This is the sixth in a blog series based on the findings of the 2015 annual European Drugs Report published by the European Monitoring Centre for Drugs and Drug Addiction. In it, I explore new interventions to prevent drug overdose deaths.
It is estimated that over 70 000 lives were lost to drug overdoses in Europe in the first decade of the 21st Century. Although the annual figure of fatal drug overdoses started to fall between 2009 and 2013, the most recent data from a number of countries, including Germany, Sweden and the United Kingdom, show an increase.
The sad fact is that drug overdose accounts for more than 3.4% of all deaths among Europeans between the ages of 15 and 39.
The type of substance used, how it is used, 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. There are also high risks associated with the misuse of certain prescription drugs (particularly benzodiazepines), and the non-medical use of prescribed substitution medications such as methadone. 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 for heroin users, disruption of treatment provision or discontinuity of treatment and care. And in certain situations, for example following detoxification, discharge from drug-free treatment, and release from prison, the tolerance of drug users to opioids is greatly reduced and as a result they are at particularly high risk of overdosing.
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.
There are two main points of intervention:
- Trying to prevent overdoses in the first place
- Reducing fatal outcome when overdoses do occur
Both strategies include the scaling-up of known protective factors and the reduction of existing risks. Below is a list of the main approaches under both categories of intervention.
There are three commonly used approaches to prevent overdoses in the first place:
Raising the awareness of and providing information about overdose risks. Many drug users are unaware of the full extent of the risks they are running, so targeted information aimed at opioid users in particular is important. There is increasing use of the Internet and new channels of communication – for example e-health overdose risk assessment tools and overdose awareness videos shown in the waiting rooms of drug treatment agencies.
Provision of effective drug treatment and retention in treatment. There’s a good evidence base that opioid substitution treatment (OST – prescribing methadone, Subutex et cetera) substantially reduces the risk of mortality – as long as doses are sufficient and continuity of treatment is maintained.
Improving throughcare between prison and community. Prison release is a very high risk time and a number of different approaches have been tried including pre-release education on overdose risks, continuing OST in prison or starting it again prerelease and improved referral to after-care and community treatment services. There is a current trial (N-ALIVE trial) testing whether giving naloxone on release to prisoners with a history of heroin injecting will reduce overdose deaths in the first 12 weeks after prison release.
Reducing fatal outcomes
There are two main categories of intervention to try to prevent overdoses from resulting in death.
Supervised drug consumption rooms (see this recent post for an up-to-date overview) aim to reach marginalised high-risk drug users and connect them with a wider network of care as well as supervising the actual injection of drugs.
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 in the best position to respond to an emergency overdose. Providing training to drug users and their families and friends and distributing naloxone (an effective antidote that can reverse opioid intoxication) is becoming increasingly common both in Europe and in the United States. Peer training on the use of naloxone appears to be a promising approach.
The number of drug overdose deaths remain stubbornly high despite the increasing amount of robust evidence to show that specific interventions can both reduce the occurrence of overdose events and prevent fatal outcomes in overdose situations.
Recently, New Psychoactive Substances have been implicated in a growing proportion of drug-related deaths, and it will be important for treatment agencies to target this group with overdose prevention messages.