reducing drug-related deaths: london 2014
TRANSCRIPT
Reducing drug related deaths:London 2014
Dr Judith Yates GP BirminghamInternational Doctors for Healthier Drug Policies
IDHDP.comSMMGP website moderator
Reducing drug related death
o National and international drug related deathso Shock of recent rise in death rates in England
o How to reduce risk of drug related death.o How to reduce risk of fatal outcome of OD.
A multi-pronged approach
Drug Related Deaths (until last month):had been falling for last four years, from 2009-2012
Source: Office for National Statistics 2013
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
500
1,000
1,500
2,000
2,500
Drug Misuse related Deaths England and Wales 1993-2012
years 1993-2012
Num
ber o
f dea
ths
Shocking rise in number of deaths registered in 2013 (Office of National Statistics: 2014)
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
200
400
600
800
1000
1200
1400
1600
1800
2000 Number of “drug misuse” Deaths 1993-2013
England
Wales
Scotland
num
ber o
f dru
g re
late
d de
aths
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
50
100
150
200
250
300
350
Number of deaths from "drug misuse" in London
London
num
ber o
f dea
ths
Heroin/Morphine deaths increased by 32% in 2013
Office of National Statistics 2014
2006 2007 2008 2009 2010 2011 2012 20130
100
200
300
400
500
600
700
800
900
1000
heroin and morphine
methadone
tramadol
novel psychoactive substance
num
ber o
f dea
hts.
Preventing accidental opioid overdose deaths in Europe
o 1.3 million users of opioids in Europeo 27 million users of opioids worldwide (0.6% world pop)
o 70,000: deaths in Europe in the first decade of the 21st centuryo 6,100: deaths in Europe 2012o 1,496 deaths in England and Wales 2012
o 250,000 overdose deaths world wide in 2010. WHO This represents 2 million years of life lost.
Preventing opioid overdoses in Europe EMCDDA, Lisbon, October 2012 (revised 2014)
UK = 5th highest rate in EU of deaths/million population.
Mortality due to drug-induced deaths in EU, Croatia, Turkey and Norway(European Monitoring committee for Drugs and Drug Addiction 2013)
Austria
Belgium
Bulgaria
Croati
a
Cypru
s
Czech Rep
ublic
Denmark
Estonia
Finlan
dFra
nce
German
y
Greece
Hungary
Irelan
dIta
lyLat
via
Lithuan
ia
Luxe
mbourgMalt
a
Netherl
ands
Norway
Poland
Portuga
l
Romania
Slova
kia
Slove
niaSp
ain
Swed
en
Turke
y
United Kingd
om (DSD
)0
10
20
30
40
50
60
70
80
90
100
drug
rela
ted
deat
hs p
er m
illio
n po
piul
ation
Number of road traffic accident (RTA) deaths in UK 1926-2012
1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 20200
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Deaths in RTA UK 1920-2012
year
Num
ber o
f dea
ths
https://www.gov.uk/government/collections/road-accidents-and-safety-statistics
Measures to Reduce Road Traffic Accidents (RTAs)
1. Use seat belts. (1983 in UK) 2. Enforcement of speed limits. 3. Prohibition of alcohol in excess of legal use while driving. 4. Prompt medical attention when an RTA occurs. 5. Put speed bumps along intersections. Drivers will be forced to reduce speed
rather than speed up to beat a changing stoplight. Speeding through intersections and running red lights are among the biggest cause of traffic accidents.
6. Zebra crossings should be provided for pedestrians for safe road crossings at appropriate places.
7. Signals for road crossings at important busy places where a large number of people have to cross the road everyday.
8. Road Safety Day/Road Safety Week in schools.
Charlton, R. and Smith, G. (2003), ‘How to reduce the toll of road traffic accidents’, Journal of The Royal Society Of Medicine, 96(10), pp. 475–476
(via Prof Ilana Crome et al EMCDDA: Preventing Opiate Overdose in Europe..October 2012. ) http://www.emcdda.europa.eu/scientific-studies/2012/preventing-overdoses
Reducing Drug Related Deaths:A multi-pronged plan
1. What increases risk?2. What reduces risk?
1.What Increases risk?
1. Lack of appropriate non-coercive Opiate Substitute Treatment (OST)
2. Reduced tolerance after abstinence (prison or planned detox)3. Mixing opiates with other respiratory depressants especially
benzodiazepines and alcohol.4. Availability - heroin - prescribed opiates
(fentanyl/tramadol/oxycodone)5. Criminalisation of drug use leads to risky secretive injecting
habits and danger of OD.6. Not testing for and treating Hepatitis C and HIV7. Poor response to overdose.
Lack of Opiate Substitute Treatment increases risk of overdose:
Mortality rate of people on waiting list for methadone treatment for in Israel, compared to those with immediate treatment access:
o The mortality while on the waiting list was higher: (5.0/100 person years) for the 225 on waiting list
o than for the 358 admitted to treatment: (0.42/100 person years, P < 0.0005)
Peles E1, Schreiber S, Adelson M.Opiate-dependent patients on a waiting list for methadone maintenance treatment are at high risk for mortality until treatment entry. J Addict Med. 2013 May-Jun;7(3):177-82.
Prison release increases risk of OD:o Heroin overdose deaths increase 7 times in the two weeks
after prison release.o Of people who have a history of injecting, 1 in 200 will die in
the first 4 weeks.o The naloxone investigation (N-ALIVE) randomized trial
commenced in the UK in May 2012• preliminary phase 5,600 prisoners on release.• 56,000 prisoners on release, and will give a definitive
conclusion on lives saved in real-world application
Strang J, Bird SM, Parmar Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. MKJ Urban Health. 2013 Oct;90(5):983-96
2. What Reduces Risk?A: Prevent overdoses from happeningB: Reducing fatal outcomes when overdoses do occur. • The first involves a set of interventions geared towards the complete prevention
of overdoses, • while the second focuses on reducing fatal outcomes when overdoses do occur
(Frisher et al., 2012)
A: Prevent overdoses from happeningo Increase access to non-coercive and non-time limited OST.o Properly planned prison and detox discharges. “N-Alive”? “Through the gate”?o Stop criminalising people who use drugs. The sky hasn’t fallen in on Portugal. o Reduce prescribed and illicit availability. “Strict regulation of drug use”. o Increase awareness of risk: information about dangers of mixing respiratory
depressants. o Test and treat for hepatitis C and HIV.
B: What reduces fatal outcome following opiate overdose?
B: Reducing fatal outcomes Amsterdam DCR: 6.10.14 when overdoses occur:
1. Drug consumption rooms
Birmingham DCR: 6.9.14
“a reduction in overdose mortality at population level was documented in the area of Vancouver, where a supervised injecting facility operates” (Marshall et al., 2011)
What reduces risk of fatal overdose?
2. Better response to opiate overdose and wider access to take home naloxone.
Talking about Naloxone: United Nations Commission on Narcotic Drugs
UNODC 2012
Resolution 55/7: “Encourages all Member States …..to share best practices ………..including the use of opioid receptor antagonists such as naloxone”
http://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-7.pdf
Talking about Naloxone: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
“Preventing Overdose Deaths” 2013
o Currently, five European countries (Denmark, Germany, Italy, Romania and the United Kingdom) report the existence of naloxone programmes. Scotland and Wales have recently launched a nationwide programme
o the measure is regarded as a low-cost approach that can empower healthcare workers and people who use drugs to save lives.
http://www.emcdda.europa.eu/topics/pods/preventing-overdose-deaths 2013
Talking about Naloxone: UNODC/WHO 2013: “Opioid overdose - preventing and
reducing opioid overdose mortality”
“Programmes in which naloxone is made available to the community… exist to some extent in more than a dozen countries, including: Afghanistan, Australia, Canada, China, India, Italy, Kazakhstan, Kyrgyzstan, Tajikistan, Thailand, United Kingdom, United States, Ukraine and Viet Nam,although generally on a pilot or experimental basis.”
(Also Denmark, Germany, Romania, Norway and Estonia mentioned in recent EMCDDA report)
Talking about Naloxone: WHO: Commission on Narcotic Drugs, Vienna 2014
Draft “normative guidance” (February 2014) :“People likely to witness opiate overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of opiate overdose”
WHO verbal statement UNCND 2014
Stigma? Approximately 20 people die of anaphylaxis (eg peanut allergy) per year. 10 of them have no previous
history of allergy.o In response to this, “In the year to 30 September 2006,
almost 165,000 prescriptions were dispensed in the community in England for Epipens, at a cost of about £8.2 million"
CHAPTER 4: The Extent and Burden of Allergy in the United Kingdom http://www.publications.parliament.uk/pa/ld200607/ldselect/ldsctech/166/16607.htm
o “Carry two adrenaline auto-injectors with you at all times..” MHRA: Guidance, June 2014
http://www.anaphylaxis.org.uk/userfiles/files/MHRA_AAI_Guidance_June2014.pdf
o Cost around £52 for two epipen kits per year. A naloxone “kit” costs £18 and lasts 3 years. Are “our”
patients worth less?
Conclusions:Four Ways to Save Lives and Also Save Money
Your help is needed:
1. Scatter gun approach to take-home-naloxone. 2. Test and treat for Hepatitis C . Don’t wait for liver failure.
3. Be willing to consider the case for “Safe Consumption Rooms” in the UK.
4. Stop the war on people who use drugs: “Support don’t punish”. An increasingly mainstream opinion.
Join (free) 747 doctors from 78 countries“International Doctors for Healthier Drug Policies” IDHDP.com
A multi-pronged approach