Ελευθερία Κοκκίνη (1), Χαράλαμπος Πουλόπουλος (2), & Χαρά Σπηλιοπούλου (3)
(1) PhD Κοινωνικής Εργασίας, Δημοκρίτειο Πανεπιστήμιο Θράκης
(2) Καθηγητής Κοινωνικής Εργασίας στις Εξαρτήσεις, Τμήμα Κοινωνικής Εργασίας, Πανεπιστήμιο Δυτικής Αττικής, https://orcid.org/0000-0001-9797-2217
email: chpoulo@uniwa.gr
(3) Καθηγήτρια Ιατροδικαστικής και Τοξικολογίας, Ιατρική Σχολή, ΕΚΠΑ
DOI: https://doi.org/10.57160/OVPZ4702
Περίληψη
Η παρούσα μελέτη αποσκοπεί να ερευνήσει τον ρόλο και τη συχνότητα εμφάνισης του αλκοόλ στους θανάτους που σχετίζονται με τη χρήση ουσιών. Τα δεδομένα αντλήθηκαν από τα αρχεία του Εργαστήριου Ιατροδικαστικής και Τοξικολογίας της Ιατρικής Σχολής του Πανεπιστημίου Αθηνών και αφορούν την περίοδο 2012-2016. Μέσω της αρχειακής μελέτης τεκμηρίων έγινε καταγραφή του κοινωνιοδημογραφικού προφίλ των θανόντων καθώς και των συνθηκών θανάτου για τη σχετική περίοδο αναφοράς. Από τους 5.467 φακέλους που μελετήθηκαν εντοπίστηκαν 178 περιπτώσεις όπου ο θάνατος σχετιζόταν με την κατάχρηση ψυχοτρόπων ουσιών. Στις περιπτώσεις αυτές τουλάχιστον μία εξαρτησιογόνος ουσία είχε ανιχνευθεί, και εξ αυτών στις 51 περιπτώσεις υπήρχε παράλληλα ή αποκλειστικά κατανάλωση αλκοόλ. Συγκεκριμένα, αναδείχθηκε ότι η πλειοψηφία των θανόντων έκανε πολλαπλή χρήση ουσιών σε ποσοστό 78,4%, όπου το αλκοόλ αποτελούσε συνοδό ουσία. Η δηλητηρίαση από εξαρτησιογόνες ουσίες αποτελεί την κύρια αιτία θανάτου σε ποσοστό 31,4% και η δηλητηρίαση από αιθυλική αλκοόλη σε ποσοστό 15,7%. Ωστόσο, η κατάχρηση αλκοόλ στην Ελλάδα, όπως και οι θάνατοι από αλκοόλ, συχνά υποτιμούνται παρά τον συνοδευτικό ρόλο που διαδραματίζει τόσο στην εξάρτηση όσο και στη θνησιμότητα.
Λέξεις κλειδιά: θνησιμότητα, κατάχρηση αλκοόλ, αρχειακό υλικό.
Παραπομπή σε APA 7th edition:
Early death, drug abuse and alcohol use in Greece
Eleftheria Kokkini (1), Charalampos Poulopoulos (2), & Chara Spiliopoulou (3)
(1) PhD Social Work, Democritus University of Thrace
(2) Professor of Social Work in the Addictions, Department of Social Work, University of West Attica, email: chpoulo@uniwa.gr, https://orcid.org/0000-0001-9797-2217
(3) Professor of Forensic Medicine and Toxicology, National and Kapodistrian University of Athens
DOI: https://doi.org/10.57160/OVPZ4702
Abstract
The present study researched the forensic files of the Department of Forensic Medicine and Toxicology of the Medical School of the National and Kapodistrian University of Athens, Greece, between 2012-2016. The socio-demographic profiles of people who died due to drug use were researched and the circumstances of their death for the relevant reference period were recorded. From a total of 5,467 files that were studied, 178 cases of drug-related deaths were identified. In these cases, at least one psychotropic substance was used prior to death occurrence. Fifty-one cases were identified where death was related to the concurrent or the exclusive use of alcohol. In most drug related deaths, the use of multiple drugs (polydrug use) was identified at a rate as high as 78.4%. In all these cases, the accompanying role of alcohol together with other substances, was identified. Drug-related intoxication was the main cause of death in 31.4% of the cases, and alcohol-related intoxication was the main cause of death in 15.7% of the cases. However, Alcohol Use Disorder and risky alcohol use is often underestimated in Greece including the accompanying role they play in both morbidity and mortality.
Key words: alcohol-related mortality, alcohol use, postmortem samples.
Introduction
Drug-related deaths, according to the European Monitoring Center for Drugs and Drug Addiction (2017, p. 8), are defined as those directly related (such as acute poisonings and overdoses) to the intake of illicit drugs. For the Greek Office for National Statistics (ONS), drug-related deaths are defined as those caused by drug intoxication, risky drug or alcohol use, or dependence and when any of the substances controlled under the law are found in the deceased. Drug-related deaths include suicides and the long-term effects of risky drug use. Most studies focus mainly on drug-related deaths other than alcohol related deaths. Alcohol related deaths are examined separately (Adfam and Cruse Bereavement Care, 2014). However, a significant number of deaths involve the simultaneous use of various substances. The main drug related to deaths, in Greece, remains heroin, combined with the intake of Central Nervous System (CNS) depressants, such as alcohol and benzodiazepines (EMCDDA, 2018).
Alcohol and other drug-related deaths are not easily accepted by the Greek society. They are perceived as being “not natural.” Or, they are associated with social prejudices and moral judgments around the way of living or the participation in illegal activities (Adfam and Cruse Bereavement Care, 2014; Dyregrov & Selseng, 2021), as risky drug use is often accompanied by delinquent or even criminal behavior. In addition, the living standards of people who misuse drugs are not well accepted (Templeton, Valentine et al., 2017).
Recent data from the European Monitoring Center for Drugs and Drug Addiction (2021a) also refers to the COVID-19 pandemic, shows that during isolation, drug use decreased, but when restrictions were relaxed it increased again to the levels prior to the curfew. However, an increase was observed in the intake of alcohol, psychedelics, and dissociative substances such as ketamine, possibly due to home use. The increase in alcohol intake and the damage it caused during the first year of the COVID-19 pandemic were also highlighted in related research by White et al. (2022).
In 2018, Greek data showed 242 drug-related deaths. Most of them involved single, unemployed men, aged 35-39 years old. The main substance involved in deaths was opioids or related drugs, with the main cause of death being overdose. In some cases, cocaine and benzodiazepines were also recorded as polydrug use. In 2019, there was an increase in alcohol related deaths, compared to the previous two years. In Greece, an increase was observed in the demand for alcohol treatment in 2016-2018, in contrast to year 2019 when there was a decrease of 7.8% (EKTEPN, 2021).
In many drug-related death cases, alcohol was an accompanying substance that increased mortality rates mainly due to polydrug use. Polydrug use involves the use of more than one substance at the same time or in succession, including alcohol and legally prescribed medication. Polydrug use and heavy alcohol intake are risk factors for substance-related deaths. A person’s judgment is affected by polydrug use, for example, in relation to how much opioids he/she can consume at the same time. It also increases toxicological risks due to the simultaneous intake of various substances, for example, opioids in combination with benzodiazepines (EMCDDA, 2021b).
In a study by Stanistreet et al. (2004), one-fourth of the drug related death cases had a co-occurring alcohol problem, while half of the cases had both alcohol and drugs detected at autopsy. According to studies focusing on the combination of benzodiazepines with other substances, it seems that alcohol intake is involved to a lesser extent than opioid analgesics, however, it still remains an important factor in overdoses from prescription of psychotropic substances (Jann et al., 2013). The mixing of substances, especially combining alcohol and/or benzodiazepines with opiates, significantly increases the risks of drug intoxication (Stanistreet et al., 2004).
Alcohol is also one of the most usual substances linked to relapse, especially in crisis circumstances, such as the death of a loved one. Relapse was associated more with alcohol intake than with any other drug. When relapse occurred during treatment initiation, alcohol intake worked as a disincentive to continue the treatment program despite the strong motivation that individuals reported (Matsa, 2012). According to Larimer and Marlatt cited in Poulopoulos (2002), data from several studies showed that the most critical time for relapse is the first year following treatment, due to the use of both opioids and other substances such as alcohol. Alcohol seems to be the first substance in which people turn to after treatment. Poulopoulos (2002) suggests that early treatment drop out also increases the likelihood of relapse. In addition, it is a risk factor for overdose mortality. Alcohol is often a pathway to relapse due to its widespread availability and because it is perceived as a safer substance, especially by people who use other drugs.
Polydrug use, the way of use, and the quantity or purity of each substance, increases the risks for negative effects. Drugs taken intravenously cause higher drug concentrations in the blood. Long-term alcohol intake affects the liver, the main organ that metabolizes substances, increasing tolerance to substance use. The combined intake of alcohol and cocaine can increase cocaine levels in the blood. The negative cardiovascular effects of cocaine are enhanced when it is taken together with opioids. Finally, the combination of opioids and benzodiazepines (with or without alcohol) increase the risks of accidents and overdose with a fatal outcome in many cases (EMCDDA, 2021b).
Long-term substance use combined with age is associated with a range of chronic health problems, making older people who use alcohol and other drugs more vulnerable to physical diseases. Vulnerability exists due to a history of poor health, poor living conditions, tobacco and alcohol intake, and a weakened immune system. Diseases include mainly cardiovascular and pulmonary problems, hepatitis infection, liver cirrhosis and other liver related problems4 that can lead to death. According to the World Health Organization (WHO), harmful alcohol intake is a risk factor for more than 200 diseases or injuries, with alcohol related deaths amounting to 3 million annually, a rate that corresponds to 5.3% of all deaths worldwide5.
There are clearly differences in the organic causes depending on the history of use and the health of the people who use alcohol and other drugs. Substance use does not follow the same rule for everyone. For example, the usually negligible increase in heart rate from cannabis intake can be painful for some who suffer from angina pectoris, while the concomitant intake of benzodiazepines and alcohol can be fatal for others (Shapiro, 2009). In the present research, all the above have been found in the natural causes of death and, therefore, these were also included in the study. In several cases where cannabis was found combined with alcohol, the cause of death was stated as “Consequence of a recent myocardial infarction”. However, in the observations of the Medical Examiner, the effect of substances on the causes of death were mentioned as follows “There is significant scientific evidence which shows that the cannabis (and especially when combined with alcohol abuse) can cause complications to the cardiovascular system and even sudden death”. The present study, therefore, focuses on highlighting differences in alcohol intake, causes of death, and socio-demographic characteristics.
Methodology
The current research was based on the systematic study and evaluation of forensic files and reports in printed and/or electronic form (Bowen, 2009). Specifically, the study focused on the deceased, their socio-demographic profile, cause of death, circumstances of death, and the substance(s) involved. The current research refers to the retrospective descriptive study of data that was conducted at the Department of Forensic Medicine and Toxicology of the School of Medicine of the National and Kapodistrian University of Athens where the forensic reports of the department were kept. The analysis of existing evidence in the forensic files, can be proven to be useful as it provides substantial information about an issue that occurred in the past, but it may affect the present understanding of the current policies and/or programs of agencies and services (Mackieson, Shlonsky & Connolly, 2018). However, it is important to bear in mind that the original purpose for which the records were compiled was not research, per se. Therefore, a meticulous study of the files was needed to achieve a better understanding of the data and interpretation of the results (Robson, 1993).
Therefore, in the current study it was important to first investigate the available data and clarify those that will constitute the field of the research according to the subject under study. Posteriori research of evidence was used to reveal relationships between the variables under study and to interpret the findings (Cohen & Manion, 2000). Evidence/documents were considered objective sources and/or facts that can highlight the issues under study or be used to explain a policy. They can also be seen as social products that deserve to be analyzed by themselves in the context of an interpretive process. The researcher in the context of the analysis interacts with the material to advance his/her own positions and/or interpretations (Karppinen & Moe, 2011).
The sample consisted of files of the deceased identified in the archives of the Department of Forensic Medicine and Toxicology of the Medical School of the National and Kapodistrian University of Athens, Greece for the period years of 2012-2016. A total of 5,467 forensic files were examined in order to identify deaths due to direct, indirect, or long-term drug(s) intake, in which at least one drug was found in the toxicological analysis (for example, cannabis, heroin, cocaine, amphetamines, methadone, alcohol, benzodiazepines, etc.). From the analyzed cases, 178 fulfilled the above criteria. Death certificates and/or other relevant documents were taken into consideration, with the main source, however, being the laboratory results of the toxicological analysis. The analysis evaluation of the files revealed that in 51 cases there was concurrent or exclusive intake of alcohol. In those cases, it was clearly reported that the deceased had a record of heavy alcohol use. Toxicological analyses were performed on blood, urine, and in some cases on organs as well (e.g., nasal swab, stomach, bile etc.). The sample was selected for homogeneity with respect to a given variable (Cohen & Manion, 2000), which in the present study was alcohol intake in toxicological analysis.
All data collected were recorded on a standardized data collection form. Deaths in which at least one addictive substance was found in toxicological analysis were recorded. The socio-demographic characteristics of the deceased and death circumstances were also researched. In order to complete the recording of the data and to be able to analyze them, the method of coding was used, i.e., the causes of death were coded for substance poisoning, suicide, natural causes, etc.
To analyze the data, descriptive analysis was conducted using the Statistical Package for the Social Sciences (SPSS v.17) using codes, categories, and cross-sectional causal relationships between variables (Krippendorff, 2004). Descriptive statistics, such as frequency tables and means, were conducted for continuous variables. The variables were coded to be recorded in SPSS. In some cases (e.g. age, amount of alcohol), to facilitate the detection of characteristic trends, the categories were merged and grouped (Kyriazi, 2009). Non-parametric measures were employed to answer the research questions (Neuendorf, 2001) (e.g. men/women, body location, occupational status, etc).
In addition, comparisons were made between the characteristics of nominal variables (chi-square tests), to measure the relationship between them. To test a hypothesis, statistical significance was calculated by conducting Pearson’s chi-square (x)2 tests for the nominal variables, where a value of p<0.05 was considered statistically significant. The cross-tabulations drawn up in the context of the bivariate analysis, through the cross-tabulation of variables, were intended to highlight connections between the studied variables.
Results
The results indicate that out of the 178 cases involving the intake of psychotropic substances (sample positive for at least one addictive substance), in 51 cases there was concurrent or exclusive alcohol intake. In some cases, the cause of death was ethyl alcohol poisoning. In others there was a parallel intake of alcohol and benzodiazepines or alcohol and cannabis. Toxicological tests were not carried out for one of the deceased due to his hospitalization and the reported natural cause of death due to chronic alcoholism. This case is reported as missing.
Therefore, the present study focuses on the 51 cases where, either alcohol played a significant role in the fatal outcome or, according to the forensic file, there was a history of alcoholism. In any case, men seem to be more affected by alcohol related deaths 86.3% (Table 1).
Table 1. Polydrug use
| Frequency | Percent | Valid Percent | Cumulative Percent | ||
| YES | 40 | 78.4 | 80.0 | 80.0 | |
| Valid NO | 10 | 19.6 | 20.0 | 100.0 | |
| Total | 50 | 98.0 | 100.0 | ||
| Missing | System | 1
51 |
2.0
100.0 |
|
|
| Total | |||||
Cross-tabulating gender with the cause of death, in women the cause of death was ethyl alcohol use. In three (3) of the cases, the cause of death was exclusively due to ethyl alcohol poisoning and in the remaining four (4), the cause of death was the combination of alcohol with benzodiazepines or other depressants, such as gabapentin (an anticonvulsant) which was reported in one case. In contrast to men, women’s distribution in terms of cause of death is more divided (Table 2).
Most drug related deaths occurred in middle adulthood, mainly amongst people who used alcohol for several years. The average age of the cases were the 46.06 years, confirming the above pattern. Ages were grouped by decade, where again it emerged that most of the deceased belonged to the 40-49 age group, followed by the 50-59 age group. Alcohol related deaths are identified within those who are most likely to be in middle adulthood, when compared to other drug related deaths (Table 3).
Table 2. Cause of Death *Gender distribution
| Sex | Total | |||
| Men | Women | |||
| Cause of death | Suicide | 3 | 0 | 3 |
| Ethyl alcohol poisoning | 5 | 3 | 8 | |
| Poisoning by addictive substances | 16 | 0 | 16 | |
| Poisoning by CNS depressants | 4 | 4 | 8 | |
| Natural cause | 7 | 0 | 7 | |
| Natural cause – substance-related death | 9 | 0 | 9 | |
| Total | 44 | 7 | 51 | |
Table 3. Age Groups
| Frequency | Percent | Valid Percent | Cumulative
Percent |
||
| Valid | 20-29 | 8 | 15.7 | 15.7 | 15.7 |
| 30-39 | 8 | 15.7 | 15.7 | 31.4 | |
| 40-49 | 14 | 27.5 | 27.5 | 58.8 | |
| 50-59 | 13 | 25.5 | 25.5 | 84.3 | |
| 60-69 | 7 | 13.7 | 13.7 | 98.0 | |
| 70 & above | 1 | 2.0 | 2.0 | 100.0 | |
| Total | 51 | 100.0 | 100.0 |
In terms of alcohol intake and the level of alcohol concentration in blood or in the urine, the following table lists the deceased in relation to the accumulation per g/L. In one case, no amount of alcohol has been recorded as the person ended up in the hospital with reported cause of death “Consequence of hemoperitoneum on the ground of cirrhosis of the liver on the ground of hepatitis C and chronic alcoholism”. The majority of those who died had alcohol levels in concentrations up to 1g/L. Therefore, alcohol intake was not solely responsible for the cause of death. However, it did support use and heavy use, indicating a pattern of multiple use. Overall, 13 cases had an alcohol concentration of 1-2 g/L, 6 cases between 2-3 g/L and 11 cases had more than 3 g/L. The cause of death based on the forensic examination is listed in the table below for the 51 cases in which alcohol is listed as a concomitant or as the main substance of use (Tables 4, 5, 6).
Table 4. Alcohol Intake
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| below 1 | 20 | 39.2 | 39.2 | 39.2 |
| 1-2 | 13 | 25.5 | 25.5 | 64.7 |
| 2-3 | 6 | 11.8 | 11.8 | 76.5 |
| Valid more than 3 | 11 | 21.6 | 21.6 | 98.0 |
| Missing | 1 | 2.0 | 2.0 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Table 5. Cause of Death *Alcohol Intake
| Alcohol | Total | ||||||
| below 1 | 1-2 | 2-3 | More than 3 | Missing | |||
| Cause of death | Suicide | 2 | 0 | 1 | 0 | 0 | 3 |
| Ethyl alcohol poisoning | 0 | 0 | 1 | 7 | 0 | 8 | |
| Poisoning by addictive substances | 9 | 6 | 0 | 1 | 0 | 16 | |
| Poisoning by CNS depressants | 0 | 3 | 3 | 2 | 0 | 8 | |
| Natural cause | 5 | 2 | 0 | 0 | 0 | 7 | |
| Natural cause – substance-related death | 4 | 2 | 1 | 1 | 1 | 9 | |
| Total | 20 | 13 | 6 | 11 | 1 | 51 | |
Table 6. Cause of Death *Gender distribution
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Suicide | 3 | 5.9 | 5.9 | 5.9 |
| Valid Ethyl alcohol poisoning | 8 | 15.7 | 15.7 | 21.6 |
| Poisoning by addictive substances | 16 | 31.4 | 31.4 | 52.9 |
| Poisoning by CNS depressants | 8 | 15.7 | 15.7 | 68.6 |
| Natural cause | 7 | 13.7 | 13.7 | 82.4 |
| Natural cause – substance-related death | 9 | 17.6 | 17.6 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Regarding the combination of substances, in 17 cases, use of cannabis was detected together with alcohol levels of up to 1 g/L (Table 7). The most frequently detected substance was heroin, which was found in 20 deaths. Also, in these cases, alcohol levels were up to 1 g/L, followed by a small difference of 1-2 g/L (Table 8). There is a difference in mixing benzodiazepines and alcohol as can be seen from the table below. Higher levels are observed for values of 2 g/L and above. There is a distinct cause of death as “Poisoning by CNS depressants” where the mixing of these two substances predominates (Table 9). Cocaine is found in very few cases overall. One case had concomitantly found with methadone and alcohol levels, up to 1 g/L BAC and 18 cases had concomitantly taken some medication (antidepressant, antipsychotic, etc.) (Table 10).
Table 7. Alcohol Intake * Cannabis use
| Cannabis | Total | |||
| No | Yes | |||
| ALCOHOL | Missing | 1 | 0 | 1 |
| below 1 g/L | 7 | 13 | 20 | |
| 1-2 | 10 | 3 | 13 | |
| 2-3 | 6 | 0 | 6 | |
| More than 3 | 10 | 1 | 11 | |
| Total | 34 | 17 | 51 | |
Table 8. Alcohol Intake * Heroin Use
| Heroin | Total | |||
| No | Yes | |||
| ALCOHOL | Missing | 1 | 0 | 1 |
| below1 g/L | 9 | 11 | 20 | |
| 1-2 | 5 | 8 | 13 | |
| 2-3 | 6 | 0 | 6 | |
| More than 3 | 10 | 1 | 11 | |
| Total | 31 | 20 | 51 | |
Table 9. Alcohol Intake *Benzodiazepines
| Benzodiazepines | Total | ||||||||
| No | Yes | ||||||||
| ALCOHOL | Missing | 1 | 0 | 1 | |||||
| below1 g/L | 14 | 6 | 20 | ||||||
| 1-2 | 9 | 4 | 13 | ||||||
| 2-3 | 2 | 4 | 6 | ||||||
| More than 3 | 9 | 2 | 11 | ||||||
| Total | 35 | 16 | 51 | ||||||
Table 10. Alcohol Intake *Cocaine
| Cocaine | Total | |||
| No | Yes | |||
| ALCOHOL | Missing | 1 | 0 | 1 |
| below1 g/L | 18 | 2 | 20 | |
| 1-2 | 11 | 2 | 13 | |
| 2-3 | 5 | 1 | 6 | |
| More than 3 | 11 | 0 | 11 | |
| Total | 46 | 5 | 51 | |
Continuing the analysis in terms of the social characteristics of the deceased, people who were reported to be married or divorced, outnumbered those who were single. This is a profile quite different from those found with illicit drugs where most were reported to be singles (Table 11). By cross-referencing the cause of death with marital status, the above is confirmed when comparing ethyl alcohol poisoning and/or CNS depressant poisoning with drug poisoning which mostly involved overdose incidents (Table 12).
Table 11. Marital Status
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Single | 22 | 43.1 | 43.1 | 43.1 |
| Unknown | 5 | 9.8 | 9.8 | 52.9 |
| Valid Divorced | 10 | 19.6 | 19.6 | 72.5 |
| Married | 14 | 27.5 | 27.5 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Table 12. Cause of Death * Marital Status
| Marital status | Total | ||||||
| Single | Unknow n | Divorced | Married | ||||
| Cause of death | Suicide | 1 | 1 | 0 | 1 | 3 | |
| Ethyl alcohol poisoning | 2 | 0 | 2 | 4 | 8 | ||
| Poisoning by addictive substances | 11 | 2 | 1 | 2 | 16 | ||
| Poisoning by CNS depressants | 3 | 0 | 2 | 3 | 8 | ||
| Natural cause | 3 | 0 | 2 | 2 | 7 | ||
| Natural cause – substance-related death | 2 | 2 | 3 | 2 | 9 | ||
| Total | 22 | 5 | 10 | 14 | 51 | ||
In terms of employment, although there is a high percentage of unknown data (25.5%), most of the deceased were reported to be unemployed (41.2%). This is also observed in the following cross-tabulation of the cause of death with employment status (Table 13).
Table 13. Employment Status
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Unknown | 13 | 25.5 | 25.5 | 25.5 |
| Unemployed | 21 | 41.2 | 41.2 | 66.7 |
| Rentier | 1 | 2.0 | 2.0 | 68.6 |
| Employee | 8 | 15.7 | 15.7 | 84.3 |
| Valid
Retired |
7 | 13.7 | 13.7 | 98.0 |
| Undergraduate | 1 | 2.0 | 2.0 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Continuing with the circumstances of death and specifically with the location where the body was found, most deaths took place in the individual’s home. Only 19.6% were found dead in a street/park or other outdoor space (Table 14). This seems to be the case for all causes of death as shown by the table below which cross-references the cause of death with the location of the body (Table 15).
Table 14. Location of the body
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Hospital | 4 | 7.8 | 7.8 | 7.8 |
| Hotel | 2 | 3.9 | 3.9 | 11.8 |
| Home | 35 | 68.6 | 68.6 | 80.4 |
| Valid
In street / park / outdoor space |
10 | 19.6 | 19.6 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Table 15. Cause of Death *Body location
| Location of the pile | Total | ||||||
| Hospital | Hotel | Home | In street / park / outdoor space | ||||
| Cause of death | Suicide | 0 | 0 | 3 | 0 | 3 | |
| Ethyl alcohol poisoning | 1 | 0 | 5 | 2 | 8 | ||
| Poisoning by addictive substances | 1 | 1 | 9 | 5 | 16 | ||
| Poisoning by CNS depressants | 1 | 1 | 6 | 0 | 8 | ||
| Natural cause | 0 | 0 | 7 | 0 | 7 | ||
| Natural cause – substance-related death | 1 | 0 | 5 | 3 | 9 | ||
| Total | 4 | 2 | 35 | 10 | 51 | ||
Regarding the residence of the people, despite the high percentage of unknown data, it seems to emerge as a pattern that heavy alcohol intake or polydrug use, in which alcohol is also present, was identified in people who were living mainly alone (Table 16). This is obvious in the frequency table of residence and in the cross-tabulation of residence and cause of death (Table 17). In most cases, however, the person who found the body was a relative (Table 18).
Table 16. Living conditions
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Unknown | 16 | 31.4 | 31.4 | 31.4 |
| Family | 10 | 19.6 | 19.6 | 51.0 |
| Roommate | 3 | 5.9 | 5.9 | 56.9 |
| Valid Alone | 20 | 39.2 | 39.2 | 96.1 |
| Guest | 2 | 3.9 | 3.9 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Table 17. Cause of Death *Living conditions
| Living with | Total | ||||||
| Unknown | Family | Roommate | Alone | Guest | |||
| Cause of death | Suicide | 1 | 1 | 0 | 1 | 0 | 3 |
| Ethyl alcohol poisoning | 2 | 0 | 1 | 5 | 0 | 8 | |
| Poisoning by addictive substances | 6 | 3 | 1 | 5 | 1 | 16 | |
| Poisoning by CNS depressants | 1 | 4 | 0 | 3 | 0 | 8 | |
| Natural cause | 1 | 2 | 1 | 2 | 1 | 7 | |
| Natural cause – substance-related death | 5 | 0 | 0 | 4 | 0 | 9 | |
| Total | 16 | 10 | 3 | 20 | 2 | 51 |
Table 18. Who found the body
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| Unknown | 15 | 29.4 | 29.4 | 29.4 |
| Neighbor | 4 | 7.8 | 7.8 | 37.3 |
| Passing | 4 | 7.8 | 7.8 | 45.1 |
| Homeowner | 1 | 2.0 | 2.0 | 47.1 |
| Hospital | 1 | 2.0 | 2.0 | 49.0 |
| Valid
Fire Department |
1 | 2.0 | 2.0 | 51.0 |
| Relative | 22 | 43.1 | 43.1 | 94.1 |
| Hotel employee | 1 | 2.0 | 2.0 | 96.1 |
| Friend | 2 | 3.9 | 3.9 | 100.0 |
| Total | 51 | 100.0 | 100.0 |
Discussion
It is rather difficult to compare the present Greek study with similar studies from other countries. There are several limitations on how each study defines alcohol related deaths, how it classifies age groups, and to what extent alcohol related deaths are reported (Hemström, 2002). What is worth pointing out is that people who die from alcohol intake are in middle adulthood, therefore, much older than those who die from other drugs. Another finding that agrees with other data and research, such as those of Adfam and Cruse Bereavement Care (2014) for the United Kingdom, relates to the age group at which alcohol related deaths are reported. This group is identified mainly at the age of 55-59. In addition, data for alcohol related death rates in year 2014 from the Office for National Statistics for England, reveals that the relevant age group is 55-64 for both men and women, with men being the majority. According to Guy (2004), deaths from alcohol occur at an older age and often because of chronic illnesses. This is supported by others’ research, such as a study by Darke et al. (2013), where the mean age at death was 47.2 years.
Alcohol is found in many cases, but in most of the cases it is not in a high enough concentration to be considered the main cause of death. The collection of data from only one Laboratory in Greece and the lack of data regarding the socioeconomic characteristics of the deceased, prevents the extraction of safe conclusions. However, there seems to be a pattern of alcohol related deaths amongst those of older age, as most of the deceased where over 44 years old and much older from those who died from other drug(s). In addition, most were married or divorced, compared to other drug users who were single. The findings agree, with the data from alcohol treatment facilities where in years 2011-2015, the corresponding reference period of the survey, approximately 43% of the reported cases were married (EKTEPN, 2017). Regarding employment status, although there is still missing data in some files, unemployment seems to prevail.
According to the latest report of EKTEPN (2022), referring to the Hellenic Statistical Authority survey for year 2019, the highest rates of alcohol intake are found in those over 55 years of age. Although there is an increase in alcohol intake for year 2020, there is a decrease in the number of people who seek treatment together with an increase in the intake of illegal substances, which confirm the pattern of multiple use.
In a similar survey for Southern Turkey, the median age of alcohol related deaths was 45.49 years and for drug poisoning deaths, 29.81 years. The percentage of deaths from prescription drugs was reaching 25% (with benzodiazepines being the predominant drug), for illicit drugs 20% (opioids at 73.87% and tetrahydrocannabinol at 21.6%), and for methyl or ethyl alcohol 14% (Battal et al., 2016). In a study carried out in Brazil by Campelo and Caldas (2010), alcohol was detected in 47.4% of the cases, cocaine in 21.6% of the cases and THC in 17.5% of all tested samples.
The current study also confirms a pattern of multiple use (78.4%). Heroin, cannabis, and benzodiazepines were the substances detected with the greatest frequency as parallel substances. Accordingly, in Corkery et al. (2017) UK survey for the years 2005-2009 for combined cocaine use, opioids were involved in 58.2% of cocaine overdoses, alcohol in 30% of cases, and benzodiazepines in 18% of the cases. In Denmark, 63% of poisonings involved a combination of opioids and benzodiazepines and/or alcohol
(Simonsen et al., 2021). Alcohol, heroin, buprenorphine, codeine, and amphetamines were the most common substances also found in a survey in Finland for the years 2000 and 2008 (Rönkä et al., 2015).
Alcohol misuse is also a risk factor for medical illness, as in several cases it is related with cardiovascular problems or liver cirrhosis. The result is often death which, however, is reported as death from natural causes and not as the result of poisoning by ethyl alcohol or of the combination of substances at the central nervous system.
Conclusion
Alcohol seems to play an important role in death rates of middle-aged people (over 40 years) in Greece, with the age variable being the most important finding of the cases studied. In those cases, alcohol is either the main substance of use, or a parallel substance. Polydrug use is also evident in the current study with alcohol being a concomitant substance of use. The current study suggests that most people who deceased due to alcohol misuse were either married or divorced, in contrast to opioid users for whom the majority were single. Understanding marital relationships might give the opportunity to develop family education and early intervention programs to prevent such instances. In addition, the study concluded that opioid users were likely to combine their preferred substance with depressants such as alcohol and benzodiazepines (Frisher et al., 2012; EMCDDA, 2021), increasing the death risks. Thus, proper training on the risks of polydrug use might be needed for this population. Therefore, the present study together with the findings of EKTEPN reports (2021; 2022) for Greece, support the evidence that there is a phenomenon of polydrug use. The reports (EKTEPN, 2021; 2022) suggest that in relation to the accompanying mental or physical health problems, alcohol misuse is also related to mortality rates. The current study also suggests that natural causes are often reported as causes of death especially amongst the middle aged. Nonetheless, natural causes of death need to be clearly linked with the use of alcohol and other substances. Therefore, proper information should be given in relation to the physical harm caused by alcohol misuse especially amongst middle age people. The role of alcohol in increasing mortality rates requires further study in Greece, where it is often underestimated.
[1] http://www.emcdda.europa.eu/publications/edr/trends-developments/2015/online/chapter2
[1] https://www.who.int/news-room/fact-sheets/detail/alcohol
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