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Public Health Report

Alcohol and other psychoactive substances - Public Health Report 2014

After alcohol, cannabis and amphetamines are the most commonly used drugs in Norway.

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Summary

  • On average, Norwegians aged over 15 years drink about 8 litres of pure alcohol per year. 
  • Since the early 1990s, the consumption of alcohol has increased by approximately 40 per cent, mostly among women and the elderly. 
  • New synthetic drugs have unknown effects and are a challenge for the health service. 
  • The number of drivers arrested for driving under the influence of cannabis or methamphetamine has increased sharply over the last five years.

Psychoactive substances are depressants, stimulants and hallucinogens

Psychoactive substances include alcohol, medicines with abuse potential and illicit drugs (narcotics) such as cannabis, amphetamine, heroin and cocaine.

Medicines with abuse potential are mainly sedatives and hypnotics of the benzodiazepine group. Most of the tablets sold on the black market are not from approved pharmaceutical manufacturers. Illicit drugs often contain a higher amount of active ingredients compared with registered products sold in pharmacies (National Criminal Investigation Service (Kripos), 2014).

Benzodiazepines are often abused in combination with narcotic substances such as amphetamines, cannabis and heroin.

The effects of psychoactive substances can be divided into three primary groups: depressant, stimulant and hallucinogenic, see Figure 1. Several drugs have a combination of these effects, for example alcohol and ecstasy.

 
FHR 2014 Alcohol Figure 1.jpg
Figure 1. Psychoactive substances can be depressant, stimulant or hallucinogenic. Several drugs have a combination of these effects. Figure: Norwegian Institute of Public Health.

Use of alcohol and other substances in Norway

Almost 8 litres of alcohol per person per year

In 2012, alcohol consumption was 6.21 litres of pure alcohol per inhabitant over 15 years of age. In addition, there is unregistered consumption from cross-border trade in Sweden and duty-free sales at Norwegian airports, which is estimated to be 1.6 litres (SIRUS, Drug statistics).

Unregistered consumption also includes other «tourist import», alcohol consumption while abroad, home brewing of beer, wine and spirits, and smuggling.

Estimates of unregistered consumption are uncertain, in particular from home brewing, smuggling, consumption while abroad and import other than cross-border trade and duty-free sales.

Duty-free sales at airports. In the period 2010-2012, duty-free sales of alcohol increased at Norwegian airports by 29 per cent for both beer and table wines and 129 per cent for fortified wine. Spirits sales declined by 11 per cent (SIRUS: Duty-free sale of alcohol).

Cross-border trade. Developments in cross-border trade with Sweden show that sales were nearly eight times greater in 2011 compared with 1995. This is according to a mapping where sales were converted to the pure alcohol equivalent. The increase was greatest for beer and wine (SIRUS: Cross-border trade).

Studies of alcohol consumption

A recent study among randomly selected drivers in normal traffic showed that 2 per 1,000 drivers (0.2 per cent) were under the influence of alcohol (Gjerde, 2013).

The "Young in Oslo 2012" study shows that approximately 45 per cent of students in the 1st grade of upper secondary school had been visibly intoxicated at least once. For the whole age group (15-17 years) this was 29 per cent. There was a higher proportion of girls than boys. There was little difference in alcohol use among young people in Oslo and young people in the rest of the country (Øia, 2012).

Alcohol consumption has increased by about 40 per cent in 20 years

Alcohol consumption in Norway is increasing and is currently around 40 per cent higher than consumption in the early 1990s if the registered annual consumption early in the 1990s and in recent years are compared (SIRUS, 2013).

Unregistered consumption from cross-border trade and duty-free sales comes in addition and in this period probably increased more than the registered consumption.

That alcohol consumption among adults is increasing is supported by the following studies:

  • Men still drink more than women, with the exception of wine, but more women drink alcohol today than previously (Sirus, 2013). 
  • During the period 1997-2008 the proportion of elderly over 70 years with problematic alcohol consumption increased from 0.5 per cent to 4.5 per cent (Støver, 2012). 
  • A study which included self-reported alcohol consumption in Norway for the period 1973-2004 showed both an increase in the number of heavy drinkers and increased alcohol use among the general population until 2004 (SIRUS; Rossow, 2014). Similar studies have not been carried out in the last 10 years.

Alcohol consumption among youths has decreased, see Figure 2 (Øia, 2012). This is shown by figures from the "Young in Oslo 2012," study compared with similar studies from 1999 and 2006.  

 
FHR 2014 Alcohol figure 2 .jpg
Figure 2. Substance abuse among youths in Oslo in 1996, 2006 and 2012. From left, solvent abuse, alcohol with visible intoxication, cannabis and other narcotics (Øia, 2012).

Differences in the population

Men drink most

Men drink most, while women's alcohol consumption has increased the most (Støver, 2012).

Less alcohol in some immigrant groups

Alcohol use among youths of immigrant origin is lower than among other students in the first grade in upper secondary school; 37 per cent compared to 12 per cent, according to the Young in Oslo study from 2012. Alcohol use among immigrant parents is also significantly lower than among ethnic Norwegian parents (Øia, 2012).

Use of other psychoactive substances than alcohol

Cannabis and amphetamines are the most commonly used illicit drugs

Drug seizures by Kripos and analyses of blood samples from drivers suspected of driving under the influence give an indication of which drugs are the most common in Norway today. Samples from random drivers in normal traffic and employees in businesses also give an indication of the frequency of drug use among the adult population.

Cannabis, methamphetamine and amphetamine are the most common illicit drugs. Ecstasy has almost been absent from the market but Kripos reports an increase in seizures (Kripos, 2014).

Cocaine is mainly used in more closed environments. The use of GHB has become more popular over the last 10 years in some youth environments.

1-2 per cent of drivers are intoxicated

Among randomly selected drivers in normal traffic, it is estimated that that 0.6 per cent are under the influence of narcotics and 1.3 percent are under the influence of medicines (Gjerde, 2013).

Analysis of saliva samples from drivers in normal traffic and employees in different companies show that about 1 per cent had used cannabis during the last two days. Among men under 30 years of age, this was 4 per cent (Gjerde, 2013).

Illicit drug use increasing

Trends in drug seizure statistics from Kripos are the same as trends in analysis findings related to suspicion of driving under the influence, violence or other criminal offences (Kripos, 2014; NIPH; Bogstrand, 2011a, b; Gjerde, 2014).

Trends from various studies and annual statistics from the police show that the use of cannabis, amphetamines and cocaine has increased, while heroin use has declined in the period from 2008/2009 to 2011/2013 (Kripos, 2014; Gjerde, 2011; NIPH, 2013). Figure 3 shows a marked increase in the detection of cannabis, amphetamines and sedatives among drivers arrested for driving under the influence.  

 
FHR 2014 Alcohol Figure 3.jpg
 Figure 3: Number of positive samples from drivers arrested for driving under the influence in the period 2007 to 2012. The figure shows the four most common substances after alcohol; amphetamines, cannabis, clonazepam and diazepam. Source: Norwegian Institute of Public Health.

Other psychoactive substances than alcohol have become more prominent than in the past when there is suspicion of driving while under the influence. In 2013, half of the cases came from substances other than alcohol.

Illicit drugs more common in larger towns

  • Comparing drug use among youths in Oslo with youths in the same age group from district municipalities shows that the use of cannabis and other narcotic substances most commonly occurs in Oslo (Øia, 2012). 
  • The use of narcotic substances is more common in and around larger towns and cities than in rural areas (Gjerde, 2011). This was shown by a study of drug use among drivers in normal traffic from South-Eastern, Western, Central and Northern Norway. 
  • In Oslo, cannabis use varies between urban districts, from approximately 11 to 16 per cent in the centre and western districts to 6-8 per cent in eastern districts (Øia, 2012). Other narcotic substances are most common in central districts (6-8 per cent) (Øia, 2012).

Socioeconomic differences in substance abuse

Alcohol use and frequency of alcohol consumption increase in line with higher education and income, but fewer in this group are alcohol dependent than in groups with low income and education (Clench-Aas, 2009). People who are not in a relationship also have higher alcohol consumption than people with a partner (Clench-Aas, 2009).

The percentage of people who take cannabis and tablets is highest among those with low socioeconomic status. Substance abuse is also more common in groups with problematic behavior and for example by pupils who frequently play truant from school (Rodje, 2004).

People with a high social status are more likely to have tried narcotic substances than people with low social status, while long-term abuse is most common in the latter group.

International comparison

The registered alcohol consumption in Norway is lower than in most other European countries, see Figures 4 (WHO, 2011). Data from the WHO show that alcohol use in several European countries has declined, while consumption in Norway has increased. The extent of unregistered alcohol consumption can be uncertain and difficult to compare.

 
FHR 2014 alcohol figure 4.jpg
 Figure 4: Alcohol consumption in different European countries. Source: OECD, 2010.


Consequences of substance abuse

Use of alcohol and other drugs is associated with several social and health consequences in terms of diseases, injuries and mental health problems and disorders.

The consequences generally depend on the type of drug and dosage, and whether they are used once or over time.

The total alcohol consumption is an important determinant for alcohol-related diseases and injuries in the population. When the total consumption in society increases so does the proportion of those with a harmful consumption.

The risk of chronic diseases related to alcohol consumption is gradually increasing. Large consumers have a high level of risk.

Health damage from alcohol is primarily determined by the total amount of alcohol that the body is subjected to, see below. Alcohol damage can therefore evolve even if a person has not been visibly intoxicated. Injuries caused by accidents and violence are often linked to occasional binge drinking, without there being a generally high consumption.

Recommendations for alcohol consumption

The Norwegian Directorate of Health recommends that alcohol intake is restricted and is not higher than 10 grams (12.5 ml pure alcohol) per day for women and not more than 20 grams (25 ml) for men. 10 grams corresponds to a little under one glass of wine or almost 3 dl of beer, see Table 1 (Norwegian Directorate of Health, 2014).

Pregnant women, breastfeeding mothers, children and adolescents are advised to abstain from alcohol.

The recommendations are based on Norwegian and Nordic expert reports and are introduced because the increased consumption of alcohol raises the risk of breast cancer, stroke and birth defects and there are also social consequences.

Table 1. Amount of wine, beer, light beer and spirits equal to 10 g and 20 g of alcohol per day. (Norwegian Directorate of Health, 2014).

Recommendations for alcohol intake *

Equivalent in wine
(12 ABV %)

Equivalent in beer, lager (4.5 ABV %)

Equivalent in light beer (1.5 ABV %) 

Equivalent in spirits
(40 ABV %)

Women: should not exceed 10 g / day

104 ml (1 dl)

278 ml (0.3 l)

833 ml (0.8 l)

31 ml (3 cl)

Men: should not exceed 20 g/day

208 ml (2 dl)

556 ml (0.6 l)

1666 ml (1.7 l)

62 ml (6 cl)

Alcohol-related illnesses and injuries

Mental health problems and disorders. Prolonged and high alcohol consumption may increase the risk of alcohol dependence and other mental disorders.

Somatic diseases. Prolonged and high alcohol consumption increases the risk of cardiovascular diseases, as well as other illnesses such as liver failure, pancreatic inflammation and lung diseases (Parry, 2011).

Moderate alcohol consumption increases the risk of cancers of the digestive system, liver, breast and some other types of cancer. The number of cancer cases attributable to alcohol is not estimated for Norway; however, there are estimates for Europe. One finding among men is that approximately 10 per cent of cancer cases are attributable to alcohol, while the proportion among women is 3 per cent (Schutze, 2011).

Binge drinking increases the risk of stroke and heart attack, and the risk increases with the frequency of the episodes (Parry, 2011). Alcohol consumption, even at moderate levels, increases the risk of atrial fibrillation (Larsson, 2014).

High consumption of medicines in combination with alcohol is particularly harmful (SIRUS, 2012).

Alcohol is a causal factor in more than 60 somatic illnesses and is the third leading cause of disease and lost years of life in the Western world (WHO, 2011).

Injuries and accidents. 27 per cent of accident-related emergency admissions to Oslo University Hospital, Ullevål during one year were alcohol-related (Bogstrand, 2011b).

The Emergency Unit in Bergen found that 70 per cent of patients who were treated for injuries from violence were under the influence of alcohol (Sten and Hundskar, 1997).

Hospital admissions. The number of hospital admissions with alcohol-related diagnoses has been considerably higher in recent years, from 4131 admissions in 2004 to 6,064 in 2012. The number has been significantly higher for men than for women. Of the total amount of hospital admissions with alcohol-related diagnoses in 2012, 4083 were men and 1981 were women (Norwegian Directorate of Health).

Alcohol-related deaths

Overall, there were more alcohol-related deaths than those recorded in the Cause of Death Registry.

  • According to data from the Cause of Death Registry, over the last 15 years, approximately 320-420 deaths have been registered annually as a direct or indirect result of alcohol consumption. The highest individual figures are related to various mental health problems and behavioural disorders, alcoholic liver disease and alcohol poisoning (Statistics Norway). 
  • Alcohol-related fatalities in traffic (Christophersen & Gjerde, 2014), alcohol-related drownings and other types of fatal accident are not included in the overview from the Cause of Death Registry.

Consequences of using other psychoactive substances than alcohol

The consumption of other psychoactive substances than alcohol also increases the risk of injuries and illnesses: 

  • overdoses 
  • accidents and injuries 
  • infectious diseases such as hepatitis and HIV from syringe use

The increase in substance abuse that has been seen over the last few years has also led to an increase in crime, violence and aggressive behavior. Over a third of fatal accidents in traffic and many of the accidents involving personal injury happen under the influence of alcohol, narcotics or psychoactive medication (Christophersen & Gjerde, 2014).

New synthetic drugs have unknown effects

Over the last few years there have been many new drugs available on the black market and these can be a challenge for the health service. Among new drugs are synthetic cannabinoids ("Spice"), amphetamine and ecstasy-like substances and cathinones, see Figure 1. Over the last few years, dozens of new varieties of new drugs have been reported. Often, several substances are combined. We know little about the health consequences from these new synthetic drugs. There are reports of: 

  • High blood pressure and acute myocardial infarction among teenagers that have used synthetic cannabinoids. 
  • Loss of consciousness, seizures, anxiety, agitation, acute psychoses and deterioration of earlier mental illness.

We know little about the long-term effects.

These new subtances can also be fatal. Users do not know not what they are ingesting, the drugs are of unknown strength and they may contain residues of chemicals or cocktails of several substances.

One example is PMMA (Paramethoxymethamphetamine), which appeared on the black market in Norway around 2010. From July 2010 to August 2012, over 29 deaths were registered in which PMMA was the main cause or contributory cause (Al-Samarraie, 2013). During this same time period, the Norwegian Institute of Public Health found PMMA in blood samples from 130 intoxicated drivers.

Teratogenic risk during pregnancy

Both alcohol and other drugs may harm the foetus in all stages of pregnancy.

Alcohol: Alcohol is harmful to the foetus throughout pregnancy, and there is no known safe lower limit for alcohol consumption in pregnancy (O'Leary, 2013; Lewis, 2012; Willford, 2006). High alcohol intake in pregnancy increases the risk of foetal alcohol syndrome (FAS) and foetal alcohol effects (FAE). Children with FAS and FAE are born with impaired growth and brain damage, which gives psychomotor development disorders and learning disabilities. Children with FAS also have distinctive facial features (Norwegian Directorate for Health and Social Affairs, 2005; Cayetanot, 2009; Kuczkowski, 2007; Lewis, 2012; O'Leary, 2013; Willford, 2006). 

Cocaine, cannabis and amphetamines: Risk of placental abruption, stillbirth, foetal growth restriction, premature birth, breathing problems after birth, sudden infant death syndrome (SIDS) and subsequent attention and behavioural difficulties (Schempf, 2007; Accornero, 2007). 

Sedatives / hypnotics: May cause foetal growth restriction and withdrawal symptoms after birth (Jain, 2005). 

Opiates / opioids: Increased risk of placental abruption, stillbirth, foetal growth restriction, premature birth and subsequent concentration / behavioural problems. Treatment for withdrawal symptoms is often required after birth (Cayetanot, 2009 Shankaran, 2007). Newer Norwegian studies have shown that methadone and buprenorphine treatment in pregnancy represents a small risk for the child. The combination of buprenorphine and naloxone (Suboxone) does not constitute any particular risk (Lund, 2012; Welle-Strand, 2013).

Social problems

High alcohol consumption is linked with social problems that often affect others than those who drink. Social problems include everything from difficulties in working life to crime, including violence in close relationships (Steen & Hunskår, 1997; Pape, 2003; SIRUS 2009).

Opportunities to prevent alcohol damage

We can prevent damage from alcohol consumption by influencing price and availability. A systematic review has shown that both political and individual interventions have an effect. Examples include alcohol taxes, advertising, blood alcohol limits and special interventions for people with an alcohol problem (Anderson, 2009).

Knowledge about substance abuse

To follow developments in substance abuse over time for both the well-known drugs and new drugs, it is important to have standardised protocols for mapping studies, close collaboration between the various disciplines and the use of both biological samples and questionnaires. In the planning of prevention it is especially important to obtain credible data which is based on as many participants as possible in mapping studies (Gjerde, 2014).

References 

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In January 2016, the Norwegian Institute for Alcohol and Drug Research (SIRUS) was incorporated into the Norwegian Institute of Public Health. The references quoted in this article refer to SIRUS as they were issued prior to this date.