Fatal poisoning among drug users in Denmark in 2017

INTRODUCTION

Knowledge of trends of illegal drug use is vital for planning initiatives to reduce accidents and deaths among drug users. The aim of this study was to describe the cause of death, abuse pattern and geographic differences in fatal poisonings among drug users in Denmark in 2017.

METHODS

All fatal poisonings among drug users examined at the three institutes of forensic medicine in Denmark in 2017 were included in the study.

RESULTS

Overall, fatal poisonings declined from a maximum of 226 in 2007 to 162 in 2017. Methadone (52%) was the most common cause of death, followed by heroin/morphine (25%). A marked increase in deaths was due to stimulants (13%), especially cocaine. The abuse pattern has changed since 2012. Methadone remained the most frequently detected drug, but clonazepam and cocaine surpassed heroin/morphine, diazepam and tetrahydrocannabinol as the second-most frequently detected drugs. Ketobemidone had disappeared, whereas buprenorphine, oxycodone, fentanyl, pregabalin and gabapentin had increased. Antidepressants/antipsychotics were detected in half (47%) of the cases. Cocaine was more frequent in the areas covered by Copenhagen and Aarhus, whereas heroin/morphine was most frequently detected in the area covered by Odense. Amphetamine was more frequent in the Aarhus area.

CONCLUSIONS

Methadone and heroin/morphine still account for most fatal poisonings. However, deaths due to stimulants, especially cocaine, have increased. The abuse pattern has changed and geographical differences have emerged.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Narcotics at street level in Denmark. A prospective investigation from 1995 to 2000

This article describes an investigation of illicit drugs at street level in six selected police districts in different regions of Denmark. The investigation was carried out during a 6-year period from 1995 to 2000. During the period, a total of 1244 samples were examined, as about 200 samples were seized each year. A total of 94% of the seized samples were familiar drugs: heroin base, heroin hydrochloride, cocaine hydrochloride and amphetamine sulphate. Only 2% of the samples contained designer drugs. From having constituted 53% of the samples in 1995, the frequency of heroin base fell during the period to 27% of the samples in 2000. The frequency of heroin hydrochloride was unchanged. In the same period, the frequency of cocaine hydrochloride increased from 10% of the samples in 1995 to about 25% of the samples in 2000. Apart from a few exceptions, cocaine had the same extension in all regions of Denmark after 1996. Amphetamine was more frequent in the west of Denmark, while heroin hydrochloride was more frequent in central Denmark. The purity of heroin base was lower in the period 1997-1999 than in the other years. During the entire period, the purity of cocaine hydrochloride and amphetamine sulphate fell, while the purity of heroin hydrochloride was unchanged. No significant differences between the various regions of Denmark were detected during the period in the purity of heroin hydrochloride, heroin base, cocaine hydrochloride or amphetamine sulphate. MDMA was the most frequent designer drug, but other types of designer drugs such as MDA and MDE and the less common PMA, PMMA and MBDB were also found.

Fatal poisoning in drug addicts in the Nordic countries

The study includes medicolegally examined fatal poisonings among drug addicts in 1997 in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden, and the results are compared to a similar investigation from 1991. A common definition of "drug addict" was applied by the participating countries. The highest death rate by poisoning in drug addicts was observed in Denmark, where it was 6.54 per 10(5)inhabitants, followed by Norway with 6.35, Sweden with 2.21, Finland with 1.63 and Iceland with 1.20 per 10(5)inhabitants. All countries showed a higher death rate in 1997 than in 1991. For all countries the distribution of deaths according to geographical regions showed a decreasing number of drug deaths in the metropolitan area and an increasing number in other cities. Heroin/morphine dominated as the cause of death and was responsible for about 90% of the cases in Norway. In Sweden and Denmark, however, heroin/morphine caused only about 70% of the fatal poisonings. About 30% of the fatal poisonings in Denmark and Sweden were caused by other group I drugs, in Denmark mainly methadone and in Sweden mainly propoxyphene. Apart from two cases in Sweden methadone deaths were not seen in the other Nordic countries. In Finland heroin/morphine deaths have increased from about 10% in 1991 to about 40% in 1997. Forty-four percent of the fatal poisonings in Finland were caused by other group I drugs, mainly codeine and propoxyphene. The two fatal poisonings in Iceland were caused by carbon monoxide. Only few deaths in this investigation were caused by amphetamine and cocaine. A widespread use of alcohol, cannabis and benzodiazepines, especially diazepam, was seen in all the countries.

[Designer drugs in Jutland]

INTRODUCTION

The aim of this investigation was to examine illegal tablets and capsules seized in Jutland, the western part of Denmark, during the period 1995-1999. The drugs are described according to technical appearance (colour, logo, score, diameter) and content of synthetic drugs.

MATERIAL AND METHODS

All illegal tablets and capsules received during the period 1995-1999 (109 cases containing 192 different samples) were examined.

RESULTS

MDMA was the most common drug and was seen during the entire period. Amphetamine was the second most common drug and has been frequently detected during the the last two years. Drugs like MDE, MBDB, BDB, and 2-CB were rarely seen and they disappeared quickly from the illegal market. MDA appeared on the market at the end of 1999. Only 53% of the tablets contained MDMA as the sole drug. Eighty-one percent of the tablets/capsules contained only one synthetic drug, whereas 13% contained a mixture of two or more synthetic drugs. Six per cent of the samples did not contain a euphoric drug/designer drug. The content of MDMA, MDE, and amphetamine in the tablets varied greatly.

DISCUSSION

MDMA is apparently the drug preferred by the users, but still only half of the tablets contained MDMA as the only drug. The rest of the tablets contained either another synthetic drug or a mixture of drugs. In conclusion, the increasing supply of various drugs with different and unpredictable effects and of miscellaneous quality brings about the risk of serious and complicated intoxications.

[Fatal intoxications among drug addicts in Denmark in 1997]

INTRODUCTION

The purpose of this study was to investigate fatal poisonings among drug addicts in 1997 and to compare the results to similar investigations from 1985 and 1991.

MATERIAL AND METHODS

All fatal intoxications among drug addicts in Denmark in 1997, investigated at the three Institutes of Forensic Medicine in Denmark.

RESULTS

The number of fatal intoxications increased by 32% from 1991 to 1997, mainly outside the metropolitan area, The average age increased from 32 to 36 years. The proportion of heroin/morphine intoxications increased from 57% to 71%. The most commonly used drugs were as in 1991 heroin/morphine, diazepam and methadone. The frequency of cocaine increased from one positive case in 1991 to 14% positive cases in 1997.

DISCUSSION

This study showed an increasing number of fatal intoxications and changes in drug abuse pattern and place of death since 1991.

[Fatal poisonings among drug addicts in the county of Funen in 1995 and 1996]

The aim of this investigation was to examine the deaths of drug addicts from poisoning in the county of Funen in 1995 and 1996. The cause of death was related to drugs on the illicit market. Social conditions (homelessness, involvement in crime, psychogenic disease, circumstance of death) are discussed. The study included 47 drug addicts. Median age was 34, age span: 20-43. The main cause of death was poisoning by heroin. In 28% of the drug addicts cocaine was detected and in 13% amphetamine. About half had used benzodiazepines. Few were employees, most were criminals and eight were homeless. Thirty-eight percent were found in public lavatories. Eight had a serious psychiatric diagnosis. We can conclude that the drug addicts are socially marginalized. They abused a mixture of drugs. The drugs detected in the drug addicts compared well with the drugs on the illicit market and cocaine had gained access to the market.

[Citalopram in forensic samples. Citalopram concentrations in samples from legal autopsies and from living persons in connection with traffic accidents or cases of violence in Denmark 1989-1996]

Citalopram was found in 92 autopsy cases and 27 cases from living persons and the concentrations are described. A range of 6.2-19 mumol/kg whole blood was found in cases where citalopram alone was the cause of death and a range of 1.9-16 mumol/kg whole blood in cases, where citalopram together with other compounds were considered to be the cause of death. In autopsy cases toxic concentrations were in the range 1.2-2.8 mumol/kg whole blood and concentrations between 0:09 and 1.9 mumol/kg were considered therapeutic. In cases from living persons the citalopram concentrations in whole blood were 0.06-0.9 mumol/kg.

A prospective toxicology analysis in alcoholics

A prospective and comprehensive investigation was done on 73 medico-legal autopsies in alcoholics. The results of the toxicology analyses are described. Alcohol intoxication was the cause of death in 8%, combined alcohol/drug intoxication in 15% and drugs alone in 19%. Alcoholic ketoacidosis was found to be the cause of death in 7%. Altogether toxicology analyses were necessary for determining the cause of death in 51% of the cases. In four cases the cause of death would not have been found, had this investigation not been made. It is concluded that toxicology analyses should be the rule rather than the exception in deaths in alcoholics.

Fatal poisonings in young drug addicts in the Nordic countries: a comparison between 1984-1985 and 1991

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 10(5) 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 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 heroin/morphine 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.

Drug addict deaths in the Nordic countries: a study based on medicolegally examined cases in the five Nordic countries in 1991

The study includes medicolegally examined deaths among drug addicts in 1991 in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition of 'drug addict' was applied by the participating countries. The greatest number of drug addict deaths per 10(5) inhabitants was observed in Denmark followed, in descending order by Norway, Sweden, Finland and finally Iceland with only four deaths. The main difference between the countries was found in the number of fatal poisonings. The distribution according to geographical regions showed that about half of all drug addict deaths occurred in the metropolitan areas. Of the capitals, the greatest number of fatal poisonings per 10(5) inhabitants was seen in Oslo, followed by Copenhagen with a similar number, Stockholm with only the half, and Helsinki with a quarter. Heroin/morphine dominated as cause of death in fatal poisonings in Norway and Sweden. In Denmark, heroin/morphine caused about half of the fatal poisonings only, and nearly one third of the fatal poisonings was caused by methadone. Except for two cases in Sweden, methadone deaths were not seen in the other Nordic countries. Amphetamine caused one tenth of the fatal poisonings in Sweden. In Finland only one tenth of the deaths were caused by heroin/morphine and more by codeine, ethylmorphine and different drugs and poisons not classified in Single Convention on Narcotic Drugs 1961 or the International Convention on Psychotropic Substances 1971. A widespread use of alcohol, cannabis and benzodiazepines, diazepam especially, was seen in all the countries.

[Fatal cases of poisonings among drug addicts in the county of Funen in 1993]

This study includes death from poisoning among drug addicts in 1993 in the county of Funen, in all 24. The development during the last five years shows an increase, especially in the largest city in the county. The drug addicts have several problems, and several of them were well-known in the social welfare system or by the police. Half of the drug addicts had received treatment for their abuse and three persons were receiving treatment at the time of their death. A few--primarily among the youngest--had only used drugs for a short time while one third had abused drugs for several years. The greater part of the deaths were caused by heroin, which is found in different concentrations in the illegal market. Five of the dead persons had just been released from prison and three people had just left 24-hour care centres when they were found dead. Co-operation between the various, treating authorities has to be given a high priority.

[Deaths among drug addicts in Denmark. A forensic medical study of deaths among drug addicts during the period 1991-1992 related to the period 1984-1985]

This study includes all deaths among drug addicts in the years 1991 (n = 219) and 1992 (n = 214) investigated at the three institutes of forensic medicine in Denmark. The results are compared with deaths among drug addicts in 1984-1985. The number of deaths among drug addicts increased by approximately 50% in 1991-1992 compared with 1984-1985. The increase was most significant among drug addicts over 35 years of age. The cause of death was intoxication in three-quarters of the cases in 1991-1992. In half of these cases heroin/morphine had caused death, while intoxications caused by methadone accounted for approximately 30% of the cases. In the metropolitan area the frequency of methadone intoxications increased significantly compared with 1984-1985, whereas the number of heroin/morphine intoxications did not change. Outside the metropolitan area, however, a significant increase in heroin/morphine intoxications was noticed. In all parts of the country the number of propoxyphene intoxications decreased to a few annual cases. The most commonly used drugs of abuse were heroin/morphine, diazepam and methadone, often in combination with alcohol.

Deaths among drug addicts in Denmark in 1987-1991

In the period 1987-1991 a total of 739 fatalities among drug addicts was investigated at the three University Institutes of Forensic Medicine in Denmark. The annual number rose from 130-140 in the first 4 years to 192 in 1991, and 80% were males. The mean and median age for both males and females increased by 1 year in the period. The main drug of abuse was heroin, in most cases supplemented by various other drugs, and in almost all cases taken intravenously. In about one-third of the cases each year there was information of abuse of alcohol in addition. In the poisoning cases, the main drug of poisoning was morphine/heroin, constituting 35-55% of the cases each year. As regards methadone-poisoning cases, the number increased significantly in 1991 compared to the first 4 years. Furthermore, the number and proportion of addicts dying while in methadone treatment increased during the 5-year period. In about half of the methadone poisoning cases, there was information of methadone treatment at the time of death. The other half obviously obtained the methadone completely illegally. Ketobemidone was the third most frequent drug of poisoning, while propoxyphene and barbituric acid only were found in a very few cases each. The results are compared to those from an earlier investigation concerning drug deaths in Denmark in 1968-1986. The importance of registering drug deaths is emphasized.

Renal myoglobin in drug addicts: occurrence and significance in a postmortem study

In a 3-year period (1989-1991) a non-selected, consecutive series of 62 deaths in drug addicts was autopsied at the Forensic Institute in Odense. The kidney sections from these addicts were examined for the presence of renal myoglobin using immunohistochemical methods. A reference group consisting of a non-selected, non-consecutive series of 58 autopsied non-addicts was likewise investigated for the presence of renal myoglobin. No major differences were demonstrated between the two groups. The presence of renal myoglobin probably indicates a prolonged course of events prior to death (unconsciousness, immobilization, hypovolemia). In sufficient amounts, renal myoglobin may be of importance as a cause of death or a contributing factor to death in both drug addicts and non-addicts.

[Fatal poisonings among drug addicts in Funen and South Jutland during the period 1989-1991]

Deaths among drug addicts in Funen and in the south part of Jutland in the period 1989-1991 are described with respect to sex, age, social conditions, cause of death etc. The material included 62 drug addict deaths. The mean age was 31 years, range 15-49 years. Seventy-seven percent died from poisoning. A heroin overdose was the cause of death in 65% of these cases. There were two (3%) deaths from methadone. In 34 of the cases we found benzodiazepines, and in 29 cases alcohol. It appeared from information from family/friends that 45 had an abuse pattern involving multiple substances, so it seems that such abuse is common.

Plasma zinc concentrations during the first 2 years after diagnosis of insulin-dependent diabetes mellitus: a prospective study

Studies of zinc status in insulin-dependent diabetes mellitus (IDDM) have shown contradictory results. Zinc is essential for many enzymes involved in the human metabolism and may play a role in the biosynthesis and storage of insulin in the B-cell. We therefore prospectively followed 26 patients (14 males and 12 females) with newly diagnosed IDDM in order to determine the plasma zinc variation at the time of diagnosis and after 1, 3, 6, 12 and 24 months. Seventy-two healthy persons (36 males and 36 females) served as controls. Only minor differences in plasma zinc were demonstrated during the first 2 years of IDDM. A sex difference was found in healthy controls but only after 24 months in the diabetics. Quantitative changes of the B-cell function, development of insulin antibodies, age, body weight and serum albumin did not correlate with the course of plasma zinc.