1. Drug-induced deaths in Europe: enhanced analysis of numbers, trends and contexts to identify possible artefacts and gain better insights into epidemiology and responses Information for action
Isabelle Giraudon
Tim Millar, Andrew Mac Auley, Hakan Leifman, Kathleen England
EMCDDA: Julian Vicente, Dagmar Hedrich, Eleni Kalamara, André Noor, Roland Simon, Paul Griffiths
Assessment of the drug-induced deaths data. DRD expert meeting 28/ sept Lisbon

2. Background – rationale
Key indicator DRD drug related deaths
30 countries
2 components : overdose and overall mortality
Monitoring based on the European protocol
General mortality register
Special mortality registers
Various systems in place
Suggested notes on the point “Various systems in place”
Some countries rely on GMR only for their reporting to EMCDDA
Others on SR only
2/3 countries provide data from 2 sources –
Some delays
Some different workflows between GMR and SR
Different coverage of autopsies and toxicology examination
Different coverages of the SR

3. Background – rationale
OD mortality rates vary in level and trends
Real differences (due to population at risk, level of risk, drugs used, provision of care, prevention, harm reduction and treatment offer/access…)
and/or
influenced by changes in methodology? data quality, data completeness? (assessment, coding, reporting)?
High/Increasing OD deaths rates in Sweden, England, Scotland, Ireland, Norway, … and may others in
what are the contexts and possible triggers?

4. Two work streams: objectives
1 - Clarify the coding of national data extracted from the GMRs, based on selected ICD codes defined in the EMCDDA protocol
2 – Analyse high and or increasing drug-induced deaths mortality in some countries  - artefacts if any, contexts, triggers and implications?

5. Objectives of Work stream 1
1 - Clarify the coding of national data extracted from the GMRs, based on selected ICD codes defined in the EMCDDA protocol
Describe the coding of the reported cases in a selected number of countries: FR, SP, IT, PL, UK (Eng.), NO, DE, BU, DK, RO
describe the changes in coding practices
where possible review the DRD datasets and also map (update) the flow of information between GMR and SR
Title of slide: Objectives Work stream 1
1) Comparability of the national data extracted from the GMRs, based on selected set of ICD codes as defined in the European protocol   You remember that this was discussed in previous DRD expert meetings, and then analysed with your help, with initial findings presented by Kathleen England (DRD national expert for Malta) and myself in Sept 2015 (see link to the conference above). We have now contracted Kathleen England to conduct a more in depth analysis of the recent data, and of the coding practices, and to help us to think of the way forward. We suggest focussing on some countries where there have been acknowledged problems, and or concerns raised about GMR data completeness or comparability - so far we think of FR, SP, IT, PL, UK (England), NO, DE, BU, DK, RO. I have been in touch bilaterally with some of you, but Kathleen will approach the concerned DRD experts and focal points to let them know what we suggest doing. For the concerned countries, we would like to invite national experts to a technical meeting on 28 Sept in Lisbon (back to back with the normal DRD meeting).
Source figure. Giraudon, England, Presented at the 2015 EMCDDA DRD annual expert meeting available from

6. Work stream 1 – steps
Technical meeting on 28/09 in Lisbon - back to back with DRD regular experts meeting to consult the national experts for discussion of the results - Questions to explore: does the DRD protocol need to change? How? E.g. to better approach monitoring of stimulants and of NPS related deaths, implication(s) and timaeframe for ICD11 Contracted expert: Dr Kathleen England (DRD expert for Malta)

7. Aims of project
1 - Reviewing coding practices and trends in DRDs in countries following the WHO ICD-10 updates 2- Reviewing of the Inventory of the national Special Mortality Registries in Europe with a focus on information flow to the General Mortality Registries (based on responses to a questionnaire to all MS) 3- Identifying examples of good practice and collaboration between the GMR and SR

8. Aims of Project
- 1 – Analyse data on DRDs in a subset of countries to evaluate the use of specific codes such as X44/X64/Y14 codes, non specific codes and the use or non use of T codes (data received so far from Bulgaria, France, Denmark, Italy, Norway, Poland, Spain, United Kingdom).

9. Workshop on the 28th of September 2016
The workshop aims to facilitate discussion around better application of the European DRD protocol to improve harmonisation and comparability across Europe and to share and discuss good national examples
Workshop 1: Data flow between SR and GMR
Workshop 2: The impact of the ICD-10 updates on reporting of DRDs
Workshop 3: Consistency and trends of data between sources

10. Objectives WS 2
2 – Analyse high and or increasing drug-induced deaths mortality in some countries  - artefacts if any, contexts, triggers and implications?
Focusing on Northern countries mainly: DK, EE, FI, IE, NO, UK (Scotland) and SE
Analyse further the data reported (i.e. EMCDDA ‘Fonte’ data, ‘Harm and Harm reduction workbooks’, but also market/seizures, treatment data... and literature (cohorts where available)
Title: Objectives Work stream 2
2) Issue of high and or increasing drug-induced deaths mortality in some countries  - contexts, triggers and implications? For this complementary work stream, we suggest focusing on Northern countries mainly (considering DK, EE, FI, IE, NO, UK (Scotland) and SE). We have contracted and will work with experts from Sweden (Hakan Leifman), England (Tim Millar) and Scotland (Andrew McAuley). This piece of work will be based mainly on analysing further the data already reported (i.e from Fonte, the Harm and Harm reduction workbooks, but also market/seizures, treatment data... as well as literature (namely mortality cohorts where available). We suggest contacting the concerned national experts for telephone structured interviews (with Andrew McAuley). This aims to share with national experts the analysis done so far, and to ask for more insights and clarifications if necessary. Andrew McAuley will be in touch with the concerned countries in April to suggest and plan these telephone conversations. We would like to invite the concerned nominated experts (2 per countries) to attend a technical meeting on 13 September in Stockholm (Sweden). Hakan Leiman will prepare this meeting and contact you in the coming weeks to this effect.

11. Steps - Work stream 2
Summary and analysis of the available national data
Structured telephone interviews with the concerned national experts for clarifications and further insights and context
Technical meeting on 13/09 in Stockholm with for each country, as possible, 1 GMR and 1 SR expert
Contracted experts : Andrew Mac Auley (Scotland, UK), Tim Millar (England, UK), Hakan Leifman (Sweden)

12. Outcomes and expected impact
Feed-back and discussion of results with the 30 national experts on September 2016, Lisbon DRD meeting
Reports from both work streams and further outputs tbd with the working group
Depending of the findings:
Revise the protocol, training?…
Share good practices in recording, registering and analyzing DRD data?
Ultimately: with the experts, critically analyze the national situations, better understand artefacts if any, triggers and dynamics of OD deaths, and contribute to inform prevention and harm reduction needs
Improve the utility and use of the data – contribute to improve practices

13. Acknowledgments
To the REITOX national focal points and their national DRD experts
To the experts contracted for these projects: Kathleen England (DRD expert for Malta); Andrew Mac Auley (Scotland, UK); Tim Millar (England, UK); and Hakan Leifman (Sweden)
Resources:
The current DRD protocol
The 2015 annual expert meeting
The 2016 annual expert meeting
Contact

14. EDR 2016
DRD expert meeting sept 2016

15.
Thank you!