Special Register in Germany: Overdose Including Prescription Opioids and New Developments in the Reporting System

Special Register in Germany: Overdose including prescription opioids and new developments in the reporting system

Dr. A. Heinemann Institute of Legal Medicine University Medical Center Hamburg- Eppendorf , Germany German SR

German SR in charge of Federal Criminal Police Office (Bundeskriminalamt)

16 regional Land Offices of Criminal Investigation report to SR (aggregated data) DRD longterm series: Germany GMR (Destatis)/ SMR (BKA): DRD longterm series: Germany GMR (Destatis)/ SMR (BKA):

-20% Opiate purity and availability German Bundesländer: Drug- related deaths per 100.000 inhabitants (2011) Germany (SMR): DRD, detection of opiates in monodrug/polydrug overdoses (%)

monovalent heroin/morphine polydrug heroine/morphine

603 571 550 529

357 346 359 326 279 290

2007 2008 2009 2010 2011 Germany (SMR): DRD/Overdose, detection of prescription opiates (%)

30,0

25,0 24,3

20,0

mono methadone (%) 15,0 13,9 % poly methadone involved (%) 12,5 11,7 11,6 buprenorphine involved (%)

10,0 8,3

4,7 4,5 4,8 5,0 4,5

1,5 0,6 0,8 0,6 0,6 0,0 2007 2008 2009 2010 2011 Schleswig- Holstein Mecklenburg- 31,4 West.Pomerania 13,7 49,2 1,3 Hamburg Bremen Lower Saxony 39,3 Berlin 26,6 Brandenburg 13,3 15,6 Northrhine- Saxony- Methadone Westfalia Anhalt 7,6 Thuringia Saxony involved in Hesse 10,4 0,0 OD (%) 4,4 (mean 2007-2011) 8,0 Rhineland Bavaria Saarland - Palatina 7,5 Baden- Wuerttemberg 23,7

21,1 Schleswig- Holstein Mecklenburg- 0,0 West.Pomerania 0,0 2,9 0,0 Hamburg Bremen Lower Saxony 0,4 Berlin 0,7 Brandenburg 0,0 0,0 Northrhine- Saxony- Buprenorphine Westfalia Anhalt involved in OD 0,3 Thuringia Saxony Hesse 0,0 (%) 0,0 (mean 2007-2011) 0,0 0,0 Rhineland Bavaria Saarland - Palatina 0,0 Baden- 0,6 Wuerttemberg 2,4 Berlin: Methadone detection rate at OD

160

140 140 135 133

120

100 99

75 80 with methadone involved (n) OD (N)

60 46 45 40 35 37 50

0 2007 2008 2009 2010 2011 Hamburg

46 45 44

40 40 38 36 35

30 26 25 with methadone involved (n) 21 DRD (n) 20 20 20

15 13

0 2007 2008 2009 2010 2011 Northrhine- Westfalia

350

300

250

200 with methadone involved (n)

150 Overdose (n)

100

0 2007 2008 2009 2010 2011 Bavaria

300

250

200

with methadone involved 150 (n) OD (n)

100

0 2007 2008 2009 2010 2011 Regional analysis across German Bundesländer: OST and methadone detection rate at OD Regional analysis across German Bundesländer: OST and methadone detection rate at OD Regional analysis across German Bundesländer: OST and methadone detection rate at OD Schleswig- Holstein Mecklenburg- 66,2 West.Pomerania 92,8 82,0 30,8 Hamburg Bremen Lower Saxony 98,8 Berlin 56,0 Brandenburg 68,5 77,0 Northrhine- Saxony- Autopsy Westfalia Anhalt 32,4 Thuringia Saxony rate in Hesse 94,6 70,4 DRD (%) 83,6 (mean 2007-2011) 94,6 Rhineland Bavaria Saarland - Palatina 100,0 Baden- Wuerttemberg 90,2

47,2 Quality of data in SMR

120

98,8 100 90,2 82 80 67,4 65,7 64,2 % 60 56,5 47,2 49,2 44,3 Autopsy rate 40,8 39,3 40 Monovalent heroin (% of OD) 32,4 30,8 Methadone detected (% of OD)

21,1 20,1 20 10,9 10,9 7,6 7,1 1,3 0 Fentanyl- related deaths (SMR, personal comm.) Fentanyl- related overdose in Bavaria (Data from Bavarian SMR, 2011/2012)

6% Fentanyl only 26% Fentanyl + alcohol

Fentanyl + psychoactive 20% medicines Fentanyl + psychoactive medicines +alcohol Fentanyl + opiates/cocaine

Fentanyl + 2% methamphetamine/others 38% Substances detected in some cases of polydrug overdose in Berlin and Hamburg in 2011

Oxycodone/Oxymorphone

Palladone/Hydromorphone

Fentanyl

Mephedrone/Methoxymethcathedrone (MMC)

Methylendioxypyrovalerone (MDPV)

Ketamine/Ketanest

Pseudoephedrine Quality of reporting: Traditional report structure of German SMR Poisoining due to Number Heroine Polydrug pois. With heroine involved Cocaine Polydrug pois. With cocaine involved Amphetamine Polydrug pois. With amphetamine MDMA MDMA polydrug Prescription opioids - methadone/polamidon - Subutex/buprenorphine Prescription opiods in polydrug pois. - with methadone/polamidone - with Subutex/buprenorphine Other illicit drugs/ unknown drug Suicide Disease due to Longterm harm of drug use Accident/ Other manners Absolute number * Traditional report structure of German SR

Poisoining due to Heroine Polydrug pois. With heroine involved Cocaine Polydrug pois. With cocaine involved Amphetamine Polydrug pois. With amphetamine MDMA MDMA polydrug Prescription opioids - methadone/polamidon - Subutex/buprenorphine Prescription opiods in polydrug pois. - with methadone/polamidone - with Subutex/buprenorphine Other illicit drugs/ unknown drug Suicide Disease due to Longterm harm of drug use Accident/ Other manners Absolute number * Traditional report structure of German SR

Poisoining due to Heroine Polydrug pois. With heroine involved Cocaine Polydrug pois. With cocaine involved Amphetamine Polydrug pois. With amphetamine MDMA MDMA polydrug Prescription opioids - methadone/polamidon - Subutex/buprenorphine Prescription opiods in polydrug pois. - with methadone/polamidone - with Subutex/buprenorphine Other illicit drugs/ unknown drug Suicide Includes Disease due to Longterm harm of drug use again Accident/ Other manners poisoinings Absolute number * Traditional report structure of German SR

Poisoining due to Heroine Polydrug pois. With heroine involved Cocaine Polydrug pois. With cocaine involved Amphetamine Polydrug pois. With amphetamine MDMA MDMA polydrug Prescription opioids - methadone/polamidon - Subutex/buprenorphine Prescription opiods in polydrug pois. - with methadone/polamidone - with Subutex/buprenorphine Other illicit drugs/ unknown drug Suicide Include Disease due to Longterm harm of drug use Accident/ Other manners also Absolute number * ??? poisoinings Hindrances

Absolute numbers of overdoses are not conclusive

Absolute numbers of indirect drug- related deaths categories were not conclusive

Share of confirmed substance detections (by autopsy/toxicology) was unknown

Comparability between German GMR and SR fails

EMCDDA Standard not applicable Table 4: Coding of values for the variables "Cause" and "Filter_D" Poisoning Filter_D Broad Cause group (see note) 18 Poisoning by opioids only (excluding methadone) 1 O 19 Poisoning by methadone only 1 O 20 Poisoning by poly-substances including opioids 1 O 21 Poisoning by (poly)substances excluding opioids 1 NO 22 Poisoning by psychoactive medicines 0 - 23 Poisoning by unspecified/unknown substances 1 NS Cause Other than poisoning # Filter_D

24 Natural/internal causes 0 - 25 Accidents other than by poisoning 0 - 26 Suicide other than by poisoning 0 - 27 Homicide other than by poisoning 0 - 28 Undetermined causes other than by poisoning 0 - # These other causes are also mutually exclusive. One case may only be coded to one cause category. Table 4: Coding of values for the variables "Cause" and "Filter_D" Poisoning Filter_D Broad Cause group (see note) 18 Poisoning by opioids only (excluding methadone) 1 O 19 Poisoning by methadone only 1 O 20 Poisoning by poly-substances including opioids 1 O 21 Poisoning by (poly)substances excluding opioids 1 NO 22 Poisoning by psychoactive medicines 0 - 23 Poisoning by unspecified/unknown substances 1 NS Cause Other than poisoning # Filter_D

Define Categories which are mutually exclusive Monodrug Opiate poisoinings should be reported separately (so far only given for heroine/ methadone/ buprenorphine ) Avoid multiple nomination in Polydrug poisonings with / without opioides Monodrug poisoings with „psychoactive medicine“ should be separated „Other illicit drugs“ should exclude opioides „Other illicit drugs detected“/ unknown substance should be separated Separation of suicidal or accidental poisonings from non- poisoning suicides and accidents. Separation of disease due to longterm harm of drug use from poisoings: Separate mixed category when both are relevant in a case New reporting structure in German SR (1)

Cases with Bundesland autopsy/toxxi No Category (n) cology (n)

A Poisoning by opioids/ opiates A.1Monodrug poisoing: Heroin/Morphine

A.2Monodrug poisoing: prescription opiate A.2.1 subgroup : methadone A.2.2 subgroup buprenorphine A.2.3 subgroup other prescription opioids (to be listed) Mixed Poisoning including opioids/ opiates (e.g. amphetamines,cocaine/crack, cannabis, hallucinogens, solvants , synthetic drugs, Sedatives, alkohol, others. Includes poisoings B with suicidal intent

Polydrug poisoning including Heroin/Morphine ("Substanzen" B.1 nach Definition unter B)

B.2Polydrug poisoning including prescription opiates B.2.1 subgroup : methadone B.2.2 subgroup buprenorphine

B.2.3 subgroup other prescription opioids (to be listed) New reporting structure in German SR (2) Cases with Bundesland autopsy/toxic (n) ology (n) C Poisoning excluding opioids/ opiates C.1 Monodrug poisoning: Cocaine/crack C.2 Monodrug poisoning: Amphetamines C.3 Monodrug poisoning: MDMA, MDE, MDA

C.4 Polydrug poisoning including cocaine/crack (without opiates)

C.5 Polydrug poisoning including amphetamines (without opiates) Polydrug poisoning including MDMA/MDE/MDA (without C.6 opiates)

Polydrug poisoing including stimulants and opiates D (subgroup of B)

D.1 Polydrug poisoning including cocaine/crack (with opiates)

D.2 Polydrug poisoning including amphetamines (with opiates)

D.3 Polydrug poisoning including MDMA/MDE/MDA (with opiates)

E Poisonings by psychoactive medicines without illicit drugs Not specified substances in poisonings (but illicit drugs F suspected) Poisonings: Others/ not assignable (to be listed) New reporting structure in German SR (3)

Cases with Bundesland autopsy/toxx (n) icology (n) G Suicides

G.1Suicide by poisoning G.2Suicide by other means than poisoning

H Disease due to longterm harm by drug use

Subgroup: Mixed cause of death: Longterm harm H.1 combined with poisoning.

I Accident (non- poisoning accidents)

J Other/ not assignable (only non- poisoning cases)

Total drug- related deaths(sum up mutually exclusive categories =A+B+C+E+G2+H+I+J) 0 0 Autopsy rate : Total (%)