In Europe, drug overdose continues to be the leading cause of death among people who use drugs (PUD) . In 2014, it was estimated that overdose caused 18.3 deaths per million population aged 15-64, and rates of more than 40 deaths per million were reported in eight European countries1 . Overdose accounts for more than 3.5% of overall deaths in males under 40 years of age, with 78% of overdose victims being male [2, 3]. Older opioid users were shown to be particularly vulnerable, although a recent slight increase in drug-induced deaths among users aged under 25 has been reported in some countries .
In spite of a promising European trend between 2009 and 2013 – when reported overdose deaths declined, thanks to the scaling-up of treatment and harm reduction interventions – the 2016 analysis showed a rise in drug-induced deaths related to heroin and other opioids . This is of particular concern in the most recent data from countries with fairly robust reporting systems (Germany, Sweden and the UK). Moreover, synthetic opioids and medical purposed drugs are acquiring a substantial role in overdose deaths in some European countries (e.g. UK, France, Ireland, Finland), with fentanyl, methadone, buprenorphine and tramadol being more frequently mentioned in toxicology reports .
This brief snapshot suggests new challenges in the realm of ‘old’ problems. The increasing complexity of Europe’s drugs situation is now challenging practioners, policy makers and researchers to formulate effective responses for the mitigation of these avoidable deaths.
The Euro HRN Project II – Overdose prevention in Europe: collating lifesaving practices
As a contribution to this challenge, the European Harm Reduction Network developed a project2 with the general purpose of identifying and sharing best practice in overdose prevention. APDES (Portugal) and Akzept (Germany) contributed to the project by providing an overview of existing programmes and devices for reducing drug-induced deaths in Europe; by conducting a review of the effectiveness of measures for preventing opioid overdoses and identifying constraints on the most promising measures; and by formulating recommendations for the prevention of opioid overdose, regarding research, policy, and practice.
On this year’s International Overdose Awareness Day, under the slogan, ‘Time to remember. Time to act’, we describe some of the gaps in overdose prevention strategies revealed during the project, as well as a selection of 10 recommendations designed to overcome them. For the complete work please click here.
1. Nationally-adapted guidelines for the development and strengthening of overdose prevention interventions should be created, under the concerted responsibility of policy-makers, researchers, practioners and people who use drugs. In Europe, only a small number of countries have guidelines for overdose prevention.
2. Drug prevention policies should include socio-economic dimensions, such as resources developed to decrease economic inequalities, poverty and unemployment rates. Poverty status appears to predict 69% of the variance in drug overdose mortality rates .
3. It is vital to promote access to drug treatment through multiple entry-points, as well as a timely response to those requesting treatment, in order to prevent drop-outs. Each day of opioid substitution treatment was associated with a reduction of 1% (in a one year period) in overdose risk .
4. Governments need to seriously discuss the implementation of Drug Consumption Rooms (DCRs) with a multi-disciplinary team holding training in overdose prevention and appropriate emergency equipment (e.g. oxygen tanks, naloxone). DCRs must adopt a pragmatic harm reduction approach, by providing access to all persons who use drugs (e.g. OST clients, poly-consumption users).
5. It is crucial that the professionals who work in drug services, as well as other professionals who have close contact with PUD (e.g. pharmacists, prison staff, police officers, and emergency staff) receive training in overdose prevention, recognition and response.
6. It is necessary to extend the provision and regularity of individual overdose risk-assessment with PUD. Almost half of European countries don’t have, or have rare to limited coverage of overdose risk assessment, while PUD tend to be greatly unaware of, or underestimate, their overdose risk.
7. There is an urgent need to scale up the provision of training programs on overdose prevention and response for people who use drugs (giving priority to those with a history of previous overdoses) and their families/social network. Current encouraging evidence on take-home naloxone programs must also be considered in training offers.
8. Emergency services must be adequately prepared to deal with overdoses, and ‘opportunistic interventions’ need to be extended: deliver overdose information, promote links to health services, and schedule a subsequent heath check-up to screen for morbidities.
9. It is necessary to refine record systems on drug-related deaths across Europe, by improving the standardisation of data collection and report procedures. This should allow an improved and timely surveillance of the phenomena, in order to provide inputs for drug prevention strategies as well as to conduct reliable inter-country comparisons.
10. The gap frequently found between drug policy design and implementation should be reduced through continuing investment and funding and via systematic assessment of interventions.
Fluctuations in the levels of fatal and non-fatal overdoses are a result of multiple factors, ranging from the individual to the broader environmental context. Thus, the demand for an effective overdose prevention strategy requires a multi-level approach.
 United Nations Office on Drugs and Crime (UNODC) (2013). Opioid overdose: preventing and reducing opioid overdose mortality. Discussion paper UNODC/WHO 2013. Vienna: UNODC. Retrieved from http://www.unodc.org/docs/treatment/overdose.pdf
 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2016). Annual report 2016: The state of the drugs problem in Europe. Luxembourg: Publications Office of the European Union.
 Data retrieved from:http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Causes_of_death_statistics#Further_Eurostat_information
 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2015). Annual report 2015: The state of the drugs problem in Europe. Luxembourg: Publications Office of the European Union.
 Marzuk, P. M., Tardiff, K., Leon, A. C., Hirsch, C. S., Stajic, M., Portera, L., & Hartwell, N. (1997). Poverty and fatal accidental drug overdoses of cocaine and opiates in New York City: An ecological study. American Journal of Drug Alcohol and Abuse, 23(2), 221–228. doi:10.3109/00952999709040943
 Darke, S., Williamson, A., Ross, J., & Teesson, M. (2005). Non-fatal heroin overdose, treatment exposure and client characteristics: Findings from the Australian treatment outcome study (ATOS). Drug and Alcohol Review, 24(5), 425–432. doi:10.1080/09595230500286005.
By the APDES Research Department