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On-going increase ofoverdose deaths : contribution of polydruguseAnna Fugelstad Sweden 2014
TOXREG – a background
•Toxreg includes all forensically examined deaths in Sweden with presence of illicit drugs or methadone, buprenorphine and fentanyl in the body at death.
•As 92 % of all unnatural deaths (intoxication or external violence) are forensically examined in Sweden, TOXREG includes the main part of acute drug-related deaths.
Objective
• The main objective is to identify trends in drug-related mortality by drug types.
• The main use of TOXREG is surveillance of the drug situation and provision of early data. Annual data are provided in March-April the next year.
• TOXREG is also used as a research register and, by linking to other national registers, information is obtained about causes of death, previous prescriptions of drugs and inpatient or outpatient care.
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Annual number of drug-related deaths according to TOXREG, number of deaths per 100,000, age
standardized
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mb
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of
de
ath
s p
er
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00
Annual number of drug-related deaths according to TOXREG, number of deaths per 100,000, age
standardized, males and females
Males
Females
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Num
ber
of d
eath
s pe
r 10
0,00
0Annual number of drug-related deaths according to T OXREG
by age group, number of deaths per 100,000
0-19 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
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50
100
150
200
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Annual number of forensically examined deaths in Sweden with presence of illicit drugs or methadone,
buprenorphine and fentanyl, by main drugs
Heroin
Methadone
Buprenorphine
Fentanyl
Amphetamine
Cocaine
Other illicit drugs
THC
0
100
200
300
400
500
600N
um
be
ro
fd
ea
ths
Annual number of drug-related deaths in Sweden according to the
general mortality register (DOR), Toxreg and the EMCDDA-index
EMCDDA DOR Toxreg
Polydrug use
•TOXREG includes information about illicit drugs, prescribed drugs and alcohol at death.
•The deaths are related to main drug according to a fixed manual but additional information about other drugs and alcohol makes it possible to show trends in polydruguse.
•There is no information about NPD and AAS as those substances are not included in the regular screening of drugs.
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100P
er c
ent
Percentage of drug related deaths with presence ofbensodiazepines in Sweden (Toxreg)
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600
700N
umbe
r of
dea
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Presence of bensodiazepines among drug-related deat hs in Sweden (Toxreg)
No bensod.
Bensodiazepine
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80
90
100P
er c
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Percentage of deaths with presence of bensodiazepines according to main drug (Toxreg)
Heroin
Methadone
Buprenorphine
Amphetamine
THC
Presence of specific drugs or alcohol in Toxreg 2013
• Diazepam/Nordazepam 21.9 %
• Alprazolam 26.6 %
• Zopiklon 14.1 %
• Pregabalin 21.4 %
• Oxycodone 5.3 %
• Tramadol 7.5 %
• Alcohol (>0.2mg/g) 22.9 %
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10
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Pe
r ce
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Presence of alcohol or other drugs in TOXREG
Oxycodon Tramadol Diazepam Alprazolam
Zopiklon Pregabalin Alcohol >0,2 mg/g
Increase of DRD after 2006
The increase in drug -related deathsafter 2006
•The increase in the total number of drug-related deaths is mainly related to an increase in the number of deaths related to methadone, buprenorphine or fentanyl.
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Annual number of drug-related deaths 1994-2013 according to TOXREG, by main drug
Heroin Methadone Buprenorphine Fentanyl
Amphetamine Cocaine Other illicit drugs THC
New regulations for substitution treatment
• In 2005 the strict rules for methadone treatment were eased after 40 years. After 2005 there was no limitation to the number of participants and it became easier to start new programmes.
• In 2005 there were 6 separate programmes with 800 persons in treatment. In 2012 there were 114 treatment units and more than 5000 persons in treatment.
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200
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400
500
600
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Annual number of drug-related deaths 1994-2013 according to TOXREG, by main drug
Heroin Methadone Buprenorphine Fentanyl
Amphetamine Cocaine Other illicit drugs THC
New regulations
Increase in prescriptions of opiates
• There has been an increase in the number of prescriptions of opiate drugs both in substitution treatment and in order to relieve pain.
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100
200
300
400
2006 2007 2008 2009 2010 2011 2012 2013
Prescriptions of Fentanyl, number of
Daily Defined Doses per 1000
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100
200
300
400
2006 2007 2008 2009 2010 2011 2012 2013
Prescriptions of Buprenorphine, number of
Daily Defined Doses per 1000
Conclusions• Both TOXREG and the General Mortality Register show an
increase in the number of drug-related deaths after 2006.
• The increase is mainly related to prescribed opioids as methadone, buprenorphine or fentanyl.
• The main source of the drugs is the health services. There is probably a leakage from substitution treatment and from prescriptions of analgesic opiates.
• A common contributing factor may be that there have been major revisions in the Swedish health service system such as an increased market orientation and performance based reimbursement.
