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Perspectives on drugs: preventing overdose deaths in Europe

 

 

Preventing overdose deaths in Europe

Introduction

Last update: 01.06.2016

It is estimated that over 70 000 lives were lost to drug overdoses in Europe in the first decade of the twenty-first century. Reducing drug-related deaths therefore remains a major challenge for public health policy. 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.

Part of the ‘Perspectives on drugs’ (PODs) series, launched alongside the annual European Drug Report, these designed-for-the-web interactive analyses aim to provide deeper insights into a selection of important issues.

1. Analysis: preventing overdose deaths in Europe

The heroin epidemics that spread across Europe in the 1980s resulted in increasing numbers of overdose deaths among opioid users (1). Although the annual number of reported deaths peaked around the turn of the millennium, drug overdose still claimed more than 70 000 lives in Europe in the subsequent decade. Contrary to the promising overall trend between 2009 and 2013, when the number of reported overdose deaths fell from around 7 100 to 6 100, the most recent data from a number of countries with relatively robust reporting systems, including Sweden, Lithuania, Ireland and the United Kingdom, show an increase.

Drug overdose continues to be a major cause of death, especially among young people in Europe, with recent data showing that it accounts for more than 3.4 % of all deaths among Europeans between the ages of 15 and 39 (Eurostat, 2013). European countries have implemented a variety of approaches in their attempt to reduce overdose deaths at the national level using evidence-based interventions drawing on an understanding of individual and environmental risk factors.ed interventions drawing on an understanding of individual and environmental risk factors.

Which 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. Heightened levels of risk are also associated with the misuse of certain prescription drugs (e.g. benzodiazepines), and the non-medical use of prescribed substitution medications and opioid analgesics (Giraudon et al., 2013). In addition, a substantial number of deaths involve polydrug use, particularly heroin in combination with other central nervous system depressants, such as alcohol or benzodiazepines.

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. And 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. For these same reasons, inadequate throughcare between prison and community has also been identified as an important environmental risk factor (Zlodre and Fazel, 2012).

Finally, the lack of response or inadequate interventions by those witnessing overdoses, whether due to poor first aid knowledge, lack of access to effective medication or fear of legal repercussions, increases the risk of an overdose event having a fatal outcome (Frisher et al., 2012).

A range of responses: reducing the number of overdoses and preventing deaths

Drawing on the insights gained from risk and protective factors, the prevention of overdose deaths is generally addressed at two levels: the first involves a set of interventions geared towards the complete prevention of overdoses, while the second focuses on reducing fatal outcomes when overdoses do occur (Frisher et al., 2012). At both levels, strategies used include the scaling-up of known protective factors and the reduction of existing risks. Below, we introduce some of the most important strategies use by countries to address these intervention levels.

Increasing awareness of and information about overdose risks

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 health 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. Twenty-eight EMCDDA reporting countries now report the distribution of overdose risk information, which is sometimes also available in different languages in order to be accessible to migrant drug users. There is increasing use of the internet and new channels of communication in this field, for example an e-health overdose risk assessment tool and overdose awareness videos, which may be projected in the waiting rooms of drugs facilities (e.g. http://vimeo.com/album/1655129). Acknowledging the similarity of trends in mortality related to prescription opioids in Europe to those witnessed in the United States, countries now have an opportunity to adapt and scale up their prevention measures, reinforce surveillance and introduce improved regulatory measures to prevent deaths reaching epidemic proportions (Giraudon et al., 2013).

Provision of effective drug treatment and retention in treatment

There is convincing evidence that opioid substitution treatment (OST) substantially reduces the risk of mortality, as long as doses are sufficient and continuity of treatment is maintained (e.g. Degenhardt et al., 2011). 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 treatment services.

With OST provision high, medical staff and service planners face the challenge of minimising the diversion of substitution medications to those without prescriptions while continuing to ensure that access to treatment is not impeded. Another widely used approach to reducing the risk of overdose is the implementation of good treatment practice, which involves the use of clinical guidelines and training doctors in prescribing practices (including benzodiazepine prescribing).

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 (Merrall et al., 2010;Binswanger et al., 2013). These include pre-release education on overdose risks and prevention, continuation and initiation of substitution treatment (Degenhardt et al., 2014) and improved referral to aftercare and community treatment services (WHO Regional Office for Europe, 2010). A randomised trial (N-ALIVE trial) is under way to test the hypothesis that giving naloxone on release to prisoners with a history of heroin injecting will reduce heroin overdose deaths in this population during the most risky period – the first 12 weeks after release (Strang et al., 2013).

Prevention of deaths in overdose situations

A second set of responses focuses on the prevention of 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 74 facilities for supervised drug consumption operate across five Member States and Norway, serving specific subgroups of highly marginalised and homeless drug users. Supervised drug consumption facilities aim 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 death associated with injecting or inhalative drug use, and to reduce public drug use (EMCDDA, 2015a). 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, 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 documents increased access to health and social services among clients of supervised drug consumption facilities, and decreased public drug use and associated nuisance. A reduction in overdose mortality at the population level was documented in the city of Vancouver, in the local area where a supervised injecting facility operates (Marshall et al., 2011). See also, Drug consumption rooms (EMCDDA, 2015b).

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. Interventions that aim to improve bystander responses consist of training peers and family members of drug users in overdose prevention, recognition and response. In their new guidelines on community management of opioid overdose, the Word Health Organization recommends that people likely to witness an opioid overdose should have access to naloxone — an effective antidote that can reverse opioid intoxication — and should be instructed in its administration (WHO, 2014. 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 recent years. In January 2016, the EMCDDA launched a publication that brings together evidence as well as experiences from take-home naloxone projects in Europe and elsewhere (EMCDDA, 2016).

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. Although the overall number of drug-induced deaths remains high, Europe has seen some positive trends and developments in recent years. The accumulated knowledge about risk and protective factors associated with overdoses, and about the successful management of overdose situations, has grown. Access to OST, which constitutes an important protective factor, has been substantially scaled up across the region. 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.

Footnotes

    1)In this analysis, the term ‘overdose deaths’ refers to deaths that are caused directly by the consumption of one or more illicit drug. Generally, overdose deaths occur shortly after the consumption of the substance(s). These deaths are also known as ‘poisonings’ or ‘drug-induced deaths’.

References

  • 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 medicine 159(9), pp. 592–600. doi:10.7326/0003-4819-159-9-201311050-00005
  • CDC (Centers for Disease Control and Prevention) (2012), ‘Community-based opioid overdose prevention programs providing naloxone — United States, 2010’, MMWR 61, pp. 101–4.
  • 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 Dependence 115, pp. 190–5. doi:10.1016/j.drugalcdep.2010.10.021
  • Degenhardt, L., Bucello, C., Mathers, B., Briegleb, C., Ali, H., Hickman, M. and McLaren, J. (2011), ‘Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies’, Addiction 106, pp. 32–51. doi:10.1111/j.1360-0443.2010.03140.x
  • Degenhardt, L. , Larney, S., Kimber, J., Gisev, N., Farrell, M. et al. (2014), 'The impact of opioid substitution therapy on mortality post-release from prison: Retrospective data linkage study 1', Addiction. doi: 10.1111/add.12536
  • Eurostat (2013), ‘Causes of death statistics’, Eurostat.
  • Frisher, M., Baldacchino, A., Crome, I., and Bloor, R. (2012), Preventing opioid overdose in Europe: a critical assessment of known risk factors and preventative measures, EMCDDA Technical paper, EMCDDA, Lisbon.
  • Giraudon, I., Lowitz, K., Dargan, P. I., Wood, D. M. and Dart, R. C. (2013), 'Prescription opioid abuse in the UK.', British journal of clinical pharmacology 76(5), pp. 823–4. doi:10.1111/bcp.12133
  • Kerr, D., Kelly, A.-M., Dietze, P., Jolley, D. and Barger, B. (2009), ‘Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose’, I 104, pp. 2067–74, doi:10.1111/j.1360-0443.2009.02724.x.
  • Kimber, J., Copeland, L., Hickman, M., Macleod, J., McKenzie, J., De Angelis, D. and Robertson, J. R. (2010), ‘Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment’, British Medical Journal (Clinical research ed.) 341, p. c3172.doi: 10.1136/bmj.c3172. 
  • Marshall, B. D. L., Milloy, M.-J., Wood, E., Montaner, J. S. G. and Kerr, T. (2011), ‘Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study’, Lancet 377, pp. 1429–37. doi:10.1016/S0140-6736(10)62353-7
  • Merrall, E. L. C., Kariminia, A., Binswanger, I. A., Hobbs, M. S., Farrell, M., Marsden, J. et al. (2010), ‘Meta-analysis of drug-related deaths soon after release from prison’, Addiction 105, pp. 1545–54. doi:10.1111/j.1360-0443.2010.02990.x
  • Strang, J., Manning, V., Mayet, S., Best, D., Titherington, E., Santana, L., Offor, E., 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 103(10), pp.1648-57.
  • Strang, J., Bird, S. M. and Parmar, M. K. B. (2013), 'Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial.', Journal of Urban Health : Bulletin of the New York Academy of Medicine 90(5), pp. 983–96. doi:10.1007/s11524-013-9803-1
  • Williams, A. V, Marsden, J. and Strang, J. (2014), 'Training family members to manage heroin overdose and administer naloxone: randomized trial of effects on knowledge and attitudes.', Addiction (Abingdon, England) 109(2), pp. 250–9. doi:10.1111/add.12360
  • WHO Regional Office for Europe (2010), ‘Prevention of acute drug-related mortality in prison populations during the immediate post-release period’, World Health Organization, Regional Office for Europe, Copenhagen.
  • Zlodre, J. and Fazel, S. (2012), ‘All-cause and external mortality in released prisoners: systematic review and meta-analysis’, American Journal of Public Health 102, pp. e67–75. doi:10.2105/AJPH.2012.300764
  • EMCDDA, European Monitoring Centre for Drugs and Drug Addiction (2015), ‘Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone’, EMCDDA Papers, Publications Office of the European Union, Luxembourg.
  • WHO (2014), ‘Community management of opioid overdose’, World Health Organization, Geneva. ISBN: 978 92 4 154881 6.
  • EMCDDA (2015a), Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone, EMCDDA Papers, Publications Office of the European Union, Luxembourg.
  • Information Services Division (2014), National Naloxone Programme Scotland – naloxone kits issued in 2013/14 and trends in opioid-related deaths, Information Services Division, Edinburgh: 28 October 2014.
  • Information Services Division (2015), National Naloxone Programme Scotland: Monitoring report 2014/15, Information Services Division, Edinburgh.
  • WHO (2014), Community management of opioid overdose, World Health Organization, Geneva. 
  • EMCDDA (2015b), ‘Drug consumption rooms: An overview of provision and evidence’, EMCDDA Perspectives on drugs, EMCDDA, Lisbon.
  • EMCDDA (2016), Preventing opioid overdose deaths with take-home naloxone, edited by John Strang and Rebecca MacDonald, EMCDDA Insights, Publications Office of the European Union, Luxembourg.

2. Video showcase: overdose prevention and take-home naloxone

Please note: these video may contain realistic depictions of drug use, including intravenous injection which some viewers may find disturbing.

Overdose: prevention and response

This video by Mutation production, produced for the Public Health Agencies of Catalonia and Barcelona is an example of an overdose-awareness video, designed to be projected in the waiting rooms of drug facilities. The video is available in different languages, which may be accessed here: vimeo.com/album/1655129.

Take-home naloxone programmes in Europe — overdose prevention

Drug overdose continues to be the main cause of death among problem drug users and heroin or its metabolites are present in the majority of reported fatal overdoses. Naloxone is a lifesaving overdose reversal drug that rapidly counteracts the effects of opioids and is currently the standard treatment for overdose. In Europe, overdose prevention programmes that include the distribution of naloxone date back to the 1990s.

3. Facts and figures

1.3 million

high-risk opioid users in Europe, including Norway

70 000

More than 70 000 overdose deaths during the first decade of the twenty-first century

660 000

clients in opioid substitution treatment in 2014

9

countries with take-home naloxone programmes

6 800

overdose deaths in 2014

7

countries, including Switzerland, with drug consumption rooms

3.4

3.4% of all deaths in adult males under 40

4. Peer naloxone distribution

Naloxone (Narcan®) is an opioid antagonist medication used worldwide in emergency medicine to reverse respiratory depression caused by opioid overdose. Naloxone is listed by the World Health Organization as an essential medicine and is available in injectable form (intramuscular and intravenous) and in some countries as an intranasal spray. The effectiveness of concentrated intranasal naloxone has been shown to be similar to that of intramuscular naloxone as a first-line treatment for heroin overdose (Kerr et al., 2009). Community-based opioid overdose prevention programmes that train potential bystanders, such as opioid users and their peers and family, on how to administer naloxone in order to reverse the effects of opioid overdose are among the range of overdose prevention responses in the United States and Europe (CDC, 2012, Clark et al., 2014; Williams et al., 2014)

A recent EMCDDA systematic review of the available studies on take-home naloxone concludes: ‘There is evidence from one interrupted time-series study, involving 2 912 opioid users at risk of overdose in 19 communities followed up for seven years, that educational and training interventions complemented by take-home naloxone decrease overdose-related mortality. There is weaker, but consistent, evidence that similar interventions for opioid-dependent patients and their peers effectively improve knowledge, while forming positive attitudes to the correct use of naloxone and the management of witnessed overdoses’ (EMCDDA, 2015).

Currently, nine European countries (Denmark, Estonia, Germany, Italy, Ireland, Lithuania, Norway, Spain and the United Kingdom) report the existence of take-home naloxone programmes, some of which are small and time-limited. Scotland and Wales run nationwide programmes of naloxone distribution to high-risk users in the community and to inmates released from prison. Latest data from the national naloxone programme in Scotland show a reduction in 2014 in the proportion of opioid-related deaths that occurred within four weeks of prison release to 3.1 % in comparison to the 2006–10 baseline of 9.8 %, although numbers are small (Information Services Division, 2014). ). In some countries legislative reform may be needed to allow the low-threshold provision of naloxone, but the measure is regarded as a low-cost approach that can empower healthcare workers and people who use drugs to save lives (WHO, 2014, p.9).

Naloxone image by Intropin (Own work) [CC-BY-3.0], via Wikimedia Commons

  • CDC (Centers for Disease Control and Prevention) (2012), ‘Community-based opioid overdose prevention programs providing naloxone — United States, 2010’, MMWR 61, pp. 101–4.
  • EMCDDA, European Monitoring Centre for Drugs and Drug Addiction (2015), ‘Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone’, EMCDDA Papers, Publications Office of the European Union, Luxembourg.
  • Information Services Division (2014), National Naloxone Programme Scotland – naloxone kits issued in 2013/14 and trends in opioid-related deaths, Information Services Division, Edinburgh: 28 October 2014.
  • Kerr, D., Kelly, A.-M., Dietze, P., Jolley, D. and Barger, B. (2009), ‘Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose’, I 104, pp. 2067–74, doi:10.1111/j.1360-0443.2009.02724.x.
  • Williams, A. V, Marsden, J. and Strang, J. (2014), 'Training family members to manage heroin overdose and administer naloxone: randomized trial of effects on knowledge and attitudes.', Addiction (Abingdon, England) 109(2), pp. 250–9. doi:10.1111/add.12360
  • WHO (2014), ‘Community management of opioid overdose’, World Health Organization, Geneva. ISBN: 978 92 4 154881 6.

Footnotes

    1)In this analysis, the term ‘overdose deaths’ refers to deaths that are caused directly by the consumption of one or more illicit drug. Generally, overdose deaths occur shortly after the consumption of the substance(s). These deaths are also known as ‘poisonings’ or ‘drug-induced deaths’.

References

  • 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 medicine 159(9), pp. 592–600. doi:10.7326/0003-4819-159-9-201311050-00005
  • 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 Dependence 115, pp. 190–5. doi:10.1016/j.drugalcdep.2010.10.021
  • Degenhardt, L., Bucello, C., Mathers, B., Briegleb, C., Ali, H., Hickman, M. and McLaren, J. (2011), ‘Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies’, Addiction 106, pp. 32–51. doi:10.1111/j.1360-0443.2010.03140.x
  • Degenhardt, L. , Larney, S., Kimber, J., Gisev, N., Farrell, M. et al. (2014), 'The impact of opioid substitution therapy on mortality post-release from prison: Retrospective data linkage study 1', Addiction. doi: 10.1111/add.12536
  • Eurostat (2013), ‘Causes of death statistics’, Eurostat.
  • Frisher, M., Baldacchino, A., Crome, I., and Bloor, R. (2012), Preventing opioid overdose in Europe: a critical assessment of known risk factors and preventative measures, EMCDDA Technical paper, EMCDDA, Lisbon.
  • Giraudon, I., Lowitz, K., Dargan, P. I., Wood, D. M. and Dart, R. C. (2013), 'Prescription opioid abuse in the UK.', British journal of clinical pharmacology 76(5), pp. 823–4. doi:10.1111/bcp.12133
  • Kimber, J., Copeland, L., Hickman, M., Macleod, J., McKenzie, J., De Angelis, D. and Robertson, J. R. (2010), ‘Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment’, British Medical Journal (Clinical research ed.) 341, p. c3172.doi: 10.1136/bmj.c3172. 
  • Marshall, B. D. L., Milloy, M.-J., Wood, E., Montaner, J. S. G. and Kerr, T. (2011), ‘Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study’, Lancet 377, pp. 1429–37. doi:10.1016/S0140-6736(10)62353-7
  • Merrall, E. L. C., Kariminia, A., Binswanger, I. A., Hobbs, M. S., Farrell, M., Marsden, J. et al. (2010), ‘Meta-analysis of drug-related deaths soon after release from prison’, Addiction 105, pp. 1545–54. doi:10.1111/j.1360-0443.2010.02990.x
  • Strang, J., Manning, V., Mayet, S., Best, D., Titherington, E., Santana, L., Offor, E., 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 103(10), pp.1648-57.
  • Strang, J., Bird, S. M. and Parmar, M. K. B. (2013), 'Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial.', Journal of Urban Health : Bulletin of the New York Academy of Medicine 90(5), pp. 983–96. doi:10.1007/s11524-013-9803-1
  • WHO Regional Office for Europe (2010), ‘Prevention of acute drug-related mortality in prison populations during the immediate post-release period’, World Health Organization, Regional Office for Europe, Copenhagen.
  • Zlodre, J. and Fazel, S. (2012), ‘All-cause and external mortality in released prisoners: systematic review and meta-analysis’, American Journal of Public Health 102, pp. e67–75. doi:10.2105/AJPH.2012.300764
  • EMCDDA (2015a), Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone, EMCDDA Papers, Publications Office of the European Union, Luxembourg.
  • Information Services Division (2015), National Naloxone Programme Scotland: Monitoring report 2014/15, Information Services Division, Edinburgh.
  • WHO (2014), Community management of opioid overdose, World Health Organization, Geneva. 
  • EMCDDA (2015b), ‘Drug consumption rooms: An overview of provision and evidence’, EMCDDA Perspectives on drugs, EMCDDA, Lisbon.
  • EMCDDA (2016), Preventing opioid overdose deaths with take-home naloxone, edited by John Strang and Rebecca MacDonald, EMCDDA Insights, Publications Office of the European Union, Luxembourg.

Find out more

Further reading

Links to overdose prevention and naloxone films (external websites)

EMCDDA_POD_2013_Preventing overdose deaths.pdf
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Page last updated: Wednesday, 01 June 2016