Opioids in Sweden

Country snapshot - Peter Moilanen

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What is your view on the quality of EMCDDA data? Does it reflect the actual situation?
Peter Moilanen: From a Swedish point of view the data sent to EMCDDA has developed at several times with improved ways of measuring, more types of drugs measured and more autopsies. So the figures now are more correct than it used to be. (https://www.can.se/app/uploads/2020/01/can-rapport-158-drug-related-deaths-in-sweden-summary.pdf)
From a European point of view, there are still difficulties comparing data between countries. As we can see Nordic countries and Northern Europe is at the top concerning the number of deaths. Does that mean that these countries should copy the policy in Rumania and Bulgaria, who are at the bottom? No seems to be the answer as the countries measure in different ways. 

Do you know other methods in your country? What do these methods show?
In Sweden, there are some other ways of collecting data according to drug-related deaths. These are broader than the EMCDDA data, so there are more people registered dead. It is not just overdoses. But the trends seem to follow each other.

Has opioid-related harm increased or decreased in your country in recent years?
Since 2006 it has increased, but in the last years, it has decreased. That is mainly due to decreased death by fentanyl. Find more HERE

If possible can you describe the procedures for data collection (autopsies, forensic investigations)?
Every year approximately 90 000 deaths happen in Sweden. Of them, approximately 5 000 is being reported to the police. These cases are almost always taken to forensic investigations and an autopsy is made. This is done at the same place in Sweden, in the city of Linkoping, to give the same way of measuring. They categorise deaths as murder, suicide, accident or illness and what did cause the death. Learn more HERE

What are the main measures taken in your country regarding opioid-related harm?
Expanding harm reduction and opioid substitution treatment, reducing availability, working with prevention.

Have there been recent changes in these policies? What are the main reasons for these changes?
Harm reduction has been expanded. Naloxone has been introduced on a broader basis in the last few years and the government has given a mission to extend the categories that can handle Naloxone. Opioid substitution treatment (OST) has expanded in the last years as well as needle exchange programs (NEP). 
In addition, the government has decided to implement an early warning system to catch drugs that don't live up to their labels.
The parliament and the government want to have a new vision: No drug-related deaths.
In part, this can be attributed to the relatively high number of drug-related deaths.

What has been valuable or effective intervention in your country?
The police and the judiciary have driven a case concerning the selling of fentanyl that was very successful. The consequence of that case is that the death of fentanyl has almost disappeared. 
There is no investigation done about it but the expansion of harm reduction should have been given results as we now see decreasing drug-related deaths. The number of persons seeking treatment for drug addiction has increased by 40 per cent the last ten years and that can also be a reason for the decrease.
On the other hand, a regional study shows that 9 of 10 that died from an opioid overdose was in contact with the officials (75 per cent with speciality hospital care) during the last year they were alive. From that point of view, contact is taken but it doesn't work that well after it has been done.

What additional policies/laws (not directly targeting drug use) do you think would be needed to improve the opioid-related situation?
More knowledge is needed. What happens after the contact with the official authorities? What are the gender and regional differences? What has been effective so far?
More availability to harm reduction is needed (OST, NEP and Naloxone) but at the same time, we need more knowledge of the leakage from OST.
Something is wrong with the organization where people that seek help still die. The different institutions do not seem to talk enough with each other and there is a lack of resources.
Early intervention is needed and the chain from here to the period after treatment.
Only one in twenty who died of an opioid overdose had been in coercive treatment, could it be used more often?
How to reduce deaths by prescribed medicines has to be developed.

How would you rate the current political commitment to deal with these problems?
The commitment is on the rise with a zero death vision but more has to be done. The parliament has been on in this matter and has been given some missions to the government. The government has then given some missions to the authorities. There is an investigation ongoing about persons with double diagnosis and there will be a new investigation about better treatment and reducing drug-related death.

What are the primary obstacles to these expected developments in your country?
Political leadership and the challenge for the municipalities to prioritise resources after Covid-19.

Peter Moilanen, Head of The Swedish Drug Policy Centre, NPC​​​

 
 
EMCDDA data

EMCDDA Data

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.

These are absolute numbers, and not all drug deaths are caused by opioids, though a majority are. In 2019 the number of overdose deaths with opiates was 473 (overall overdose deaths - 540).

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A 2011 study estimated that there were 8 000 people who inject drugs in Sweden, the majority of whom used opioids and/or amphetamine. There is no national estimate on the prevalence of high-risk drug use by substance.

In 2017, 626 drug-induced deaths were reported in Sweden, slightly more than in the previous year. Around three quarters of deaths were of males. The mean age was 41 years. Toxicology reports indicate the presence of opioids in the vast majority of deaths; at the same time, the presence of more than one psychoactive substance is noted in a large proportion of cases, indicating that polydrug use is common.

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County councils are responsible for the provision of detoxification facilities and opioid substitution treatment (OST) and for the treatment of psychiatric comorbidities. Municipalities have overall responsibility for long-term rehabilitation through social services, for example in so-called ‘homes for care and living’ or ‘family homes’.

 

Many of these ‘homes’ are privately operated. OST with methadone (introduced in 1967) and buprenorphine-based medications (introduced in 1999) can be prescribed by a medical doctor. In general, the national OST guidelines give priority to buprenorphine-based medication in OST treatment.

Heroin seized in Sweden, typically originating from Afghanistan, is trafficked via the Balkan route. Following a downward trend during the period 2006-11, there has been a marginal increase in heroin seizures in Sweden in recent years. In addition, seizures of synthetic opioids, mainly medicines, have been increasing, including high-potency fentanyl derivatives.

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Is it possible to compare death rates between Portugal and Sweden?

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

Author: Pierre Andersson

Many opinion pieces on decriminalising drugs published in Sweden compare the drug-related mortality rates between Portugal and Sweden. The comparison is rewarding: According to the tables compiled by the EU’s drug agency, EMCDDA, Portugal is among the lowest and Sweden is second highest. The two countries have roughly the same population size, which makes comparisons even more enticing.


The differences in the data are striking. The drug-related mortality rate was at its highest in Portugal in 2001, when 76 deaths were reported to the EMCDDA (according to selection criteria “Selection B”). In the same year, Sweden reported 204 deaths. After that, the differences in the reported figures have only increased. In 2016, Portugal reported 30 deaths and Sweden 590.

In the first few years Portugal saw a downward trend, but the death rate has since risen again. The official figure for 2017 is not yet been published by the EMCDDA, but according to a SICAD report it was estimated at 51 deaths, an increase of 30% compared to the previous year. This is significantly more than in 2002 and almost as many as in 2000, the year before decriminalisation. 

In Sweden, the situation was fairly stable until 2006, when a sharp increase began. The reason for this increase is not entirely clear, but in a 2016 report, researcher, Håkan Leifman, believes that around half the increase over the last decade is due to changes in methodology.

The real increase in Sweden from 2006 to 2016, if Håkan Leifman is right, is 40-50%, not the sharp doubling seen in the official statistics. The increase appears to be linked to higher availability and use of opioids. Heroin has remained stable during the period, while mortality associated with methadone and buprenorphine (medicines used in substitution therapy) has increased.

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.

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Additional reading
 

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: Lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities

Harm Reduction Journal, May 2019

Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables.

Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

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Opioid prescriptions remained elevated two years after critical care

KAROLINSKA INSTITUTET, February 2021

Nearly 11 percent of people admitted to an intensive care unit in Sweden between 2010 and 2018 received opioid prescriptions on a regular basis for at least six months and up to two years after discharge. That is according to a study by researchers at Karolinska Institutet published in Critical Care Medicine. The findings suggest some may become chronic opioid users despite a lack of evidence of the drugs' long-term effectiveness and risks linked to increased mortality.

 

"We know that the sharp rise in opioid prescriptions in the U.S. has contributed to a deadly opioid crisis there," says first author Erik von Oelreich, PhD student in the Department of Physiology and Pharmacology at Karolinska Institutet. "Now, there are signs that opioid prescriptions have increased in parts of Europe and it is therefore important to find out to what extent opioid prescriptions during and after intensive care may contribute to long-term use and its consequences."

 

Opioids such as morphine and fentanyl are commonly used in critical care for sedation and pain management. There is, however, a lack of evidence to support the use of opioids as a long-term solution to dealing with chronic pain. In addition, misuse of prescription opioids has turned into major health problems in countries such as the U.S. where, on average, 130 Americans die per day from an opioid overdose.

 

In this study, the researchers found that nearly 11 percent (22,138) of 204,402 individuals continued to receive opioid prescriptions for at least six months and up to two years after critical care treatment in Sweden. The study included all adults who survived at least six months after being admitted to an ICU between 2010 and 2018.

 

Average opioid consumption peaked in the first quarter after admission and declined continuously during the 24-month follow-up period but never returned to the pre-admission level, according to the study.

The study also found that chronic opioid users had a 70 percent higher risk of death six to 18 months after critical care, also after adjustment for other risk factors. The same finding was seen in patients not using opioids before ICU admission.

The fatal opioid poisonings have returned to a stable high level

Läkartdidningen, January 2021

Drug deaths have increased sharply during the 2000s, mainly due to opioids. The increase can be partly explained by generally increased access to drugs in society and forensic chemical method improvements.

 

In this study, the acute, fatal opioid poisonings in Sweden 2014–2019 have been mapped.

 

The results show that deaths initially increased as a result of fentanyl analogues, with the culmination in 2017. Deaths due to other opioids were relatively constant during the time period.

 

A careful mapping of both causes of death and methods of death is a prerequisite for effective preventive measures aimed at reducing the number of deaths due to opioids in society.

A total of 2,069 deaths caused by acute opioid poisoning in Sweden in 2014–2019 were included. The number varied annually (311–393) with an average of 345 deaths per year. Related to population, this corresponds to 3.05–3.88 deaths per 100,000 inhabitants annually. Deaths increased until 2017 (3.88 per 100,000) and then decreased by just over 20 percent (to 3.06 per 100,000) in 2019 (Figure 1). 

 

Heroin caused the most deaths (n = 466), followed by fentanyl / analogues (n = 370). Heroin, fentanyl / analogues, methadone (n = 302) and buprenorphine (n = 270) accounted for almost 70 percent (1,408 / 2,069) of all opioid deaths. Other deaths were mainly caused by tramadol, oxycodone or morphine. Combination opioid poisoning occurred in 140 deaths (7 percent) (Figure 2).

Heroin was the dominant opioid in Sweden in 2014, 2018 and 2019, while fentanyl / analogues caused the most deaths in 2015–2017 (Figure 3). Over time, no significant difference in mortality for heroin, methadone or buprenorphine could be detected. For fentanyl / analogues, an increase from 37 cases in 2014 to 84 cases in 2015 and a decrease from 101 cases in 2017 to 20 cases in 2018 were demonstrated (Figure 3).

The results are in line with what appears from the Public Health Agency's and the National Board of Health and Welfare's publications [2, 7] and indicate that deaths due to acute, pure opioid poisoning have decreased soon, despite the prevalence of opioids in society [10], with the exception of the outbreak of fentanyl analogue deaths that culminated in 2017. The development of current deaths caused by mixed poisoning with opioids and sedatives as well as prescribing opioids during the same time period remains to be mapped. Separate studies also deserve deaths where the cause of death was not primarily opioids but where they occurred in the body at death, which is likely to increase the risk of violence and accidents.

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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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CAN, June 2017

In order to get a better understanding of the trends in drug-related deaths, and of the comparability of the Swedish with the data from other European countries, detailed analyses of mainly toxicological forensic data have been conducted. The data cover all forensically investigated deaths in Sweden over the past 15-20 years.

The estimations made in this report suggest that a real increase in drug deaths, and most likely drug-related deaths, has occurred, but that the previously reported increasing trends have been greatly exaggerated. The main reason for this exaggerated picture is that the changes − or improvements − in methods of analyses within forensic investigations (more cases tested, and lower threshold for drug detection) have led to the detection of more deaths with positive findings of drugs. As reported by the National Board of Health and Welfare (NBHW, 2016), changes in
coding practices have also contributed to a false rate of increase.

The increase that remains after controlling for changes in methodology is still rather substantial and is due to an increase in the number of opioid deaths (from 2008 to 2014 with approximately 33% in absolute numbers and 27%, per inhabitants aged 15 or over). Today, most drug deaths, and drug-related deaths, are tied to opioids, usually synthetic opioids such as methadone, buprenorphine and fentanyl.

Studies of the combined use of opioids with alcohol and/or benzodiazepines revealed that alcohol involvement in opioid deaths (and all drug deaths) has decreased (from about from about 36% of all opioid deaths in year 2000 to less than 25% in year 2014), whereas benzodiazepine involvement has increased at more or less the same pace as opioid deaths (in 2014: ~65% of all opioid deaths). Interestingly, of the four groups of opioid deaths, with or without alcohol or benzodiazepine involvement, it is only the group of opioid deaths combined with benzodiazepines that shows a clear and substantial rising trend since 2006. Opioid deaths with no benzodiazepines and no alcohol show a modest increase, whereas the two groups of opioid deaths including alcohol, one including and one not including benzodiazepines, show no increase during the entire study period (here 1994-2014). The same patterns and trends for combined use are revealed for all drug deaths, i.e., opioid deaths plus deaths with illicit drugs.

It is obvious from this report that the Swedish drug-related deaths statistics, and especially the handling and reporting of data, have been confusing. An important lesson for the future is that one must keep track of changes in statistics that are related to case ascertainment, investigation and recording practices. This has certainly not been done in Sweden. The inconsistencies revealed in the statistics are difficult to comprehend, given that Sweden is generally known for high-quality statistics. More or less all death data that could be needed are compiled and available from certain sources. The problem is that these data are spread out and not linked together, making it difficult to achieve a reliable assessment of drug-related death trends.