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Drug and Alcohol Review (January 2015), 34, 82–89 DOI: 10.1111/dar.12182

Personally prescribed psychoactive drugs in overdose deaths among drug abusers: A retrospective register study SANNA RÖNKÄ1, KAROLIINA KARJALAINEN2,3, ERKKI VUORI4 & PIA MÄKELÄ2 1

Department of Social Research, University of Helsinki, Helsinki, Finland, 2Alcohol and Drugs Unit, National Institute for Health and Welfare, Helsinki, Finland, 3School of Health Sciences, University of Tampere, Tampere, Finland, and 4Hjelt Institute, University of Helsinki, Helsinki, Finland

Abstract Introduction and Aims. Psychoactive prescription drug (PPD) abuse-related overdose deaths have increased in many countries in recent decades.We aimed to investigate the role of personally prescribed psychoactive drugs in abuse-related overdose mortality and explore any associations with level of social disadvantage. Design and Methods. This register linkage study included all 243 people who had died of abuse-related drug-induced poisoning in Finland in 2000 and 2008. Data on registered purchases of psychoactive drugs within one and three years of death were linked to data on the psychoactive drug/s contributing to death in each case. Social disadvantage was measured by receipt of income support, long-term unemployment and disability pension. Results. Thirty-six percent of those abusers who had died of a drug overdose had purchased a similarly acting drug within three years of death. In all overdoses, the proportion increased from 20% in 2000 to 49% in 2008 ( P < 0.001).A similar increase was seen in purchases within one year of death; from one-tenth in 2000 to one-third of all cases in 2008 ( P < 0.001). The majority (83%) of the deceased had received income support, while only 13–14% were long-term unemployed or on disability pension. Disability pension recipients had significantly more prescribed psychoactive drug purchases than nonrecipients ( P < 0.001 for three and one years within death). Discussion and Conclusions. Personally prescribed PPDs pose a potential threat to people who abuse drugs. Health-care services should invest greater effort in identifying people who abuse drugs and in monitoring their drug prescriptions. [Rönkä S, Karjalainen K,Vuori E, Mäkelä P. Personally prescribed psychoactive drugs in overdose deaths among drug abusers: A retrospective register study. Drug Alcohol Rev 2015;34:82–9] Key words: psychoactive prescription drug, drug poisoning, social disadvantage, register-based study.

Introduction The consumption and non-medical use of psychoactive prescription drugs (PPD) have increased in many parts of the world in recent decades [1].This is especially true for prescription opioids [2–6]. PPD-related overdose deaths have also increased [7–9]. One reason for the increased abuse of PPDs may be the growth of the pharmaceutical industry since the 1990s [10]. As well as helping to reduce human suffering, the expanding use of pharmacotherapy has led to increased non-medical use of prescription drugs [11,12]. In terms of abuse, PPDs are mainly obtained from the illicit market, from doctors as well as from family and friends [12,13]. Drugs of abuse can be obtained from doctors in two ways: either by feigning

diseases [14,15] or by receiving prescriptions for legitimate medical conditions. People who abuse drugs often have a dual diagnosis, that is, both drug dependence and some other mental disorder at the same time [16– 18], which may help them to not only access drugs of abuse easily, but also be a legitimate medical reason for these drugs. In Finland, recent studies and statistics show little change over the past 10 years in drug use. Among the general population in Finland, misuse of prescription opioids is very low compared with North America [19– 21]. However, PPDs have become a popular replacement of illicit drugs among heavy drug users. For example, heroin use has been replaced by buprenorphine injecting and snorting, and heroin has become in practice non-existing in the Finnish drug

Sanna Rönkä MSSc, Doctoral Student, Karoliina Karjalainen PhD, Senior Researcher, Erkki Vuori MD, PhD, MSci, Emeritus Professor, Pia Mäkelä PhD, Head of Unit. Correspondence to Ms Sanna Rönkä, Department of Social Research, University of Helsinki, PO Box 16, Helsinki FI-00014, Finland. Tel: +358 2941 21795; E-mail: [email protected] Received 17 February 2014; accepted for publication 2 June 2014. © 2014 Australasian Professional Society on Alcohol and other Drugs

Prescription drugs in overdose deaths

market in the 2000s [3]. PPDs of abuse are not only diverted from the health-care system, but also smuggled in from abroad, especially the Baltic countries and France [3]. Although the drug situation otherwise is quite stable, the number of drug-related deaths has increased since the beginning of the 2000s. This is explained by the increase in poisonings from prescription opioids, especially buprenorphine, often in combination with other drugs and alcohol [22]. Polydrug use—the concurrent or simultaneous use of several illicit or licit substances—is in fact common in all Western countries [23–28]. It is linked to several adverse health risks, such as overdose [29]. According to a US study, 63% of unintentional pharmaceutical overdose deaths were associated with pharmaceutical diversion and 21% with evidence of doctor shopping [30]. Apart from this study, there is only limited information about the origins of PPDs in fatal abuse-related poisonings. This study aims to determine to what extent overdose mortality among people who abuse drugs is related to personally prescribed PPDs. Problem drug users often have a lower socioeconomic status compared with the general population. For example, in Canada only 6–27% of untreated illicit opioid users had an income from paid work [13], and in Europe 47% of outpatient and 71% of inpatient drug treatment clients were unemployed [14]. However, it is possible that PPD abuse is more evenly distributed across socioeconomic groups as it does not necessarily require contact with an illegal market. This register study aims, firstly, to examine the role of personally prescribed PPDs (with the exception of substitute treatment medication) in overdose mortality among people who abuse drugs in Finland in 2000 and 2008. These two years were chosen to reflect the shift that took place during this period in the Finnish drug scene, from heroin to buprenorphine abuse [3]. We consider the possibility of both more and less direct PPD involvement. For the more direct connection, we examined whether the deceased had purchased a drug identical to that causing the fatal poisoning. To assess the possibility of a less direct connection, we included purchases of both identical and similarly acting substances. Even in the former case, fatal poisonings were not necessarily caused by the exact same package of PPDs prescribed by the doctor. As drug use patterns often become problematic over a longer period of time, we assess whether personally prescribed PPDs have contributed to abuse either in the shorter or longer term. Therefore, the drugs causing overdose deaths are compared with medicine purchases within one and three years of death. For this analysis, we used register data of toxicologically identified substances in drug poisoning deaths and recorded prescription drug pur-

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chases. The coverage of the Finnish purchase data has been shown to be good [31], except that most of the substitute treatment medication is dispensed directly at the opioid substitution clinics and therefore not covered by the register. The second aim of our study is to determine whether the association between personally prescribed PPDs and overdose mortality is influenced by level of social disadvantage as indicated by receipt of unemployment benefit, income support and disability pension.

Methods Data and measurements The data on drug abuse-related deaths were obtained from the Forensic Toxicological Register maintained by the Hjelt Institute (University of Helsinki), which is responsible for all post-mortem forensic toxicological analyses in Finland. The Institute classifies a case as drug abuse related when there is an illicit or licit drug positive toxicological finding and the ‘social autopsy’ (see next paragraph) shows evidence of abuse. Hence, according to this classification, for example, nonmisusers who have merely chosen overdose of prescription drugs as a method of suicide are not included in the data. By law, a post-mortem examination conducted by the police is required in the event of an unexpected and sudden death. The medicolegal autopsy rate in these cases is 90% [32]. As a part of the post-mortem process, the police may interview health officials, friends and family members.This procedure (i.e. ‘social autopsy’) will alert the police to any history of drug abuse. Drug abuse history will be further documented in the final police report on the post-mortem examination, in the pathologist’s referrals to a forensic toxicologist and in death certificates which include a written section of circumstances around the death in the case of accidental death. Copies of these post-mortem documents and reports of toxicological analysis are available at the Hjelt Institute; these were the sources used in this study to determine whether the case was drug abuse related. Drug abuse can manifest itself in the documents in several ways. Common examples include friends reporting binge drug taking prior to death, family members reporting treatment for substance abuse problems, the police reporting a history of drug use or drug use-related offences, and the pathologist reporting numerous needle marks on the deceased body. There were altogether 417 drug abuse-related deaths in Finland in 2000 and 2008 (Figure 1). These years were chosen to reflect the shift in the Finnish drug scene in the beginning of 2000s, with 2008 being the © 2014 Australasian Professional Society on Alcohol and other Drugs

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All deaths related to drug abuse in Finland in 2000 and 2008 (n = 417)

Deaths due to other causes (n = 166) All poisoning deaths related to drug abuse (n = 251) Poisonings induced by alcohol alone (n = 8)

Poisonings induced by PPDs and illicit drugs and alcohol (excluding alcohol poisonings) (n = 243)  

Overdoses induced by PPDs (including combinaons with illicit drugs and/or alcohol (n = 172) Overdoses induced by illicit drugs (including combinaons with alcohol) (n = 71)

Figure 1. Data flow chart.

latest available year during the data collection. All the paper documents on these 417 deaths were read thoroughly by S. R. to double-check that deaths were indeed abuse related. All the relevant data were entered into a file. The current analysis focuses on the subset of poisoning deaths. Death certificates, which include both a written description and the International Classification of Diseases (ICD)-10 code on the underlying cause of death, were used to determine whether the death was caused by poisoning. The inclusion criteria were ICD-10 codes X40–44, X60–64, X69, Y10–14 and Y69. Poisonings induced by alcohol alone (n = 8) and other causes (n = 166), which were due to accidents (mainly motor vehicle related), homicides, nonpoisoning-related suicides and illnesses, were excluded. Thus, the data used in the analyses comprised 243 cases. The drug(s) causing the poisoning in each case were identified from the death certificate. The substances contributing to death were identified from the death certificate primarily on the basis of ATC codes (World Health Organization’s Anatomical Therapeutic Chemical Classification System). In some cases, the pathologist had chosen to use ICD-10 T codes (T36-T50 Poisoning by drugs, medicaments and biological substances) instead of ATC codes. In these cases, the written descriptions on the death certificates were consulted for greater accuracy. From the substances contributing to death, we identified PPDs, which were divided into six categories: opioids, stimulants, benzodiazepine derivatives, antipsychotics, antidepressants and anticonvulsants (gabapentin and pregabalin, which are known to be abused). Data on prescribed psychoactive drug purchases were sourced from the Register on Reimbursed Medical Purchases (Social Insurance Institution of Finland), which provides information on all outpatient © 2014 Australasian Professional Society on Alcohol and other Drugs

prescription medicine purchases reimbursed by the Social Insurance Institution since 1993. Reimbursement of medical expenses is available for all residents of Finland, covering 35–100% of the cost of medicines prescribed for the treatment of an illness. The reimbursement is deducted from the price on presentation of a health insurance card at the pharmacist. Both public and private health-care clients get this compensation. The data consisted of all medicinal purchases from 1993 until death in 2000 or 2008. The medicinal products were registered based on the ATC system. In addition to ATC code, the register data included the date of the purchase. The Register on Reimbursed Medical Purchases has good coverage of all benzodiazepine (71.5%), antipsychotic (72.1%) and antidepressant (89.9%) purchases at pharmacies [31]. No information is available on the coverage of opioid analgesics. In Finland, opioids are mainly available by prescription only. The only overthe-counter products that contain opioids and that are suitable for misuse are certain cough medicines. The register does not include medication given in facilities of inpatient or outpatient treatment. Most of the opioid substitution medication (buprenorphine and methadone) is dispensed directly at the opioid substitution clinics in Finland. This means that for the most part, our data do not cover opioid substitution medication, although by definition they are considered as PPDs. Indicators measuring social disadvantage were income based. Long-term unemployment was defined as receipt of unemployment benefit for 500 days or more within three years of death. The maximum number of unemployment benefit days in a year is approximately 260. Receipt of income support was defined as getting income support for the deceased person’s household in at least one month during the year of death or the year before. Income support is a

Prescription drugs in overdose deaths

last-resort form of income security. It is generally granted for 1 month at a time and it is intended to cover the client’s most basic expenses. Receipt of disability pension was defined as having an ongoing disability pension at the time of death or getting a disability pension during the year of death or the year before. Data on social disadvantage were obtained from the Unemployment Benefits Register (Social Insurance Institution), Pension Register (Social Insurance Institution) and the Social Assistance Register (National Institute for Health and Welfare). Unemployment Benefits Register variables included information on the start date of unemployment and the number of days compensated. Pension Register variables covered the year of disability pension, the number of months paid, and information on whether the pension decision was permanent or temporary. The data from the Social Assistance Register consisted of information on the year of income support and the number of months awarded. All data were linked using a personal identity code, a unique person identification number given to all residents of Finland. After linkage, these personal identity codes were replaced by artificial identifiers.

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Results There were 243 drug overdose deaths, 107 of which occurred in 2000 and 136 in 2008. Men accounted for 207 (85%) cases and women for 36 (15%). The gender breakdown was similar in 2000 and 2008. Persons under 35 accounted for 79% of all the deceased, 87% in 2000 and 72% in 2008. In 172 of the 243 cases (Figure 1) there was at least one PPD contributing to death, possibly in combination with illicit drug and alcohol (later ‘PPD induced deaths’). In the other 71 cases, the poisonings were induced by illicit drugs only (and possibly alcohol); the drug mainly being heroin (56 cases) and in the rest of the cases a stimulant (15 cases). Most (156/243) of the poisonings in the data were caused by two or more substances, and alcohol contributed to death in 25% of these multi-poisonings. The five substances contributing most frequently to death in all cases were alcohol (61 cases), heroin (56 cases), buprenorphine (48 cases), codeine (38 cases) and amphetamines (34 cases). Purchases of similarly acting drugs

To examine the role of personally prescribed PPDs in overdose mortality, the PPDs responsible for the poisoning were compared with the medicine purchases of the individual concerned during the year of death (later ‘within one year of death’) as well as during the year of death and two previous years (later ‘within three years of death’). The analysis was twofold. Firstly, the aim was to determine what proportion of the deceased had made prescribed psychoactive drug purchases of a similarly acting substance for at least one of the substances causing death, that is, whether they had made purchases in the same drug category. Secondly, purchases of identical substances were compared. Statistical analyses were conducted with SPSS Statistics 20 (IBM Corporation, Armonk, New York, United States). Statistical significance was calculated by using Pearson’s chi-Square (χ2); P values < 0.05 were considered statistically significant.

Thirty-six percent (87/243) of those who had died of a drug overdose had purchased a similarly acting drug within three years of death (Table 1). The proportion was higher for PPD-induced overdoses, that is, 51% (87/172). As shown in Table 1, the proportion of deaths with a prescription match within three years of death has increased; from 20% in 2000 to 49% in 2008 (P < 0.001). As a proportion of PPD-induced deaths only, the figure is rather stable, showing an increase from 50% (21/42) to 51% (66/130) (not shown as a table). A similar increase is seen for purchases within one year of death: 10% had prescription purchases in 2000 and one-third in 2008 (P < 0.001).There were no gender differences in prescription purchases (P = 0.68). There were no systematic age group differences across the two years studied for purchases within three years of death. In 2000, the age group differences were not statistically significant (P = 0.468), while in 2008 the age group 25–34 had the most prescription purchases (P < 0.05). The differences were not statistically significant for purchases within one year of death either in 2000 (P = 0.485) or in 2008 (P = 0.095).

Research ethics

Purchases of similarly acting substances and social disadvantage

Permits for data collection were obtained from the relevant registrars. In addition, the study received an ethical approval from the Ethics Board of the Social Insurance Institution.

The majority (83%) of the deceased had received income support, but only 13–14% were long-term unemployed or on disability pension (Table 2). Prescribed psychoactive drug purchases were evenly

Statistical analysis

© 2014 Australasian Professional Society on Alcohol and other Drugs

16 33 26 14 14 33 10 2

22 43 15 7

73 14

24 43 39 50

25 22 51 8

87

35 39

24 59

36

n % n

%

Within the last 3 years Within the last 1 year

Poisoning deaths with prescription match

Total

S. Rönkä et al.

distributed between those who had received income support and those who had not (within three years of death, P = 0.733, and within one year of death, P = 0.476), and between the long-term unemployed and others (within three years of death, P = 0.83, and within one year of death, P = 0.22). However, those who were on disability pension had many more drug purchases than those who were not (within three years of death, P < 0.001, and within one year of death, P < 0.001).

37 42 16 6 90 101 38 14 14 34 13 5 11 26 9 2

26 47 32 20

33 62 46 50

85 15 207 36 56 10 41 7

36 33

49 48

— 243 66 48

35

49

% n % n % n

Within the last 3 years Within the last 1 year

Poisoning deaths with prescription match

2008

All poisoning deaths

Purchases of identical drugs Of the 87 persons who had purchased similarly acting drugs within three years of death, 62 had purchased identical substances. Each individual could have had several different drug findings, and there were a total of 92 purchases of identical substances (Table 3). The biggest group was benzodiazepines, with 36 cases of purchases of the identical substance within three years of death contributing to the fatal poisoning. The single substance with the most purchases was alprazolam (n = 12). Among opioids, the most purchases were recorded for tramadol (n = 9). An emerging drug of abuse, pregabalin, had been purchased in four cases. There were no matches in stimulants. Discussion

32 40 21 7 43 55 28 10 17 20 20 50 8 9 2 2 6 15 10 0 44 43 9 4 47 46 10 4

3 7 1 0

85 15 115 21 18 27 17 4 11 7 86 14 92 15

10 1

— 136 20 21 10 —

All Sex Male Female Age group 15–24 25–34 35–44 45–54

107

11

% n % n % n % n

Within the last 3 years Within the last 1 year All poisoning deaths

Poisoning deaths with prescription match

All poisoning deaths

Summary of main results

2000

Table 1. Number of poisoning deaths and proportion with a prescription match within 1 and 3 years of death by gender and age in 2000 and 2008

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© 2014 Australasian Professional Society on Alcohol and other Drugs

Our analysis showed that in 36% of the drug poisonings, the deceased had bought a similarly acting prescription drug as the one causing or contributing to the poisoning within three years of death. In the case of PPD-induced poisonings, the figure was 51%. There was a marked increase from 2000 to 2008. In 2000, only 20% had prescribed psychoactive drug purchases within three years of death, whereas in 2008 the figure was 49%. Among those deceased persons who were on disability pension, three in four had purchased similarly acting drugs that later caused or contributed to the poisoning. However, when income support or longterm employment was used as a measure of social disadvantage, social disadvantage seemed to have no effect on the connection between personally prescribed PPDs and fatal overdoses. A comparison of active drugs in poisonings and purchases of identical drugs showed that tramadol (opioid) and alprazolam (benzodiazepine) were the most common substances. Interpretation of results Our results show that in 36% of the fatal drug poisonings, the person had purchased a similarly acting drug within three years of death. This implies that personally prescribed PPDs pose a potential threat to people who abuse drugs. We do not know whether the drugs were

Prescription drugs in overdose deaths

87

Table 2. Number of poisoning deaths and proportion with a prescription match of similarly acting drugs by income-based social disadvantage in 2000 and 2008 combined

All poisoning deaths

All Receiving income support Not receiving income suppport Long-term unemployed Not long-term unemployed Receiving disability pension Not receiving disability pension

Poisoning deaths with prescription match within the last 1 year

Poisoning deaths with prescription match within the last 3 years

n

%

n

%

n

%

243 201 42 32 211 33 210

— 83 17 13 87 14 86

59 47 12 5 54 18 41

— 23 29 16 26 55 20

87 71 16 12 75 24 63

— 35 38 38 36 73 30

prescribed for legitimate medical conditions or whether they were acquired by feigning diseases. Either way, it is feasible to suspect that in the majority of cases, they were abused, as the deceased had a known and often long history of drug abuse. Antipsychotics and antidepressants play a noticeable role in the results. Presumably, this is an indication of a high incidence of dual diagnosis among the deceased. Tramadol and pregabalin can be identified as new, emerging drugs of abuse. The shift observed from 2000 to 2008 reflects a shift in the supply of drugs and in user culture. The availability of licit drugs has increased; for instance, the consumption of prescription opioids has doubled in the past 15 years in Finland and a similar increase has occurred with antidepressants [33]. In the user culture, the focus of drug abuse is moving from illicit narcotics towards licit drugs. Paradoxically, abusers themselves consider PPDs to be safe because they are registered as pharmaceuticals and because their purity and potency are known [34]. This trend is seen not only in Finland, but also it is commonly observed across developed countries [2–6]. It has been suggested that this transition will result in a paradigm shift in the whole drug addiction field as interventions, policy and research adjust to the changing situation [35]. The main source of income for those dying of drug poisoning was income support, a last resort benefit in the Finnish social insurance system [36]. All in all, the results indicate that drug abusers who died of a drug overdose are economically disadvantaged. The small proportion of unemployment benefit recipients is probably explained by the complexity of the application process rather than by an unlikely large number of people in the labour force. Those on disability pension had a much larger number of purchases of similarly acting drugs. This is understandable in view of the fact that their disability pension will have been granted on

grounds of chronic illness, which is likely to entail frequent visits to the doctor and medical therapy. The connection between disability pension and PPD purchases is underscored by the fact that mental health disorders are the single most common reason for disability pension in Finland [37], and they are also very common among people who abuse drugs [16–18]. Drug abusers who are on disability pension are an obvious risk group for fatal drug poisoning. It should also be noted that while they are generally safe, PPDs are potentially harmful in the hands of polydrug users. Drugs are often taken at the same time to cumulate or complete effects. In addition, the effects of one drug are often countered with another, for instance by taking sedatives to induce sleep after using stimulants [38]. Most overdoses are caused by the simultaneous use of different substances, including alcohol and pharmaceuticals [39]. Therefore, more effort should be made to identify people who abuse drugs and to monitor their drug prescriptions. Strengths and limitations An important strength of this study is that it was based on a unique dataset comparing toxicologically identified substances in drug poisoning deaths with recorded prescription drug purchases. The Forensic Toxicological Register has very good coverage: approximately 90% of unexpected and sudden deaths in Finland are subject to medicolegal autopsy, which usually includes toxicological analysis [27]. There are some limitations in the data. The Register on Reimbursed Medical Purchases does not include medicines used in opioid substitution treatment, namely methadone or buprenorphine (including recombinant products with naloxone) and other medication possibly given at drug treatment clinics.The recent revision of the Decree on the substitution treatment of opioid addicts © 2014 Australasian Professional Society on Alcohol and other Drugs

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Table 3. Purchases within 3 years of death of identical drugs causing or contributing to lethal poisoning in 2000 and 2008 combined Opioids Tramadol Buprenorphine Oxycodone Benzodiazepine derivatives

12 9 2 1 36

Alprazolam Diazepam Temazepam Oxazepam Clonazepam Zopiclone Midazolam

12 10 6 3 2 2 1

Antipsychotics

9

Clozapine Quetiapine Levomepromazine Chlorprothixhene Perphenazine Sulpiride Antidepressants Venlafaxine Sertraline Moclobemide Mirtazapine Citalopram/escitalopram Amitriptyline Doxepin Paroxetine Fluoxetine Fluvoxamine

2 2 2 1 1 1 31 6 4 5 2 3 3 3 2 2 1

Anticonvulsants

4

Pregabalin

4

Total

92

In addition, the following psychoactive substances were involved in poisonings, but there were no identical drug purchases: codeine, fentanyl, morphine, dextropropoxyphene, metadone, chlordiazepoxide, promazine, trimipramine, gabapentin, efedrine.

(33/2008) paved the way to the distribution of buprenorphine and naloxone-containing products through pharmacies from January 2008. However, because these products were not reimbursed until August 2009, patients preferred to obtain their drugs directly from the clinic. This meant that any purchases © 2014 Australasian Professional Society on Alcohol and other Drugs

they made would not have been registered, as the data only cover reimbursed purchases. Furthermore, the coverage of benzodiazepine purchases by people who died in 2000 might have been affected by previous reimbursement regulations. Until 2006, there was a minimum limit of 10 euros for reimbursement of medical purchases, and the cheapest benzodiazepine products were under this limit. For this reason, the results for 2000 may be somewhat underestimated. In addition, it should be noted that the latest data are from 2008. There might be changes in the patterns of substance abuse in Finland since then. Conclusions Personally prescribed PPDs pose a potential threat to people who abuse drugs and prescription practices need to be improved. As suggested by Dhalla et al. [40], a national centralised electronic prescription database would help to prevent ‘doctor shopping’, giving doctors the ability to monitor patients’ prescription rates and patterns. An electronic system would also make it harder to forge prescriptions. On the other hand, our results show that people who abuse drugs often have contact with health-care professionals and social workers, which is an opportunity for the provision of care and support. At a minimum, it is important that patients are informed about the potentially fatal consequences of combining PPDs, illicit drugs and alcohol. Acknowledgements Sanna Rönkä received grants for this study from the Finnish Foundation for Alcohol Studies and the Finnish Cultural Foundation. References [1] International Narcotics Control Board. Annual Report 2011. 2012. [2] Substance Abuse and Mental Health Services Administration. The TEDS Report: Substance Abuse Treatment Admissions Involving Abuse of Pain Relievers: 1998 and 2008. Rockville, MD. Available at: http://www.oas .samhsa.gov/2k10/230/230PainRelvr2k10.htm (accessed November 2013). [3] Tanhua H, Virtanen A, Knuuti U, Leppo A, Kotovirta E. Drug Situation in Finland 2011. National Institute for Health and Welfare. 2011;63. [4] Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician 2012;15(3 Suppl.):ES191–203. [5] Larance B, Ambekar A, Azim T, et al. The availability, diversion and injection of pharmaceutical opioids in South Asia. Drug Alcohol Rev 2011;30:246–54. [6] Wilkins C, Sweetsur P, Griffiths R. Recent trends in pharmaceutical drug use among frequent injecting drug users, frequent methamphetamine users and frequent ecstasy users in New Zealand, 2006–2009. Drug Alcohol Rev 2011;30:255–63.

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Personally prescribed psychoactive drugs in overdose deaths among drug abusers: a retrospective register study.

Psychoactive prescription drug (PPD) abuse-related overdose deaths have increased in many countries in recent decades. We aimed to investigate the rol...
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