposure to narcotics and psychodysleptics (hallucinogens), not elsewhere classified" (X42) or 43% of all cases. Secondly, the structure of deaths is "Poisoning by and exposure to narcotics and psychodysleptics (hallucinogens), not elsewhere classified, undetermined intent" (Y12) or 27% of all cases. To cause "Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotics, antiparkinsonian and psychotropic drugs, not elsewhere classified" (X61) is defined cause of death of 13% of all deceased due to drug use.

Two more sources of information have been used as an alternative source of DRD data for 2012 – (1) the Forensic Medicine and Deontology Centers (FMDC) in Sofia (Aleksandrovska Hospital and (2) the Ministry of Interior (MI). The FMDCs have provided data for deaths when autopsy has been done and any drug use has been detected. The data has been classified by gender, age, type and quantity of the detected substances as well as organs where they were detected. Date of death, the cause and the place of deaths have been indicated too. 36 deaths caused by drug poisoning during 2012 are reported by the FMDCs, only for Sofia. The average age of the deceased by drug use is 29,8.

The Ministry of Interior has provided annual DRD data about all the country for 2012 summarized by the administrative regions. Data is classified by gender and by age (in 3 groups – under 18; 18 – 30; above 30). However the data does not include the death causes.

Summarized data for drug related deaths will be available in the Annual Report 2011 of NFP and respective Standard Tables.


Results of mortality data analysis based on a retrospective national mortality study of the treatment demand cohort for 10-year period are available. Mortality Rate and Standardized Mortality Ratio estimates are calculated and presented in the Standard Table 18 through the National Annual Report 2010.


The mortality rate of DRD in 2012 in Bulgaria according NSI is slightly increased than that for 2011. The ratio “deceased males/females” keeps being in males favour.

The average age of the deceased in 2012, a slight decrease compared to 2011. There are no significant changes in the structure of drug deaths by cause.

Recent developments concerning the DRD Key Indicator in Croatia


The mode of data collection has not changed. There is a fully functional system of data collection which makes it possible to retroactively collect the data missing in a DC, when vital for determining and coding the underlying cause of death. The system is based on a network of public health institutes which supports the collection of data missing from the DC on the county level. The results of toxicological analyses conducted in the labs of the institutes of forensic medicine and the MI may be used to determine the underlying cause of death. Responsible for determining and coding the underlying cause of death, based on the data from the DC, is the CNIPH, which applies the rules and methodology recommended by the WHO in ICD 10th Revision, Volume 2 (used since 1995). In line with the recommendations of the WHO, Eurostat and EMCDDA, we have been applying ICD-10 updates in coding of narcotic drug poisoning in registered addicts since 2006. In 2011 we started with implementation of new death certificate.

In Croatia there are two sources of data on the number of drug-related deaths (DRD). The first one being the General Mortality Registry (GMR) based on DCs, and the second one the Treated Drug Addicts Registry, which among other thing monitors causes of death among drug addicts. Successful cooperation between these two registries has made it possible to upgrade data quality.

This report has used data from the GMR, applying the “Selection B” protocol for drafting standard ST5 and ST6 tables.

In 2012, 48 persons died as a direct result of drug abuse (DRD), which is 11 less deaths than the previous year. 39 deceased persons were men (81%) and 9 women (19%). Average age of the deceased was 35.1, for men 35.3 and 34.3 for women. The decreasing trend in the number of DRDs continued in 2012. The average age of deceased decreased because we registered two deaths in children. According to the results of toxicology reports for 2012, opiates are still the predominant type of drug (83%).


No new study in 2012.


In 2012 two accidental drug poisoning were registered in children (boy three and girl two years old). Three deaths were related to overdoses of cocaine.

Recent developments concerning the DRD Key Indicator in Cyprus


Overdoses





Recent developments concerning the DRD Key Indicator in the Czech Republic


Overdoses

Data from Special register still not available. In General mortality register 2012: increase of cases from 27 to 45 cases (Selection B plus overdose by volatile substances) in all substance groups.Special mortality register 2011: 28 cases (Selection D), majority by metahmphetamine, which was far the lowest number of direct DRDs reported ever in Special register.


No new data from cohort study(ies). Crude mortality in substitution register 3 per 2298 registered in 2012 (steady decrease from 2008).


Published results of the study on alcohol attributable mortality in the Czech Republic.


Difficult to assess since 2012 data from forensic medicine and toxicology still not available. 2011 was remarkable decrease in DRDs (especially opiates and volatiles dropped).In the last 2-3 years, increasing use of opiates from medicines (fentanyl, Vendal (morfin), codeine), but not reflected in fatal or non-fatal overdoses so far.

Recent developments concerning the DRD Key Indicator in the Denmark


Overdoses





Recent developments concerning the DRD Key Indicator in Estonia


The number of overdoses increased in 2012 to 170 (131,7 per million population) of which 152 were males and 18 females. The most frequent substance causing overdoses is fentanyl coded to T40.4, often combined with stimulants, benzodiazepines, ibuprofen and alcohol. (Table 1). Vast majority of the deceased were residents of capital city Tallinn and surrounding areas (N=101) and North-East Estonia (N=52).

Table 1. Drug-related death in Estonia (Selection B) by sex and ICD-10 codes(M=males, F=females, T=total)

2009 2010 2011 2012Cause of death Substance M F T M F T M F T M F T

F11.2 1 0 1X41 T43.6 7 1 8 4 4 17 2 19X42 T40.0 1 0 1

T40.1 2 2 2 2T40.2 2 0 2 1 1 2 1 1 2T40.3 2 1 3 3 1 4 10 1 11 11 1 12T40.4 14 0 14 71 9 80 87 12 99 112 14 126T40.5 1 1 3 3T40.6 88 11 99 5 5 1 1 5 1 6T40.9 3 0 3 1 1

X62 T40.2 1 0 1T40.9 1 0 1

Y11 T43.6 1 1

Y12T40.3 1 1T40.4 1 0 1 1 1 3 3T40.6 6 1 7

Total 120 13 133 89 12 101 108 15 123 152 18 170


There were no significant changes in characteristics of victims or substances used; the only change is continuous growth in numbers.

Recent developments concerning the DRD Key Indicator in Finland


Overdoses





Recent developments concerning the DRD Key Indicator in France


Overdoses





Recent developments concerning the DRD Key Indicator in Germany


Overdoses





Recent developments concerning the DRD Key Indicator in Hungary


Overdoses Latest non-fatal overdose (emergency) statistics (study) available on year 2011 only. It showed large increase in ‘cannabis related’ cases (suspiciously due to synthetic cannabinoids) and in the category of ‘other stimulants’ (possibly due to new psychoactive substances: cathinones, new amphetamines, triptamins, piperazines’. However, these cases are not confirmed with detailed analysis of biological samples.

Mortality among drug users We experience large decrease in heroin/morphine related cases from 2010 on. Level of cases with methadone remained stable. New concerns emerged related to new psychoactive substances.


On drug-related mortality only our Special Register provides (individual, non-aggregate) information with detailed toxicological analysis, it is drafted for the National Report. No specific study was available in 2012.


Emerging figures related to new psychoactive substances (alone and in combination) (5-IT, 4-MEC, amt, PMA, PMMA, mephedrone) and their injecting use.

Increased concern about forensic and laboratory capacities, uncertainties about detection and lethal dose cut-offs around NPSs.

Emerging concerns about GHB/GBL related cases; both in emergency and mortality.


Recent developments concerning the DRD Key Indicator in Ireland


Overdoses





Recent developments concerning the DRD Key Indicator in Italy


Overdoses in the 2012, 390 drug induced deaths (+ 7.7% than the previous year) were recorded: 343 men, 47 women (M/F ratio equal to 7.3), mean age was 36.8 ys. Eighteen cases (22.2% of them females) were < 20 ys old; near 1 case out of 4 (94 cases, 18% of them females) was under 30. Females were 10% of the reminder 297 deaths. Among the 390 cases recorded, 163 referred to heroin, 41 to cocaine, 7 to methadone (15 cases in 2011), 2 to MDMA-amphetamine, 1 to barbiturates, 176 to unspecified drug. Opiates were still the predominant drugs even if a decreasing fatal intoxications by heroin was noticed (42% vs 48.1 % in 2011); on the contrary, increasing deaths by cocaine (10.5% vs 8,0% in 2011) as well as by substances other than heroin and cocaine was pointed out as the high percentage of “unspecified” drug suggests (45.1% vs 38,4% in 2011): some fatal intoxications were likely due to substances hard to identify on circumstantial basis. The 54 % of the cases (72,3% of the female victims) happened at home, 6,7% on the hospital, 9 % in a public place, 13.1% on the street, 17.2% somewere else.

Mortality among drug users No study was recently carried out in Italy


Mortality of patients hospitalized for drug related diseases was carried out at national level by cases’ extraction from the hospital discharge forms coming from the Ministry of Health. The forms 2011 with drug use related diagnosis were 23,131 (about 2‰ of all the hospitalizations) and 210 deaths were recorded (+ 1% respect of the previous year)

In Italy, more than 4% of deaths in traffic accidents is due to alcohol and drugs. In 2011, at national level, data showed a decreasing on alcohol related accidents and deaths (-3.5% and -10.3% respectively); drug-related accidents instead increased (+ 4.5%) whereas deaths remained steady (n=35).

Thanks to the Association of Italian Forensic Toxicologists (GTFI), data 2010-2012 on DRD have been gathered from Forensic toxicologies (FT). As opportune remark, GTFI does not include all forensic laboratories, besides in Italy toxicological analyses are not carried out for all drug-related or induced deaths. Data were forwarded from 16 Forensic toxicologies and 179 drug-related deaths were reported for 2012 (14.5% females). Mean age was 37.7 ys. Heroin was the main drug (54.2%) followed by cocaine and methadone (20.7% and 10.6% respectively). Cocaine was the concomitant drug in the 65.3% of the cases. In 8 cases out of 10 death occurred by overdose and 4 deaths out of 10 occurred by polydrugs use,


Emerging concern is related to NPS use and laboratory capacity to detect them both in acute intoxication and in post-mortem.In 2012, according to GTFI data only one death where NPS, synthetic cannabinoids, were implicated, has been recorded. This may be partially due to the lack or poor availability of standards for laboratory testing. To enhance the identification of many NPS, within our National EWS (N.E.W.S.) analytical reference materials for 36 NPS were supplied to the collaborative laboratories. No cases recorded by the SR: NPS are hard to “identify” on circumstantial basis

A number (19.6%) of non-poisoning deaths among drug users was recorded by the respondent FT in 2012: these cases were mainly due to traumatic or medical causes.

5 deaths related to heroin-methorphan acute intoxication occurred in 2012; 33 reports (12 on 2012) about seizures of heroin adulterated with methorphan came to the NEWS.

Lack of adequate information on substances related to death remains a major hindrance to better understand and use the DRD indicator.

Recent developments concerning the DRD Key Indicator in Latvia


Overdoses





Recent developments concerning the DRD Key Indicator in Lithuania


Overdoses

The national “drug related death“ definition used in this chapter for data presentation are almost the same as the EMCDDA standard definition for the General Mortality Registries ICD-10 Selection B. The national drug-related death definition aims death cases, where the main death cause was marked in the death certificate with one of these ICD-10 codes: F11; F12; F14; F15; F16; F18, F19 ; X42; X62; Y12, the national definition does not include cases with ICD codes X41, X61, Y11 with T40 codes. During reported year was registered 70 deaths cases (66 males and 4 females) due to drugs and psychotropic substance use. Compared to 2011 was noticed increase on Drug-related deaths in Lithuania and this level accounts for 0,17 percent of all deaths registered in Lithuania (in 2011 – 0,12 percent).


Lithuania collects data regarding persons registered in the health care institutions due to mental and behavior disorders using drugs and psychotropic substances (ICD codes: F11-F14, F15, F18 , F19). In 2012, 42 individuals registered as patients dependent on drugs and psychotropic substances died, i.e. 32 men and 10 women.


No studies in 2012.


After some decrease in death cases due to drug and psychotropic substance use noticed in 2010 and 2011, an increase of drug-related death cases was registered in 2012 in Lithuania (Table 3-1).

Table 3-1. Number of deaths caused by drug and psychotropic substance use, by age 2009-2012

Age group 2009 2010 2011 2012Under 15 - 1 0 015–19 years - 0 1 120–24 years 6 12 6 925–29 years 24 9 14 2130–34 years 16 10 10 1635-39 years 10 11 6 839 years and more 12 8 8 15Total 68 51 45 70

Information Source: the Department of Statistics under the Government of the Republic of Lithuania (data until 2010) and the Institute of Hygiene (data from 2010)

In 2012, the main death cause was intoxication with drugs and psychotropic substances (68 deaths), as in previous years mostly opiates – 44 deaths cases (of them in 1 cases was found methadone), unknown or non-specified narcotic or psychotropic substance – 23 cases, cocaine – 1 case.

Table 3-2. Number of deaths caused by drug and psychotropic substance use, by death cause in 2009-2012

Death causes by ICD-10 code/ age group 2009 2010 2011 2012

F11 2 1 1 1F18 1 0 0 0F19 10 5 0 1X42 54 37 40 57X62 0 1 0 1Y12 1 7 4 10Total - deaths 68 51 45 70Information Source: the Department of Statistics under the Government of the Republic of Lithuania and the Institute of Hygiene

Note:F11 – Mental and behavioural disorders using opiates; F18 –Mental and behavioural disorders due to use of volatile solvents F19 - Mental and behavioural disorders using several drugs and other psychoactive substances; X42 – Incidental intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere; X62 – Deliberate intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere; Y12 - Intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere, motivation unknown.

In 2012, the number of deaths of individuals registered as patients dependent on drugs and psychotropic substances decreased (Table 3-3). ,As before, in 2012, among the deaths the biggest number was opioid dependent persons - 31.

Table 3-3. Distribution of death cases of patients dependent on drugs and psychotropic substances, by gender and dependence diagnosis, 2009 -2012

2009 2010 2011 2012Total - deaths 80 47 50 42Incl. men 70 44 40 32Incl. women 10 3 10 10

Codes of dependence diseases according to ICD-10F11 64 38 31 33F12 - - - -F13 2 2 2 -F14 - - 1 -F15 1 1 2 -F18 2 3 1 1F19 11 3 13 8

Information Source: the State Mental Health Centre

Note:F11 – Mental and behavioural disorders using opiates; F18 –Mental and behavioural disorders due to use of volatile solvents F19 - Mental and behavioural disorders using several drugs and other psychoactive substances; X42 – Incidental intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere; X62 – Deliberate intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere; Y12 - Intoxication with drugs and other psychodysleptics and their effect, unclassified elsewhere, motivation unknown.

Recent developments concerning the DRD Key Indicator in Luxembourg


Overdoses





Recent developments concerning the DRD Key Indicator in Malta


Overdoses





Recent developments concerning the DRD Key Indicator in Norway


Overdoses





Recent developments concerning the DRD Key Indicator in Portugal


Overdoses





Recent developments concerning the DRD Key Indicator in Slovakia


50 deaths caused by the direct effects of psychoactive substances were reported in 2012. The important proportion of these were caused by opioids only - 7 cases and by opioids in combination with various substances – 10 cases, which represents together 65% of all direct deaths caused by illicit drugs and solvents. Another 24 deaths (48%) of all direct deaths were caused by medicines. Other substances excluding opioids were identified in 9 cases (18%).


Reported numbers of DRD in 2004 and 2005 in Slovakia were very similar. The number of drug-related deaths reported in 2006, 2007 and 2008 was lower. The number of reported cases has increased again in 2009 and 2010. The total number of cases reported in each year were 124 (2004), 123 (2005), 102 (2006), 85 (2007), 96 (2008), 115 (2009) and 112 in 2010. Direct drug-related deaths were the same in 2004 and 2005 – 46, while in 2006 there were 32 cases, in 2007 28 cases and in 2008 there were 46 cases reported again. During last two years the number of direct DRD had increased up to 56 cases in 2009 and has decreased again in 2010 to 42 cases. The number of cases of direct DRD in the year 2011 was the same – 42 cases as in the year 2010. In the year 2012 in Slovakia number of direct DRD has slightly increased. Tramadol was detected in twelve cases of direct deaths i.e. in 70% of deaths connected with opiates/opioids and in three cases of indirect deaths.


There were not realized recent specific analyses or studies on drug-related mortality except of routine data collection and evaluation in the year 2012.


There are not bigger problems with data collection in Slovakia at the moment. There were no new substances detected and reported in the both groups of drug-related deaths during the year 2012.

Recent developments concerning the DRD Key Indicator in Slovenia


The highest number of deaths among illicit drug users is moving towards the older age group, which togeather with increasing median age at death, and decreasing number of years of potential life lost (YPLL), point to the fact that drug users die older than previously.

Mortality rates due to direct death are different in Slovene regions, and there are two of them with rather high excess deaths.

Picture 1 Mortality rates per 100 000 person years due to direct deaths in inhabitants 15 to 64 years old in Slovenia, in 2004-2012, by regions.

00,5

11,5

22,5

33,5

44,5

Statistic regions

Mor

talit

y ra

tes/

100

000

Source: IPH (Medical dath certificate - IPH 46.

In Zasavska region low level of economic, educational and social factors together with underdeveloped community and health infrastructure might be the reason. In the contrast, Obalno Kraška region is much better in socioeconomic sense, but the position adjacent to Italian border, and town Koper influence, the biggest Slovene harbour, have a clue role in drug availability and consumption. A gap among the age at first treatment and the first use of any drug or the main drug was widening. Together with the decreasing number of drug users treated first time in their lives, in unchanged or increasing number of drug users, points to the possible increase of heavy pathology among drug users and the potential increase of deaths.

Among treated drug users entering in treatment, cocaine, benzodiazepins and canabis as a main or additional drug represent more than a half of all demands for treatment. As in Slovenia only opioid substitution program is available this situation call for developing additional specific programmes for coping particular drug dependancy and problems connected to these drugs use.


Four scientific papers published in medical journal or in a collection of a scientific conference papers:

Young addicts (10-24 years) in Slovenia: analyses of addiction, treatment demand and causes of fatal overdoses.

Drug-related mortality in Slovenia: differences between deceased treated and untreated illicit drug users.

Intentional self-poisoning versus other methods of suicide in illicit dug users, according to gender.

The intentionality of fatal poisonings among illicit drug users, and predictors for intentional intoxication in Slovenia during the years 2002-2007


In the year 2012 there were 26 direct DRDs. The number of deaths was less than the average number commputed from the last seven years. All deceased were men with mean and median age at death at 35,9 years. 35-39 year age group contains the highest number of deaths.

The number of DRD (intentional, unintentional or of unknown intent due to poisonings by drugs) is decreasing from 2007 on, but in men, in 2012, the number increased. The rate ratio of an average DRD among men and women in the period 2004-2012 showed a little less than six fold higher risk for death among men than women.

Heroine poisinings, the leading during the whole previous period, became equal with the number of deaths due methadone, which is growing from 2010 on.

Among drug users registered for treatment ( cohort members) mortality rate is almost two times higher than among the Slovene population of the same age. After nine years of follow up mortality risk is decreasing in women but not in men the reason is cocaine and methadone deaths increasing in the last few years. The percent of accidental poisonings is higher among those who entered in treatment first time in their lives, but suicides are more often among those in treatment for longer period.

Besides poisonings there were also traffic accidents and the other violent acts responsible for deaths in a cohort members, and among natural causes, alcoholic liver cirrhosis and cardiovascular diseases prevailed.


Presentation 1 (title and one or sentences of brief rational)

Presentation 2 (title and one or sentences of brief rational)

Recent developments concerning the DRD Key Indicator in Spain


Overdoses





Recent developments concerning the DRD Key Indicator in The Netherlands

National level

In the Netherlands, statistics on drug-related deaths at national level come available each year from the General Mortality Register (GMR), or Causes of Death Statistics, held by Statistics Netherlands (CBS). In this national register the causes of death are classified according to the International Classification of Diseases, Injuries and Causes of Death (ICD). The 10th edition of the ICD has been in use in the Netherlands since 1996. Although the register has national coverage, in its standard form it only includes deceased residents of the Netherlands who were registered at a municipal register. However, data on drug-related deaths among non-residents are available from an additional database.

The General Mortality Register (GMR) specifically provides data on acute mortality due to drug use, that is poisoning by drugs, or drug 'overdose'. These are the cases in which death is directly related to drugs. The GMR data do not make a distinction between experimental and habitual drug users, and are not suitable for tracing deaths due to rare toxicological substances like various synthetic drugs. Nonetheless, the registered cases can be selected according to the EMCDDA standard definition of acute drug-related death, as reported for the Netherlands in the Standard Tables ST5_2013_NL_01 and ST6_2013_NL_02.

Overall trend

Figure 1 shows the number of cases recorded from 1996 up to including 2012. These cases are selected according to the EMCDDA standard selection of ICD-codes. The figure only includes cases from residents that were registered at a municipal register. Among non-residents, an additional […] cases were registered in 2012 in a separate archive. Between 1996 and 2012, the total number of recorded drug-related deaths among residents fluctuated between a minimum of only 94 cases in 2010 and a maximum of 144 cases in 2001.

Despite some fluctuations over the years, the total number of drug-related deaths in the Netherlands has remained relatively low. This might be explained by a low number of socially marginalized problem drug users, successful harm reduction measures among the problem drug users, and protective factors, such as the nationwide availability of methadone-maintenance treatment, heroin-assisted treatment, and a low rate of intravenous drug use.

Opiates and cocaine

Cases of "opiates" and "cocaine" refer to cases in which these substances were explicitly stated as the primary cause of death on the death certificate. From 1996 up to including 2001, opiate intoxications were the most common causes of drug-related death recorded among Dutch residents. In this period, the casualty rate fluctuated between 81 and 75 cases. In 2002, the number of opiate deaths decreased and reached about the same level as the number of acute cocaine deaths, which had slowly increased since the late nineties. Since 2003 these trends have diverged again and each year there were more opiates deaths than cocaine deaths. However, in 2012 the number of opiate cases (28) came close again to the number of cocaine cases (22).

Psychostimulants

In 2012, there were only 3 cases that were coded to poisoning by psychostimulants (other than cocaine), compared to just four cases in 2009, two cases in 2008 and 2011, and only one case in 2007 and 2010. Whether these fatal intoxications concerned amphetamines, MDMA, or other psychostimulants is not known. Although only a few cases occur each year, ecstasy-related deaths receive much media attention in the Netherlands. 1 Deaths related to hallucinogenic mushrooms also receive media attention.2

1 http://www.nu.nl/binnenland/3494141/meisje-overleden-gebruik-sterke-xtc.html , 06-06-2013;http://www.nu.nl/binnenland/3496316/politie-onderzoekt-dood-21-jarige-man-bosch.html, 09-06-2013;http://www.telegraaf.nl/binnenland/21839312/__Meisje__16__dood_na_drugs__.html?cid=rss, 26-08-2013;http://www.telegraaf.nl/binnenland/21874638/__Alarm_na_drugsdood_Lisa__.html?cid=rss, 09-09-2013.2http://www.parool.nl/parool/nl/4/AMSTERDAM/article/detail/3487888/2013/08/06/Slechte-trip-kan-laatste-zetje-geven-aan-toerist.dhtml , 06-08-2013.

http://www.parool.nl/parool/nl/4/AMSTERDAM/article/detail/3487888/2013/08/06/Slechte-trip-kan-laatste-zetje-geven-aan-toerist.dhtml

http://www.telegraaf.nl/binnenland/21874638/__Alarm_na_drugsdood_Lisa__.html?cid=rss

http://www.telegraaf.nl/binnenland/21839312/__Meisje__16__dood_na_drugs__.html?cid=rss

http://www.nu.nl/binnenland/3496316/politie-onderzoekt-dood-21-jarige-man-bosch.html

http://www.nu.nl/binnenland/3494141/meisje-overleden-gebruik-sterke-xtc.html

Figure 1: Number of acute drug-related deaths in the Netherlands according to the EMCDDA selection of ICD-10 codes from 1996 up to including 2012*

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012Total 108 108 110 115 131 144 103 104 127 122 112 99 129 139 94 103 118Opiates 81 71 71 63 68 75 37 53 52 60 44 34 52 52 37 33 28Cocaine 10 8 11 12 19 26 34 17 20 23 21 23 22 30 14 19 22Other 17 29 28 40 44 43 32 34 55 39 47 42 55 57 43 51 68

0

20

40

60

80

100

120

140

160Number

*Only residents that were registered at a municipal register in the Netherlands are included. Among non-residents, an additional […] cases of acute drug-related deaths were registered in 2012. EMCDDA selection of ICD-10 codes: F11-F12, F14, F16, F19; and X42, X41, X62, X61, Y12, Y11 (selected in combination with T40.0-9 or T43.6). Source: Causes of Death Statistics, Statistics Netherlands

(CBS).

Age and gender

The population of problem drug users is ageing, and this trend is reflected in the increasing age of drug users that have died from drugs. Figure 2 shows that the percentage of deceased aged 35 years and above increased from 40% during the period 1991 up to including 1995 to 71% during the period 2006 up to including 2012.

Between 1996 and 2012, the percentage of female cases varied from 15 to 28% per year, without showing a clear trend. In 2012, the proportion of female cases was 19%.

Figure 2: Trends in the age distribution of cases of acute drug-related deaths in the Netherlands, according to the EMCDDA definition, from the period 1991-1995 up to including the period 2006-2012

1991-1995 1996-2000 2001-2005 2006-2012>=65 y 3 3 3 535-64 y 37 50 62 6615-34 y 60 47 36 29

0%

20%

40%

60%

80%

100%%

Source: Causes of Death Statistics, Statistics Netherlands (CBS).

Regional level: Amsterdam

The Public Health Service of Amsterdam (GGD Amsterdam) traces drug-related deaths by means of the Central Methadone Register. This regional monitor is part of the Public Mental Health Care monitor (OGGZ monitor) of Amsterdam (Buster and Van Brussel 2011). The data on the fatal poisonings ('overdoses') from the Amsterdam coroners also include tourists and drug users that stay illegally in the Netherlands and are therefore not included in the Population Registry. Figure 3 gives the number of acute deaths (overdoses) that were found according to this procedure among the drug users in Amsterdam. Between 2001 and 2011 the number of acute deaths fluctuated around an average of 25 acute deaths per year. The number of 18 cases in 2011 is the lowest number since 1978. Cases of drug swallowers (4 cocaine cases in 2011) are not included in these figures.From the 18 cases in 2011, 4 were female, 14 were male, and the age ranged from 26 to 67 years, the average age being 42 years. The following substances were found: cocaine (10 times), opiates (10 times), amphetamines/MDMA (8 times), GHB/GBL (5 times), and other medications (10 times).There were indications of suicide in 9 cases. In 2 suicide cases, among other substances, GHB/GBL was used.Apart from the fatal poisonings ('overdoses'), no new data have become available from the mortality cohort study in Amsterdam (ST18_2012_NL_01).

Figure 3: Number of acute deaths (overdoses) among drug users in Amsterdam from 1994 to 2011

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Overdose 39 26 26 22 25 27 31 32 29 21 22 29 21 25 22 29 27 18

0

5

10

15

20

25

30

35

40

45Number

Source: Public Health Service of Amsterdam (GGD Amsterdam)

Recent developments concerning the DRD Key Indicator in Turkey


Overdoses





Recent developments concerning the DRD Key Indicator in United Kingdom

New information


Using the DRD Standard, there were 1,666 deaths in the UK in 2012 (1,785 in 2011, down 6.7%); males 75.4%, females 26.4%. Males are generally about 5 years younger than females. Most deaths occurred in the 35-39 age-group. The number of deaths per 100,000 population shows that differences exist between the different countries within the UK. Thus, in 2012 the rate using the DRD Standard was 10.31 in Scotland compared to 1.89 in England & Wales and 2.41 in Northern Ireland. The UK average was 2.62 in 2012 (1.98 in 1996). Overall, the largest proportion of deaths in England & Wales using the wider ONS definition was described in 2012 as accidental poisoning (1541/2597 - 59.3%), followed by intentional/undetermined poisonings (947 or 37.5%), and then mental & behavioural disorders (101 or 3.9%). Males are more likely to die at a younger age of drug dependence/non-dependent abuse of drugs and females at an older age by means of intentional/undetermined poisoning.

In England & Wales in the period 1993-2012, more than one drug was involved in 32.5% and alcohol in 25.9% of all DRDs (using the wide definition employed by ONS). Deaths in 2012 where heroin/morphine was mentioned numbered 579 (down from 596 in 2011, but up from 155 in 1993). The number of cases in which methadone was implicated rose steadily from 206 in 1993 to peak at 437 in 1997, falling to 199 in 2002, before rising to a new peak of 408 in 2009; but fell back to 355 in 2010 before reaching an all-time high of 486 in 2011 and then declining to 414 in 2012. Mentions of cocaine, although still comparatively few compared to heroin/morphine, rose more than 20-fold over the period 1993-2008 as a whole (from 11 to 235) but fell to 202 in 2009 and 112 in 2011 before increasing again in 2012 to 139. Deaths involving ecstasy accounted for only 1% of drug-related deaths; they rose from 12 in 1993 to 56 in 2002, fell to 43 in 2004, rose again to 58 in 2005, but fell to 27 in 2009 and to only 8 in 2010 (the lowest since monitoring started) but recovered to 31 in 2012. GHB/GBL were mentioned in 76 deaths recorded by the ONS between 1996 and 2009, and had followed a rising trajectory in the last few years, but fell in 2009-2010 before rising in 2011 only to fall back in 2012. Mentions of piperazines started to appear on death certificates in 2009 (n=9) and 2010 (n=5) but fell in 2010 (n=6) and 2011 (n=2), but rose to 9 in 2012. Methcathinones such as mephedrone made their first appearance in 2010 (n=6), remaining at that level in 2011 before trebling to 18 in 2012.

2. Recent trends

Over the period 1996-2001, the total number of deaths rose by 73.2% from 1,152 to 1,995; fell by 20.1% to 1,595 in 2003, and then increased by 39.9% to 2,231 in 2008, before falling by 25.3% to 1,666 in 2012. There were rises of 29.9% and 122.3% for males and females respectively over the period 1996 to 2012. There was a male: female ratio of 3.1:1 in 2012. Using the broad ONS definition, the overall number of deaths fell by 3.5% between 2010 and 2011 and by 2.1% between 2011 and 2012. Table 1 shows, during the last year, an increase in the number of deaths involving cannabis (+157.1%), ecstasy-type (+83.3%), tramadol (+23.9%), diazepam (+22.0%), anti-depressants (+16.8%), cocaine (+14.5%), antipsychotics (+3.5%), benzodiazepines as a group (+2.5%), and a slight rise in heroin/morphine (+0.6%). There were falls in the number of mentions of methadone (13.7%), paracetamol (-13.2%), amphetamine (-6.9%), but no change in cases where temazepam was recorded.

Published data show there were 46 deaths associated with Volatile Substance Abuse in 2009 (38 in 2008). This is the second lowest figure since data collection methods became stable in 1983 and compares with the all-time peak of 152 in 1990 (Ghodse et al, 2012b). In addition, there were 46 deaths resulting from the inhalation of helium, compared to 26 in 2008.

Deaths of IDU (including sex between men and IDU) AIDS victims accounted for 7.9% (1,505/19,039) of the total number of AIDS deaths in England & Wales up to the end of December 2011. The levelling off in the number of deaths of IDU AIDS victims seen in recent years gave way to a slight increase in 2009. The UK figure of 63 for 2011 (66 in 2010) is about 30% of the peak level in 1995 (212). By the end of December 2012, 36 deaths had been reported for that year (Personal communication to John Corkery from Health Protection Agency, 18 April 2013).

Table 1: Mentions of selected drugs on death certificates, United Kingdom, 2002-12

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012DrugHeroin/morphine 1,118 883 977 1,045 985 1,130 1,230 1,215 1,063 820 825Methadone 300 292 300 292 339 441 550 586 535 765 660Cocaine 161 161 192 221 224 246 282 239 181 152 174Amphetamine 64 43 53 62 60 62 72 57 52 72 67Ecstasy-type 79 66 61 75 62 64 52 32 9 24 44Cannabis 49 32 24 25 22 20 20 22 11 7 18All benzos, of which 500 427 385 321 297 345 414 442 469 514 527Diazepam 356 282 216 210 187 223 277 302 315 336 410Temazepam 89 114 88 55 56 57 50 48 38 45 45Antidepressants 478 524 565 484 454 436 512 528 528 529 618Antipsychotics 68 77 94 96 104 114 117 110 116 143 148Paracetamol 647 547 632 490 376 306 319 302 251 257 223Tramadol 45 51 56 75 109 116 126 135 185 205 254All ONS definition deaths 3,464 3,168 3,381 3,326 3,238 3,356 3,754 3,678 3,531 3,503 3,441Notes: A revised data collection form was introduced in Scotland in 2008 which has resulted in more specific drugs being identified than in previous years; ONS revised how they deal with paracetamol in compounds in 2010, and revised their figures retrospectively. ONS have made revisions to their historic data; data for Northern Ireland have been extracted for us by NISRA and are slightly different in some years to what had been previously extracted.Year of registration of death, not year death occurred.


MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') is a psychoactive substance, sold primarily over the Internet and in 'head' shops as a 'legal high'. Synthesised and used as a research chemical in the 1990s, MDAI has structural similarities to MDMA (3,4-methylenedioxy-N-methylamphetamine) and shares its behavioural properties. Recreational use of MDAI appears to have started in Europe around 2007, with a noticeable increase after 2009 in the UK and other countries. Calls to National Poisons Information Services started in 2010, although there were few presentations to emergency departments by patients complaining of undesirable physical and psychiatric effects after taking

MDAI. Recreational use of this drug has been reported only occasionally by online user fora. There is little scientifically based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of this drug. Corkery et al (2013) presented information on the first three UK deaths involving MDAI use in 2011 and 2012. 'Serotonin syndrome' appears to be a possible factor in these fatalities. It is vital that any other cases, including non-fatal overdoses, are documented so that a scientific evidence base can be established for them.

The new designer drug 5-(2-aminopropyl)indole (5-IT) is an indole derivative with stimulant properties. Its synthesis was first described by Albert Hofmann and Franz Troxler in 1962. Seetohul and Pounder (2013) report four deaths associated with 5-IT and a validated high-performance liquid chromatography method for quantitation of the drug. In all four deaths, an autopsy was performed, and femoral venous blood, heart blood, urine and vitreous humour were submitted for toxicological analysis. The blood specimens were subjected to comprehensive testing that included alcohol analysis by headspace gas chromatography (GC-FID), acidic/neutral, basic drug and opiates screening by liquid chromatography-mass spectrometry (LC-MS-MS), and acidic/neutral, basic and acidic drugs screening by HPLC. In Case 1, a 25-year-old male, 3,4-methylenedioxymethamphetamine (MDMA; <0.08 mg/L) and 5-IT (preserved femoral blood 1.2 mg/L; unpreserved femoral blood 0.8 mg/L; cardiac blood 1.2 mg/L; vitreous 0.8 mg/L and urine >10 mg/L) were detected, and death was attributed to the toxic effects of 5-IT. In Case 2, a 25-year-old female, 3,4-methylenedioxy-N-methylcathinone (methylone, not quantitated), 6-(2-aminopropyl)benzofuran (6-APB; femoral blood <0.08 mg/L) and 5-IT (preserved femoral blood 1.0 mg/L; unpreserved femoral blood 0.9 mg/L; cardiac blood 2.6 mg/L; vitreous 1.4 mg/L and urine >10 mg/L) were detected, and death was attributed to the toxic 'cocktail effects' of the drugs. In Case 3, a 22-year-old male with a history of epilepsy, 5-IT (0.5 mg/L femoral blood) and 6-APB (0.2 mg/L femoral blood) were detected, and death was attributed to the toxic effects of the drugs, with the role of epilepsy being indeterminate. In Case 4, a 25-year-old female, 5-IT (0.4 mg/L femoral blood), amphetamine (0.4 mg/L femoral blood), MDMA (1.5 mg/L femoral blood), 4-methyl-N-ethylcathione, 3,4-methylenedioxyamphetamine HCl (MDA), benzylpiperazine and 6-APB were detected, and death was attributed to the 'cocktail effect' of the drugs.

Mephedrone (4-methylmethcathinone) is the beta-keto analogue of 4-methylmethylamphetamine. Before its control in April 2010, it became popular as a legal high in the UK, displacing MDMA as the stimulant drug of choice. The drug has stimulant and psychoactive properties, and therefore has forensic significance in criminal and morbid toxicology. The purpose of a study by Cosbey et al (2013) was to survey casework involving the drug (impaired driving and sudden death). The cases were received in the laboratory for analysis between late 2009 and the end of 2010. Analysis of blood samples for mephedrone was conducted by liquid chromatography-mass spectrometry (LC-MS). Routine screening for alcohol and a range of other pharmaceuticals and drugs of abuse was conducted using a combination of enzyme-linked immunoassay, gas chromatography (GC) headspace, GC-MS and high-performance liquid chromatography with diode array detection. Mephedrone was detected in a total of 12 fatal cases. Most of these cases involved death by mechanical means; in two cases, death was attributed directly to mephedrone intoxication (blood concentrations of 2.1 and 1.94 mg/L). Mephedrone was detected in a total of 32 impaired driving cases. Blood concentrations ranged up to 0.74 mg/L (mean 0.21, median 0.10). The casework evidence in this study indicated that recreational use of the drug can produce to blood levels as high as 0.74 mg/L, although the most common value encountered is likely to lie between 0.2 and 0.3 mg/L.

4. Emerging problems: new substances, characteristics of victims…

Legal highs/Novel psychoactive substances (NPS)Whilst opiates and opioids continue to dominate in the UK, towards the end of 2009 there was a noticeable decline in the number and proportion of cases involving stimulants. To some extent these changes appear to have been reversed slightly for amphetamines and ecstasy-type drugs. Substances such as piperazines, ketamine and GBL which at the time of the 2009 report were ‘legal highs’ but became controlled drugs, continue to be present in post-mortem toxicology reports - although possibly declining in the case of piperazines. Towards the end of 2009 new substances, chiefly methcathinones such as mephedrone started to appear in reports to np-SAD. These increased during 2010 and into 2011. As these became controlled, new substances emerged; of particular concern are phenazepam, PMA, benzofurans and indoles.

Blood borne viruses/AnthraxThere is an ongoing outbreak of anthrax among people who inject drugs in a number of countries in Europe with 14 cases now identified since early June 2012. The latest case in Scotland brings the total number affected in the UK to eight – five in England (including four fatalities), two in Scotland (including a fatality) and one in Wales. The source is presumed to be contaminated heroin. It is unclear whether the British cases are linked to the

European outbreak, which has affected drug users in Denmark, Germany and France. The Health Protection Agency (HPA) continues to monitor the situation.

In May 2013 Scottish health officials in Lanarkshire issued an alert after the deaths of two injecting drug users who had contracted necrotising fasciitis, there was also a possible case in a patient with a history of injecting drug use.

ICD codingTowards the end of 2009 new substances, chiefly methcathinones (such as mephedrone, methylone and MDPV), and naphyrone started to appear in reports to np-SAD and are still occurring. In addition new classes of substances, such as aminoindanes, benzofurans, indoles, methoxetamine and synthetic cannabinoids have caused fatalities. The past year or two have seen some important changes in the types of drugs being used recreationally and consequently beginning to contribute to drug-related morbidity and mortality. The UK expert has discussed with the GMRs difficulties in respect of ICD-10 coding for novel psychoactive substances/’legal highs’ for which there are no specific codes or guidance. These points have been relayed to the EMCDDA in Lisbon, and fed into the discussions of the WHO body drawing up ICD-11.

Selected new reports:

ACMD. (2013). ACMD consideration of tramadol. 13 February. London: Home Office. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/144116/advice-tramadol.pdf

Corkery, J., Casula, S., Claridge, H., Gimeno Clemente, C., Goodair, C., Loi, B., Schifano, F. (2013). UK deaths associated with ‘Z’ drugs (Zopiclone, Zolpidem & Zaleplon). Appendix 1 (pp. 19-29) in Z-drugs: a review of the evidence of misuse and harm. Advisory Council on the Misuse of Drugs. London: Home Office. 5 September. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/237037/ACMD_advice_Z_drugs.pdf

Corkery, J.M., Elliott, S., Schifano, F., Corazza, O., Ghodse, A.H. (2013). MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') toxicity: a brief overview and update. Hum Psychopharmacol. Jul, 28(4):345-55. doi: 10.1002/hup.2298.

Cosbey, S.H., Peters, K.L., Quinn, A., Bentley, A. (2013). Mephedrone (methylmethcathinone) in toxicology casework: a Northern Ireland perspective. J Anal Toxicol. Mar, 37(2):74-82. doi: 10.1093/jat/bks094. Epub 2013 Jan 24.

Ghodse, H., Corkery, J. Claridge, H., Goodair, C., & Schifano, F. (2013). Drug-related deaths in the UK: Annual Report 2012. Drug-related deaths reported by Coroners in England, Wales, Northern Ireland, Guernsey, Jersey and the Isle of Man; Police forces in Scotland; & the Northern Ireland Statistics and Research Agency – Annual Report January-December 2011. 28 February. London: International Centre for Drug Policy, St George's University of London. Available at: http://www.sgul.ac.uk/research/projects/icdp/pdf/np-sad-13th-annual-report-2012.pdf

Ghodse, H., Corkery, J., Ahmed, K. and Schifano, F. (2012b). Trends in UK deaths associated with abuse of volatile substances, 1971-2009. Report 24. International Centre for Drug Policy, St George's, University of London. 15 November 2012. Available at: http://www.sgul.ac.uk/research/projects/icdp/our-work-programmes/substance-abuse-deaths

Haig, S.D., Kelly, C., Morden, C. (2013). A report of an outbreak of toxicity from a novel drug of abuse: ERIC-3. Emerg Med J. 2013 Jul;30(7):543-5. doi: 10.1136/emermed-2012-201631. Epub 2012Aug 27.

Hoolachan, J., Hecht, G., Galbraith, L., Graham, L. (2013). The National Drug-related Deaths Database (Scotland) Report 2011. 30 April. ISD: Edinburgh. Available at: http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2013-04-30/2013-04-30-NDRDD-Report.pdf?69897097350

http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2013-04-30/2013-04-30-NDRDD-Report.pdf?69897097350

http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2013-04-30/2013-04-30-NDRDD-Report.pdf?69897097350

http://www.sgul.ac.uk/research/projects/icdp/our-work-programmes/substance-abuse-deaths

http://www.sgul.ac.uk/research/projects/icdp/pdf/np-sad-13th-annual-report-2012.pdf

http://www.sgul.ac.uk/research/projects/icdp/pdf/np-sad-13th-annual-report-2012.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/237037/ACMD_advice_Z_drugs.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/237037/ACMD_advice_Z_drugs.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/144116/advice-tramadol.pdf

King, R., Bird, S.M., Overstall, A., Hay, G., Hutchinson, S.J. (2013). Injecting drug users in Scotland, 2006: Listing, number, demography, and opiate-related death-rates. Addict Res Theory. 2013 Jun;21(3):235-246. Epub 2012 Aug 20.

Mathers, B.M., Degenhardt, L., Bucello, C., Lemon, J., Wiessing, L., Hickman, M. (2013). Mortality among people who inject drugs: a systematic review and meta-analysis. Bulletin of the World Health Organization, 91:102-123. doi: 10.2471/BLT.12.108282. Available at: http://www.who.int/bulletin/volumes/91/2/12-108282/en/index.html

Meghji, S., Judd, O., Carr, E. (2013). Fatal cutaneous anthrax in a heroin user. J Laryngol Otol. Apr, 127(4):423-5. doi: 10.1017/S0022215112003210. Epub 2013 Feb 4.

Merrall, E.L., Bird, S.M., Hutchinson, S.J. (2013). A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 1996-2006. Addiction. Feb, 108(2):377-84. doi: 10.1111/j.1360-0443.2012.04066.x. Epub 2012 Nov 1.

National Forum. (2013). National Forum on Drug-Related Deaths in Scotland - Annual Report 2011/12. 1 March. Edinburgh: Scottish Government. Available at: http://www.scotland.gov.uk/Resource/0041/00415579.pdf

NISRA. (2013). Drug-Related Deaths and Deaths due to Drug Misuse registered in Northern Ireland (2002-2012). 23 May 2013. Belfast: Northern Ireland Statistics & Research Agency. Available at:http://www.nisra.gov.uk/archive/demography/publications/drug_deaths/Drug_Tables_12.xls

NRS. (2013). Drug related deaths in Scotland in 2012. Edinburgh: National Records of Scotland. 27 August 2013. Available at:http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2012/drugs-related-deaths-2012.pdf - page=61&zoom=100,0,842http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2012/drugs-related-deaths-2012.pdfhttp://www.gro-scotland.gov.uk/statistics/theme/vital-events/deaths/drug-related/2012/list-of-tables-and-figures.html

ONS. (2013). Deaths related to drug poisoning in England and Wales, 2012. Statistical Bulletin. 28 August 2013. Newport, Gwent: Office for National Statistics Available with accompanying spreadsheets at: http://www.ons.gov.uk/ons/dcp171778_320841.pdfhttp://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2012/drugs-reference-tables.xls

Scottish Government (2011). National Forum on Drug Related Deaths in Scotland: Annual Report 2010-11. Scottish Government, Online Publication. Available at:http://www.scotland.gov.uk/Resource/0039/00391832.pdf

SDF. (2012). Scottish Drugs Forum Annual Report 2011/12. Glasgow: Scottish Drugs Forum. 31 October. Available at: http://www.sdf.org.uk/index.php/download_file/view/330/126/

Seetohul, L.N., Pounder, D.J. (2013). Four Fatalities Involving 5-IT. J Anal Toxicol. Sep, 37(7):447-51. doi: 10.1093/jat/bkt053. Epub 2013 Jul 16.

John Corkery, UK FP DRD expertResearch Co-ordinator, Department of Pharmacy, University of Hertfordshire, Hatfield, UK Programme Manager of National Programme on Substance Abuse Deaths (np-SAD) &Volatile Substance Abuse mortality register, International Centre for Drug Policy, St George’s University of [email protected] [email protected] 2013

mailto:[email protected]

mailto:[email protected]

http://www.sdf.org.uk/index.php/download_file/view/330/126/

http://www.scotland.gov.uk/Resource/0039/00391832.pdf

http://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2012/drugs-reference-tables.xls

http://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2012/drugs-reference-tables.xls

http://www.ons.gov.uk/ons/dcp171778_320841.pdf

http://www.gro-scotland.gov.uk/statistics/theme/vital-events/deaths/drug-related/2012/list-of-tables-and-figures.html

http://www.gro-scotland.gov.uk/statistics/theme/vital-events/deaths/drug-related/2012/list-of-tables-and-figures.html

http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2012/drugs-related-deaths-2012.pdf

http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2012/drugs-related-deaths-2012.pdf#page=61&zoom=100,0,842

http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2012/drugs-related-deaths-2012.pdf#page=61&zoom=100,0,842

http://www.nisra.gov.uk/archive/demography/publications/drug_deaths/Drug_Tables_12.xls

http://www.scotland.gov.uk/Resource/0041/00415579.pdf

http://www.who.int/bulletin/volumes/91/2/12-108282/en/index.html

background - emcdda home page | · web viewdifficult to assess since 2012 data from forensic...

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