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.

Fatal poisoning in Nordic drug addicts in 2002.

The present study from 2002 includes medicolegally examined fatal poisonings among drug addicts in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition "drug addict" is applied by the participating countries. The number of deaths, age, sex, place of death, main intoxicant and other drugs present in the blood are recorded in order to obtain national data, as well as comparable Nordic data and data comparable to earlier studies from 1997 and 1991. The Icelandic results are commented on separately due to the low number of cases. The most fatal overdoses are seen in Norway, in both the death rate (number per 100,000 inhabitants=8.44) and in absolute number (n=232). The comparable figures for the other four countries are Denmark 5.43 (n=175), Iceland 3.6 (n=6), Finland 2.93 (n=94) and Sweden 2.56 (n=136). In earlier studies from 1991 and 1997, the highest death rate is seen in Denmark, with Norway as number two. Denmark is the only country where the death rate decreases from 1997 to 2002. A relatively large increase in deaths in the younger age groups (<30 years) is noted from 1997 to 2002, except in Denmark, where only a small increase in overdose deaths in very young people (15-19 years) is observed. Females account for 12-20% of the overdoses (three out of six deaths in Iceland). Relatively fewer deaths are recorded in the capital areas in 2002 than in 1997 and 1991, suggesting more geographically widespread drug use in the Nordic countries. Heroin/morphine is the single most frequently encountered main intoxicant, varying from 10% of the cases in Finland to 72% of the cases in Norway. Finland differs from the other countries in that a high percentage of the fatal overdoses in Finland are not caused by an illicit drug; buprenorphine overdoses are seen, and relatively few deaths resulting from heroin are seen. Methadone is the main intoxicant in 41% of the Danish overdose cases, 15% of the Norwegian cases, 4% of the Swedish cases and none of the Finnish overdose cases, an observation probably linked to different national prescription rules for methadone. The analytical screening reveals extended polydrug use. Frequently seen substances, in addition to the main intoxicant are amphetamine, tetrahydrocannabinol (THC), benzodiazepines and ethanol.

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.

Fatal combined intoxication with new antidepressants. Human cases and an experimental study of postmortem moclobemide redistribution.

Three cases are presented in which death was caused by suicidal intoxication with moclobemide in combination with a selective serotonin reuptake inhibitor. Both antidepressant drug types are considered to be relatively safe with regard to lethal overdose. However, the combination may cause the serotonin syndrome, a condition with a high mortality rate. In one of the cases, there was clinical information consistent with the serotonin syndrome, in the two other cases, there was no information of the clinical course. Postmortem redistribution of the selective monoamine oxidase inhibitor moclobemide was investigated in a rat model. Postmortem concentrations in blood from the vena cava and the heart were found to be in good accordance with antemortem concentrations. Postmortem concentrations in vitreous humour and various tissues were also measured. The apparent volume of distribution was calculated to be 0.95 +/- 0.10 l/kg, which is in the same range as that reported in man.

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 10(5) 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.

Drug addict deaths in the Nordic countries: a study based on medicolegally examined cases in the five Nordic countries in 1991.

The study includes medicolegally examined deaths among drug addicts in 1991 in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition of 'drug addict' was applied by the participating countries. The greatest number of drug addict deaths per 10(5) inhabitants was observed in Denmark followed, in descending order by Norway, Sweden, Finland and finally Iceland with only four deaths. The main difference between the countries was found in the number of fatal poisonings. The distribution according to geographical regions showed that about half of all drug addict deaths occurred in the metropolitan areas. Of the capitals, the greatest number of fatal poisonings per 10(5) inhabitants was seen in Oslo, followed by Copenhagen with a similar number, Stockholm with only the half, and Helsinki with a quarter. Heroin/morphine dominated as cause of death in fatal poisonings in Norway and Sweden. In Denmark, heroin/morphine caused about half of the fatal poisonings only, and nearly one third of the fatal poisonings was caused by methadone. Except for two cases in Sweden, methadone deaths were not seen in the other Nordic countries. Amphetamine caused one tenth of the fatal poisonings in Sweden. In Finland only one tenth of the deaths were caused by heroin/morphine and more by codeine, ethylmorphine and different drugs and poisons not classified in Single Convention on Narcotic Drugs 1961 or the International Convention on Psychotropic Substances 1971. A widespread use of alcohol, cannabis and benzodiazepines, diazepam especially, was seen in all the countries.

Slow progression to AIDS in intravenous drug users infected with HIV in Norway.

STUDY OBJECTIVE: To study the rate of progression to AIDS and to death, and the causes of death among intravenous drug users in Norway. DESIGN: This was a prospective study. The study population was followed from diagnosis of HIV seropositivity until death or the end of the study period. The mean follow up was 56 months (range 1-73 months). SETTING: Subjects were recruited from a public HIV test clinic and followed by linkage to the National AIDS Registry and the National Cause of Death Registry. PARTICIPANTS: A total of 131 HIV positive intravenous drug users were included. The study population represented 75% of all intravenous drug users who had been diagnosed as HIV positive in Norway before 1987. None were lost to follow up. MAIN RESULTS: Four years after study entry, 3% (95% confidence interval, 0, 6%) had developed AIDS, while 15% (95% CI, 9, 21%) had died. Of the 25 subjects who died during the follow up period, 21 died from unnatural causes. Drug overdose accounted for 17 of these deaths. AIDS was the cause of death of three subjects only. Age more than 30 years at entry to the study was associated with short survival. CONCLUSIONS: These results suggest that the progression rate to AIDS in intravenous drug users is slow.

[Mortality among drug addicts 1980-1989. A comparative study of fatal poisonings among drug addicts examined at the institutes of forensic medicine in Arhus and Oslo]. / Narkomandødsfald 1980-1989. En sammenlignende undersøgelse af forgiftningsdødsfald blandt narkomaner undersøgt ved de retsmedicinske institutter i Arhus og Oslo.

Cases of fatal poisonings among drug addicts examined at the Institutes of Forensic Medicine in Aarhus (n = 238) and Oslo (n = 263) are compared and discussed on the basis of the availability of illicit and medical drugs during the 1980s. The annual number of deaths in age groups over 30 years increased in both countries. Heroin and/or morphine-related deaths comprised one-third of the Danish material compared with three-quarters of the Norwegian material. The registered medical drugs propoxyphene, methadone and ketobemidone accounted for half of the Danish cases. Alcohol and benzodiazepines were present in more than one-third of the cases in both countries.

Drug-related deaths during the 1980s. A comparative study of drug addict deaths examined at the institutes of forensic medicine in Aarhus, Denmark and Oslo, Norway.

Cases of fatal poisoning among drug addicts examined at the institutes of forensic medicine in Aarhus, Denmark (n = 238) and Oslo, Norway (n = 263) are compared and discussed on the basis of the availability of illicit and medical drugs during the 1980s. The annual number of deaths among drug addicts in age groups over 30 years increased, but there was no increase in the number of deaths among younger drug addicts in either country. More than 80% of the drug addicts in both samples were men. Heroin-/morphine-related deaths comprised three-quarters of the Norwegian material compared with one-third of the Danish material. The registered medical drugs propoxyphene, methadone and ketobemidone accounted for half of the Danish cases but only a small number of the Norwegian cases. Amphetamine caused few deaths in either country. Alcohol and benzodiazepines were present in more than one-third of the cases in both countries, indicating frequent use of these substances.

[Deaths caused by antidepressive agents and neuroleptics. Risk groups illustrated by a forensic material]. / Dødsfall forårsaket av antidepressiva og neuroleptika. Risikogrupper belyst ved et rettsmedisinsk materiale.

At the Institute of Forensic Medicine, University of Oslo, legal autopsy was performed on 153 persons who died from poisoning by neuroleptics and/or antidepressants from 1986 to 1989. In one third of the cases, only neuroleptics were found at autopsy, and in little less than half of these cases the post mortem blood concentrations were considered rather low in relation to the fatal outcome. A larger proportion of alcohol abusers were found in the group with low post mortem concentrations of neuroleptics than in the rest of the material. This group contained mainly men and was further characterized by a high proportion of unintentional deaths. In the light of these facts the authors speculate whether neuroleptics represent increased risk of sudden death among alcohol abusers. The deaths due to an overdose of antidepressants were mostly suicides, and involved high post mortem blood concentrations of the drugs.

Haptoglobin subtypes in Norway and a review of HP subtypes in various populations.

Isofocusing and immunoblotting of reduced serum samples identify the common haptoglobin alpha-chain variants 1S, 1F, 2FS, 2SS, 2FF, 3, as well as several rare alpha- and beta-chain variants. The gene frequencies found in 6,668 unrelated persons involved in Norwegian paternity cases were: HP*1S: 0.22, HP*1F: 0.16, HP*2FS: 0.58, HP*2SS: 0.04, HP*2FF: 0.004, HP*3: 0.0004, other HP* alpha variants: 0.0004, HP* beta variants: 0.0008. The corresponding gene frequencies in 153 unrelated Norwegian Saamis (Lapps) were: HP*1S: 0.19, HP*1F: 0.07, HP*2FS: 0.70, HP*2SS: 0.04. Norwegians and Norwegian Saamis differed both in phenotype and allele distribution. An earlier Norwegian population study has shown a lower HP*1 frequency in the north than in the south. This regional difference in haptoglobin gene distribution was reflected in the present material as a lower 1F frequency, indicating a Saamish influence in northern Norway. Furthermore, the relatively low 2FF frequency in the north coincides with the lack of observed 2FF genes in the Saamish population. Non-Scandinavians involved in Norwegian paternity cases did not differ from the rest of the material. A review of published haptoglobin gene frequencies shows the 1F frequency to be a good indicator of ethnic origin, and that 2FF and 2SS frequency determinations may also be valuable in genetic population studies.

[Opiate-related deaths among drug addicts. Autopsy findings, circumstances and forensic toxicologic analyses regarding deaths]. / Opiatrelaterte dødsfall hos stoffmisbrukere. Obduksjonsfunn, omstendigheter og rettstoksikologiske analyser ved dødsfallene.

The study is based on autopsies of 86 drug addicts who died during the period 1986-88 after an opiate ingestion. The average postmortal concentration of morphine after ingestion of heroin was 0.88 mumol/l blood, ranging from 0.0 to 3.1 mumol/l, which is substantially lower than values that have been reported from patients receiving morphine intravenously as an analgetic. Postmortal blood concentrations of morphine were significantly lower among deceased with only fresh needle marks than among deceased with both old and fresh needle marks, suggesting that a pause in the drug abuse may have led to a decrease in opiate tolerance. There was no relationship between the detected organ pathology finding of other ingested substances and the postmortal concentration of morphine. In 20% (n = 17) of the deceased the HIV-antibody test was positive and the average blood concentration of morphine was higher in this sub-population than in the rest of the cases.

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.

[Fatal poisoning in Scandinavia--narcotic addicts are a high-risk group]. / Dödliga förgiftningar i Norden--narkomaner en utsatt grupp.

This study on fatal intoxications in the Nordic countries indicates an over-representation of drug addicts in Denmark, Norway and Sweden. All cases of fatal intoxications in persons 15-34 years of age submitted to medicolegal autopsy and subsequent toxicological examination in the Nordic countries during 1984-1985 included in the study. A comparison between the Nordic countries is possible because the same definition of a drug addict and classification of drugs are used. The numbers of fatal intoxications among drug addicts per 10(5) population were 6.3 in Denmark, 2.1 in Norway, 1.3 in Sweden, 0.6 in Finland and none in Iceland. About 70 per cent of the drug addicts in Norway and Sweden died from heroin/morphine intoxication. In Denmark only 55 per cent of the drug addicts died from heroin/morphine and 36 per cent died from overdoses of the legal drugs methadone, dextropropoxyphene and ketobemidone.

Forensic aspects of haptoglobin: electrophoretic patterns of haptoglobin allotype products and an evaluation of typing procedure.

A procedure used for haptoglobin (Hp) typing in paternity cases has been evaluated. All serum samples have been subtyped with a one-dimensional isoelectric focusing/immunoblotting method, and samples with rare or questionable patterns have been further examined by two-dimensional electrophoresis with isoelectric focusing in the first dimension followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis in the second dimension. The electrophoretic Hp-patterns of common and rare alpha- and beta-chain variants are shown, including allotype patterns of two new beta-chain variants and three new alpha-chain variants. Retyping of nearly 2000 individuals at intervals between 1 to 12 months revealed a typing error frequency of about 0.3%, which is considered acceptable, provided new blood samples are required in every case of paternity exclusion. Comparison of typing results obtained with the present procedure and with routine starch gel electrophoresis in more than 5000 serum samples gave conflicting results in 6 samples. The sensitivity of the described one-dimensional subtyping method was slightly better than that of starch gel electrophoresis. In 4110 unrelated individuals, involved in cases of disputed paternity the Hp 2SS 0.038, Hp 2FF 0.004, and Hp 3 (Johnson) 0.0005. These allele frequencies give a theoretical paternity exclusion rate of 32.5%, which is in accordance with the observed rate in 2200 paternity cases with more than 600 non-fathers. It is concluded that the present procedure represents a definite improvement for Hp subtyping in practical paternity diagnostics. Preliminary results with retyping of weak Hp patterns using a staining technique involving the biotin/avidin complex indicate that the sensitivity of the one-dimensional subtyping method may be substantially increased.(ABSTRACT TRUNCATED AT 250 WORDS)