Drug-induced deaths – the current situation in Europe (European Drug Report 2024)

cover of the European Drug Report 2024: Drug-induced deathts

Estimating the mortality attributable to drug use is critical for understanding the public health impact of drug use and how this may be changing over time. 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 2024, the EMCDDA's annual overview of the drug situation in Europe.

Last update: 11 June 2024

Improving our understanding of drug-related mortality is a key requirement for developing effective responses

Estimating the mortality attributable to drug use is critical for understanding the public health impact of drug use and how this may be changing over time. Understanding the factors driving trends in this area is also likely to be key for the development of effective responses. However, despite improvements over the last decade, there are still important limitations in the information currently available to us, and this hampers the development of both policies and responses.

The term drug-induced deaths is used for an indicator that is intended to capture those deaths that are directly attributable to the consumption of drugs, sometimes referred to as drug overdose deaths. It should be noted that estimates of drug-induced deaths only represent a share of the overall mortality associated with drug use, as this measure does not include mortality from motor vehicle and other accidents, violence, suicides by means other than drug poisoning or chronic disease, where drug use may have played a role. A need exists therefore, through cohort studies and other approaches, to extend our understanding in these other important areas of drug-related mortality.

Despite these limitations, an assessment of drug-induced deaths is still a key measure for understanding the harm that the use of illicit drugs can cause, but it is also a challenging one to interpret for methodological and data availability and quality issues. This is particularly true when interpreting recent trends in drug-induced deaths, where data for the most recent reporting year (2022) are available for only 21 of the 29 countries covered by this indicator, and estimated values must therefore be calculated if an overall EU estimate is to be derived. Given the speed at which new drug threats can emerge, improving the timeliness and completeness of data in this area is an important priority for the future.

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 need to made with caution. In addition, a lack of detailed toxicological information in some countries currently means that our overall understanding of the role different drugs play in driving rates of drug-induced deaths over time is limited. The lack of detailed toxicological information can also hamper an understanding of the role played by different drugs when used in combination. As the majority of fatal overdoses involve the use of more than one substance, and as drug consumption patterns are becoming ever more complex, there is also therefore a growing need to improve our understanding of how changes in patterns of polydrug use are impacting on mortality. A positive development in this area is that the launch of the new European Union Drugs Agency (EUDA) in 2024 will strengthen the capacity for rapid threat assessment, early warning and the issuing of alerts, and support measures to improve routine reporting capacity in this area. Importantly, the new agency will also coordinate a new network of forensic and toxicological laboratories, increasing the analytical capacity available to monitor how different drugs and drug combinations are impacting on trends in mortality. 

While opioids are often present, most drug-induced deaths are associated with the consumption of multiple substances 

For the year 2022, the number of reported drug-induced deaths increased slightly in some EU countries and fell in others. The provisional overall estimate of about 6 400 drug-induced deaths in 2022 represents a slight increase on 2021, but this figure should not be over-interpreted, as a number of countries with large populations have yet to provide data, and estimated values have necessarily been used to compute this provisional total.

Although detailed toxicological information is not available on all death cases, the information that does exist suggests polydrug toxicity is the norm, and where detailed toxicological information is available, it usually reports the presence of multiple substances.

The available information highlights that opioids, usually in combination with other substances, remain the group of substances 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. It is estimated that heroin was involved in more than 1 800 deaths in the European Union, and heroin remains the drug commonly identified as involved in opioid-related deaths in some western European countries. However, the data available suggest heroin is now present in the majority of overdose deaths in only a few countries, and both other opioids and other drugs are now playing a more important role. Opioids other than heroin, including methadone and, to a lesser extent, buprenorphine, pain-relief medicines containing opioids, and other synthetic opioids are associated with a substantial share of overdose deaths in some countries.

The data on drug mortality are also indicative of an ageing opioid-using cohort in Europe as illustrated by the two-thirds increase in the number of drug-induced deaths among 50- to 64-year-olds between 2012 and 2022. Despite public perceptions that drug overdoses are a problem that impacts mostly on young people, cases of mortality linked to drug consumption are typically found among males aged 40 or older.

The available data also suggest the deaths where stimulants are implicated are rising in some countries, although with important caveats here. Stimulant deaths are likely to be particularly prone to under-reporting, and stimulants are often implicated in deaths where other drugs, including opioids, are also found to be present. There is also some information to suggest that stimulants appear to be more commonly implicated in deaths reported among younger age cohorts.

Concerns growing about deaths linked to synthetic opioids

Potent synthetic opioids, such as the fentanyl derivative carfentanil and nitazene opioids, some of which are significantly more potent than fentanyl, have been associated with some outbreaks of fatal and non-fatal poisonings. However, with the exception of some Baltic countries, these drugs do not currently figure prominently in the routine data available at EU level. Nonetheless, developments in this area are worrying because of the potential of these substances to impact negatively on public health in Europe in the future.

Of particular concern in this area is the recent appearance of the nitazene opioids, which were involved in localised poisoning outbreaks in Ireland and France during 2023. In Ireland, nitazenes were mis-sold as heroin resulting in inadvertent consumption and multiple overdoses (see New psychoactive substances – the current situation in Europe). Due to their high potency and novelty, there are concerns that nitazene opioids may not be routinely detected in procedures commonly used for post-mortem toxicology. This raises the possibility that the number of deaths reported could be an underestimate. Some evidence of this exists from countries in the Baltic area, where improvements in testing methods have resulted in an increase in the detection of these substances. In provisional data from Estonia, the drugs were identified in almost half the drug-induced deaths (56 of 117, 48 %) in 2023. This compares with 32 of 82 drug-induced deaths (39 %) in 2022. In Latvia, both the national statistics and the forensic registers provisionally reported a doubling in the overall number of drug-induced deaths, from 63 in 2022 to 130 in 2023, with nitazenes identified in 38 (29 %) of these cases. Although systematic testing for nitazenes was not possible in 2022, there was a dramatic rise in the number of acute drug toxicological presentations involving opioids (from 1 936 in 2021 to 2 357 in 2022). Anecdotal reports from clinical staff suggesting that greater doses of naloxone were required raise concerns that synthetic opioids may have been involved.

Another source of information on drug mortality is provided by deaths reported to the Early Warning System on new psychoactive substances. At least 150 cases of deaths with confirmed exposure to nitazenes have been reported to this mechanism from 5 countries during 2023. However, this figure includes cases where the cause of death has not been confirmed.

The challenges of responding to deliberate self-poisonings 

Determining the intention of a person who has died from a drug overdose can be difficult. Many overdose deaths are reported as accidental, and others have an undetermined intent. However, in some countries more information is available on intention, and a relatively high proportion of reported overdose deaths (1 in 6 overall) were classified as intentional (that is, with a suicidal intent). In all countries in the European Union, Norway and Türkiye, the most recent available data show that the proportion of overdose deaths with a suicidal intent was higher among women. In a few countries (Hungary, Netherlands, Slovenia, Sweden), more than a third of the reported overdose deaths among women were classified as having a suicidal intent. In Bulgaria, Poland and Finland, a suicidal intent was recorded for more than a quarter of the overdose deaths among females reported in 2022. These findings indicate the need for interventions that target deliberate self-harm and suicidal intent among people who use drugs, and especially to recognise the disproportional risk that females may experience in this context.

Preventing opioid-related overdoses and deaths remains difficult 

Responses aimed at reducing opioid-related deaths include interventions geared towards preventing overdoses from happening in the first place and those that focus on preventing death when overdoses do occur (see Figure 11.1). 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 deaths. 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.

Figure 11.1. Interventions to prevent opioid-related deaths, by intended aim and evidence of benefit

  • Reducing fatal outcomes if overdose occurs
    • Naloxone administration*
    • Naloxone distribution and training* (specialist services and first responders, community)
    • Drug consumption facilities*
    • Fatal-overdose prevention apps
  • Reducing the risk of overdose occurring
    • Opioid agonist treatment, retention and continuity of care*
    • Targeted interventions at times of reduced tolerance (e.g. release from prison or interrupted treatment)
    • Overdose risk assessment, awareness raising and harm reduction
    • Overdose prevention strategies
    • Prevention of diversion of medicines
    • Drug checking and public health alerts
    • Supporting transition from injecting to smoking opioids
    • Targeted treatments (naltrexone treatment, heroin-assisted treatment)
  • Reducing vulnerability
    • Integrated care with mental health and generic health services
    • Interventions to improve access to social and health care
    • Housing programmes
    • Support to employment programmes
    • Interventions to reduce or prevent stigma

Note: Interventions where there is evidence of benefit and where we can have a high or reasonable confidence in the available evidence are highlighted in bold and with an asterisk (*).

Notes: Interventions where there is evidence of benefit and where we can have a high or reasonable confidence in the available evidence, are highlighted in a bolder frame. Much of the current evidence on interventions listed in this figure is either emerging or deemed insufficient, in part because of the practical and methodological difficulties of conducting research, especially in developing randomised controlled trials (see Spotlight on... Understanding and using evidence) and also because service delivery models often differ considerably.

The evidence is also growing that the increasing availability of opioid antagonists can play an important role in preventing fatal opioid 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 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. In some countries, drug consumption rooms are also provided in part as a response to reducing overdose mortality. These facilities are now operational in 10 EU countries and Norway (see 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. For more information on the health and social responses to prevent opioid-related deaths see the EMCDDA’s recent miniguide.

Key data and trends

Mortality rates due to overdose

  • The mortality rate due to overdoses in the European Union in 2022 is estimated at 22.5 deaths per million population aged 15 to 64.
  • The mortality rates due to overdose are typically 3 to 4 times higher among males compared with females (Figure 11.2), with men aged 25 to 39 the most affected. Overdose mortality rates in this age group can be considerably higher than for the male population aged 15 to 64 (adults). For example, in Sweden, the overdose mortality rate for men aged 25 to 39 was 122 deaths per million in 2022, compared with 73 deaths per million adult men in the country. In Estonia, the comparable figures were 197 deaths per million men aged 25 to 39 and 62 deaths per million adult men; and in Ireland, the mortality rate was 183 deaths per million men aged 25 to 39 compared with 85 deaths per million among all adult men.
  • Men aged 40 to 59 are those most affected by overdose mortality in a number of European countries, including Denmark, Spain, Italy, the Netherlands, Portugal and Norway.
Figure 11.2. Proportion of males among drug-induced deaths in the European Union, Norway and Türkiye in 2022, or most recent year (percent)
 

Overdose deaths 

It is estimated that at least 6 392 overdose deaths involving drugs occurred in the European Union in 2022 (6 166 in 2021). This is a minimum estimate as some countries report that their monitoring system is missing some cases. For example, a cross-validation of the 2022 data from the different registers in Spain suggested that only 4 out of 5 cases might be reported. In Germany, the mortality register only contains cases that have come to the attention of the police. Thus cases outside of police focus may be under-reported. However, the extent of the underestimation is unknown.

  • Opioids, including heroin and its metabolites, often in combination with other substances, were estimated to be present in three quarters (74 %) of the fatal overdoses reported in the European Union in 2022 (see Figure 11.3 and Figure 11.4). It should be noted that multiple drugs are commonly found in toxicology reports from drug-induced deaths.
Figure 11.3a. Drug-induced deaths
 

EU+2 refers to EU Member States, Norway and Türkiye.

Figure 11.3b. Drug-induced deaths in the European Union: age at death, 2022 or most recent available data (percent)
 
Figure 11.3c. Trends in drug-induced deaths in the European Union, Norway and Türkiye
 

Note. For Germany, from the year 2021 the data fully comply with the European protocol defining cases to be extracted from special mortality registers such as those of police and forensic services. Comparable data for the previous years is not available. For this series and graph, the previous years where filled in with the first available datapoint (2021) in order to avoid mixing of different data series with different methods. However, it should be noted that Germany saw an increase in drug-related deaths during this period, according to the national definition.

Figure 11.3d. Age distribution (percent) of drug-induced deaths reported in the European Union, Norway and Türkiye in 2022 or the most recent year
 
Figure 11.4. Proportion of drug-induced deaths cases with opioids mentioned, 2022 or most recent available data
 

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.

  • The data available have limitations with respect to quality and coverage. Nevertheless, the information available suggests that heroin remains involved in large numbers of deaths in some western European countries: over 728 cases in Germany, 222 in Spain, 173 in France, 142 in Austria (heroin or morphine), 127 in Italy and 104 in Sweden. Overall, it is estimated that more than 1 800 deaths involved heroin in the European Union.
  • Heroin was present in the majority of overdose deaths in a relatively small number of EU countries, namely Austria (heroin or morphine) (77 %) and Italy (57 %). Heroin has been reported in approximately two fifths to one fifth of overdose deaths in Portugal (42 %), Slovenia (42 %), Romania (41 %), Türkiye (35 %), France (26 % in 2021), Denmark (24 %), Spain (24 % in 2021), Norway (22 %) and Sweden (21 %). In 2022, heroin was reported in fewer than 1 in 6 overdose deaths in Estonia, Latvia, Lithuania and Finland.
  • In preliminary data subject to further updating, 5 countries reported the presence of nitazenes in at least 150 deaths in 2023: Estonia (56), Latvia (76), Finland (8), Sweden (1) and Norway (13).
  • Among 19 European countries providing data for 2021 and 2022, cocaine, mostly in the presence of opioids, was involved in 996 (23 %) overdose deaths in 2022 (807 or 20 % in 2021).
  • Deaths involving cocaine are now also being reported in countries where they were previously less common, such as Denmark, the Netherlands, Austria and Slovenia. Cocaine was involved in 52 % of the overdose deaths in Spain (477 of the 910 cases with information available) in 2021 and in 67 % of the overdose deaths in Portugal (46 of 69 cases) in 2022.
  • In France, cocaine was involved in 39 % (259 of the 662 deaths with information available) of the cases in 2021. This is an increase from 23 % (130 of 567 deaths with information available) in 2020, suggesting that cocaine is contributing to the overall increase in the number of overdose deaths in the country.
  • Stimulants other than cocaine, including amphetamine and methamphetamine, are involved in many deaths, often alongside opioids. Out of 20 countries with post-mortem data available for 2022, 18 reported deaths where non-cocaine stimulants were involved. The highest numbers of deaths involving non-cocaine stimulants were reported by Germany (476 cases), Türkiye (186), Denmark (68), Norway (63), Latvia (62), Finland (34), Estonia (33) and Austria (32). While the numbers reported by the countries may vary from year to year, the total numbers of such cases for the 16 countries that reported comparable data in all three years were 496 in 2020, 462 in 2021 and 492 in 2022. Beyond these drug-induced deaths, other stimulant-related deaths, such as those associated with cardiovascular problems, may go undetected.
  • The number of overdose deaths reported in the European Union among those aged 50 to 64 is estimated to have increased by 69 % between 2012 and 2022 (by 43 % among women and by 101 % among men) (Figure 11.5).
Figure 11.5. Number of drug-induced deaths reported in the European Union in 2012 and 2022, or the most recent year, by age band
 
 
  • In half of the 20 countries with post-mortem toxicological data available for 2022, at least 1 in 4 drug-induced deaths involved methadone. The opioid agonist medicine was mentioned in around a third of the cases reported in Germany, France (2021), Spain (2021) and Croatia. There is little information available on whether the medicines were prescribed, misused or acquired on the black market. However, the mention of the drug does not mean that it was the cause of the poisoning, as overdoses often involve polydrug use with other opioids, alcohol and other medicines such as benzodiazepines. In 2022, buprenorphine was identified in 56 % (107) of the drug-induced deaths reported in Finland, in 19 % (92) in Sweden, in 7 % (20) in Denmark and in 7 % (49) of the deaths reported by the special register in France in 2021. 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 about 6 % (177) of reported overdose deaths in 12 European countries in 2022. However, it was involved in 47 % of the deaths reported by the French registry of medicine misuse-related deaths in 2020, suggesting that improving surveillance and toxicological investigation might increase the detection of deaths associated with opioid-containing medicines.
  • Where available, data indicate that fentanyl and fentanyl derivatives were linked to 163 overdose deaths in 2022. Germany reported the largest number of deaths with the drug involved (73). However, some of these fatalities might be associated with diverted fentanyl medicines rather than illicit fentanyl. The other cases were reported in 2022 in Lithuania (33 deaths), followed by Denmark (20), Sweden (17), Estonia (8), Austria (4), Finland (3), Latvia (4), Türkiye (1). Preliminary 2023 data from Estonia and Latvia indicate that the number of drug-induced deaths involving new synthetic opioids further increased. In drug-induced deaths involving nitazenes, the most prominent nitazenes detected in Estonia in 2023 were protonitazene (38 of 56, 68 %) and metonitazene (27 of 56, 48 %); isotonitazene (32 of 38, 84 %) was most common in Latvia. Figures for 2023 are preliminary and might be underestimates. In countries with available data, between 2021 and 2022, oxycodone was reported as being involved in 327 drug-induced deaths, mainly in Denmark, Estonia, Finland and Sweden.
  • Consuming opioids in combination with benzodiazepines increases the risk of overdose. In 2022, benzodiazepines, together with other substances, primarily opioids, were detected in the majority of overdose deaths in Denmark, Luxembourg, Austria and Finland, and in more than 4 out of 10 cases in Portugal and Slovenia (Figure 11.6). In addition, benzodiazepines were detected in high proportions of the overdose deaths reported in the most recent data available for Spain, Cyprus and Romania. In Bulgaria, where the total numbers of overdose deaths are small and caution is warranted due to year on year fluctuations, benzodiazepines are rarely detected. In many countries, this information is not available and in others, post-mortem toxicology findings are not reported for all cases.
Figure 11.6. Proportion of drug-induced deaths with benzodiazepines involved, 2020 to 2022, selected countries (percent)
 
  • Few countries report information on the involvement of pregabalin in drug-induced deaths. Among those that do, Finland reported 87 deaths in 2022 (90 in 2021). Several countries reported an increase in the number of deaths with pregabalin mentioned: Denmark (from 48 deaths in 2021 to 58 in 2022), Austria (from 37 in 2021 to 54 in 2022), Spain (from 41 in 2020 to 81 in 2021), and Türkiye (from 5 in 2021 to 25 in 2022).
  • Deaths linked to synthetic cannabinoids declined to 8 in Türkiye in 2022 (46 in 2021). Seven countries with available data reported 27 deaths with synthetic cathinones involved in 2022, mainly in Finland (13 cases), Estonia (5 cases), Portugal (4 cases), Austria (2), Romania (2) and Slovenia (1). Where data are available for 2021 and 2022, the numbers increased in Estonia (from 3 to 5), Finland (from 6 to 13), Portugal (from 0 to 4), Romania (from 1 to 2) and Slovenia (from 0 to 1), and decreased in Austria (from 7 to 2).

All-cause drug-related mortality

  • Cohort studies show that all-cause mortality is much higher among people who use drugs than among their peers in the general population. 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.

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