Special Register in Germany: Overdose including prescription opioids and new developments in the reporting system

Dr. A. HeinemannInstitute of Legal Medicine

University Medical Center Hamburg-Eppendorf , Germany

German SR

� German SR in charge of Federal Criminal Police Office (Bundeskriminalamt)

� 16 regional Land Offices of Criminal Investigation report to SR (aggregated data)

DRD longterm series: Germany GMR (Destatis)/ SMR (BKA):

DRD longterm series: Germany GMR (Destatis)/ SMR (BKA):

-20%

Opiate purity and availability

German Bundesländer:Drug- related deaths per 100.000 inhabitants (2011)

Germany (SMR): DRD, detection of opiates in monodrug/polydrug overdoses (%)

550

603571

529

279

357 346 359326

290

2007 2008 2009 2010 2011

monovalent heroin/morphine polydrug heroine/morphine

4,7 4,5 4,5 4,8

8,3

11,712,5

13,9

11,6

24,3

0,6 0,8 0,6 0,61,5

0,0

5,0

10,0

15,0

20,0

25,0

30,0

2007 2008 2009 2010 2011

mono methadone (%)

poly methadone involved (%)

buprenorphine involved (%)

Germany (SMR): DRD/Overdose, detection of prescription opiates (%)

%

49,2

13,3

31,4

1,3

26,6

7,6

13,7

39,3

15,6

10,40,0

4,4

8,0

7,5

21,1

23,7

Bavaria

Baden-Wuerttemberg

Saxony-Anhalt

Thuringia

Hamburg

Bremen

Northrhine-Westfalia

Lower Saxony

Hesse

Rhineland- PalatinaSaarland

Saxony

Berlin

Mecklenburg-West.Pomerania

Schleswig-Holstein

Brandenburg

Methadoneinvolved in OD (%) (mean 2007-2011)

2,9

0,0

0,0

0,0

0,7

0,3

0,0

0,4

0,0

0,00,0

0,0

0,0

0,0

2,4

0,6

Bavaria

Baden-Wuerttemberg

Saxony-Anhalt

Thuringia

Hamburg

Bremen

Northrhine-Westfalia

Lower Saxony

Hesse

Rhineland- PalatinaSaarland

Saxony

Berlin

Mecklenburg-West.Pomerania

Schleswig-Holstein

Brandenburg

Buprenorphine involved in OD (%) (mean 2007-2011)

Berlin: Methadone detection rate at OD

46 45

35 37 50

140135 133

99

75

0

20

40

60

80

100

120

140

160

2007 2008 2009 2010 2011

with methadone involved (n)

OD (N)

Hamburg

21

13

20 20

26

46

38

44

36

40

0

5

10

15

20

25

30

35

40

45

50

2007 2008 2009 2010 2011

with methadone involved (n)

DRD (n)

Northrhine- Westfalia

0

50

100

150

200

250

300

350

2007 2008 2009 2010 2011

with methadone involved

(n)

Overdose (n)

Bavaria

0

50

100

150

200

250

300

2007 2008 2009 2010 2011

with methadone involved

(n)

OD (n)

Regional analysis across German Bundesländer: OST and methadone detection rate at OD

Regional analysis across German Bundesländer: OST and methadone detection rate at OD

Regional analysis across German Bundesländer: OST and methadone detection rate at OD

82,0

68,5

66,2

30,8

56,0

32,4

92,8

98,8

77,0

94,670,4

83,6

94,6

100,0

47,2

90,2

Bavaria

Baden-Wuerttemberg

Saxony-Anhalt

Thuringia

Hamburg

Bremen

Northrhine-Westfalia

Lower Saxony

Hesse

Rhineland- PalatinaSaarland

Saxony

Berlin

Mecklenburg-West.Pomerania

Schleswig-Holstein

Brandenburg

Autopsy rate in DRD (%) (mean 2007-2011)

Quality of data in SMR

30,8 32,4

47,2

64,2

82

90,2

98,8

65,7 67,4

40,8

56,5

7,1

44,3

10,9

1,3

7,6

21,1 20,1

49,2

10,9

39,3

0

20

40

60

80

100

120

Autopsy rate

Monovalent heroin (% of OD)

Methadone detected (% of OD)

%

Fentanyl- related deaths (SMR, personal comm.)

Fentanyl- related overdose in Bavaria (Data from Bavarian SMR, 2011/2012)

8%

6%

20%

2%38%

26%Fentanyl only

Fentanyl + alcohol

Fentanyl + psychoactivemedicines

Fentanyl + psychoactivemedicines +alcohol

Fentanyl + opiates/cocaine

Fentanyl +methamphetamine/others

Substances detected in some cases of polydrug overdose in Berlin and Hamburg in 2011

� Oxycodone/Oxymorphone

� Palladone/Hydromorphone

� Fentanyl

� Mephedrone/Methoxymethcathedrone (MMC)

� Methylendioxypyrovalerone (MDPV)

� Ketamine/Ketanest

� Pseudoephedrine

Quality of reporting: Traditional report structure of German SMR

Poisoining due to Number

Heroine

Polydrug pois. With heroine involved

Cocaine

Polydrug pois. With cocaine involved

Amphetamine

Polydrug pois. With amphetamine

MDMA

MDMA polydrug

Prescription opioids

- methadone/polamidon

- Subutex/buprenorphine

Prescription opiods in polydrug pois.

- with methadone/polamidone

- with Subutex/buprenorphine

Other illicit drugs/ unknown drug

Suicide

Disease due to Longterm harm of drug use

Accident/ Other manners

Absolute number *

Traditional report structure of German SR

Poisoining due to

Heroine

Polydrug pois. With heroine involved

Cocaine

Polydrug pois. With cocaine involved

Amphetamine

Polydrug pois. With amphetamine

MDMA

MDMA polydrug

Prescription opioids

- methadone/polamidon

- Subutex/buprenorphine

Prescription opiods in polydrug pois.

- with methadone/polamidone

- with Subutex/buprenorphine

Other illicit drugs/ unknown drug

Suicide

Disease due to Longterm harm of drug use

Accident/ Other manners

Absolute number *

Traditional report structure of German SR

Poisoining due to

Heroine

Polydrug pois. With heroine involved

Cocaine

Polydrug pois. With cocaine involved

Amphetamine

Polydrug pois. With amphetamine

MDMA

MDMA polydrug

Prescription opioids

- methadone/polamidon

- Subutex/buprenorphine

Prescription opiods in polydrug pois.

- with methadone/polamidone

- with Subutex/buprenorphine

Other illicit drugs/ unknown drug

Suicide

Disease due to Longterm harm of drug use

Accident/ Other manners

Absolute number *

Traditional report structure of German SR

Poisoining due to

Heroine

Polydrug pois. With heroine involved

Cocaine

Polydrug pois. With cocaine involved

Amphetamine

Polydrug pois. With amphetamine

MDMA

MDMA polydrug

Prescription opioids

- methadone/polamidon

- Subutex/buprenorphine

Prescription opiods in polydrug pois.

- with methadone/polamidone

- with Subutex/buprenorphine

Other illicit drugs/ unknown drug

Suicide

Disease due to Longterm harm of drug use

Accident/ Other manners

Absolute number *

Includes again poisoinings

Traditional report structure of German SR

Poisoining due to

Heroine

Polydrug pois. With heroine involved

Cocaine

Polydrug pois. With cocaine involved

Amphetamine

Polydrug pois. With amphetamine

MDMA

MDMA polydrug

Prescription opioids

- methadone/polamidon

- Subutex/buprenorphine

Prescription opiods in polydrug pois.

- with methadone/polamidone

- with Subutex/buprenorphine

Other illicit drugs/ unknown drug

Suicide

Disease due to Longterm harm of drug use

Accident/ Other manners

Absolute number * ???

Include also poisoinings

Hindrances

� Absolute numbers of overdoses are not conclusive

� Absolute numbers of indirect drug- related deaths categories were not conclusive

� Share of confirmed substance detections (by autopsy/toxicology) was unknown

� Comparability between German GMR and SR fails

� EMCDDA Standard not applicable

Table 4: Coding of values for the variables "Cause" and "Filter_D"

CausePoisoning Filter_D Broad

group(see note)

18 Poisoning by opioids only (excluding methadone) 1 O

19 Poisoning by methadone only 1 O

20 Poisoning by poly-substances including opioids 1 O

21 Poisoning by (poly)substances excluding opioids 1 NO

22 Poisoning by psychoactive medicines 0 -

23 Poisoning by unspecified/unknown substances 1 NS

Cause Other than poisoning# Filter_D

24 Natural/internal causes 0 -

25 Accidents other than by poisoning 0 -

26 Suicide other than by poisoning 0 -

27 Homicide other than by poisoning 0 -

28 Undetermined causes other than by poisoning 0 -

# These other causes are also mutually exclusive. One case may only be coded to one cause category.

Table 4: Coding of values for the variables "Cause" and "Filter_D"

CausePoisoning Filter_D Broad

group(see note)

18 Poisoning by opioids only (excluding methadone) 1 O

19 Poisoning by methadone only 1 O

20 Poisoning by poly-substances including opioids 1 O

21 Poisoning by (poly)substances excluding opioids 1 NO

22 Poisoning by psychoactive medicines 0 -

23 Poisoning by unspecified/unknown substances 1 NS

Cause Other than poisoning# Filter_D

24 Natural/internal causes 0 -

25 Accidents other than by poisoning 0 -

26 Suicide other than by poisoning 0 -

27 Homicide other than by poisoning 0 -

28 Undetermined causes other than by poisoning 0 -

# These other causes are also mutually exclusive. One case may only be coded to one cause category.

Issues to be solved

� Define Categories which are mutually exclusive� Monodrug Opiate poisoinings should be reported separately (so

far only given for heroine/ methadone/ buprenorphine )� Avoid multiple nomination in Polydrug poisonings with / without

opioides� Monodrug poisoings with „psychoactive medicine“ should be

separated� „Other illicit drugs“ should exclude opioides� „Other illicit drugs detected“/ unknown substance should be

separated� Separation of suicidal or accidental poisonings from non-

poisoning suicides and accidents. � Separation of disease due to longterm harm of drug use from

poisoings: Separate mixed category when both are relevant in a case

No Category

Bundesland

(n)

Cases withautopsy/toxxicology (n)

A Poisoning by opioids/ opiates

A.1Monodrug poisoing: Heroin/Morphine

A.2Monodrug poisoing: prescription opiate

A.2.1 subgroup : methadone

A.2.2 subgroup buprenorphine

A.2.3 subgroup other prescription opioids (to be listed)

B

Mixed Poisoning including opioids/ opiates (e.g.

amphetamines,cocaine/crack, cannabis, hallucinogens, solvants, synthetic drugs, Sedatives, alkohol, others. Includes poisoingswith suicidal intent

B.1

Polydrug poisoning including Heroin/Morphine ("Substanzen"

nach Definition unter B)

B.2Polydrug poisoning including prescription opiates

B.2.1 subgroup : methadone

B.2.2 subgroup buprenorphine

B.2.3 subgroup other prescription opioids (to be listed)

New reporting structure in German SR (1)

New reporting structure in German SR (2)

Bundesland

(n)

Cases withautopsy/toxicology (n)

C Poisoning excluding opioids/ opiates

C.1 Monodrug poisoning: Cocaine/crack

C.2 Monodrug poisoning: Amphetamines

C.3 Monodrug poisoning: MDMA, MDE, MDA

C.4 Polydrug poisoning including cocaine/crack (without opiates)

C.5 Polydrug poisoning including amphetamines (without opiates)

C.6Polydrug poisoning including MDMA/MDE/MDA (without opiates)

DPolydrug poisoing including stimulants and opiates (subgroup of B)

D.1 Polydrug poisoning including cocaine/crack (with opiates)

D.2 Polydrug poisoning including amphetamines (with opiates)

D.3 Polydrug poisoning including MDMA/MDE/MDA (with opiates)

E Poisonings by psychoactive medicines without illicit drugs

FNot specified substances in poisonings (but illicit drugs suspected)

Poisonings: Others/ not assignable (to be listed)

New reporting structure in German SR (3)

Bundesland (n)

Cases with

autopsy/toxxicology (n)

G Suicides

G.1Suicide by poisoning

G.2Suicide by other means than poisoning

H Disease due to longterm harm by drug use

H.1

Subgroup: Mixed cause of death: Longterm harm

combined with poisoning.

I Accident (non- poisoning accidents)

J Other/ not assignable (only non- poisoning cases)

Total drug- related deaths(sum up mutually exclusive

categories =A+B+C+E+G2+H+I+J) 0 0

Autopsy rate : Total (%)