2022 EMCDDA expert meeting on the epidemiological indicator Drug-related deaths (DRD)

This year particular attention is given to:

• Threat assessment with ‘Tour de table’ of the nominated national experts
• Overall mortality among drug users: beyond overdoses, large excess risk of death - focus on suicide
• Signals of concern: diversification and increase in opioid deaths
• Preliminary discussion of the data reported in 2022
• Outbreak and threats: a range of stimulants and other drugs causing deaths and harms
• Acute drug-toxicity and morbidity: insights from sentinel poison control centres and emergency services
• Latest developments in responses, including drug treatment

• Agenda expert meeting 2022
• EMCDDA (2022). Frequently asked questions (FAQ): drug overdose deaths in Europe
• EMCDDA Statistical Bulletin 2022 — overdose deaths
• Drug-related deaths and mortality in Europe: update from the EMCDDA expert network in 2021 (for reference)

A summary of key points discussed during this meeting in November 2022 is available below. Recommended citation: EMCDDA (2022), Drug-related deaths (DRD) in Europe: Updates and main findings from the annual meeting of the EMCDDA DRD expert network 3–4 November 2022.

More information, the full report and presentations are also available in the restricted area for the national focal points and the national experts (and on request). Most up-to-date analyses of drug-related deaths are available in the European Drug Report published in June 2023.

Growing and multifaceted concerns with opioids

• While there is uncertainty about the impact of the COVID-19 pandemic and the war in Ukraine on the complex problem of drug-related harms and deaths, continuous, rapid and robust action-oriented monitoring is needed in Europe.
• Large countries report increases in deaths in 2021 and opioids are driving this trend, while the available data for 2021 do not suggest that Europe overall has experienced a crisis of drug-related deaths (in contrast to the crisis observed in North America), the number of deaths has increased in several countries, including the Netherlands, Austria and Germany. Signals of increases in the number of deaths related to opioids are confirmed in these and other countries.
• The surge in deaths is due in part to potent opioids in the Baltic countries. In Lithuania, carfentanyl has replaced heroin on the market. Most reported deaths were due to strong opioids and polydrug use involving amphetamines, medicines and other drugs. In Estonia, provisional data for 2022 show a large increase in the number of overdose deaths. Synthetic opioids, including the nitazene group, are involved in almost half of the typical polydrug use fatalities. In Latvia, acute drug toxicity presentations to emergency settings increased in 2021.
• Diversity in the opioids involved in the deaths: The opioids landscape (prevalence, use and harm) is complex and rapidly evolving across Europe. There are differences between countries in the populations using opioids and, in the type of opioids available and used, including heroin, methadone, buprenorphine, fentanyl, tramadol, new opioids and a range of prescription opioids.

Increase in the harms related to other drugs and medicines

• An increasingly diversified population at risk of overdose deaths: polydrug use is the rule rather than the exception and a range of medicines are identified in post-mortem analyses. The medicines include benzodiazepine, pregabalin and opioids. In some countries, women, people on benefits, and those in their 50s or older are at particular risk. The increase in the number of deaths with medicines implicated occurs in the context of increased volumes of prescription drugs in some countries.
• Increase in the harms related to stimulants: Turkey reports large increases in the number of deaths related to methamphetamine. Other countries report on different contexts and motivations of use. Nitrous oxide: several countries report an increase in acute toxicity, road traffic accidents and long-term neurological damage among young users unaware of the risks associated with the drug.
• Acute toxicity and other harms related to stimulants and to cannabis: Emergency settings such as hospital emergency services and poison control centres provide timely data on drug-related harms  Increased acute and chronic harms related to nitrous oxide are reported across countries and sources in 2021–22.

Improved availability and quality of the data but important gaps remain

• New and consolidated registers: Spain has extended the coverage of the special register throughout the country. Greece started reporting data from the general mortality register. Several countries, including Croatia and Lithuania, have recently initiated studies or continued the analysis of the overall mortality among drug users.
• Gaps and major delays: Some of the largest countries, including France and Ireland, do not have any data from their main register source after 2018. Therefore caution is required in interpreting the European-level data currently available.
• One in six (one in three among females) overdoses are reported as intentional. There are gaps and limitations in this data. The number of overdoses with suicidal intent is probably an underestimation, with many cases that might remain unascertained or unreported. Prevention, screening, referral to care and treatment of psychiatric co-morbidity should be prioritised. Robust and useful data is available in some countries (such as Ireland and Norway) but more is needed across Europe if overdose deaths are to be prevented.

Rolling out responses across Europe

• There are gaps in estimating the coverage of OAT among eligible opioid users. Although OAT is a cornerstone of the evidence-based prevention of deaths among people who use opioids, there is a lack of available data and many countries have no recent estimates on the coverage of these treatments.
• Take-home naloxone (THN): This is progressing, but far from reaching all eligible persons. THN programmes are available in many countries but the volumes distributed in some countries are very low (a few dozen kits) and the coverage is limited (for example in Austria, France and Slovenia). Reported barriers to access to the training and material might include insufficient involvement of pharmacies, lack of training of staff, little access to harm reduction services and stigma in some countries.
• Safe consumption rooms opened in 2022 in Brussels (Belgium) and Oporto (Portugal). However, some countries report difficulties in setting up or expanding these facilities, including Belgium, France, Ireland and Portugal. An up-to-date map (including the drug consumption room opened in Athens in 2022) is available here.
• Buprenorphine OAT was introduced in several countries in 2022 (including Croatia and Lithuania). The treatment in different forms (combined with naloxone, transdermal, and weekly/monthly injections) is an alternative to methadone, both in the community and prison.
• Innovation in harm-reduction communication: Countries develop large campaigns to destigmatise the risk of opioid deaths in the general population and to produce harm-reduction material in different languages to reach high-risk users in their native languages.

Mortality studies:  excess risk of deaths from all causes among people who use drugs compared to the general population

• Increasing mortality rates in Athens might be due to the long-term impact of the pandemic on the health of people who inject drugs. Preventive programmes such as THN distribution and community involvement to increase harm reduction, screening, and uptake of antiretroviral and chronic hepatitis C treatments are urgently needed.
• All European studies reviewed in 2021–22 show an excess mortality risk among people who use drugs compared with the risk observed in the general population of the same sex and age. The excess risk ranges from 3 to 20 times and users in some countries or some settings or circumstances are at particularly high risk of death. A range of integrated social, harm-reduction and treatment measures are needed, along with new and updated studies to assess the impact of the COVID-19 pandemic and the current crisis, and to guide responses.