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Drug-related deaths

The aim of this indicator is to obtain comparable and reliable routine statistics on the number and characteristics of people who die as a consequence of drug use in the EU Member States. This is an important indicator of the health impact of the more severe forms of drug use, and can also be useful for monitoring trends in problem drug use.

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Methods and Definitions: summary

Drug-related deaths and mortality

The concept of “drug-related mortality” is complex and it is often used with different meanings in scientific or policy publications. These different uses of the terms “drug-related mortality” and “drug-related deaths” cause difficulties in interpretation of results of research, and in the policy conclusions and definitions of priorities.

Drug-related mortality includes several components. Here some of them are presented, although the list may not be exhaustive.

The first and more traditional component is the deaths directly attributable to the pharmacological action of the drugs, alone or in combination, happening shortly after the consumption of the substances. These deaths are usually call overdoses or poisonings. The term “drug-induced deaths” has been use also to refer to these deaths, in particular in American publications, and it will be used also here as more clear than “drug-related deaths” for this particular case. Most national statistics refer to these deaths (See section “Drugs directly attributable to drug use- Drug-induced deaths”).

An additional component is the deaths caused indirectly by the use of drugs, usually by concurrent factors related to the method of use (e.g. deaths due to Aids where the transmission factor was sharing of injection equipment) or to external circumstances (e.g. deaths due to traffic accidents where drug use was a determinant factor in combination with other elements such as conditions of the vehicle, visibility or roads).

A different perspective is the mortality among problem drug users, which usually is very high due to overdoses but also due to other causes. In some cases these other causes are well identified as related to drug use (such as infectious diseases related to injection) but a considerable component of mortality among drug users is less well know as related to drugs (for instance, violence, accidents, suicide, cardiovascular –in particular in the case of cocaine-).

An additional and more innovative dimension is the total burden mortality attributable to problem drug use (PDU) in a community. It puts in relation the prevalence of problem drug use and mortality related to it (see before and 2008 Annual Report section on drug-related mortality). It should be notice that some deaths related to drugs maybe not be related to problem drug use as it is defined in the PDU indicator of EMCDDA, for instance deaths related to recreational ecstasy or cocaine use (both deaths directly caused by the substances and indirectly –e.g. accidents-). The EMCDDA Report CT.00.RTX.22 presents an example of methodology to estimate the “total burden of mortality” related to drug use that includes both deaths directly and indirectly related to drugs (Annex 1, pages 47 to 53), and a new methodological project will explore during 2008 further developments in this topic.

Also, sometimes it is used as equivalent to “drug-related deaths” those deaths where drugs are found in the post-mortem toxicological analysis. In some cases, these deaths may be directly caused by the substances (drug-induced deaths or overdoses), but in other cases it could be indirectly caused by the drug –e.g. a traffic accident while intoxicated-, or even in others may not related –e.g. an incidental finding on post-mortem analysis of a person dying of a natural cause-. The number of these deaths may depend on the proportion of all deaths subjected to toxicological examinations. Finally there are deaths related to drugs but due to circumstantial reasons, but even without the presence of substances –e.g. violence related to drug trafficking or drug-related crime.

An important issue is to consider which substances are taken into account in the compilation of statistics, in particular regarding drug-induced deaths (overdoses). It should be made explicit whether only cases with illegal drugs are included or whether also are included cases with presence only of psychoactive medicines (and eventually alcohol). Many deaths can be considered poydrug deaths, including different type of substances –drugs, medicaments, alcohol-. But on the other hand, despite that obviously there are deaths related to abuse of psychoactive medicines, many deaths with only psychoactive medicines may be more related to mental health issues (e.g. suicide in the context of depression) than to substance abuse.

All these components are important, but it is of great importance to specify clearly about the criteria and case definition used in a concrete study or policy document. Sometimes research and statistics are difficult to interpret if the case definition is not clearly stated, and there is the risk that conclusions about policies and interventions could be misleading.

1) EMCDDA definition (below see the “National Definitions”)

In the EMCDDA Annual Report, unless specified otherwise, the figures presented refer to deaths happening shortly after consumption of one or more psychoactive drugs, and directly related to this consumption. Often these deaths are referred to as “overdoses”, although equivalent concepts are also “deaths directly related to drug use” or “poisonings”. From this year, the term “drug-induced deaths” will be used to refer to these deaths instead of “drug-related death” which is of less clear interpretation.

Most national statistics on “drug-related deaths” refer to these deaths directly related to consumption. National statistics are usually recorded through General Mortality Registries –GMR- or Special Registries –SR-(Forensic or Police).

The EMCDDA has developed a common definition, in agreement with the expert group of national experts (see below summary definition and also the DRD-Standard protocol) focusing on those deaths directly related to consumption of illegal substances (although alcohol or psychoactive medicines are also found frequently in the toxicological analysis).

At present, national statistics are improving in most countries and their definitions are becoming the same, or with small differences, to the common EMCDDA definition (called “Selection B” for the GMR and “Selection D” for the SR). A few countries still include cases due to psychoactive medicines or non-overdose deaths, generally as a limited proportion of the total (The Part 2 of this Methodological Note details definition of “drug-related death” used in each Member State).

In addition, there are still differences between countries in procedures of recording cases, and in the frequency of post-mortem investigation (including autopsy rates). In some countries information exchange between General Mortality Registries and Special Registries (forensic or police) is insufficient or lacking, which compromise the quality of information. However considerable progress has been obtained during the last years in quality and reliability of information on many Member States.

Direct comparisons between countries in the numbers or rates of drug-related deaths should be made with caution; but if methods are maintained consistently within a country, the trends observed can give valuable insight when interpreted together with other drug indicators.

The EMCDDA definition of drug-related deaths

The EMCDDA definition of drug-related death in the Key Indicator “Drug-related deaths and mortality among drug users” refers to those deaths that are caused directly by the consumption of drugs of abuse. These deaths occur generally shortly after the consumption of the substance(s).

In operative terms the cases are selected as follows:

(1) The preferred method to estimate the number of deaths is to extract cases from existing General Mortality Registries according to the following criteria,

based on the WHO International Classification of Diseases, 9^th edition -ICD-9-

Cases will be counted when their underlying cause of death was drug psychoses, drug dependence, nondependent drug abuse, accidental poisoning, suicide and self-inflicted poisoning, and poisoning with undetermined intent.

Cases will be included when the death was due to a standard list of specific drugs: opiates, cocaine, amphetamines and derivatives, cannabis, and hallucinogens.

The precise ICD-9 codes to be selected are the following:

Category of drug-related death

Selected ICD-9 code(s)

Drug psychoses

292

Drug dependence

304.0, 304.2-9

Nondependent drug abuse

305.2-3, 305.5-7, 305.9

Accidental drug poisoning

E850.0, E850.8¹⁾, E854.1-2, E855.2, and E858.8¹⁾

Suicide and self-inflicted drug poisoning

E950.0¹⁾, E950.4¹⁾

Drug poisoning undetermined intent

E980.0¹⁾, E980.4¹⁾

Category of drug-related death	Selected ICD-9 code(s)
Drug psychoses	292
Drug dependence	304.0, 304.2-9
Nondependent drug abuse	305.2-3, 305.5-7, 305.9
Accidental drug poisoning	E850.0, E850.8¹⁾, E854.1-2, E855.2, and E858.8¹⁾
Suicide and self-inflicted drug poisoning	E950.0¹⁾, E950.4¹⁾
Drug poisoning undetermined intent	E980.0¹⁾, E980.4¹⁾

¹⁾ In combination with N-codes (N965.0, and/or N968.5, and/or N969.6, and/or N969.7

This selection was agreed by the EMCDDA Expert Group on Drug-related deaths. It was called “Selection B” for General Mortality Registries based on ICD-9.

based on the WHO International Classification of Diseases, 10^th edition -ICD-10-

Case will be counted when their underlying cause of death was mental and behavioural disorders due to psychoactive substance use (see list of substances below) or poisoning accidental, intentional or undetermined intent (see list of substances below)

Harmful use, dependence, and other mental and behavioural disorders due to:

opioids (F11)
cannabinoids (F12)
cocaine (F14)
other stimulants (F15)

hallucinogens (F16)

multiple drug use (F19)

Accidental poisoning (X41, X42), intentional poisoning (X61, X62), or poisoning by undetermined intent (Y11, Y12) by:

opium (T40.0),
heroin (T40.1),
other opioids (T40.2),
methadone (T40.3),
other synthetic narcotics (T40.4),
cocaine (T40.5),
other and unspecified narcotics (T40.6),
cannabis (T40.7),
lysergide (T40.8),
other and unspecified psychodysleptics (T40.9),
psychostimulants (T43.6)

The T-codes are to be selected in combination with the respective X-codes and Y-codes.

Underlying cause of death

Selected ICD-10 code(s)

Disorders

F11-F12, F14-F16, and F19

Accidental poisoning

X42¹⁾, X41²⁾

Intentional poisoning

X62¹⁾, X61²⁾

Poisoning undetermined intent

Y12¹⁾, Y11²⁾

¹⁾ in combination with the T-codes: T40.0-9, ²⁾ in combination with T code: T43.6.
This selection was agreed by the EMCDDA Expert Group on Drug-related deaths. It was called “Selection B” for General Mortality Registries based on ICD-10.

Underlying cause of death	Selected ICD-10 code(s)
Disorders	F11-F12, F14-F16, and F19
Accidental poisoning	X42¹⁾, X41²⁾
Intentional poisoning	X62¹⁾, X61²⁾
Poisoning undetermined intent	Y12¹⁾, Y11²⁾

Effect of the ICD-10 updates

Several ICD-10 updates for codification of deaths due to drug intoxications were adopted by WHO in 2002 and 2003 by the Heads of WHO Collaborating Centres for International Classifications in Health Care. They should enter into force from 1st January 2006.

For the countries that have already implemented these ICD-10 updates (very few for the time being) some additional combination of codes should be included. They are:

X44, X64 and Y14 in combination with main injury codes (T codes) T40.0 through T40.9 and T43.6

Notice that X44, X64 and Y14 alone, without combination of T codes, or without the implementation of the updates are not part of the DRD-Standard

(2) An alternative method is to estimate the number of deaths by extracting cases from existing Special Registers (Forensic or police registries). The method based on the Special Registries will be applied in countries where the preferred method cannot be implemented, but also will be used whenever possible as a backup estimate for the General Mortality Registries.

Cases will be counted when the death was due to poisoning by accident, suicide, homicide, or undetermined intent.

Cases will be included when the death was due to opiates, amphetamines, cocaine (or crack), cannabis, hallucinogens, solvents, or synthetic designer drugs like amphetamine derivatives.

The precise groups of deaths are the following:

Category of drug-related death

Selected groups

Poisoning by accident, suicide, homicide, or undetermined intent

Opiates only (excluding methadone only)

Methadone only

Poly-substances including opiates

Poly-substances excluding opiates

Unspecified/unknown

Category of drug-related death	Selected groups
Poisoning by accident, suicide, homicide, or undetermined intent	Opiates only (excluding methadone only)
Methadone only
Poly-substances including opiates
Poly-substances excluding opiates
Unspecified/unknown

- “poly-substances” should include at least one of the above mentioned substances
- “unspecified/unknown” will be included when it is assumed to include one of the above mentioned substances

This selection was agreed by the EMCDDA group of experts. It was called “Selection D” for Special Registries.

For more information on EMCDDA work on Drug-related Deaths see >>

For the EMCDDA protocol “DRD-Standard Protocol” see >>

2) Drug-related Deaths: “National Definitions”

Definitions of ‘acute drug-related death’ in EU Member States, as used to report cases for the EMCDDA annual report

(It is recommended that for reporting to the EMCDDA, the national definitions are in line with DRD-Standard –Selection B for GMR and Selection D for SR.)

Belgium
Case Definition	EMCDDA definition for General Mortality Registries (“Selection B” for ICD-9)
Technical information	“Selection B” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure	Cases are reported by Health authorities of the French and Flemish Communities that collect death certificates filled by physicians. The National Institute of Statistics centralizes the morbidity statistics of the two communities
Reference	National Institute of Statistics. General Mortality Registry:. Personal communication (Ad-hoc data extraction for REITOX National Focal Point for the 2002 National Report).
Remarks	Since 1998, cases will be selected by ICD-10 codes
Bulgaria
Case definition	Cases of death which underlying cause of death is Drug Psychosis, Drug Addiction, Drug Abuse, Accidental Poisoning
Technical information	The cases are selected according to the ICD-10 codes: F11-F12, F14-F16, and F19, disorders X42, X41, accidental poisoning X62, X61, intentional poisoning Y12, Y11, Poisoning undetermined intent The combination with T-codes is not possible.
Data collection procedure	Death certificates filled in by family doctors do not specify the substance even if they have reasonable doubts. Deaths occurring in hospitals are followed by toxicological examination.
Reference	Ad hoc data extraction by National Focal Point from General Mortality Registry for the 2006 Reitox National Report
Remarks	There are difference in number of cases obtained from the General Mortality Registry (40) and from police reports (36) in 2005 From 2005 onwards cases are selected by ICD-10 codes
Czech Republic
Case definition	Deaths due to poisoning caused by psychoactive substances (drugs of abuse and psychoactive medicines). Notice that for the purpose of EMCDDA analysis (characteristics, rates, trends), it is used the Selection D.
Technical information	Selection D of EMCDDA standard definition (drugs of abuse) PLUS deaths due to poisonings by psychoactive medicines
Data collection procedure.	Special semiautomatized electronic registry run by National Focal Point and Society of Forensic Medicine and Toxicology.
Reference	Národní monitorovací stredisko pro drogy a drogové závislosti and SSLST CLS JEP (2006) Speciální registr úmrtí spojených s uzíváním drog v r. 2005. Praha: NMS. (Special Mortality Register - Drug-Related Deaths in 2005. Prague: National Monitoring Centre for Drugs and Drug Addiction) Notes: unpublished
Remarks	Most of the cases included in the national definition as such are due to psychoactive medicines Since the practice in Czech Republic does not allow to include into the GMR any examination newer than 3 days after the death, this registry is not observed for the purposes of drug epidemiology as appropriate.
Denmark
Case definition	EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification)
Technical information	--
Data collection procedure
Reference	General Mortality Registry
Remarks	Notice that until previous year, the Danish data used for EMCDDA analysis were based on police information, with a broader case definition specific for Denmark The case definition was: A death is included in the statistics, if (1) the dead is caused by poisoning (or) (2) there is a strong causal relation between use of drugs and death. Also the definition was formulated as: A death is included in the statistics, if the death is caused by poisoning and also non-overdose deaths, such as for example accidents and suicides. The definition includes deaths due to all forms of narcotic substances.
Germany
Case definition	Deaths following intentional or unintentional overdose. Deaths as a result of long-term abuse. Deaths due to suicide resulting from despair about the circumstances of life or the effects of withdrawal symptoms. Deaths due to fatal accidents suffered by people under the influence of drugs
Technical information	--
Data collection procedure	Cases are reported by local police units that are working jointly with the forensic physicians, to the National Police Department, the Federal Criminal Police Office (BKA) that records the information.
Reference	Bundeskriminalamt OA21 (2006). Bundeslagebild Rauschgift 2005. Wiesbaden: Bundekriminalamt.
Remarks	From 1985 through 1990, the figures only refer to the former West Germany (the old Länder). Since 1991, the figures refer to the reunited Germany, which includes the old and the new Länder.
Estonia
Case Definition	EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification)
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure
Reference	Drug Situation "Estonia 2006" for the EMCDDA
Remarks
Ireland
Case definition	Deaths due to drug dependence. Deaths due to poisoning by opiates and related narcotics. From 2003 onwards,EMCDDA definition for General Mortality Registries (“Selection B” for ICD-9)
Technical information	“Selection B” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure	Cases are reported by regional registrars of births and deaths, who collect information from doctors, the police, and coroners, to the General Mortality Register at the Central Statistics Office (CSO).
Reference	General Mortality Register, Vital Statistics, Central Statistics Office
Remarks	The increase between 1995 and 1997 is (partly) due to an increased awareness of the need for more accurate information and reporting. In September 2005, Ireland set up a special register. The first data from this register will be available at the end of 2007. This register will be able to comply with the requirements of EMCDDA selection D
Greece
Case definition	EMCDDA standard definition for Special Registries (“Selection D”) In national terms: Deaths caused by overdose. Deaths caused by the synergic activity of different drugs.
Technical information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure	Cases of sudden death are notified to the police who refer the cases to the forensic department for autopsy and toxicology, which notifies the police of the results. Cases are then reported by local police units to Section C of the Directory of Public Security at the Ministry of Public Order (Hellenic Police). Statistics are reported by the National Anti-Drug Coordinative Unit, National Anti-Drug Intelligence Unit, Joint Secretariat.
Reference	Hellenic Police, 2006.
Remarks	44 additional reported deaths are still being investigated.
Spain
Case definition	The following codes (ICD-10) were selected from the General Mortality Registry: F11, F12, F14, F15, F16, F19, X42, X44, X62, Y12
Technical information	--
Data collection procedure	--
Reference	General Mortality Registry
Remarks	Note that until previous year another source of information was used: the Special Registry covering six large cities since 1983 (Barcelona, Bilbao, Madrid, Sevilla, Valencia, and Zaragoza). Cases are reported by medical pathologists for the Mortality Indicator at the Delegación del Gobierno para el Plan Nacional Sobre Drogas (DGPNSD). These especial registry can produce Selection D.
France
Case definition	The following codes (ICM 10) were selected from the General Mortality Registry: - F11-F12, F14-F16 and F19; X42 and Y12.
Technical information	--
Data collection procedure	Codification is based on the death certificate provided by the physician, and data are processed and facilitated by INSERM
Reference	General Mortality Registry
Remarks	Note that until previous year another source of information was used: Office Central pour la Répression du Traffic Illicite de Stupéfiants (OCRTIS) at the Ministry of the Interior. In this registry, the case definition was “Deaths due to overdose in the strictest sense of the term” or “Deaths occurring directly and immediately after consumption of drugs”
Italy
Case definition	EMCDDA standard definition for Special Registries (“Selection D”) In national terms: Deaths directly attributed to drug misuse (acute intoxication, overdose) and reported by local and special police units to the Central Drugs Directorate.
Technical Information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure	Cases are reported by local and special police units to the Central Drugs Directorate at the Ministry of the Interior.
Reference	Relazione "Annuale 2005" della Direzione Centrale per i Servizi Antidroga - Ministero dell'Interno
Remarks	--
Cyprus
Case definition	EMCDDA standard definition for Special Registries (“Selection D”)
Technical information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure
Reference	Cyprus NFP, 2006, 2006 Annual Report of EKTEPN, published.
Remarks
Latvia
Case definition	Cases according to the EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification)
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure
Reference	Health Statistics and Medical Technologies State Agency; Death Cause Database.
Remarks
Lithuania
Case definition	Cases according to the EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification) Cases codified with X41, X61 and Y11 (with T40 codes) are not included.
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure
Reference	Narkotiku kontroles depertamento prie Lietuvos Respublikos Vyriausybes metinis pranešimas: 2006 / parenge Narkotiku kontroles depatramentas prie Lietuvos Respublikos Vyriausybes. - Vilnius, 2006.- P. 207.-ISSN 1822-0576
Remarks	National definition is not officially approved. There are agreement with data providers, that “Drug-related deaths” refers to those deaths that are caused directly by the consumption of drugs of abuse. In 2005 data there is only one case difference between national definition and selection B (coded as X41 and T43.6)
Luxembourg
Case definition	Deaths caused by acute/direct reaction to the use of illegally acquired high risk consume (HRC) drugs.
Technical information	Fatal (accidental, intentional or of undetermined intention) intoxication caused by (a) the use of at least one illicitly acquired drug or (b)other drug(s) in case the victim has been known as a persistent user of illicitly acquired drugs. Death is due to the acute pharmacological and or toxicological effects(s) of the consumed substances(s)
Data collection procedure	All suspected deaths require a judicial enquiry, and after forensic evidence from autopsy, cases are reported by the local police to the Special Drug Section (SDU) of the Judicial Police. Data from the General mortality Registry are used for validation purposes.
Reference	Origer,A. (2006): National report on the state of the drugs problem - RELIS2005, NF CES/CRP-Sante Luxembourg.
Remarks	--
Hungary
Case definition	EMCDDA standard definition for Special Registries (“Selection D”) Cases of poisoning (where the concentration of the substance is considered to be lethal, based on Clarke’s: Isolation and Identification of Drugs, Pharmaceutical Press, London, 1986.) and cases where there is a casual relationship between the consumption of illegal substance(s) and the death. A toxicological confirmation is required in all cases.
Technical information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure
Reference	National Statistical Data Collection Programme, data corrected by the Institute of Forensic Medicine
Remarks
Malta
Case definition	Cases according to the EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification)
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure
Reference	National Mortality Registry - Department of Health Information 2005
Remarks
Netherlands
Case definition	EMCDDA definition for General Mortality Registries (“Selection B”) From 1985 through 1995, based on ICD-9 Since 1996, based on ICD-10
Technical information	“Selection B” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure	Cases are reported by municipal registrars, who collect information from physicians and coroners, to the Causes of Death Statistics at Statistics Netherlands.
Reference	Causes of death statistics, Statistics Netherlands (CBS)
Remarks	Only persons retrievable in the Dutch population register are included
Austria
Case definition	EMCDDA standard definition for Special Registries (“Selection D”)
Technical information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure.	Cases are reported by the police and hospitals to the Federal Ministry of Health and Women, which orders and checks the results of forensic examinations.
Reference	Suchtgiftbezogene Todesfälle-Statistik; Federal Ministry of Health and Women
Remarks
Poland
Case definition	Cases selected according to ICD 10 – codes: F11-12, F14-16, F19, X42, X62, Y12, X44, X64, Y14
Technical information	The additional T codes are not available. Missing X41, X61 and Y11 (with T43.6) and included X44, X64, Y14 (considered to include relevant cases in Poland).
Data collection procedure
Reference	Ad-hoc data extraction from General Mortality Registry for Reitox National Focal Point
Remarks
Portugal
Case definition	A person whose post-mortem toxicological analysis is positive for any illicit drug of abuse (whatever was the cause of death –overdose, traffic accident…-).
Technical information	The proportion of cases with positive toxicology and information on presumed cause of death suspected to be acute drug-related deaths were: 58% (2005), 51% (2004), 44% (2003), 58% (2002) and 73% (2001) The cases refer to Lisbon, Oporto and Coimbra regions
Data collection procedure	Cases are reported to the delegations at the three Forensic Institutes of the Ministry of Justice.
Reference	Relatório Anual do IDT - 2005
Remarks	Due to under-reporting in previous Annual Reports, more cases are reported in the Annual Report since 1995.
Romania
Case definition	Cases according to the EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification) Drug-related deaths refers to those deaths that are caused directly by the consumption of drugs of abuse
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure
Reference	Ad hoc data extraction by National Focal Point from General Mortality Registry for the 2006 Reitox National Report
Remarks	Coverage is only Bucharestand few neighbouring counties.
Slovenia
Case definition	Cases according to the EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10 classification) Deaths due to drug abuse; that means deaths happening during the time drugs is affecting the organism (accidental poisonings, intentional poisonings, poisonings of undetermined intent)
Technical information
Data collection procedure	From 2002 onwards cases were obtained by linkage of four different databases: i) General Mortality Registry, ii) Police database, iii) First Treatment Demand database and iv) Toxicology Department at the Institute of Forensic Medicine
Reference	Ad-hoc data extraction from General Mortality Registry for Reitox National Focal Point
Remarks	Information of the GMR is completed with Forensic and Toxicology data, with police data and with First Treatment Demand data
Slovakia
Case definition	EMCDDA standard definition for Special Registries (“Selection D”)
Technical information	“Selection D” is described in the protocol EMCDDA-DRD Standard, version 3.0 (for Special Registries)
Data collection procedure
Reference	Ad-hoc data extraction from the Special Registry
Remarks
Finland
Case definition	From 1988 through 1995 (ICD-9, Finish adaptation), deaths due to identified drugs by: Diseases (dependence, harmful use, substance induced brain syndrome accidental poisoning events of undetermined intent. From 1996 onwards, EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10)<
Technical information	From 1988 through 1995 cases selected by ICD-9 (Finish adaptation. See Finish National Report 2003, Appendix 7) From 1996 onwards, “Selection B” for ICD10, which is described in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure	Collection and processing of causes of death statistics at Statistics Finland.
Reference	Statistics Finland, Cause of Death Statistics (unpublished data)
Remarks	The Finish adaptation of ICD-9 did not allow the implementation of “Selection B” of DRD standard protocol. For these reason, Selection B is only available from 1996 onwards, where ICD-10 was implemented. The breach of trends observed between 1995 and 1996 could be in part due to change from ICD-9 to ICD-10 and to change from national definition to Selection B
Sweden
Case definition	EMCDDA definition for General Mortality Registries (“Selection B” for ICD-10) Cases codified with T40.4 are excluded (in Sweden are mainly due to dextropropoxifen poisonings)
Technical information	“Selection B” is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)
Data collection procedure	Cases are reported by physicians to the Cause of Death Register at Statistics Sweden and are reported and published by the Epidemiological Centre of the National Board of Health and Welfare (NBHW).
Reference	National Death Cause Registry (Run by the Epidemiological Centre, at the NBHW)
Remarks	In 2003 “national case definition” was adapted to the EMCDDA definition (Selection B) with the exception described
United Kingdom
Case definition	Deaths due to drug dependence. Deaths due to nondependent abuse. Deaths due to accidental, suicidal, or undetermined poisonings.
Technical information	England and Wales, Northern Ireland and Scotland (“ONS standard definition”) Based on ICD-9 Classification (until 1999 in Scotland and until 2000 in England and Wales and N. Ireland): 292 (Drug psychoses), 304 (Drug dependence), 305.2 - 9 (Non-dependent abuse of drugs), E850 - E858 (Accidental poisoning by solid or liquid substances - drugs, medicaments, and biologicals), E950.0 - 5 (Suicide and self-inflicted poisoning by solid or liquid substances - drugs and medicaments), E980.0 - 5 (Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted - drugs and medicaments), E962.0 (Assault by poisoning - drugs and medicaments) Scotland (From 2000) and England & Wales and N Ireland (From 2001) (“ONS standard definition” Based on ICD-10 Classification: F11-F16, F18, F19, X40-X44 (accidental poisoning), X60-X64 (intentional self poisoning), Y85 (assault by drugs, medicaments and biological substances), Y10-Y14 (poisoning undetermined intent)
Data collection procedure	Cases from England and Wales are reported to the Office for National Statistics (ONS), cases for Northern Ireland are reported to the General Register Office (Northern Ireland) and cases for Scotland are reported to the General Register Office (Scotland).
Reference	See Health Statistics Quarterly, Nos 5, 7, 9, 11, 13, 17, 21 and 25, ONS 200, 2001, 2002, 2003, 2004 & 2005
Remarks	Drug Strategy Definition In 2001an additional national definition was developed that is referred to in these reports as the “UK Drug Strategy Definition” The UK Drug Strategy Definition is a more restrictive extract from the ONS description that focuses on drugs controlled under the Misuse of Drugs Act of 1971. Drugs controlled by the Misuse of Drugs Act include class A, B and C drugs. A description of this definition is given in the Annexed Box 1) “UK Drug Strategy Definition”. This definition produces estimates similar to the EMCDDA Standard “Selection B” Figures reported on the basis of this definition are presented separately in the online Statistical Table “Number of acute drug-related deaths recorded in EU countries (according to national definitions)”. National Programme on Substance Abuse Deaths (np-SAD) In addition, in the UK there is a Special Registry on drug-related deaths within the National Programme on Substance Abuse Deaths (np-SAD). This registry is based on data submitted voluntarily by coroners. This registry can produce estimates for the EMCDDA Standard “Selection D” A description of this Special Registry is given in the Annexed Box (2) “UK np-SAD”
Norway
Case definition	Death due to misuse of illegal drugs (Drug dependence or poisoning). mental and behavioural disorders due to drug use accidental or undetermined poisoning by drugs of abuse
Technical information	Up to 1996, cases were selected by ICD-8 and ICD-9 codes (304). Since 1996, the ICD-10 codes used (underlying causes) are: F11-F12, F14-16, F19, X42 and Y12 in combination with T40.0-9 X41 and Y11 in combination with T43.6.
Data collection procedure	Registry of Causes of Death, from Statistics Norway. Data from Statistics Norway are manly based on autopsy reports from the National Institute of Forensic medicine.
Reference	Statistics Norway
Remarks	National definition is an approximation to “Selection B” for ICD-10 but excluding “intentional poisoning” (X61 and X62)

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