1. 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

2. Funding and Conflicts of Interest
Euro-DEN and Euro-DEN Plus :
Financial support from the EU DPIP/ISEC Programme :
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)

3. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. Euro-DEN Plus
31 sentinel
centres in
20 countries

14. 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 years
Median (IQR) age 31 (24-39) years
Mode: 25y
66.3% aged 20-39y

16. 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%

18. ‘Top 20’ most comonly reported drugs
2.7%

19. 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%

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

21. New Psychoactive Substances (NPS)

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

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

24. Most commonly reported opioids
no hydrocodone or hydromorphone

25. Most commonly reported benzodiazepines/Z drugs

26. 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

27. 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

28. ‘Top 20’ drugs in the prescription medicine only presentations

29. Three year cohort: Clinical Features

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

31. 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

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

33. 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