Cause of death and drug use pattern in deceased drug addicts in Sweden, 2002-2003

Compared with their contemporaries, individuals abusing illicit drugs suffer a higher risk of premature death. In Sweden, a simple protocol for registration of fatalities among abusers of alcohol, pharmaceuticals, illicit drugs, or other substances, has been used by the forensic pathologists since 2001. This routine was introduced to allow for an evaluation of the cause and manner of death, and patterns of abuse among different groups of abusers. We explored the data on drug abusers (i.e. abusers of illicit drugs) subjected to a forensic autopsy 2002-2003. The Swedish forensic pathologists examined 10,273 dead victims during the study period and 7% (743/10,273) of the cases were classified as drug abusers. Toxicological analyses were carried out in 99% (736/743) and illicit drugs were detected in 70% (514/736) of these. On average, 3.8 substances (legal or illegal) were found per case. The most common substances were ethanol and morphine, detected in 43 and 35% of the cases, respectively. When exploring the importance of the different substances for the cause of death, we found that the detection of some substances, such as fentanyl and morphine, strongly indicated a poisoning, whereas certain other substances, such as benzodiazepines more often were incidental findings. In total, 50% (372/743) died of poisoning, whereas only 22% (161/743) died of natural causes. Death was considered to be directly or indirectly due to drug abuse in 47% (346/743), whereas evidence of drug abuse was an incidental finding in 21% (153/743) or based on case history alone in 33% (244/743). We believe that this strategy to prospectively categorize deaths among drug addicts constitutes a simple means of standardizing the surveillance of the death toll among drug addicts that could allow for comparisons over time and between countries.     

Drug abuse in western Denmark during the eighties. II. Fatal poisonings among drug abusers.

Cases of fatal poisoning among drug addicts (n = 246) and abusers of medical drugs (n = 138) are discussed on the basis of the availability of illicit and medical drugs during the eighties. Propoxyphene was frequently the cause of death among both drug addicts and abusers of medical drugs. Deaths caused by analgesics and psychoactive drugs, mainly barbiturates and antidepressants, predominated among abusers of medical drugs. During the late eighties the number of deaths caused by barbiturates and propoxyphene declined as a result of changes in the distribution regulations for both drugs. Heroin/morphine accounted for only one-third of the poisonings in drug addicts. No trends concerning the prevalence of deaths caused by these drugs were observed throughout the decade. The number of deaths caused by the synthetic opiates methadone and ketobemidone, however, increased during the late eighties, probably due to an increased availability of these drugs in the illicit drug market. Alcohol was detected in half of all the poisoning cases and benzodiazepines in one-third.     

Fatal intoxications in the age group 15-34 years in Denmark in 1984 and 1985. A forensic study with special reference to drug addicts

This survey deals with the Danish part of a study on fatal intoxications conducted in the Nordic countries in 1984 and 1985 with special reference to drug addicts. There were 315 cases of fatal intoxications in people 15-34 years of age. These were examined at the Forensic Institutes in Denmark and described with reference to cause of death, sex, age and drug addiction. Of the deceased, 194 were drug addicts according to a specific definition of this term. Women accounted for 28% of all the fatalities investigated in the study and 24% of those in addicts. More than 90% of the deaths were caused by drugs, with ethanol as a contributory factor in approximately 40% of cases. Deaths caused by heroin/morphine predominated, causing 50% of the deaths among drug addicts, but legal drugs, such as dextropropoxyphene, methadone and ketobemidone were also frequent causes of death in this group. In half the cases the concentration of morphine in blood following injection of heroin/morphine was found to be equal to or less than 0.5 mumol/kg, and in only about one-tenth of cases was the blood concentration above 2.0 mumol/kg.     

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 10⁵ 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.     

Fatal intoxications in Denmark following intake of morphine from opium poppies

In Denmark it is legal to grow opium poppies for the production of poppy seeds and until 1986 for decoration purposes, too. Danish poppy capsules contain 0.3-5 mg morphine per capsule and the content of morphine in opium exuded from the capsules may amount to 24%. This has resulted in misuse as both fresh and dried poppy capsules have been used for the production of "opium tea". During the period 1982-1985, seven casualties occurred among drug addicts in Denmark which were solely or partly caused by these opium poppies.     

Fatal dextropropoxyphene poisonings in Jutland, Denmark

For many years dextropropoxyphene (dxp) has been the medicament most frequently occurring in drug poisoning cases examined at the Institute of Forensic Medicine, University of Aarhus. This study includes 85 cases of acute fatal poisoning examined in the period 1985-1987 in which dxp alone (40 cases) or in combination with alcohol (29 cases) and/or other drugs (16 cases) contributed significantly to death. Two-thirds of the deceased were men and one-third women. The average age was 37 years for both sexes. More than half of the deceased were drug and/or alcohol misusers. Eighteen were drug addicts. Half of the deaths resulted from accidents, while 40% were suicides. Accidental deaths prevailed among younger men. In a majority of the cases the drug had been taken orally. In these cases the median total blood concentration of dxp and the metabolite nordextropropoxyphene (ndxp) was 17 mg/kg in the suicide cases and 7.1 mg/kg in the accident cases. The corresponding figures for dxp without metabolite were 9.4 mg/kg and 2.2 mg/kg, respectively. The median value of the quotient dxp/ndxp was 1.9 in the suicide cases and 0.5 in the accident cases. The quotient, together with the concentrations of the drug, may therefore indicate the manner of death in many cases.     

Chemical profile of counterfeit buprenorphine vials seized in Tehran, Iran

Buprenorphine, commonly known by the trademark Temgesic, is one of the most popular drugs of abuse among the opioid-addicted young individuals in Iran. Temgesic, Bungesic, etc. are the most popular and important illicit opioid drugs in Tehran's illicit drugs black market, and are now among the most widely abused by opioid addicts. Because of this, counterfeiting of this drug has increased in Tehran. In this study, the qualitative analysis of counterfeit buprenorphine by gas chromatography-mass spectrometry (GC-MS) and high performance liquid chromatography (HPLC) demonstrates the presence of diacetylmorphine, acetylcodeine and pheniramine, as well as the absence of buprenorphine. In conclusion, due to the absence of quality control and difficulties in differentiating counterfeit buprenorphine from genuine products, the use of counterfeit buprenorphine leads the opioid abusers to health risks.     

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.     

应用斑点酶标法检测吸毒者尿液中常见毒品

目的建立吸毒者尿液中常见毒品的斑点酶标法检测分析方法。方法生物检材为尿液,采用免疫学酶标法理论和斑点酶标法的高通量技术,应用于人体尿液中常见毒品的检测。结果同时分析多人尿液中是否含有苯丙胺、巴比妥、天使尘、美沙酮及吗啡。尿液中的最低检测量达ng级。结论本方法可用于吸毒者尿液中常见毒品的检测分析。     

Drug abuse in Denmark (Jutland and Funen). A forensic study based upon drugs seized in 1982-1987

Two thousand fifty-three samples submitted to forensic chemical analysis during the period 1982-1987 were characterized according to their content of narcotics and the year of seizure. Heroin and cannabis dominated the material, but a significant decrease in the number of heroin samples was observed in 1987. Amphetamine, on the contrary, hardly seen during the period 1982-1984, accounted for half of the narcotics submitted in 1987. The misuse of morphine, especially in the form of poppy capsules, was a problem for some years, whereas cocaine has not yet been a drug of abuse in Denmark. The mean concentrations of the heroin and the amphetamine samples were 30% and 44%, respectively, both for retail drugs and the entire material.     

Patterns of Crime and Substance Abuse among Israeli Ex-Addict Female Inmates

The current study examined the relationship between drug addiction and crime involvement among Israeli female prisoners, and further examined the differential contribution of early onset of drug, sexual abuse and poly drug use, to predict involvement in offenses against person. Fifty-four ex-addict female inmates participated in this study. Research findings indicated that a majority began using drugs prior to their involvement in crime and most were convicted of drug-related crimes. In addition, almost half had a history of sexual abuse. Female inmates who were sexually abused were characterized by an early onset of drug and poly drug use. A relationship was observed between poly drug use and offenses against person. Also, the duration of drug abstinence corresponded to a lower sense of coherence and higher level of trait anxiety among female inmates. The implications of these findings for substance abuse treatment are discussed. Gila Chen, PhD, is a lecturer in the Criminology Department at Ashkelon Academic College and Bar-Ilan University. Her academic interests include youth at risk, female offenders, self-help groups, and drug addiction.     

Fatal poisoning in drug addicts in the Nordic countries in 2007

The frequency of medico-legally examined fatal poisonings in 2007 among drug addicts was investigated in five Nordic countries; Denmark, Finland, Iceland, Norway, and Sweden. The number of deaths, age, sex, place of death, main intoxicant, and other drugs present in blood samples were recorded to obtain national and comparable Nordic data, as well as data to compare with earlier studies in 2002, 1997, and 1991. Norway had the highest incidence of drug addict deaths by poisoning followed by Denmark, with 8.24 and 6.92 per 100,000 inhabitants, respectively. The death rates in Finland (4.02), Iceland (4.56), and Sweden (3.53) were about half that of Norway and Denmark. Compared with earlier studies, the death rates were unchanged in Denmark and Norway, but increased in Finland, Iceland, and Sweden. In all countries, fewer deaths (29-35%) were recorded in the capital area compared with earlier studies. Females accounted for 11-19% of the fatal poisonings. Iceland deviates with a more equal distribution between men and women (40%). Deaths from methadone overdoses increased in all Nordic countries, and methadone was the main intoxicant in Denmark in 2007, accounting for 51% of the poisonings. In Norway and Sweden, heroin/morphine was still the main intoxicant with a frequency of 68% and 48%, respectively. In Iceland, 3 deaths each were due to heroin/morphine and methadone, respectively. Finland differs from other Nordic countries in having a high number of poisonings caused by buprenorphine and very few caused by heroin/morphine. The total number of buprenorphine deaths in Finland doubled from 16 in 2002 to 32 in 2007, where it constituted 25% of deaths. The general toxicological screening program showed widespread multi-drug use in all countries. The median number of drugs per case varied from 3 to 5. The most frequently detected substances were heroin/morphine, methadone, buprenorphine, tramadol, amphetamine, cocaine, tetrahydrocannabinol, benzodiazepines and ethanol.     

Heroin maintenance in Britain and heroin for the relief of pain in the United States of America

SUMMARY

The British themselves have recognized that heroin may not be the safest and most appropriate form of treatment for heroin addicts. The percentage of narcotic addicts in Britain being treated with methadone alone has risen steadily from 58% (of 1,549 addicts) in 1971 to 67% (of 2,588 addicts) in 1981. Also, the percentage of narcotic addicts receiving heroin alone has dropped from 7.1% (of 1,549 addicts) in 1971 to 2.6% (of 3,844 addicts) in 1981. The amount of heroin prescribed to addicts also fell from 22,778 grams in 1969 to 8,501 grams in 1978.

Further increases in the use of oral methadone and sterile injectable methadone, and resulting decreases in unsterile injections of heroin, would no doubt greatly diminish the incidence of death and severe disability in the treatment of British addicts.

On the issue of heroin's use for intractable pain, there is no evidence that heroin has unique advantages over other drugs. When given in equivalent doses, morphine has been proven to be as effective as heroin, orally or subcutaneously, for the relief of pain. In fact, heroin is rapidly converted into morphine in the body. Given the fact that heroin is the drug most narcotic addicts prefer, legally stocking the drugs in pharmacies, hospitals, and hospices would pose serious security and personal safety risks at these facilities. It is possible, in fact, that most pharmacies would refuse to stock the drug.     

HIV-related deaths outside medical institutions in Stockholm

During a 3-year period (August 1st, 1985 to July 31st, 1988) a systematic investigation of medico-legal autopsy cases with regard to the presence of antibodies for HIV-virus was carried out at the Department of Forensic Medicine in Stockholm, Sweden. Prior to autopsy, blood samples were taken from femoral or subclavian veins and were investigated by use of ELISA-screening and Western blotting test. During the first year of study, HIV infection was demonstrated in 11 out of 3464 deaths (0.32%), during the second year in 29 out of 3483 deaths (0.83%), and during the last year in 13 out of 3107 deaths (0.42%). It was shown that 48 out of the total of 53 HIV positive cases were previously registered, but information about the infection was available to the autopsist in only 27 cases. Drug addicts dominated 41 of 53 cases. There were only eight homo- and bisexual males, two non drug addict Central Africans and two persons who received blood transfusions. Eight of the 53 persons died of natural causes whereas 45 deaths were due to violence and drugs. The causes of death of the HIV positive drug addicts were compared to the causes of death of the HIV negative addicts. The HIV positive drug addicts tended to die suddenly in connection with the intravenous administration of heroin and at lower blood concentrations of morphine more often than the HIV-negative addicts. No increase in the suicide frequency was noted in drug addicts in Stockholm during the studied period.     

Concentrations of Opiates and Psychotropic Agents in Polydrug Overdoses: A Surprising Correlation Between Morphine and Antidepressants

Abstract: The relationship between postmortem concentrations of morphine and co‐detected psychoactive drugs in fatal overdoses is examined. Morphine and other drugs were detected in 161 medicolegal autopsy cases. Subsets of these morphine‐positive cases based on drug class were established, including opioids, antidepressants, ethanol, benzodiazepines, and “other.” Each subset was split into high or low concentration groups based on median drug concentrations. Morphine concentrations of the [high] and [low] groups were compared, with no significant difference in morphine concentration identified in the opioid, ethanol, or benzodiazepine subsets. The “other” drug class was too heterogeneous for statistical assessment. Morphine concentrations did show a significant direct relationship (p = 0.01) with antidepressants, namely increased concentrations of antidepressant drugs are associated with an increased concentration of morphine. This trend probably remains even after excluding cocaine‐positive cases. The unsuspected finding that postmortem concentrations of antidepressants positively correlate with morphine levels may be important in the treatment of depression in drug addicts.     

Trends and pattern of drug abuse deaths in Maryland teenagers

The Office of the Chief Medical Examiner of Maryland recorded a total of 149 drug abuse deaths of teenagers aged 13-19 years between 1991 and 2006. Of these deaths, 96 (64.4%) were caused by the use of narcotic drugs only, 29 (19.5%) by both narcotics and cocaine, four (2.7%) by both narcotics and methylenedioxymethamphetamine, six (4.0%) by cocaine only, and 14 (9.4%) by volatile substances (e.g., butane, Freon, nitrous oxide, and propane). The annual death rate from drug abuse for teenagers increased from 1.4 deaths per 100,000 population in 1991 to 2.7 deaths per 100,000 population in 2006 (chi-square test for time trend, p<0.01). The increase in teenager drug abuse deaths occurred in 1999 and since has remained at a higher rate. Further analysis revealed that the increase in drug abuse deaths was attributable to a large degree to narcotic drugs, particularly heroin/morphine and methadone, and was confined to teenagers residing in the suburban and rural areas.     

Fatal intoxications in the Nordic countries. A forensic toxicological study with special reference to young drug addicts

Fatal intoxications in the 15-34 age group in the five Nordic countries during the years 1984 and 1985 (Sweden only in 1984) were investigated. The known drug addicts were studied separately. The highest incidence of intoxications, calculated per 10(5) population, was found in Finland (11.3), followed by Denmark (10.3), Sweden (8.5), Iceland (7.2) and Norway (6.6). The percentage of intoxications caused by drugs was 92 in Denmark, 71 in Norway, 66 in Sweden, 50 in Finland and 17 in Iceland. Ethanol intoxications were seen 5-7 and 2-3 times as frequently in Finland and in Iceland, respectively, than in the other three countries. Carbon monoxide intoxications accounted for two-thirds of all fatal intoxications in Iceland. Drug addicts accounted for 62% of all fatal intoxications in the Danish material. The corresponding figures were 33% in the Norwegian, 16% in the Swedish and 5% in the Finnish material. No deaths in drug addicts were found in Iceland. Most drug addicts in Denmark, Norway and Sweden died of hard drugs and most in Norway and Sweden, from heroin or morphine, whereas in Denmark other strong analgesics, such as methadone, dextropropoxyphene and ketobemidone, accounted for 40% of all hard-drug-related fatal intoxications. To a certain extent the results reflect differences in the legal autopsy routines in the various Nordic countries. However, the ascertainment of drug addicts is assumed to be near-complete in each country.     

Violent crime and substance abuse: a medico-legal comparison between deceased users of anabolic androgenic steroids and abusers of illicit drugs

Several case reports and survey studies have indicated that abuse of anabolic androgenic steroids (AAS) often leads to increased aggressiveness and feelings of hostility that may occasionally trigger violent behaviour. Other observations indicate that many users of AAS also abuse alcohol and/or various illegal substances. Since substance abuse is a well-known risk factor for violent behaviour, it could be that violence committed by AAS users might, at least in many cases, actually be caused by abuse of other drugs. In order to examine this possibility further here, the criminal histories (in terms of incidences of convictions) of deceased users of AAS with (AASpos-subst.pos) and without (AASpos-subst.neg) signs of abuse of other illegal substances were compared to the corresponding histories of deceased users of illicit substances testing negatively for AAS (subst.pos-AASneg) at the time of autopsy. The risk of being convicted for a crime against property was significantly higher in the subst.pos-AASneg group than in either the AASpos-subst.neg or AASpos-subst.pos groups (RR=0.048 versus 0.408). At the same time, the risk of being convicted for a crime of violence was at least as high for the two AAS-positive groups as for the AAS-negative group. Furthermore, when compared with the first 3 years after the first criminal conviction, a pronounced increase in the proportion of incidence of violent crimes and a marked reduction in the proportion of incidence of crime against property was observed during the 3-year period immediately preceding death only among the AASpos-subst.neg subjects. In conclusion, the incidence of violent crime among users of AAS without signs of other drug abuse was comparable to the corresponding incidences for drug addicts without AAS use. This observation suggests that the violent criminality observed among AAS users is not confounded in any systematic fashion by abuse of other drugs. The findings also indicate that use of AAS in certain predisposed individuals might cause a high rate of violent crimes, especially if the use of AAS is combined with the use of other illegal substances.     

NARCOTIC ADDICTS AND CRIME Analysis of Recent Trends

This study attempts to shed light on the types of crime committed by drug addicts and the possible changes in criminal behavior over time. The study revealed that arrests for crimes against the person are becoming more prominent among addicts although acquisition of property appeared to be the prime motive in these offenses Over the four-year period analyzed, arrests for crimes against property and drug offenses remained the more numerically important categories even though arrests for crimes against the person increased. It was also found that, for each type of offense, more persons were arrested after than before they initiated thew drug abuse patterns.