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Drug-Related Deaths in Sweden – Estimations of Trends, Effects of Changes in Recording Practices and Studies of Drug Patterns

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Drug-Related Deaths in Sweden – Estimations of Trends, Effects of Changes in Recording Practices and Studies of Drug Patterns Drug-related deaths in Sweden – Estimations of trends, effects of changes in recording practices and studies of drug patterns CAN Rapport 158 Håkan Leifman Centralförbundet för alkohol- och narkotikaupplysning, CAN 1:a upplagan, 1:a tryckningen (1–300) Layout inlaga: Britta Grönlund, CAN Layout omslag: Jimmie Hjärtström, CAN Tryck: EO Grafiska, 2016 ISSN: 0283-1198 ISBN: 978-91-7278-267-9 (tryck) URN:NBN:se:can-2016-4 (pdf) Drug-related deaths in Sweden – Estimations of trends, effects of changes in recording practices and studies of drug patterns Håkan Leifman Centralförbundet för alkohol- och narkotikaupplysning Rapport 158 Stockholm 2016 Contents Foreword .......................................................................................................................................... 5 Svensk sammanfattning (Swedish summary) .................................................................................. 6 Summary .......................................................................................................................................... 9 1. Introduction ................................................................................................................................. 12 2. Statistics on drug-related deaths in Sweden ............................................................................... 14 The three indicators on drug-related deaths an drug deaths ................................................ 15 Previously reported trends in drug-related deaths and drug deaths, according to the three indicators ........................................................................................................................... 17 3. The impact of changes in recording practices on reported statistics ......................................... 20 Coding practices ......................................................................................................................... 20 Forensic investigations and toxicological improvements ........................................................... 21 The presence of different drugs in forensically investigated deaths ....................................... 21 Trends in different opioids ..................................................................................................... 25 The effects of lowering the threshold values for positive toxicology ...................................... 28 The effects of increased screening........................................................................................... 31 Other changes in toxicological testing practices .................................................................... 38 Estimated total effects of all changes in toxicological forensic analyses ................................ 39 Summary ................................................................................................................................ 43 4. Drug deaths patterns – gender and age differences, polydrug use and manners of death ........ 44 Men and women ......................................................................................................................... 44 Age groups .................................................................................................................................. 44 Polydrug use ........................................................................................................................... 49 Manners of death in poisoning cases ..........................................................................................54 5. Discussion ................................................................................................................................... 56 6. References .................................................................................................................................. 59 Appendix 1 ................................................................................................................................... 61 Foreword CAN is an NGO and a national centre of competence with core funding from the Swedish government. Our major tasks are to monitor the drug trends in Sweden and disseminate our findings. We collect data on consumption, morbidity and drug-related mortality in the population, among other areas. In order to fulfil our major tasks, indicators of high validity are a necessity. As a consequence, CAN is often engaged in different kinds of validity studies and in developing methods. This report is a result of that type of commission. The report describes the situation of drug-related mortality in Sweden and constitutes a basis for the expert meeting in Stockholm in September 2016 as part of an EMCDDA project on drug- related deaths which focuses on seven European countries (project title: To contribute to the EMCDDA assessment of the drug-induced deaths data and contextual information in selected countries). The main focus is on the statistics used to monitor drug-related deaths; if they have been subject to changes in recording practices and to what extent such changes may have affected the reported mortality rates over time, as well as the comparability with the data produced according to the EMCDDA European protocol. Suggestions for improvements are also presented. The report also includes a description of gender and age differences in drug-related mortality, as well as of polydrug use patterns among the deceased. The matter of possible causes for the changes observed is not addressed in this report, but will be the main theme in a second forthcoming report. Although several of the analyses in the study have been conducted by CAN in dialogue with the National Board of Forensic Medicine, the author is solely responsible for all reporting, interpretations and conclusions. Stockholm, August 2016 Håkan Leifman Director, CAN Acknowledgements I want to thank every one of you who has given me valuable comments on the road and who has read, more or less, line by line in this report. I refer particularly to colleagues at the EMCDDA, the National Board of Forensic Medicine (RMV), National Board of Health and Welfare (Socialstyrelsen) and the CAN. A special thanks to Anna Jönsson, Henrik Druid and Johan Ahlner who have patiently explained the basics of toxicological analyses and data and to Isabelle Giraudon who guided me through this very important EMCDDA-project on drug-related deaths. Drug-related deaths in Sweden 5 Svensk sammanfattning (Swedish summary) Denna rapport ger en närmare beskrivning av narkotikarelaterad dödlighet i Sverige. Rapporten utgör ett underlag för ett expertmöte i Stockholm i september som en del av ett projekt om narkotikarelaterad dödlighet initierat av EU:s narkotikamyndighet EMCDDA. Enligt den statistik som används i Sverige har den narkotikarelaterade dödligheten mer än fördubblats under de senaste tio åren, framförallt som ett resultat av fler dödsfall med opioider. Men tillförlitligheten av statistiken har ifrågasatts av både myndigheter och forskare och frågan har därför väckts om ökningen verkligen varit så pass kraftig som en fördubbling. Framförallt har man pekat på att olika metodförändringar i analysarbetet kan ha bidragit till att ge en felaktig bild av utvecklingen. Huvudsyftet med studien är att försöka ge en så god bild som möjligt av den faktiska utvecklingen genom att ta hänsyn till olika metodförändringar som genomförts över tid. Analyserna baseras i huvudsak på rättsmedicinska toxikologiska data och täcker alla rättsmedicinskt undersökta dödsfall under de senaste 15–20 åren. Enligt svensk lag ska alla onaturliga dödsfall rapporteras till polisen av den läkare som utfärdar dödsorsaksintyget och för i stort sett alla dessa fall begär polisen sedan en rättsmedicinsk undersökning. Onaturliga dödsfall är sådana dödsfall där man kan misstänka att döden beror på en yttre orsak, till exempel våld eller förgiftning men också när den avlidnes identitet inte kan fastställas eller om kroppen genomgått betydande förändringar. Nästan alla dödsfall som bedöms som narkotikarelaterade har genomgått rättsmedicinsk undersökning, inklusive toxikologiska analyser. Rättsmedicinska data utgör därför basen för alla de indikatorer över narkotikarelaterade dödsfall som används i Sverige. Över 5 000 dödsfall genomgår varje år rättsmedicinsk undersökning av totalt ca 90 000 dödsfall per år. Andelarna har varit förhållandevis konstanta under de senaste ca 20 åren. Analyserna i denna studie har genomförts av CAN men i flera fall i dialog med Rättsmedicinalverket (RMV), som är central förvaltningsmyndighet för rättspsykiatrisk undersökningsverksamhet, rättsmedicin, rättskemi och rättsgenetik. På RMV:s avdelning för rättskemi och rättsgenetik genomförs de toxikologiska analyserna av de rättsmedicinskt undersökta dödsfallen. Det förtydligas i rapporten att rättsmedicinska toxikologiska data visar på förekomsten av olika substanser bland avlidna utan hänsyn tagen till om substanserna orsakat dödsfallen. Därför bör indikatorer som baseras på dessa data kallas för narkotikadödsfall (och när det gäller exempelvis opioider som opioiddödsfall). Detta till skillnad från siffror som bygger på dödsorsaksregistret där orsakssambandet har utretts. Dödsfall baserade på dödsorsaksregistret och som bedöms som orsakade av narkotika, benämns i denna rapport som narkotikarelaterade dödsfall (och när det gäller opioider som opioidrelaterade dödsfall). De skattningar som redovisas i denna rapport tyder på att det skett en faktisk ökning av antalet dödsfall med narkotikaförekomst och även,
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