1. Factors associated with fatal overdoses in Oslo 2006-2008 Linn Gjersing, Thomas Clausen, Jørgen Bramness, Helge Waal, Stian Biong & Edle Ravndal

2. Definitions Drug-induced deaths –Deaths directly due to use of illegal substances, although these often occur in combination with other substances such as alcohol or psychoactive medicines. These deaths occur generally shortly after the consumption of the substance Overdoses or poisonings (EMCDDA 2009) Universitetet i Oslo

3. Definitions Drug-induced deaths –Deaths directly due to use of illegal substances, although these often occur in combination with other substances such as alcohol or psychoactive medicines. These deaths occur generally shortly after the consumption of the substance Overdoses or poisonings Drug-related deaths –Drug-induced deaths –Deaths caused indirectly by the use of drugs, usually by concurrent factors related to the method of use Motor vehicle accidents, violence, suicide (EMCDDA 2009) Universitetet i Oslo

4. Background Universitetet i Oslo EMCDDA 2009 s 84

5. Background City council of Oslo –March 2009 –Investigate all overdoses in Oslo and identify possible causes Norwegian Centre for Addiction Research (Seraf) –November 2009 –To identify all drug-induced deaths in Norway 2006-2008 –To assess the drug-induced deaths in Oslo Assess toxicology Place of death (street, low threshold housing facilities, hospitals) Possible causes Role of primary and secondary health care services Universitetet i Oslo

6. Methods Epidemiological study –Cross-linked Qualitative research study Universitetet i Oslo

7. Ethics The project has received all approvals –Ethical committee –Data inspectorate –Oslo University Hospital –The Higher Prosecuting Authority Universitetet i Oslo

8. Cases Overdoses –European Monitoring Centre for Drugs and Drug Addiction’s (EMCDDA) definition –T42.4 benzodiazepines Alcohol –F100 Acute intoxication –X45 Accidental poisoning –X65 Intentional poisoning < 70 år Universitetet i Oslo

9. Underlying cause of deaths EMCDDA’s definition Disorders F11 Opioids F12 Cannabinoids F14-F16 Cocaine, other stimulants, hallucinogens F19 Multiple drug use Accidental poisoning X41* antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified: Antidepressants, barbiturates, hydantoin derivatives, iminostilbenes, methaqualone compounds, neuroleptics, psychostimulants, succinimides, oxazolidinediones, tranquillizers X42** narcotics and psychodysleptics [hallucinogens], not elsewhere classifide: cannabis (derivatives), cocaine, codeine, heroin, lysergide [LSD], mescaline, methadone, morphine, opium (alkaloids) X44 other and unspecified drugs, medicaments and biological substances: agents primarily acting on smooth and skeletal muscles and the respiratory system, anaesthetics (general)(local), drugs affecting the: cardiovascular system, gastrointestinal system, hormones and synthetic substitutes, systemic and haematological agents, systemic antibiotics and other anti-infectives therapeutic gases, topical preparations, vaccines, water-balance agents and drugs affecting mineral and uric acid metabolism Intentional poisoning X61* X62** X64 Poisoning undetermined intent Y11* Y12** Y14 *T43.6 Psychostimulants with abuse potential ** T40.0-.9 Narcotics and psychodysleptics

10. Identification of cases General Mortality Registry –Cause of death –Contributing cause of death –Age –Date of death –Residency according to Directory of Residents –Region of death –Place (hospital, home, street etc) Universitetet i Oslo

11. Registries The Incarceration Registry –2/3 time, end of time, date of release Registry for Drug-related Deaths –Toxicology reports The Drug Prescription Registry –The Norwegian institute of Public Health –Prescribed medications previous 12 months before death Universitetet i Oslo

12. Patient records Hospitals Community health care services Outpatient emergency clinics Low threshold facilities –Housing, street clinics Outreach services Social welfare offices Treatment centres Detoxification units –Salvation army, Bymisjonen, P22, Fredheim, Tyrilistiftelsen Universitetet i Oslo

13. Preliminary results Deaths in Oslo 200620072008Total EMCDDA deaths 1067382261 Oslo residents71%63%76%70% Women28%22%21%24% Median age Women 44 yrs (20-57) 43 yrs (18-59) 47 yrs (19-59) 44 yrs Men 34yrs (22-68) 37yrs (22-56) 40yrs (19-64) 36 yrs Universitetet i Oslo

14. Age of death <25 yrs26-36 yrs37-50 yrs> 50 yrs Total32 (12%)93 (36%)97 (37%)39 (15%) Women22%14%28%41% Universitetet i Oslo

15. Place of death 200620072008Total At home41%38%28%36% Other places35%33%24%31% Hospitals or institutions8%11%9% Unknown16%18%39%24% Universitetet i Oslo

16. Type of deaths 200620072008Total Disorders3 (3%)1 (1%)2 (2%)6 (2%) Accidental93 (88%)63 (86%)71 (87%)227 (87%) Women26%16%18%47 (21%) Intentional10 (9%)9 (12%)9 (11%)28 (11%) Women60%67%33%15 (54%) Universitetet i Oslo

17. Release from prison 200620072008Total 6 months before death9 (9%)5 (7%)5 (6%)19 (7%) No of women1113 Time in prison (range)162 days (0-181) 176 days (39-179) 127 days (58-182) 162 days (0-182) Time from prison release (range) 20 days (1-182) 6 days (3-143) 55 days (0-124) 20 days (0-182) Universitetet i Oslo

18. Age and death after prison release <25 yrs26-36 yrs37-50 yrs> 50 yrs Total no21250 Universitetet i Oslo

19. Preliminary conclusions 70% Oslo residents 20% women Women older than men Most deaths accidental First month after prison release critical Majority of those that die after prison release were between 26 and 36 yrs Universitetet i Oslo