Psychoactive substances in natural and unnatural deaths in Norway and Sweden – a study on victims of suicide and accidents compared with natural deaths in psychiatric patients

摘要

BackgroundSubstance abuse is a major public health problem and a risk factor for premature death in intentional, accidental, and natural circumstances, and can have a severe economic, emotional, and society impact on individuals, families and within communities [1,2,3]. In forensic medicine, determination of manner of death as intentional or accidental can be particularly challenging in deaths caused by poisoning or related to substance abuse, where there is no clear evidence for suicidal intention.. Hence, the frequency and accuracy of post-mortem examinations, including toxicological analyses, may ultimately impact death statistics [4]. In the USA, the percentage of drug poisoning classified as having undetermined manners of death range from 1 to 85% between states and specification of the drugs involved varies by type of death investigation system [5].Few studies have systematically examined the post-mortem occurrence of psychoactive substances according to classified manner of death: natural death, accident, suicide or undetermined manner of death. In a large observational study from England on drug-related fatal injuries, the most frequent substance detected was alcohol (36%), followed by sedative-hypnotics, cannabis, heroin and cocaine. Antidepressants were more often detected in intentional fatal injuries (suicides by other methods than poisoning) compared with accidents (12% vs 2%) [6]. An important proportion of suicides is committed by mentally ill persons that are or have been treated with psychoactive prescription drugs [7,8,9]. Hence, it is likely that such drugs are commonly detected in this category of deaths. In a Swedish study on suicides by hanging and poisoning, paracetamol, citalopram, diazepam, sedative antihistamines, and zopiclone were amongst the top-ten drugs detected [10].Opioid poisoning is relatively frequent among drug abusers [11], and the associated manner of death may be registered as a suicide, accident or natural death [12]. The pattern of substance abuse varies between countries. Norway reports a relatively high prevalence of intravenous drug abuse compared with the other Scandinavian countries, Sweden and Denmark [13, 14]. In all three countries, among drug abusers, poisoning by opioids is reported as the main cause of death, with methadone more commonly detected in deaths in Denmark and Sweden, and heroin/morphine in Norway [14]. Regional differences in substance abuse may reflect general availability, but aside from opioid overdoses, less is known about patterns of toxicological findings in the general population of suicides and accidents in Scandinavia. Since a peak in 2001, there has been no definite decline in deaths due to accidental poisoning in Norway [15]. According to the Swedish official death statistics there has been a gradual increase of drug related deaths with some fluctuations during the past five decades and a marked increase during the period 2006–2014 [16]. In the latter period, the rate of drug related deaths increased from 3.6 to 8.1 per 100.000 inhabitants per year, and most of the deaths involved opioid overdose [14].In order to enable societies to implement relevant prevention strategies to reduce premature deaths, increased knowledge about related substance abuse patterns is necessary. The main purpose of this study was to analyse the occurrence and pattern of various psychoactive substances in a population of suicides and accidents as well as in natural deaths with a psychiatric diagnosis. In addition to describe patterns of substance findings according to manner of death, and deaths due to acute poisoning versus other methods, we aimed to compare datasets from two neighbouring countries; Norway and Sweden.