Opioids

Opioids have long been used in medicine as painkillers. As such opioid analgesics have been included on the Essential Medicines List (EML) since the first edition was published in 1977 and were included in the first Model List of Essential Medicines for Children (EMLc) in 2007. The EML includes the naturally occurring opioids, codeine and morphine, as well as the synthetic opioids, fentanyl and methadone. The EMLc includes morphine and methadone for use in children. Synthetic opioids, hydromorphone and oxycodone are accepted in the Lists as possible therapeutic alternatives to morphine for analgesia.

THE PROBLEM

At the same time, opioids are addictive and can cause death. The non-medical use, prolonged use, misuse, and use without medical supervision of opioids can lead to opioid dependency and many other health problems, including the risk of overdose.

Opioids, mainly heroin or its metabolites, often combined with other substances, are present in more than three-quarters of fatal overdoses reported in Europe. More than one substance is detected in most drug-induced deaths, indicating polydrug use.

USA

Regulation of opioids started with The Harrison Narcotic Control Act in 1914 in the USA, passed in response to the sudden emergence of street heroin abuse and iatrogenic morphine dependence.

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers, and healthcare providers began to prescribe them at greater rates. Opioids were mainly prescribed for chronic pain, and the duration of treatment indicates prolonged use. Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive. As a result, the second wave of deaths came from a heroin market that expanded to attract already addicted people. The third wave of deaths has arisen from illegal synthetic opioids like fentanyl. Since 2013/14, fentanyl has become the leading cause of opioid-related overdose deaths in North America, most likely due to the adulteration of heroin with illicitly manufactured fentanyl.

EUROPE

Europe has also seen a steady increase in prescription opioid use over the past ten years, mainly due to increased tramadol, fentanyl, and oxycodone prescribing.

Although heroin is still the most frequently abused opioid in Europe, there are a growing number of reports on the abuse of other – mainly synthetic – opioids. Nevertheless, the level of prescription opioid use and opioid-related deaths in most European countries is still much lower than in the USA. Opioid-related mortality in the EU was 1.4 per 100,000 population in 2019, while it was 21.6 in the USA.

The NordAN Network is committed to keeping track of developments in our region, studying trends across countries and learning from the past. This website contains specific opioid-related pages under each country's page.

EMCDDA - Overdose deaths, TRENDS

Source: EMCDDA

National definitions usually refer to acute deaths directly related to drug consumption ("overdoses", "poisonings" or "drug-induced"). Note that, in a few countries, the figures might include also a limited number of cases of deaths indirectly related to drug use (e.g. accidents with positive toxicology). Note in addition that in some countries, statistics published at national level may differ from those presented here, owing to differences of case definition used at national level.

Comparisons between countries must be made with caution, because mortality rates and trends are influenced by factors such as practices of reporting, recording information and coding overdose cases that may vary across countries and time.

EMCDDA - Overdose deaths, Current situation > Toxicology > With opiates

The EMCDDA drug-related deaths (DRD) indicator focuses on deaths directly caused by illegal drugs (drug-induced deaths) and mortality among drug users.

The EMCDDA encourages countries to both harmonise their data collection and reporting. Nevertheless, differences in the availability of autopsies and in coding practices between countries will influence the interpretation and comparability of the results.

The number of drug-induced deaths provides one perspective on the drug situation and should be considered within the broader range of information available. Cross-referencing between data-sets provides both additional insights and a check of validity. The DRD indicator also considers mortality amongst drug users derived from cohort studies.

Learn more about EMCDDA methods and definitions

Opioid substitution treatment > All clients

Needle and syringe programmes > Sites > Fixed

NSP (Needle and syringe programmes) site: The term ‘site’ is used to describe physically distinct outlets where syringes can be obtained for free or in exchange against used ones.

Norway: is based on a harm reduction equipment survey in Norwegian municipalities. This was carried out for the third time in 2019 with a response rate of 73%. 77 municipalities reported syringe delivery. 77 municipalities reported syringe delivery. Around 77 municipalities reported fixed NSP-locations. Due to the fact that not all of the municipalities who reported syringe delivery stated the type of NSP, this number should be treated as an estimate. Despite the high number of participating municipalities, some cities/villages with an NSP site are not represented in the survey.

Legal framework > Initiation OST

Notes: 'Y' indicates whether a specific provider is involved in initiating opioid substitution treatment.

Specialized medical doctors' refers to specifically trained or accredited office-based medical doctors or general practitioners practicing outside specialised drug treatment centres.

'Any medical doctor' refers to office-based medical doctors practicing outside specialised drug treatment centres.

Where a specific provider is not allowed to initiate a specific treatment, the table entry is left empty. Exception for Sweden for which data were not available

Why comparing death rates between different countries is problematic

Decriminalisation of Drugs report (The Swedish Drug Policy Centre, 2020)

Comparing death rates between different countries is more problematic and more complex than usually comes out in discussions on the subject. The EMCDDA itself says that any comparison between countries must be made with caution “since it is underreported in some countries”. In a technical report, EMCDDA has also identified significant differences between countries in a number of areas:

The number and quality of post-mortem examinations and forensic analyses carried out. Procedures vary for when a post-mortem and forensic analysis is to be carried out.
Availability of information to the medical doctor determining the cause of death.
Different classification systems are used, and the quality of the classifications is considered to vary.
The standard of available laboratory equipment varies

In the case of Portugal and Sweden, the differences in the way in which deaths are collated and reported appear to be so vast that comparisons between the countries become meaningless in practice. Most people argue that the differences in method vary widely across Europe in general. Is Sweden really at the top in the EU when it comes to drug mortality? Nobody knows for sure.