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Latest estimates show that drug overdose deaths in Europe have risen for the fifth consecutive year, with a record 9 461 lives lost in 2017 (EU 28, Turkey and Norway). Reducing drug-related deaths is therefore a major public health challenge. Ahead of International Overdose Awareness Day, the EU drugs agency (EMCDDA) recently launched three new resources looking at drug overdoses in Europe and the interventions in place to prevent them.

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Preventing drug-related deaths – risks and responses

Most overdose deaths in Europe are linked to the use of opioids (heroin or synthetic opioids), although cocaine, other stimulant drugs and medicines also play a role. In a new online resource, Prevention of drug-related deaths in Europe, the agencyprovides an overview on the issue and the risk factors involved.

Fatal overdoses are most likely to occur in specific situations, such as lost or reduced tolerance to opioids shortly after prison release, hospital discharge, interruption of treatment or completing a course of residential detoxification. Using opioids with other substances (e.g. alcohol, benzodiazepines and other medicines) also increases the risks of death, as does the lack of, or inadequate, response by those witnessing an overdose.

The EMCDDA illustrates how overdose prevention can be addressed on three levels: reducing vulnerability to overdose (e.g. accessible treatment and services); reducing the risk of overdose (e.g. retention in opioid substitution treatment, prison aftercare and overdose risk assessments); and reducing the likelihood of fatal outcomes (e.g. take-home naloxone policies and supervision of drug consumption) (see Figure 1). Currently, 87 supervised drug consumption facilities exist in 8 EU Member States, Norway and Switzerland providing a safer drug-using environment (1).

Take-home naloxone can save lives – a first overview of programmes

Many people overdose in the presence of their partners or peers, therefore empowering friends, family and other bystanders to act effectively, before emergency services arrive at the scene, can save lives. While naloxone — a medicine used to reverse opioid toxicity — has been used in hospitals for over 40 years, it is also now available in the community in many countries (2). The EMCDDA recently launched its first overview of Take-home naloxone (THN) programmes in Europe.

The new online resource describes how these programmes developed and became more common over the past decade (see timeline). Providing naloxone and training in emergency response to those likely to witness an overdose is set out as an overdose prevention measure in the EU Action Plan on Drugs 2017–2020 and THN programmes are now expanding. In 2019, 11 EU Member States and Norway report running such programmes (see map and national fact sheets) or allowing access to the medicine without a prescription (3). Since 2016, pharmacists in a majority of US states have been able to give out naloxone on the basis of a standing order (and do not require a patient-specific prescription). Prescription-free distribution is now permitted in several other countries worldwide, including Australia, Canada, Italy, theUK and France.

Practical solutions have been found to allow non-medical personnel to receive and administer injectable naloxone and enable the distribution of the medication to the homes of potential bystanders. Some countries now make the emergency medication available without a prescription to, or have lifted prescription regulations for, specific establishments or those registered as formally trained. The resource summarises the different products used in THN programmes, including naloxone nasal spray, authorised in 2017 by the European Commission for marketing in all EU countries.

Drug overdose deaths in Europe – frequently asked questions

Where have drug-related deaths increased most over the last 10 years? Are women and men affected equally? What are the current concerns in Europe? These are some of the questions answered in new Frequently asked questions (FAQs): drug overdose deaths in Europe published today on the EMCDDA website. These present the overdose situation and trends as well as a range of maps and graphics. ‘Focus’ sections highlight overdose trends in Scotland — currently the country with the highest overdose mortality rate per capita in Europe — and illicitly manufactured fentanyl and its derivatives, involved in large numbers of deaths in some countries, including Sweden (which saw a peak in 2017) and Estonia.

In Scotland, a country with a high prevalence of high-risk drug use, a record 1 187 drug-related deaths were reported in 2018 (up 27% from 2017). Scotland’s drug-death rate among adults (15–64 years) is higher than those reported for all the EU countries. Most cases in Scotland are associated with opioids (9 in 10) and benzodiazepines (7 in 10), but almost all (85%) involve more than one drug. Recent increases are primarily seen in 35–44 and 45–54 year-olds. Other northern European countries (e.g. Estonia, Sweden, Norway) also have high overdose mortality rates (in some countries, there may be under-reporting).

The EMCDDA monitors closely alerts on harms related to fentanyl and its derivatives due to the very high toxicity of these substances and their potential to result in large clusters of incidents and deaths. In 2017, following reports that fentanyl or carfentanil introduced into the heroin supply in the north of England had caused a number of deaths, public health authorities issued warnings on the harms related to these heroin mixtures and advised on naloxone dosing regimes in the event of an overdose.

EMCDDA Director Alexis Goosdeel recently said:

‘Overdose deaths are preventable. We know from research that many of those who die have been struggling and living on the margins of society for years. We know that those who overdose once are at a very high risk of overdosing again. And we know that effective preventive and response measures exist that would allow us to avoid many deaths. Bystanders must also be empowered to save lives and prevent irreversible organ damage with effective medication’.

Through its Strategy 2025, the EMCDDA is committed to contributing to a healthier Europe. While opioids are involved in the vast majority of overdose fatalities, other substances (e.g. cocaine, benzodiazepines, synthetic cannabinoids) also contribute to the overdose burden and should not be neglected. The resources released today contribute to a better understanding of drug overdoses and responses to them in Europe to support sound policymaking in this area.

Notes

1. EU 8: BE, DK, DE, ES, FR, LU, NL, PT.
2. An EMCDDA review of the effectiveness of naloxone delivery found that overdose mortality was reduced through programmes combining naloxone provision with overdose education and first aid training.
3. EU 11: DK, DE, EE, IE, ES, FR, IT, LT, AT, SE, UK.

On this occasion, the United Nations Office on Drugs and Crime and the World Health Organization are promoting their Stop Overdose Safely (S-O-S) initiative. This sets targets to enhance access to opioid overdose prevention in line with WHO guidelines on the community management of opioid overdose.

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