Tramadol-related deaths 2016 Survey overview

Isabelle Giraudon, Federica Mathis, Klaudia Palczak

Paralel workshop Opioids, medicines and focus on Tramadol

European joint DRD expert meeting

Lisbon, 29-30 September 2016

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Background and rational

• One of the missions of EMCDDA is to collect, register,

analyse information on ‘emerging trends in polydrug use,

including combined use of licit and illicit psychoactive

substances’

• Particular attention to the medicines with high potential for

misuse or for which alerts or signals of public health

concerns have been reported

• Increase of UK tramadol-related deaths

Ad-hoc data collection exercise launched in September

2013: National DRD experts were asked to provide information on

Tramadol related deaths registered in their countries. Data were

provided by 9 countries.

• A new call for data was launched in 2016

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EMCDDA project on tramadol

• A new call for data was launched in 2016 in view of the new EMCDDA

project on misuses of tramadol in the context of poly drug use;

• To be implemented in 2017 with selected number of MS (France, UK,

Germany, Sweden) and in collaboration with the EMA in London;

• The objective of the study is to provide a comprehensive overview of

tramadol, including its pharmacology and toxicology; availability and

legal status, information on the levels of misuse and the risk and harms

related with tramadol consumption, in the context of polydrug use,

• Based on the case studies but will strive to provide a European

perspective where possible (EMCDDA and EMA) - e.g. data sets and

today meeting as a first step

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Methods

Short questionnaire on:

• number of deaths

• age

• gender

• trends since 2000

• intentionality

• background on regulation

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Results

13 countries provided data:

Country 2013 2016

Austria P P

Czech Republic P

Cyprus P

Estonia P

Finland P P

France P

Hungary P P

Ireland P

Latvia P P

Lithuania P P

Slovakia P P

Slovenia P

Spain P

Turkey P

United Kingdom P P

For 2016 survey

Cyprus,

Hungary, and

UK provided

qualitative

information only

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Tramadol-related deaths – 2013 survey

110

18 16 13 12

5 2 1 1

0

20

40

60

80

100

120

UK FI CZ AT SK SI LV LT HU

Num

ber

of

cases

report

ed

Country

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Tramadol-related deaths – most recent data (2016 survey)

22

4

13

0 0

4

26

5

30

0

5

10

15

20

25

30

35

UK FI CZ AT SK SI LV LT HU FR IE EE ES CY

Num

ber

of

cases

report

ed

Country

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Tramadol-related deaths – 2013 vs 2016 survey

110

21

16 13 12

5 2 1 1 1

26 24

0

20

40

60

80

100

120

UK FI CZ AT SK SI LV LT HU FR IE EE ES CY

2012

2014

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Finland – trend in the number of tramadol-related deaths

1 2

8

3 4

6

14 14 14

24

30

23

21

26

22

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

2000-2008 according to 2013 data

2009-2014 according to 2016 data

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Finland – trend in the % of tramadol-related deaths (selection D)

1.0

3.3

12.1

4.5 5.4

8.3

15.9 15.2

12.5

22.9 23.1

13.9 13.5

16.0 16.1

0.0

5.0

10.0

15.0

20.0

25.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

2000-2008 according to 2013 data

2009-2014 according to 2016 data

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Ireland – trend in the number of tramadol-related deaths (NDRDI)

2

11

8

5 5

8

13

11

8

13 14

22

26 26

0

5

10

15

20

25

30

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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Ireland – trend in the % of tramadol-related deaths (NDRDI vs ST6 selection D)

1.8

10.1

6.3

4.8

3.9

4.8

6.9

5.3

3.7

6.0

8.0

9.5

13.8

11.9

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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Spain – trend in the number of tramadol-related deaths

2 1

3

7

2

11

2

24 24

30

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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Spain – trend in the % of tramadol-related deaths (selection D)

0.8 0.5

1.6

5.0

1.1

6.0

1.2

12.3 12.2

17.4

0

2

4

6

8

10

12

14

16

18

20

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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Austria – trend in the number of tramadol-related deaths

0 0 0 0 0 0

10

12

7

4 4

11

13

7

4

0

2

4

6

8

10

12

14

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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Austria – trend in the % of tramadol-related deaths (selection D)

5.1

6.9

3.5

1.9 2.1

5.5

8.1

5.1

3.3

0

1

2

3

4

5

6

7

8

9

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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Trends comparison in the numbers of tramadol-related deaths

• Finland

1 2

8

3 4 6

14 14 14

24

30

23 21

26

22

05

101520253035

2

11 8

5 5 8

13 11

8

13 14

22

26 26

0

5

10

15

20

25

30

35

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

• Ireland

• Spain • Austria

0 0 0 0 0 0

10 12

7

4 4

11 13

7

4

0

5

10

15

20

25

30

35

2000 2002 2004 2006 2008 2010 2012 2014

2 1 3

7

2

11

2

24 24

30

0

5

10

15

20

25

30

35

2000 2002 2004 2006 2008 2010 2012 2014

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Trends comparison in the numbers of tramadol-related deaths

• Finland • Ireland

• Spain • Austria

0.0

5.0

10.0

15.0

20.0

25.0

0.0

5.0

10.0

15.0

20.0

25.0

2000 2002 2004 2006 2008 2010 2012

0

5

10

15

20

25

2000 2002 2004 2006 2008 2010 2012 2014

0

5

10

15

20

25

2000 2002 2004 2006 2008 2010 2012 2014

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Finland – age and gender profile of the tramadol-related deaths, 2011 (N=18)

<15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-10 -8 -6 -4 -2 0 2 4 6 8 10

Number of deaths reported

Female

Male

83% males

Mean age 27,8

Slide 2013 left for

comparison. Note: n

was 18, now for 2011

n = 23

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Finland – age and gender profile of the tramadol-related deaths, 2014 (N=22)

<15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-10 -8 -6 -4 -2 0 2 4 6 8 10

Number of deaths reported

Female

Male

82% males

Mean age 31.3

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Ireland – age and gender profile of the tramadol-related deaths, 2014 NDRDI (N=26)

<15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-10 -8 -6 -4 -2 0 2 4 6 8 10

Number of deaths reported

Female

Male

61.5% males

Mean age 40.7

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Spain – age and gender profile of the tramadol-related deaths, 2014 (N=30)

<15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-10 -8 -6 -4 -2 0 2 4 6 8 10

Number of deaths reported

Female

Male

60% males

Mean age 45.5

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• Increase in sales are reported by France, Ireland, Latvia

• Stable sales are reported in Finland, Lithuania, Hungary

• A reduction of 5% occurred in UK in 2015 after a pick in 2013

and 2014

• Caution: absolute numbers - do not take into account

changes in the population

Changes in sales

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• Cyprus: In 2002 Tramadol was included in the list of controlled substances. In

2003, relevant regulations were issued; besides penalties for illegal trading,

prescription rules were included, as well as a need of notification in case of

addiction from the particular drug.

• Latvia: Despite the fact that there already were tramadol control actions

(prescription to specific recipes, registration in the strict accountability register and

inclusion of narcotic analgesics lists), changes in legislation were made in 2014:

tramadol was classified as psychotropic substance and it was included in the list of

controlled substances.

• Spain: Tramadol is a legally commercialized pharmaceutical drug which requires

medical prescription under the rules of the Spanish Ministry of Health, Social

Services and Equality. However, apparently, this opiate derivative can be “easily”

purchased in the Internet bypassing the medial prescription requirement.

Notes on regulations at a national level

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Discussion & conclusions

• Limited information (short time series)

• Small number of cases

• Large countries and countries having issues with

medicines-related harm are missing in this survey

• Different trends in different countries. Trend profiles similar

both considering absolute numbers and percentages of

cases among DRD

• Different age profiles of the tramadol-related deaths across

countries

• Apparently no recent change in regulations / availability of

tramadol (except in Latvia)

• Standard Table 5 – Toxicology reporting should be

encouraged

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• Some updates of previously reported numbers • Finland now there were 24 cases in 2009 instead of 16, 30 in 2010 vs 27, 23 in 2011 vs

18, 21 in 2012 vs 18; I

• Austria in 2008 now result 7 cases in 2008 instead of 5;

• Latvia in 2012 now 0 instead of 2

• Lithuania in 2012 now 0 instead of 1

• Ireland: data from NDRDI

• For some questionnaires, we may ask you some clarifications

and tables filled in, where possible

• Some analyses limited to the countries with at least 10 cases

Some comments

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Ackowledgements

• To the national experts and or focal points who

contributed with data analysis and comments

• To João Matias who did the analysis of the

previous survey

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United Kingdom – trends in the number of

tramadol-related deaths

2537

45 51 56

75

109116

126135

185

205

254

10

3219

3646

53

7683 79

114 113

156

106

0

50

100

150

200

250

300

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Number of cases in UK GMRs(Deaths registerd in a year)

Number of cases in SR (np-SAD)(Deaths occurring in a year)

To be

updated

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United Kingdom – age and gender profile of the tramadol-related deaths, 2012 (n=110)

<15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-15 -10 -5 0 5 10 15

Number of deaths reported

Female

Male

61% males

Mean age 43,5 years

(male 43, female 50)

To be

updated