Take-home naloxone as integral part of toolkits for public health providers: priorities across settings Dagmar Hedrich, EMCDDA Lisbon, 25 October 2017 LisbonAddictions2017, Structures Session 25

Drug-induced deaths reported in Europe in 2015 In the EU, someone dies from a drug overdose every 70 minutes ( USA in 2016 = 8 min). Polydrug intoxication is the norm, but background of heroin and other opioids involvement in most cases. E.g. in Finland, the average number of drugs found was 5 Other factors associated with fatal and non-fatal OD: Not being in drug treatment Injecting use Simultaneous use of alcohol, benzodiazepines, other drugs Poor mental health Homelessness Previous overdose Using drugs alone Time immediately after release from prison or discharge from drug treatment (Purity) and availability Provision of harm reduction/treatment services

Overdose deaths are increasing again Trends in overdose deaths 2006-2015 Overdoses: The numbers are likely to be conservative, as national data may be affected by under-reporting or under-ascertainment of drug-induced deaths. Opiods: Opioids, mainly heroin or its metabolites, are present in the majority of drug-induced deaths reported in Europe. In the 23 countries providing data in 2009 or 2010, opioids accounted for the large majority of all cases, with 15 countries reporting proportions of equal to or over 80%, of which six were over 90%. [i] Table DRD-1 part ii. 23 countries are all 30 countries minus BE (because most recent data was 2005) and 6 countries where no toxico data on % of opioid was available: BU, DE, HL, SP, NL, PL [ii] Table DRD-1 part ii 15 countries with >=80%: EE, IE, LU, AT, PT, HR, CY, HU, MT, RO, FI, SE, UK, HR, TR, NO [iii] Table DRD-1 part ii 6 countries with >80%: EE, IE, LU, AT, PT, HR 80% males. Men account for most overdose deaths reported in Europe (80% overall). Patterns differ between countries, with a higher proportion of males reported in southern countries (Greece, Italy, Romania, Portugal, Croatia) and in Estonia, Latvia and Lithuania, as well as in Turkey. In the Member States that joined the EU since 2004, reported drug-induced deaths are also more likely to occur among males and in younger people. Polydrug use for example in Rome’s report - Scotland investigation 97% of the OD cases have several substances,, and in DN more than 3. In Ireland lots with BZD, as well as in NO. The overall picture is of frequent involvment of mixing drugs. Some cultural particularities as well, linked to the availability of the substances (e.g. methadone diverted) and to the culture e.g. Alcohol in Ireland Mortality rates due to overdose.

Population rates of drug-induced deaths show North-South gradient More detailed analyses suggest that this mainly reflects regional differences in problem drug use prevalence.

Increasing average age of drug overdose victims (22-year trend) Increases in drug-induced deaths reported in Europe in 2014 and 2015, by age-band Over these 22 tears, from 1990s til 2012, the mean age of the OD victims has increased from lbeing in the late 20s to the late 30s in many (old EU) pre-2004 countries But deaths not just among the oder users: between 2014 ad 2015, the number of deaths in almost all age bands has increased.

Age pyramids of overdose cases – different country situations and populations at risk: e.g. Germany – Ireland – Estonia – Norway, 2011/12 Gender and age distribution vary between countries. Overall 8 in 10 cases are males - blue An illustration of the various profiles of DUs, e.g. in EE, relatively youger, vast majority injecting, small proportion of women

Context of THN programmes Europe Effective treatment scaled up: >50% POUs in opioid substitution treatment; Ongoing increase of overdose deaths since 2012. Heroin using populations in Europe are ageing and physically vulnerable. Number of deaths increases across most age groups. Synthetic opioids play increasing role. more than 7500 overdoses in 2015 in the EU; after decrease, a newly increasing trend since 2012; drug-related mortality 1-2%; Interventions directed at: reducing vulnerability;

Interventions to reduce the risk of opioid-related deaths reducing the risk of overdoses to occur; and reducing mortality of overdoses

Interventions in place in European countries that can reduce opioid-related deaths

Scaling up of TH-Naloxone: snapshot TH-NLX in 10 countries: DK, EE, DE, FR, IE, IT, ES, (LT), NO, UK. INSERT FIGURE TIMELINE HERE

Performance … and lots of diversity 53.000 doses/kits given out; Scotland 55%, Wales 20% 20.000 people trained*, of which 6.000 last year *except Italy, Berlin, Scotland Local”fit”: large variation in the characteristics of programmes

Barriers for THN coverage Legal/regulatory barriers prescription-only use limited to medically trained personnel handling & storage restricted Formulation Injectable (IV, IM, SC) use of syringe an obstacle? ‘off-label’ IN use in some THN projects Nasal spray/applicator now developed but not yet available in most EU countries

Challenges A main challenge for take-home naloxone programmes is to achieve sufficient coverage of the at risk populations so that substantial reductions in opioid overdose deaths can be attained. Intranasal (injection-free) formulations are entering the market may facilitate paradigmatic shifts: (less need for training, less risk of injury, etc), removal of prescription requirement (e.g. Canada)….

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