The Euro-Drug Emergencies Network (Euro-DEN) ED presentations with acute toxicity related to the misuse of prescription medicines 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 2013-15: Financial support from EU DPIP/ISEC Programme 2015-date: Support from EMCDDA Prescription Medcine Misuse RADARS funding Research grants from RADARS for prescription medicine misuse web monitoring and internet surveys; honoraria and expenses to present at RADARS scientific meetings Personal Member: EMCDDA Scientific Committee, GSK Global Analgesics Panel, UK Advisory Council on the Misuse of Drugs (ACMD) Advisor: World Health Organisation (WHO), US Food and Drug Administration (FDA) and United Nations Office on Drugs and Crime (UNODC)

Hospital Coding Systems Hospital admissions (discharges) coded using ICD-10 ICD-10 is reliable for routine medical / surgical conditions Previous studies of acute illicit drug / NPS toxicity Cases coded by clinical feature(s) and the drug(s) are often not included in the code Only admitted cases coded: 70+% discharged from ED Overall ~ 10-20% identifiable drug-related code Pilot data from our group confirms this is also the case for prescription medicine misuse presentations to the ED Therefore not possible to automate data collection on acute prescription medicine toxicity presentations

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

Sentinel centre model Collect data on ED presentations with acute toxicity related to the use of illicit drugs/NPS and/or misuse of prescription/OTC medicines Specialist centres with an interest in emergency medicine and clinical toxicology Lead centre: London; steering group: EMCDDA, Mallorca, Oslo

Definition of a Euro-DEN case: “An individual who presents to the sentinel centre acute care facility with clinical features consistent with acute recreational drug toxicity and/or directly related to recreational drug use” Recreational drug definition "A psychoactive compound that was taken for the purpose of recreational activities rather than for medical or work purposes or as part of (deliberate) self-harm” “Misuse of prescription and over the counter (OTC) medicines for recreational purposes” [hereafter called prescription medicine]

Euro-DEN Methods All ED presentations to the sentinel centre with acute illicit drug / NPS / prescription medicine misuse toxicity drug(s) involved: patient self-report Exclusions lone alcohol toxicity cases not related to acute toxicity e.g. trauma, infection, self-harm Euro-DEN minimum dataset (60 parameters) collected from routine 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

31 sentinel centres in 20 countries Euro-DEN Plus 31 sentinel centres in 20 countries 2014 – 2016: 16,033 presentations

The Euro-Drug Emergencies Network (Euro-DEN) ED presentations with acute toxicity related to the misuse of prescription medicines 2 year Euro-DEN Plus dataset: Oct 2013-Sept 2015 Data from the 16 original sentinel centres 10,956 presentations involving 16,986 drugs

10,956 presentations involving 16,986 drugs 2 year Euro-DEN Plus dataset: Oct 2013-Sept 2015 Data from the 16 original sentinel centres 10,956 presentations involving 16,986 drugs

‘Top 20’ most commonly reported drugs Classical, illicit drugs Prescription medicines NPS

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

Prescription medicine only cases 68.7% male, 31.3% female Median (IQR) age 37 (28-46) years Mode: 32 years All Euro-DEN cases 76.0% male, 24.0% female Median (IQR) age 31 (24-39) years Mode: 25 years

Outcome Disposition from the ED Length of Stay 9 (0.6%) fatalities 53.0% medical discharged, 16.9% self-discharge from ED 16.7% medical, 8.6% critical care, 4.3% psychiatry admission Length of Stay Median (IQR) 6h 09m (3h 21m-14h 51m) <12h: 70.0%, <24h: 86.3% 9 (0.6%) fatalities 3 methadone 1 oxazepam, zolpidem, baclofen, ethanol 2 fentanyl 1 no analytical data (history: benzodiazepine, ethanol) 1 buprenorphine, fentanyl, diazepam 1 morphine, codeine, ethanol

Conclusions Euro-DEN Plus: Unique insight into acute illicit drug, NPS, prescription medicine misuse toxicity presentations in Europe Over ¼ of acute recreational drug toxicity ED presentations involve misuse of a prescription medicine 13% involve only a prescription medicine Geographical variation Benzodiazepines and opioids are most common Different pattern of opioids to North America Triangulation with other datasets: greater understanding of the phenomenon and inform prevention strategies

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