Prevention of drug-related deaths – topic overview

Prevention of
drug-related deaths

Introduction

Worldwide, overdose is the leading cause of avoidable death among people who inject drugs. It accounts for nearly half of all deaths among people who inject heroin, exceeding HIV and other disease-related deaths (UNODC, 2017).

More than 9 000 lives were reported to be lost to drug overdoses in Europe (28 EU Member States, Norway and Turkey) in 2017, the latest reporting year, and this is an underestimate. The number of drug-related deaths in Europe has been rising for 5 years (EMCDDA, 2019a). Reducing drug-related deaths therefore remains a major challenge for European public health policy.

The groups most likely to experience an overdose are people with an opioid dependency and those who inject them. It has been found that overdose deaths are more likely to occur in specific situations, for example the period shortly after prison release, hospital discharge or completing a course of residential detoxification or recovery treatment. Other risk factors for opioid overdose include using opioids in combination with other central nervous system depressants, such as alcohol or benzodiazepines, and using them unaccompanied. The type of opioid used also plays a role. In some countries (in particular the United States and Canada), overdose risks have substantially increased because of the circulation of fentanyl-laced drugs. The high potency of even small amounts of fentanyl, a synthetic opioid, in combination with its unknown concentration in drug mixtures, presents an elevated risk of overdose (see Spotlight: Fentanyl).

In recent years, several documents addressing the prevention of drug-related deaths have been issued by international organisations, and reducing premature mortality is a target under Sustainable Development Goal 3.

Table 1 presents an overview of the main documents and the key issues mentioned in each one. 

Table 1: Overview of the main documents on drug-related deaths issued by the United Nations system since 2012

Year

Document

Overview

2012

Commission on Narcotic Drugs (CND) Resolution 55/7: Promoting measures to prevent drug overdose, in particular opioid overdose

‘Encourages all Member States to include effective elements for the prevention and treatment of drug overdose, in particular opioid overdose, in national drug policies, where appropriate, and to share best practices and information on the prevention and treatment of drug overdose, in particular opioid overdose, including the use of opioid receptor antagonists such as naloxone’

2013

United Nations Office on Drugs and Crime (UNODC)/World Health Organization (WHO) Discussion Paper: Opioid overdose: preventing and reducing opioid overdose mortality

Contribution of the UNODC and WHO to improving responses by Member States to the increasing problem of opioid overdose deaths

2014

WHO guidelines: Community management of opioid overdose

The guidelines recommend that people who are likely to witness an opioid overdose, including people who use opioids, and their family and friends should be given access to naloxone and training in its use so that they can respond to opioid overdose in an emergency if a medical response is not available

2015

Sustainable Development Goals

Target 3.4 of Goal 3 on the 2030 Agenda for Sustainable Development is: ‘By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’

2017

UNODC/WHO: The S-O-S initiative

The UNODC, in collaboration with WHO, launched the ‘S-O-S’ initiative to set global implementation targets and to enhance adequate access to opioid overdose prevention in line with recommendations of the WHO guidelines on community management of opioid overdose

At the EU level, the reduction of drug-related deaths has been a goal throughout all EU drugs strategies, and providing trained laypeople with access to naloxone is explicitly included in the current EU Action Plan on Drugs 2017-2020. Table 2 provides an overview of the goals and targets in this field, laid down in recent EU drugs policy documents.

Table 2: The prevention of drug-related deaths in EU drug policy goals

EU Drugs Strategy 2005-2012
Goal: Reducing drug-related health and social damage

EU Drugs Strategy 2013-2020
Goal: Reducing the number of drug-related deaths is a priority in the policy field drug demand reduction

EU Drugs Action Plan (2005-2008)

Action 17: Reduction of drug-related deaths to be included as a specific target at all levels with interventions specifically designed for this purpose...

EU Drugs Action Plan for 2009-2012

Action 10: Ensure access to harm reduction services, in order to … reduce the number of drug-related deaths in the EU

EU Action Plan on Drugs 2013-2016

Action 7: Ensure that treatment and outreach services incorporate greater access to risk and harm reduction options to lessen the negative consequences of drug use and to substantially reduce the number of direct and indirect drug- related deaths (…)

EU Action Plan on Drugs 2017-2020

Action 8(b): Better prevent drug-related deaths ... by providing access to authorised pharmaceutical dosage forms of medicinal products containing naloxone specifically certified to treat opioid overdose symptoms by trained laypersons in the absence of medical professionals

This analysis describes some of the factors that increase the risk of fatal and non-fatal overdoses and a number of interventions developed to prevent these events.

Overdose deaths

Overdose deaths in Europe

Heroin epidemics that spread across Europe in the 1980s resulted in increasing numbers of overdose deaths among opioid users, which peaked for the first time around the turn of the millennium. Since then, over 7 000 overdose deaths have been reported in Europe every year. Recent data show an increasing trend for the fifth consecutive year, with a new record number of 9 461 overdose deaths registered in 2017 in the countries reporting to the EMCDDA (the 28 EU Member States, Norway and Turkey).

Over three quarters of those dying from overdose are male (78 %). The mean age at death continued to increase, reaching 39.4 years of age in 2017, with the average for men being 2 years lower than that for women. The mortality rate due to overdoses in Europe in 2017 is estimated to be 22.6 deaths per million population aged 15-64 years (EMCDDA, 2019a). More detailed information on numbers, rates and trends is available on the Frequently asked questions (FAQ): drug overdose death (EMCDDA).

Risk factors

Risk factors

What factors increase the risk of fatal and non-fatal overdose?

The type of substance used, the route of administration and the health of the user all have an impact on the risk of overdose. Most overdose deaths are linked to the use of opioids, primarily the injection of heroin or synthetic opioids. Polydrug use is also very common and the combination of heroin or other opioids with other central nervous system depressants, such as alcohol or benzodiazepines, bears particularly high risks.

Spotlight: Fentanyl

Highly potent new synthetic opioids seem to play an increasing role in drug overdose in Europe. Of particular concern are the fentanyl derivatives, which make up the majority of the new opioids monitored by the EMCDDA. Because of the high potency of these substances, minute quantities can cause life-threatening conditions, due to rapid and severe respiratory depression. This makes them especially dangerous, particularly for unsuspecting users who believe that they are using heroin, other illicit drugs or pain medicines. The dangers to public health posed by these substances are being witnessed in the United States, where synthetic opioids other than methadone, mostly illicitly manufactured fentanyls (Scholl et al., 2019), are now one of the main drivers behind a continuing surge in overdose deaths. A rapid increase in deaths attributed to this group of substances has been noted over recent years, with 28 466 deaths in 2017, corresponding to 9 deaths per 100 000 population, which represents a nine-fold increase from 1 death per 100 000 population in 2013. From 2016 to 2017, synthetic opioid-involved overdose death rates increased by 45.2 %. A 2019 EMCDDA publication focuses on deaths related to fentanyl and fentanyl analogues in Sweden, the United Kingdom and other countries (EMCDDA, 2019b).

A number of environmental factors increase the risk of drug overdose death including, in the case of opioid users, disruption of treatment provision or discontinuity of treatment and care. In certain situations, for example following detoxification or discharge from drug-free treatment, the tolerance of drug users to opioids is greatly reduced and, as a result, they are at particularly high risk of overdosing if they resume use. For these same reasons, inadequate throughcare between prison and community life has also been identified as an important environmental risk factor (WHO, 2014; Zlodre and Fazel, 2012). In a cohort study in England, differences in the risk of fatal opioid poisoning were identified, depending on the type of treatment received: opioid users who received only psychological support appeared to be at greater risk than those who received opioid-agonist pharmacotherapy (Pierce et al., 2016).

Finally, the lack of response or inadequate interventions by those witnessing overdoses, whether due to poor first-aid knowledge, a lack of access to effective medication or a fear of legal repercussions, increases the risk of an overdose event having a fatal outcome (Frisher et al., 2012). A study in Bergen, Norway, analysed differences in the time that emergency services needed to arrive after overdose call-outs to private or public addresses. Ambulance response times were more likely to be longer for private locations and victims found in private homes were more likely to be left at the scene after being treated and less likely to be taken to hospital (Madah-Amiri et al., 2016).

Drawing on the insights gained from risk and protective factors, the prevention of overdose deaths is generally addressed at three levels (see Figure 1). As a basis for a successful response, broader public health approaches, such as providing outreach and low-threshold services and enabling environments, can reduce access barriers and thus reduce vulnerability to overdose, while empowering drug users to protect themselves may create an environment in which overdoses are less likely. The second level involves a set of interventions geared towards preventing the occurrence of overdoses, while the third level focuses on reducing morbidity and fatal outcomes when an overdose has happened (EMCDDA, 2017). Below, we introduce some of the most important strategies used by countries in overdose prevention.

Figure 1: What interventions can help to reduce and prevent opioid overdose deaths?

key approaches for reducing opioid related deaths

Reducing risk

Reducing risk

Increasing awareness of and information about overdose risks

A history of opioid use is a risk factor for overdose, and those who report prior overdoses are at a higher risk of overdosing again. As many drug users either are unaware of or seriously underestimate overdose risks, effective communication with users can act as a catalyst for reducing harm. Ideally, overdose prevention, education and counselling interventions would be provided by trained professionals as a matter of routine in the relevant healthcare and primary care settings. Screening for overdose risk by those treating heroin users may contribute to reductions in overall mortality (Darke et al., 2011), while the use of overdose risk assessment interventions can assist the early identification of high-risk individuals. All EU Member States and Norway report distributing overdose risk information, which is sometimes also available in different languages so that it is accessible to migrant drug users.

Provision of effective drug treatment and retention in treatment

There is convincing evidence that opioid substitution treatment substantially reduces the risk of mortality, as long as doses are sufficient and continuity of treatment is maintained (EMCDDA Best practice portal; Pierce et al., 2016). A prospective observational cohort study conducted in Edinburgh confirmed that survival is increased by cumulative exposure to treatment (Kimber et al., 2010). As retention in drug treatment is a protective factor against overdose deaths, many European countries have given priority to increasing access to and coverage of drug treatment services. It is estimated that one in two problem opioid users receives opioid substitution treatment. Following good treatment practice, which involves the use of clinical guidelines and training doctors in prescribing practices, is essential for optimising treatment gains.

Improving throughcare between prison and community

Several interventions are recommended to help reduce the high number of overdose deaths among former prisoners in the period shortly after leaving prison (Binswanger et al., 2013; Merrall et al., 2010). These include pre-release education on overdose risks and prevention, continuation and initiation of substitution treatment (Degenhardt et al., 2014), naloxone distribution (Meade et al., 2018) and improved referral to aftercare and community treatment services (WHO Regional Office for Europe, 2014). An EU-funded multi-country project entitled ‘My first 48 hours out’ (Belgium, Germany, France and Portugal) has compiled information on best practices in pre- and post-prison release interventions to reduce the risk of mortality upon release from prison.

See also:

Preventing deaths

Preventing deaths

Another set of responses focuses on preventing fatalities when overdoses occur. These include a range of targeted interventions, the purpose of which is to enhance safety and ensure a rapid and effective response in emergency situations.

Supervised drug consumption rooms

A total of 87 facilities for supervised drug consumption operate across eight EU Member States (Belgium, Denmark, Germany, Spain, France, Luxembourg, the Netherlands and Portugal), Norway and Switzerland, serving specific subgroups of highly marginalised and homeless drug users. Supervised drug consumption rooms have shown to reach marginalised high-risk drug users and connect them to the wider network of care, to reduce the acute risks of diseases and overdose deaths associated with injecting or inhaling drug use, and to reduce public drug use (Belackova and Salmon, 2017). Drug consumption rooms are highly targeted services, usually integrated within facilities that offer a broad range of other health and social services. They provide a safer drug use environment and advice on safer injecting and medical supervision and are equipped to manage drug overdoses and reduce related morbidity and mortality. Millions of injections have been supervised and no overdose fatalities have occurred in the facilities. Evidence from robust studies shows increased access to health and social services among clients of supervised drug consumption facilities, decreased public drug use and associated nuisance, and reductions in overdose mortality (Kennedy et al., 2017).

See also:

Improved bystander response

Most overdoses occur when others are present and most injecting drug users have witnessed or experienced overdoses. Therefore, drug users themselves, or their friends and family, are likely to be both bystanders and potential first responders in emergency overdose situations (Strang et al., 2008). These human networks, with appropriate training and awareness raising, can be utilised to prevent overdose deaths.

Development of take-home naloxone policies

This was recognised by the Commission on Narcotic Drugs in 2012, which adopted a resolution that addressed measures to prevent drug overdose, in particular opioid overdose, and encouraged United Nations (UN) member countries to include the use of naloxone among other responses. Subsequently, the World Health Organization (WHO), as the competent UN agency, reviewed the evidence and convened an expert group to define guidelines for the community management of opioid overdose. The guidelines, published in 2014, recommend that people who are likely to witness an opioid overdose should have access to naloxone (see Table 3).

Table 3: WHO guidelines on community management of opioid overdose

Recommendation

Strength of recommendation

Quality of evidence

People likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for emergency management of suspected opioid overdose

Strong

Very low

Naloxone is effective when delivered by intravenous, intramuscular, subcutaneous and intranasal routes of administration. Persons using naloxone should select a route of administration based on the formulation available, their skills in administration, the setting and local context

Limited

Very low

In suspected opioid overdose, first responders should focus on airway management, assisting ventilation and administering naloxone

Strong

Very low

After successful resuscitation following the administration of naloxone, the level of consciousness and breathing of the affected person should be closely monitored until full recovery has been achieved

Strong

Very low

Source: WHO, 2014

Interventions that aim to improve bystander responses consist of training peers and family members of drug users in overdose prevention, recognition and response and providing them with naloxone. Evidence shows that educational and training interventions for peers and family members, complemented by take-home naloxone, help decrease overdose-related mortality. With evidence on its effectiveness growing, take-home naloxone provision has gained more attention in Europe in recent years. A recent EMCDDA publication brings together evidence as well as experiences from take-home naloxone projects in Europe and elsewhere (Strang and McDonald, 2016).

See also:

Conclusions

Drug overdose deaths are preventable, and there is good evidence to show that specific interventions can both reduce the occurrence of overdose events and prevent fatal outcomes in overdose situations. The accumulated knowledge about risk and protective factors associated with overdoses, and about the successful management of overdose situations, has grown. Access to opioid substitution treatment, which is an important protective factor for opioid-related deaths, has been substantially scaled up across Europe. In addition, some countries have introduced new and targeted approaches, searching for innovative ways to identify those at risk of overdose, to raise risk awareness and to enable those who witness overdoses to intervene and prevent fatal outcomes.

References

References

References for Table 1

References for main text

Belackova, V. and Salmon, A. M. (2017), Overview of International literature : supervised injecting facilities & drug consumption rooms / Uniting Medically Supervised Injecting Rooms, 1st ed. Uniting MSIC, Sydney.

Binswanger, I. A., Blatchford, P. J., Mueller, S. R. and Stern, M. F. (2013), ‘Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009’, Annals of Internal Medicine159(9), pp. 592–600.

Darke, S., Mills, K. L., Ross, J. and Teesson, M. (2011), ‘Rates and correlates of mortality amongst heroin users: findings from the Australian Treatment Outcome Study (ATOS), 2001-2009.’, Drug and Alcohol Dependence115(3), pp. 190–95.

European Monitoring Centre for Drugs and Drug Addiction (2017), Health and social responses to drug problems: a European guide, Publications Office of the European Union, Luxembourg.

European Monitoring Centre for Drugs and Drug Addiction (2019a), European Drug Report 2019: Trends and Developments, Publications Office of the European Union, Luxembourg.

European Monitoring Centre for Drugs and Drug Addiction (2019b), Update from the EMCDDA expert network Drug-related deaths and mortality in Europe. Rapid Communication, Publications Office of the European Union, Luxembourg.

Degenhardt, L., Larney, S., Kimber, J., Gisev, N., Farrell, M., Dobbins, T., Weatherburn, D. J., et al. (2014), ‘The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study’, Addiction109(8), pp. 1306–17.

Frisher, M., Baldacchino, A., Crome, I. and Bloor, R. (2012), Preventing opioid overdoses in Europe : A critical assessment of known risk factors and preventative measures. Final report, EMCDDA: Lisbon.

Kennedy, M. C., Karamouzian, M. and Kerr, T. (2017), ‘Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review’, Current HIV/AIDS Reports14(5), pp. 161–83.

Kimber, J., Palmateer, N., Hutchinson, S., Hickman, M., Goldberg, D. and Rhodes, T. (2010), ‘Harm reduction among injecting drug users — evidence of effectiveness’, in Harm Reduction: evidence, impacts and challenges edited by T. Rhodes and D. Hedrich, Publications Office of the European Union, Luxembourg, pp. 115–64.

Madah-Amiri, D., Clausen, T., Myrmel, L., Brattebø, G. and Lobmaier, P. (2016), ‘Circumstances surrounding non-fatal opioid overdoses attended by ambulance services’, Drug and Alcohol Review(January), doi:10.1111/dar.12451. 

Meade, A. M., Bird, S. M., Strang, J., Pepple, T., Nichols, L. L. E. A., Mascarenhas, M., Choo, L., Kumar, M. and Parmar, B. (2018), ‘Methods for delivering the UK’s multi-centre prison-based naloxone- on-release pilot randomised trial ( N-ALIVE ): Europe ’ s largest prison-based randomised controlled trial’, Drug and Alcohol Review37(4), pp. 487–98.

Merrall, E. L. C., Kariminia, A., Binswanger, I. A., Hobbs, M. S., Farrell, M., Marsden, J., Hutchinson, S. J. and Bird, S. M. (2010), ‘Meta-analysis of drug-related deaths soon after release from prison.’, Addiction (Abingdon, England)105(9), pp. 1545–54.

Pierce, M., Bird, S. M., Hickman, M., Marsden, J., Dunn, G., Jones, A. and Millar, T. (2016), ‘Impact of treatment for opioid dependence on fatal drug-related poisoning: A national cohort study in England’, Addiction111(2), pp. 298–308.

Scholl, L., Seth, P., Wilson, N., Baldwin, G., Kariisa, M., Wilson, N. and Baldwin, G. (2018), ‘Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017’, MMWR Morbidity and Mortality Weekly Report67(5152), doi:10.15585/mmwr.mm6751521e1.

Strang, J., Manning, V., Mayet, S., Best, D., Titherington, E., Santana, L., Offor, E. and Semmler, C. (2008), ‘Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses.’, Addiction (Abingdon, England)103(10), pp. 1648–57. 

Strang, J. and McDonald, R. (2016), Preventing opioid overdose deaths with take-home naloxone, Publications Office of the European Union, Luxembourg.

United Nations Office on Drugs and Crime and World Health Organization (2017), ‘The S-O-S initiative Stop Overdose Safely: Emergency community management of heroin and opioid overdose including interim naloxone’, WHO Department of Mental Health and Substance Abuse.

World Health Organization (2014), Community management of opioid overdose, World Health Organization, Geneva.

Zlodre, J. and Fazel, S. (2012), ‘All-cause and external mortality in released prisoners: systematic review and meta-analysis.’, American Journal of Public Health102(12), pp. e67-75.

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