Drug-induced deaths – the current situation in Europe (European Drug Report 2023)
Drug-induced deaths are those that are directly attributable to the use of drugs. On this page, you can find the latest analysis of drug-induced deaths in Europe, including key data on overdose deaths, substances implicated and more.
This page is part of the European Drug Report 2023, the EMCDDA's annual overview of the drug situation in Europe.
Last update: 16 June 2023
Diverse opioids causing overdose deaths among ageing polydrug-using population – response implications
Drug-induced deaths are those that are directly attributable to the use of drugs. This is clearly a key area for understanding the harms the use of illicit drugs can cause, but it is also a complex one where, for both methodological and data availability issues, there are considerable areas of uncertainty and any conclusions must be made with caution. This is especially true when interpreting recent and short-term trends, considering that data for the current reporting year (2021) were available for only 22 of the 29 reporting countries. It should also be noted that, for methodological reasons, the numbers of drug-induced deaths identified are likely to represent minimum estimates; that reporting capacity varies between countries, meaning that national comparisons should be made with caution; and that a lack of detailed toxicological information in several countries currently means that our understanding of the role different drugs play in driving rates of drug-induced deaths over time is limited. Moreover, estimates of drug-induced deaths only represent a share of the overall mortality associated with drug use, as they do not include mortality from accidents, violence, suicides by means other than drug poisoning or chronic disease, where drug consumption may have played a role.
Despite these limitations a review of the current information available in this area is informative. It highlights the fact that opioids, usually in combination with other substances, remain the group of substances that are most commonly implicated in drug-induced deaths. Overall, trends in deaths where opioids are implicated appear stable, but the proportion of deaths in older age groups is increasing. Importantly, heroin remains involved in many opioid-related deaths, but the data available suggest it is now present in the majority of overdose deaths only in a few countries, and other opioids are now playing a more important role. The data also suggest the deaths where stimulants are implicated are rising in some countries, although with the important caveats that these are likely to be particularly prone to under-reporting and stimulants are often implicated in deaths where other drugs, including opioids, are also present. Stimulants also appear to be more commonly implicated in deaths among younger age cohorts. Viewing the data as a whole highlights the important role polydrug use plays in drug-related mortality and also a corresponding need for improved toxicological information to understand this issue better. For example, the data are limited but do suggest that, at least in some countries, benzodiazepines are also found to be present in the majority of drug-induced deaths with opioids involved. Benzodiazepines are central nervous system depressants and can potentiate the effects of other depressants such as opioids, alcohol and some prescription medicines. However, the implications of this for overdose reduction need to be better understood.
In 2021, the number of reported drug-induced deaths increased slightly in some EU countries and fell in others. The provisional estimate for the overall number of drug-induced deaths also rose slightly in total, but this observation should not be over-interpreted, as a number of countries with large populations have yet to provide data, and the increase is mostly explained by higher figures reported from Germany, where further analysis is needed to understand how this should be interpreted.
Available data suggest polydrug toxicity is the norm and that opioids other than heroin, including methadone and, to a much lesser extent, buprenorphine, oxycodone and fentanyl, are associated with a substantial share of overdose deaths in some countries. Potent synthetic opioids, such as the fentanyl derivative carfentanil and benzimidazole opioids (nitazenes), consumed in the context of polydrug use involving amphetamines, medicines and other drugs, do not currently figure prominently in the data available at EU level but are observed to be causing an increasing number of deaths in the Baltic countries, including Estonia and Lithuania in 2021. In Latvia, both the national statistics and the forensic registers reported a three-fold increase in the number of drug-induced deaths in 2022 compared with 2021. Part of the reported increase relates to improvements in laboratory capacity since June 2022, and year-on-year changes need to be interpreted with caution. However, recent shifts in the opioid market may also have played a role in this increase: while polydrug use dominates, xylazine was identified in one fatality in 2022, and nitazenes appear to be involved in a number of fatalities from December 2022, when these substances first became detectable, and through the early months of 2023. National data also suggest that acute drug toxicity presentations involving potent synthetic opioids increased in 2022 in emergency services in Latvia.
The often hidden, illegal and stigmatised nature of high-risk drug use makes preventing and responding to overdoses and deaths complex. The number of overdose deaths among 50- to 64-year-olds increased by 69 % between 2012 and 2021. A review of 36 studies covering 13 EU countries and Norway estimated that the excess risk of death among people engaged in high-risk drug use ranged from 3 times to more than 20 times that of people of the same age and sex in the general population. The excess risk is not only associated with overdose. Other causes of death where drug use may be implicated are also important but are not easy to quantify at the EU level: these include accidents, violence, cardiovascular and respiratory diseases, cancer and infections such as HIV and viral hepatitis, and suicide.
Cases of deliberate overdose may be included in the number of drug-induced deaths provided by some countries, further complicating the analysis of data in this area. Determining the intention of a person who has died from a drug overdose can be challenging. Many overdose deaths are reported as accidental, and others have an undetermined intent. However, in the data available from some countries, a high proportion of reported overdose deaths (one in six overall) were classified as intentional (i.e. with a suicidal intent). In all countries where such data are available, the proportion of overdose deaths with a suicidal intent was higher among women. In a few countries, more than a third of the reported overdose deaths among women were classified as having a suicidal intent.
Changes in both the population of people who inject opioids and the types of substances they are using create new and greater challenges for interventions designed to reduce overdose death. These include the challenge to develop differentiated programmes to target the needs of different groups and, particularly, to be sensitive to the necessity to configure services to be appropriate to the needs of different age cohorts. Enrolment in opioid agonist treatment is strongly evidenced as a protective factor against opioid overdose and some other causes of death, yet coverage and access issues still exist in many countries. Similarly, the evidence is growing that the increasing availability of opioid antagonists can play an important role in preventing fatal overdoses. However, again, the extent to which this approach is available varies between and within countries. The implementation of naloxone programmes, including pilot projects, to prevent overdose deaths was reported by 16 European countries up to 2022. Changing consumption patterns may also require services to review current delivery protocols. Overdoses involving potent synthetic opioids may require, for example, the administration of multiple doses of naloxone to reverse the opioid effects. Drug consumption rooms are provided in part as a response to reducing overdose mortality in some countries, and are now operational in 10 EU countries and Norway (see the section Harm reduction — the current situation in Europe). Where multicultural and new immigrant populations are present, increased own-language harm reduction messaging is desirable for high-risk drug users.
Key data and trends
- The mortality rate due to overdoses in the European Union in 2021 is estimated at 18.3 deaths per million population aged 15 to 64.
- It is estimated that at least 6 166 overdose deaths involving illicit drugs occurred in the European Union in 2021 (5 796 in 2020). This total rises to an estimated 6 677 deaths if Norway and Türkiye are included (6 434 in 2020). This number is provisional and is an underestimate, due to reporting delays and other limitations in reporting capacity apparent in some countries.
EU+2 refers to EU Member States, Norway and Türkiye.
- Opioids, including heroin and its metabolites, often in combination with other substances, were estimated to be present in three quarters (74 %) of fatal overdoses reported in the European Union. It should be noted that multiple drugs are commonly found in toxicology reports from drug-induced deaths.
- The data available have limitations in respect to quality and coverage, however, the information available suggests that heroin was only present in the majority of overdose deaths in a relatively small number of EU countries. A significant share of overdose deaths was reported by Austria (67 %), Italy (56 %), Ireland (46 % in 2017), Poland (44 % in 2016) and Romania (43 %). In 7 other European countries, heroin was found in approximately a quarter to a third of reported overdose deaths: Portugal (37 %), Slovenia (33 %), Denmark (36 %), France (33 % in 2020), Türkiye (32 %), Spain (28 % in 2020) and Norway (23 %). In 2021, in the north of Europe, less than 1 in 6 overdose deaths in Finland, Sweden and in the Baltic countries was reported to involve heroin.
- Stimulants other than cocaine, including amphetamine and methamphetamine, are involved in many deaths, often alongside opioids. Out of 21 countries with post mortem data available for 2021, 19 reported deaths where stimulants were involved. Germany (348 cases) Türkiye (184), Finland (49), Norway (47), Austria (41), Sweden (36) and Denmark (35) reported the highest numbers of deaths involving these stimulants. The total numbers of such cases for the 17 countries that reported comparable data in all three years were 435 in 2019, 512 in 2020 and 477 in 2021. These data are provisional and should be regarded as an underestimate. Beyond these drug-induced deaths, other stimulant deaths, for example those associated with cardiovascular problems, may go undetected.
- The number of overdose deaths reported among those aged 50–64 increased by 69 % between 2012 and 2021 (by 31 % among women and by 86 % among men).
- In half of the 22 countries with post mortem toxicological data available for 2021, at least 1 in 5 drug-induced deaths involved methadone. The medicine was often identified with other opioids, alcohol and other medicines such as benzodiazepine. Buprenorphine was identified in 60 % of the drug-induced deaths reported in Finland in 2021, and 9 % of the deaths reported by the special register in France in 2020. In all other countries with available data, buprenorphine was reported in less than 5 % of fatal overdose cases or not reported at all.
- Tramadol, an opioid medicine used to treat moderate to severe pain, was involved in less than 5 % (93) of reported overdose deaths in 12 European countries in 2021. However, it was involved in 42 % of the deaths reported by the French registry of medicine misuse-related deaths, suggesting that improving surveillance and toxicological investigation might increase the detection of deaths associated with opioid medicines.
- Where available, data indicate that fentanyl and fentanyl derivatives were linked to 49 deaths in 2021 in Europe. With the inclusion of data from Germany, this number may be higher, rising to a minimum estimate of 137 deaths. Preliminary analysis, however, suggests that many of these fatalities might be associated with diverted fentanyl medicines rather than illicit fentanyl.
- Preliminary 2022 data from Estonia indicate that the number of drug-induced deaths involving new synthetic opioids doubled to 79 deaths (39 in 2021). The share of deaths related to new synthetic opioids involving benzimidazoles increased from 10 % (4/37) in 2021 (isotonitazene) to 37 % (29/79) in 2022 (protonitazene, metonitazene and isotonitazene).
- In countries with available data, between 2020 and 2021, oxycodone was reported as being involved in 103 drug-induced deaths, mainly in Denmark, Estonia, France and Finland.
- Cohort studies reveal overall far higher all-cause mortality among people that use drugs. Examples include the finding that between 2018 and 2022 the excess mortality risk of people who inject drugs in two Greek cities was 17 times that of the general population. Between 2010 and 2019, patients with opioid use disorders in Croatia had an excess mortality risk 17 times higher in females and 8 times higher in males compared with the general population.
Although information on toxicology is not available for data reported through the general mortality registers (preferred source) in Spain and Poland, available data from the alternative source (forensic special mortality registers) suggest that most drug-induced deaths in these countries involved opioids.
- In 2021, the proportion of overdose deaths involving benzodiazepines increased in a number of countries in which data were available, although the numbers were sometimes small. In some countries and where data exist, benzodiazepines are detected in a relatively large share of overdose deaths, including in over half of cases in Denmark (120), Luxembourg (4), Austria (119), Portugal (43) and Finland (127).
For Greece, the most recent data available for this analysis were from the general mortality register (2017–2019).
- Few countries report information on the involvement of pregabalin in drug-induced deaths. Among those that do, Finland reported an increase from 63 deaths in 2020 to 90 in 2021.
- Deaths linked to synthetic cannabinoids declined to 16 in Hungary in 2021 (34 in 2020) and to 46 in Türkiye in 2021 (49 in 2020). Seven countries reported 26 deaths with synthetic cathinones involved in 2021, mainly in Austria (7 cases), Hungary (7 cases) and Finland (6 cases). Where data were available for 2020 and 2021, the numbers were stable, except in Austria, where only 2 cases were reported in 2020.
Source data
The data used to generate infographics and charts on this page may be found below.
About this page
Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2023), European Drug Report 2023: Trends and Developments, https://www.emcdda.europa.eu/publications/european-drug-report/2023_en
Identifiers:
HTML: TD-AT-23-001-EN-Q
ISBN: 978-92-9497-865-3
DOI: 10.2810/161905