Professor Paul I Dargan The European Drug Emergencies Network Euro-DEN Plus A model for data collection on acute drug and NPS toxicity in Europe Professor Paul I Dargan Guy’s and St Thomas’ NHS Foundation Trust and King’s College London London, UK

Funding and Conflicts of Interest Euro-DEN and Euro-DEN Plus 2013-2015: Financial support from the EU DPIP/ISEC Programme 2015-2017: Support from EMCDDA since August 2015 Personal Member EMCDDA Scientific Committee GSK Global Analgesics Panel UK Advisory Council on the Misuse of Drugs Advisor to US Food and Drug Administration (FDA) World Health Organisation (WHO) United Nations Office on Drugs and Crime (UNODC)

Acute Drug/NPS Toxicity Data Systematic data is available and reported on a number of key indicators Prevalence of drug use Drug seizures Problematic drug use Drug-related deaths No systematic data reported on acute drug or NPS toxicity Despite this being a key public health indicator on the impact of drug/NPS use

Acute Drug/NPS Toxicity Data What data is currently collected? Euro-DEN Survey 2014: REITOX National Focal Points

Why is systematic data on acute drug toxicity not available? 12/36 countries: national data on classical drugs 10/36 countries: national data on NPS Why is systematic data on acute drug toxicity not available? BUT: Limited dataset No consistency

Hospital Coding of Acute Drug Toxicity Hospital admissions (discharges) coded using ICD-10 ICD-10 reliable for routine medical/surgical conditions ICD-10 codes: not available for most drugs No: amphetamine, MDMA, ketamine … definitely not NPS Yes: heroin, cocaine, LSD BUT Cases often coded by predominant clinical feature Only admitted patients coded: 60+% discharged from ED Overall only 10-20% of acute drug toxicity cases receive an appropriate ICD-10 code Therefore not possible to automate data collection on acute drug / NPS toxicity

Triangulation with other potential data sources: Part of the jigsaw puzzle to fill the significant public health data gap in our knowledge of acute drug toxicity in Europe Triangulation with other potential data sources: In vitro and animal studies Population/subpopulation surveys, user forums Poisons centres Case reports/series; ambulance service data NPS

Sentinel centre model to collect data on ED presentations with acute recreational drug and NPS toxicity Specialist centres with an interest in emergency medicine and clinical toxicology Lead centre: London, steering group: EMCDDA, Oslo, Mallorca

Euro-DEN Methods All ED presentations with acute drug toxicity clinical features consistent with acute drug / NPS toxicity or toxicity related to prescription medicine misuse drug(s) involved: patient self-report, clinical interpretation Exclusions lone alcohol toxicity cases not related to acute drug toxicity e.g. trauma, infection, self-harm Euro-DEN minimum dataset (60 parameters) collected from clinical records entered onto Excel spreadsheet and data returned to London for collation

Euro-DEN: Year 1 Oct 2013 – Sept 2014 16 sentinel centres in 10 countries 5529 presentations

Euro-DEN Plus 31 sentinel centres in 20 countries

Euro-DEN Plus: 3yr dataset 2014 to 2016 16,033 presentations to the Euro-DEN Plus centres Up to 3.2% of presentations to the ED 70.1% of presentations brought to the ED by ambulance 76.4% male Age range 11-90 years Median (IQR) age 31 (24-39) years Mode: 25y 66.3% aged 20-39y

Polydrug and ethanol use 24,538 drugs (excl ethanol) used in the 16,033 presentations Mean±SD: 1.5±0.8 drugs (excl ethanol) per presentation Ethanol use Not recorded in 30.9%; Yes 41.5%, No 27.6%

‘Top 20’ most comonly reported drugs 2.7%

New Psychoactive Substances (NPS) 1,753 NPS in Euro-DEN Plus presentations Over 120 different NPS Over the 3 year period: 7.1% of drugs were NPS 2014: 6.3% 2015: 8.4% 2016: 6.8%

New Psychoactive Substances (NPS) 73.2% of the cathinones were mephedrone

New Psychoactive Substances (NPS)

New Psychoactive Substances (NPS) 7 centres >20% cases involved one or more NPS 9 centres <2% cases involved one or more NPS

Prescription Medicines Subset analysis of 2 years Oct 2013-Sept 2015 10,956 presentations involving 16,986 drugs

Most commonly reported opioids no hydrocodone or hydromorphone

Most commonly reported benzodiazepines/Z drugs

Prescription medicine presentations 3,139 (28.6%) presentations included at least one prescription medicine 1,426 (45.4%) of the prescription medicine presentations involved only prescription medicine(s) 13.0% of all Euro-DEN Plus presentations involved only a prescription medicine significant geographical variation

Overall: 13.0% prescription medicine only cases Prescription medicine only presentations % of total presentations to Euro-DEN Plus centres Overall: 13.0% prescription medicine only cases 4 centres >20% prescription medicine only cases 5 centres <5% prescription medicine only cases

‘Top 20’ drugs in the prescription medicine only presentations

Three year cohort: Clinical Features

Analytical Screening Management Undertaken in 18.4% 51.9% required some intervention This included: Sedation: 20.6% Naloxone: 16.5% Intubation: 5.3%

67 (0.42%) fatal cases Most commonly opioids (33), stimulants (26), NPS (9) Of the NPS cases all involved cathinones: 2 lone NPS, 7 involved ≥1 other illicit drug

Median (IQR): 4h 41m (2h 31m – 9h 45m) 71.7% <12 hours; 81.6% <24 hours

Holy grail - key indicator on acute drug/NPS toxicity Conclusions Limited systematic data on acute drug and NPS toxicity Hospital coding systems don’t allow national data collection Euro-DEN Plus: Unique insight acute drug and NPS toxicity in Europe 31 centres in 20 countries with continued recruitment Outputs with scientific and policy relevance Limited by patient self-report but size of dataset and triangulation with complimentary datasets will increase public health relevance and fill this significant data gap Holy grail - key indicator on acute drug/NPS toxicity