Fatal poisoning in Nordic drug addicts in 2002.

The present study from 2002 includes medicolegally examined fatal poisonings among drug addicts in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition "drug addict" is applied by the participating countries. The number of deaths, age, sex, place of death, main intoxicant and other drugs present in the blood are recorded in order to obtain national data, as well as comparable Nordic data and data comparable to earlier studies from 1997 and 1991. The Icelandic results are commented on separately due to the low number of cases. The most fatal overdoses are seen in Norway, in both the death rate (number per 100,000 inhabitants=8.44) and in absolute number (n=232). The comparable figures for the other four countries are Denmark 5.43 (n=175), Iceland 3.6 (n=6), Finland 2.93 (n=94) and Sweden 2.56 (n=136). In earlier studies from 1991 and 1997, the highest death rate is seen in Denmark, with Norway as number two. Denmark is the only country where the death rate decreases from 1997 to 2002. A relatively large increase in deaths in the younger age groups (<30 years) is noted from 1997 to 2002, except in Denmark, where only a small increase in overdose deaths in very young people (15-19 years) is observed. Females account for 12-20% of the overdoses (three out of six deaths in Iceland). Relatively fewer deaths are recorded in the capital areas in 2002 than in 1997 and 1991, suggesting more geographically widespread drug use in the Nordic countries. Heroin/morphine is the single most frequently encountered main intoxicant, varying from 10% of the cases in Finland to 72% of the cases in Norway. Finland differs from the other countries in that a high percentage of the fatal overdoses in Finland are not caused by an illicit drug; buprenorphine overdoses are seen, and relatively few deaths resulting from heroin are seen. Methadone is the main intoxicant in 41% of the Danish overdose cases, 15% of the Norwegian cases, 4% of the Swedish cases and none of the Finnish overdose cases, an observation probably linked to different national prescription rules for methadone. The analytical screening reveals extended polydrug use. Frequently seen substances, in addition to the main intoxicant are amphetamine, tetrahydrocannabinol (THC), benzodiazepines and ethanol.

Drugs in injured drivers in Denmark.

As part of the project Impaired Motorists, Methods of Roadside Testing and Assessment for Licensing (IMMORTAL) under the European Commission's Transport RTD Programme of the 5th Framework Programme [I.M. Bernhoft, Drugs in accidents involved drivers in Denmark, D-R4.3 of the project Impaired Motorists, Methods Of Roadside Testing and Assessment for Licensing (IMMORTAL), , 2005], a study regarding drugs in accident-involved drivers was carried out in Denmark. The main objectives of this study were: (1) to collect and analyse samples from injured drivers for the presence of drugs; (2) to give an indication whether drugs may have contributed to traffic accidents; and (3) to get information on the drug-positive drivers and their drug use. This paper focuses on objective 1. Injured drivers who were treated in hospital were asked to give a saliva sample, a blood sample or both. The samples were screened for the following substances: opiates, amphetamines, methamphetamines, incl. MDMA (ecstasy), cannabinoids and metabolites, cocaine and metabolites and benzodiazepines. Screenings were carried out by means of Cozart Microplate EIA kit. Positive screenings were confirmation analysed by gas chromatography-mass spectrometry (GC-MS) or liquid chromatography/tandem mass spectrometry (LC/MS/MS). In total, 26 out of 330 patients were confirmed positive for one or more of the six drug groups. However, three patients were excluded from the survey for various reasons. Of the remaining 23 drug-positive patients 15 were found positive for one drug group, and in five of these cases alcohol was present in a concentration over the legal limit in Denmark (0.05%). The other eight patients were found positive for two drug groups, and in four of these cases, alcohol was also present in a concentration over the legal limit. Alcohol was found both in combinations with medicinal drugs, with illegal drugs and with both. Based on the saliva or blood concentrations, we estimate that there is a strong suspicion of impairment in 9 out of 23 cases, and in another six cases it was likely that the drivers were impaired.

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.

Drugged driving in the Nordic countries--a comparative study between five countries.

The purpose of this study was to compare whether the high incidence of drugged driving in Norway was different to that in the other Nordic countries. All blood samples received by Nordic forensic institutes during one week in 1996, from drivers suspected by the police of driving under the influence (Denmark: n = 255, Finland: n = 270, Iceland: n = 40, Sweden: n = 86, Norway: n = 149), were analysed for alcohol and drugs (benzodiazepines, cannabinoids, amphetamines, cocaine, opiates and a number of antidepressant drugs) independent of the primary suspicion, and using the same analytical cut-off levels at the different institutes. The primary suspicion was directed towards drugs in more than 40% of the Norwegian cases, drugs were detected in more than 70% of these samples. In only 0-3% of the cases from Denmark, Finland and Iceland, were drugs suspected, while the corresponding frequency for Sweden was 17%. However, evidential breath analyses were used for about three-quarters of the Swedish drivers suspected to be influenced by alcohol. Blood alcohol concentrations (BAC's) below the legal limits were found in 32, 18 and 2% of the Norwegian, Icelandic and Finnish cases, respectively (BAC < 0.05%), in 10% of the Danish cases (BAC < 0.08%) and in 20% of the Swedish cases (BAC < 0.02%). Drugs were most frequently found in the Norwegian and Swedish cases with no alcohol (80-83%). Similar frequencies of drugs in samples with BAC's above the legal limits (19-22%), were obtained for all countries. Benzodiazepines, tetrahydrocannabinol and amphetamine represented the most commonly detected drugs. Our results show that differences between Norway and other Nordic countries with regard to drugs and driving, are connected to the selection criteria made by the police and with more focus on drugged driving in Norway.

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.

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 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.

Intrathecal administration of morphine for the relief of pains in labour and estimation of maternal and fetal plasma concentration of morphine.

Thirteen healthy women in active labour received an intrathecal injection of morphine 1.0 mg. Eighty-five percent (11 patients) experienced acceptable or good pain relief. Analgesia set in 15-45 min after injection and reached a maximum after 15-120 min and lasted until delivery. Eighty-five percent (11 patients) of the patients developed mild side-effects i.e., pruritus, nausea and emesis. The intrathecal injection of morphine did not adversely affect the condition of the infant. Venous blood samples from the patients and umbilical cords for estimation of plasma morphine showed extremely low concentrations. No patients experienced any discomfort during the injection of morphine. These results indicate that morphine 1.0 mg administered intrathecally decreases labour pains to an acceptable level.

Prehospital treatment of patients with i.v. heroin overdose: what are we treating?

OBJECTIVE: To measure blood levels of morphine and additional drugs in patients suspected of intravenous (i.v.) heroin abuse and to evaluate the effects of antidote treatment. DESIGN: Prehospital blood sampling in 52 patients. RESULTS: Forty-five patients were blood-positive for heroin, eight of whom were hospitalized. Forty-one patients also had abused additional drugs: minor tranquilizers, ethanol, amphetamine, cocaine, and/or carbamazepine. Seven patients had taken either only methadone or ketobemidione: one was admitted. Treatment with increasing doses of naloxone indicated a necessity for hospitalization. Six of 14 patients treated with naloxone (1.8 mg were hospitalized. Seven patients had an extremely high blood level of morphine (0.2 mg/kg), that could be reverted with naloxone in moderate doses. CONCLUSION: This study indicates that under prehospital conditions, it is difficult to identify a patient intoxicated only with intravenous heroin. Nearly all patients treated were cases of multiple drug/alcohol overdoses. Even the symptoms associated with extremely high blood levels of morphine could be reversed with naloxone in moderate doses.

[Amphetamine abuse in Denmark]. / Amfetaminmisbruget i Danmark.

Over a five-year period (1985-1989) among a population of 5 million, a survey was made of the presence of amphetamine in 741 cases, in living persons where the police had asked for analyses for amphetamine(s), narcotics, heroin-like compounds, methadone etc. Cases, where the requisition was for morphine (heroin) only, were not included, on account of analytical reasons. Two hundred and fifty-nine cases were found to be positive for amphetamine, with only 18 cases in 1985 followed by approximately 60 cases per year during the remainder of the period. Most of the cases concerned men (93%). The age range was 15-58 years with a median of 26 years. In 194 of the amphetamine-positive cases where relevant information was available, 56% were cases of violation of the traffic laws, 17% were cases of violence, 3% were cases of sexual offence and 9% were cases of robbery. Nineteen of the 259 amphetamine-positive cases were analysed only for amphetamine and, in 75 cases, only amphetamine was found. In the 165 remaining cases, there were 279 positive findings of other drugs/narcotics than amphetamine with benzodiazepines, morphine, cannabis and methadone as the main groups with 86, 57, 49 and 44 findings respectively.

[Triazolam (Halcion) poisoning]. / Forgiftninger med triazolam (Halcion).

Benzodiazepines have been regarded as relatively "safe" drugs where fatal poisonings are concerned. The very potent benzodiazepines have, to a certain extent, changed this viewpoint and since triazolam was introduced in Denmark in 1978, six fatal intoxications have occurred in East Denmark. Triazolam analyses were performed by capillary gas chromatography with an electron capture detector. In the only case where no ethanol was present, a blood triazolam concentration of 0.3 mumol/kg was detected. In one case no blood was available because of putrefaction, and muscle was analysed for triazolam instead of blood. The concentration range in the four cases with an ethanol concentration of 1-2 mg/g is 0.1-0.6 mumol/kg. The blood concentrations from these six fatal intoxications are compared to blood concentrations from living persons. The whole blood concentrations from living persons were in the range 0.005-0.08 mumol/kg (n = 28) with an average concentration of 0.034 mumol/kg.

[Fatal poisonings in Eastern Denmark 1984-1991]. / Forgiftningsdødsfald i Ostdanmark 1984-1991.

From 1984 to 1991, both years included, 1884 cases of deaths from poisoning by drugs or poisons were found by the forensic chemical analyses at the Institute of Forensic Chemistry in Copenhagen, covering a population of 2.3 million. Most deaths occurred in the age group 30-39 years. Looking at the period as a whole, morphine was by far the most frequently occurring compound followed by propoxyphene, carbon monoxide, methadone and alcohol. However, looking at the annual distribution, the number of deaths due to propoxyphene declines over the period, while the number of deaths due to methadone increases. Barbiturate poisonings, which were formerly among the most frequently occurring, are only seen in low numbers.

[Fatal poisoning among narcotic addicts in Denmark in 1984-1985]. / Forgiftningsdødsfald blandt narkomaner i Danmark 1984-1985.

A material of 194 deaths from poisoning among drug addicts investigated in the Medico-Legal Institutes in 1984 and 1985 is described as regards type of poisoning, sex, age, housing etc.. This investigation is part of a Nordic project concerned with deaths from poisoning among young adults in the age group 15-34 years in the Nordic countries with particular attention to deaths from poisoning among drug addicts. Cases of heroin/morphine poisoning constitute half of the deaths while legal drugs such as dextropropoxyphene, methadone and ketobemidone were the causes of death in 30% of the cases. In approximately 40% of the cases of poisoning, alcohol was involved (blood alcohol concentrations greater than 0.5%). Deaths from heroin occurred most commonly in Copenhagen while deaths due to dextroproxyphene were relatively most common in the provinces. Less than half (42%) of the drug addicts examined lived in Copenhagen.

[Benzodiazepines in blood samples with 0 alcohol content sent to the Institute of Forensic Chemistry]. / Benzodiazepiner i blodprøver indsendt til alkoholbestemmelse på Retskemisk Institut, og hvor alkoholpromillen var 0.

The Institute of Forensic Chemistry, Copenhagen, receives approximately 29,000 blood samples annually for alcohol determination from drivers suspected of drinking and driving. The incidence of benzodiazepines were estimated in the 877 alcohol-negative samples from six months (01.01-07.31 1983). Eight samples had to be excluded because of insufficient material. Screening for benzodiazepines was made by means of a radioreceptor-method. Quantification and identification of the benzodiazepines was performed by gas- and liquid-chromatography. 15% of the samples were found to be positive for benzodiazepines (13% positive for diazepam and desmethyldiazepam), while an earlier investigation of the same type of material, but including all blood samples, both alcohol-positive and negative showed only 5.8% of the samples positive for benzodiazepines (5.5% positive for diazepam). These findings are in agreement with the results of other investigations. 59% of the diazepam cases had a total concentration of diazepam and desmethyldiazepam higher than 1 mumol/kg. 69% were men and 31% were women. Most cases were found in the age group 20-30 years old. In only 22% of the cases, had the police required analyses for benzodiazepines. Due to the known difficulties in instituting proceedings against drivers influenced by drugs, it is feared, that the drug problem in connection with driving will be forgotten, all the while it is increasing steadily.

[Drug and narcotic use among Danish drivers]. / Laegemidler og narkotika i danske trafikanter.

An investigation was made of the presence of drugs and narcotics in samples from Danish drivers having violated the Danish Road Traffic act in 1993. Four hundred and twenty-five cases were received, but only 317 cases were analysed for drugs or narcotics. In 256 cases drugs or narcotics were found present with a total of 531 findings. In 112 of the cases only one compound was found present. Benzodiazepines, morphine, methadone, cannabinoids and amphetamine were the most frequently occurring compounds with 239, 52, 42, 32 and 28 findings, respectively. The study has shown that especially the benzodiazepines together with the illicit drugs seem to constitute a threat to traffic safety. For two countries very much alike, namely Denmark and Norway this study has shown a remarkable difference in the number of samples analysed and the results found.

[Methadone and drug addicts]. / Metadon og narkomaner.

Dead drug addicts from Copenhagen City and County in 1981 and 1989 respectively were analysed for methadone. Ninety-four cases from 1981 and 70 cases from 1989 were analysed; from 1981, 16% were found positive for methadone, while in 1989, 37% were positive. Methadone alone was found to be the cause of death in 50% more cases in 1989 than in 1981. Only half of the methadone positive dead drug addicts had been in methadone treatment. Morphine and benzodiazepines were the most frequently occurring other substances in both 1981 and 1989. Alcohol was found present in only about 30% of the methadone-positive cases. Medians for methadone whole blood conc. were 0.9 mumol/kg with no alcohol present and 0.5 mumol/kg with alcohol present in addicts dying from methadone. In living persons using methadone, the median was 0.4 mumol methadone/kg whole blood with no alcohol present and 0.3 mumol/kg with alcohol present.

[Fatal poisonings during a 5-year period in Eastern Denmark]. / Forgiftningsdødsfald over en 5-årig periode i Ostdanmark.

In the period 1992-1996, both years included, 1079 cases of deaths from poisoning by drugs or poisons were found by forensic-chemical analyses at The Institute of Forensic Medicine, Dept. of Forensic Chemistry, in Copenhagen, covering a population of 2.4 million. Morphine was by far the most frequently occurring compound accounting for 421 deaths, followed by methadone with 185 deaths. Then alcohol, ketobemidone, and carbon monoxide were represented with 80, 74 and 66 deaths, respectively. Drug addicts dominated in the survey with 549 cases. According to Danish law, autopsy with following chemical analyses must be performed on all dead drug addicts, whereas many other deaths by poisoning are defined only from the medicine found in the vicinity of the dead body.

[Substances other than alcohol found in the blood among Danish road-users during a week in 1996]. / Andre stoffer end alkohol i blodet hos danske trafikanter. En undersøgelse af trafiksager fra en uge i 1996.

INTRODUCTION: This investigation is the Danish contribution to a Nordic comparative study of other drugs than alcohol found in road users. MATERIAL AND METHODS: 255 blood samples received from the police for alcohol and/or drug determination during one week in 1996 were investigated for drugs. RESULTS: 56 (22%) of the 255 blood samples were positive for other drugs than alcohol. Cannabis was detected in 11%, benzodiazepines, mainly diazepam and flunitrazepam, in 9% and amphetamine in 5% of the blood samples. DISCUSSION: The police suspected other drugs than alcohol in 3% of the 255 blood samples, but drugs were detected in 22%. This investigation showed that the frequency of other drugs than alcohol was similar in Denmark and Norway for the blood samples with an alcohol concentration above the statutory limit. This contrasts with the fact that the number of blood samples from road users investigated for substances other than alcohol is about 200/year in Denmark and 4000/year in Norway.

[Incidence of drugs and euphoretic agents among motorists on the roads of Denmark. A possible relationship to traffic safety]. / Forekomsten af laegemidler og euforiserende stoffer blandt motortrafikanter i Danmark. En eventuel relation til trafiksikkerheden.

All of the Medicolegal Committee's cases from the period 1981-1985 concerning the influence of drugs on motorized road-users were reviewed. Only cases where a drug was demonstrated in blood and/or urine were included. A total of 442 cases were included in this investigation and 100 different agents, drugs and narcotics were demonstrated. In all of the cases the two drugs most frequently demonstrated were diazepam (46%) and morphine (19%). In the 46 cases where diazepam was demonstrated alone (blood alcohol concentration = 0, a significant correlation could be demonstrated between the sum of the blood concentration of diazepam and demethyldiazepam and the degree of intoxication as estimated by the clinical examination. In 87% of the cases, the road-users were men. Cannabis users had a lower age (21 years) than the road-users who had taken diazepam (28 years) or morphine (26 years) while individuals who had taken methadon had a higher average age (29 years) than those who had taken morphine. The frequencies of accidents in cases with morphine or methadon were lower than in the material as a whole while the frequency of accidents for dextropropoxyphen was higher compared with the other opiods and the material as a whole.

[Fatal intoxications among drug addicts in Denmark in 1997]. / Forgiftningsdødsfald blandt narkomaner i Danmark i 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.