Use of addictive medicine

Opioids are strong analgesic drugs (painkillers). There has been a sharp rise in the prescription of opioids in many western countries during the last two decades, with a corresponding increased death toll due to opioid related deaths[1][2]. The centre in the brain that generates regular breathing rhythm is depressed by opioids. This mechanism and other pathways that depress breathing explains the toxicity of opioids.

Figure 1 shows that the Nordic countries have largely been spared for the prescription opioid epidemic. Rather, prescription opioid use has been on the decline in most of the Nordic countries during the past two decades, except in Åland. There has been a substantial decrease in Denmark, the Faroe Islands and Sweden while Norway has remained fairly unchanged.

Iceland has the highest sales with 23.8 DDD of opioids sold per day per 1 000 inhabitants in 2018. Figure 1 also shows that the Faroe Islands, Åland and Greenland have the most cautious use of opioids.

The opioid death toll more than doubled in Sweden from 2011 to 2016[3]. This increase in opioid related deaths in Sweden cannot, unlike in many other countries, be ascribed to a parallel increase in prescription opioids sold since it actually decreased in Sweden during this period as figure 1 shows. The risk of death from opioids greatly increases if other sedative medications are used simultaneously. Figure 2 shows the most commonly used sedatives, i.e. benzodiazepines and benzodiazepine-like drugs (Z-drugs). These drugs are addictive and frequently taken simultaneously with opioids, increasing the opioids’ lethality.

Figure 2 shows that the sales of prescription benzodiazepines and benzodiazepine-like drugs has been declining in most Nordic countries during the last decade. As with the opioids, Iceland has the highest sale of prescription benzodiazepines with 77.8 DDD per 1 000 persons per day. The Faroe Islands and Greenland have, together with Denmark, a relatively modest consumption of prescription benzodiazepines. Denmark, in particular, has enjoyed a remarkable success in reducing the sales of benzodiazepines, from 55.5 to 17.2 DDD sold per 1 000 inhabitants per day between the years 2000 to 2018.

What could be the reason for this difference in benzodiazepine use between the Nordic countries shown in figure 2? Benzodiazepine use has declined more in Norway and Denmark during the past decade than for instance in Sweden and Iceland. Some 10 years ago, Norway and Denmark introduced a strict, clear-cut, unambiguous upper limit for the amount of sedative medications that could be prescribed to an individual without affecting the individual’s right to drive a motor vehicle. Exceeding this limit leads to suspension of the driving license. Other Nordic countries, among them Sweden and Iceland, did not take such actions and interestingly, the same decline in sales of benzodiazepine cannot be seen for these two countries. However, there may be many other explanations. For instance, a number of ambitious interventions have been put in place in Denmark to counteract benzodiazepine use which may also partly explain Denmark´s remarkable success in this field.

Figure 3 shows that the sales of prescription medications for Attention Deficit Hyperactivity Disorder (ADHD) has been rapidly rising in all the Nordic countries.

The most striking feature in figure 3 is the sale of ADHD medications in Iceland, about three times higher than in the other Nordic countries. What could be the explanation for this? Several hypotheses have been put forward. Icelanders have lived on fishing through the centuries and it has been suggested that hunter populations have a higher prevalence of ADHD. However, the sales of ADHD medication in the Faroe Islands is not high despite the fact that its’ inhabitants also live on fishing.  The sales of opioids, benzodiazepines and ADHD drugs in the Nordic countries are lowest in sparsely populated countries such as Greenland, Åland and the Faroe Islands. Iceland is also sparsely populated, however, 80 per cent of the population lives in Reykjavik and vicinity. Here the accessibility to doctors and psychologists who can diagnose ADHD is excellent due to extensive private practice on top of the official health care system. Is it unavoidable that the use of addictive medications will be more prevalent in areas with good coverage of medical doctors? No, data on the steep decline in sales of benzodiazepines in Denmark shows that this does not need to be the case at all. 

When health care policy makers from the Nordic countries meet, the easily accessible NOMESCO data can be the foundation for discussions and decisions that are based on data, i.e. data driven health care policies. For instance, those countries that wish to reduce the use of benzodiazepines could investigate which actions have been taken in Denmark and those who want to reduce opioid use could learn how Sweden has approached this problem. 

[1] Helmerhorst o.fl., „An Epidemic of the Use, Misuse and Overdose of Opioids and Deaths Due to Overdose, in the United States and Canada“.

[2] Verhamme og Bohnen, „Are We Facing an Opioid Crisis in Europe?“

[3]„Urgent action needed to address growing opioid crisis - OECD“.