The document discusses reducing drug-related deaths through a multi-pronged approach. It identifies factors that increase the risk of overdose such as a lack of treatment and reduced drug tolerance. It also outlines measures that can reduce the risk of overdose like increasing access to opioid substitution treatment, planning for prison releases, and wider access to naloxone to reverse overdoses. The document advocates for a comprehensive strategy involving both preventing overdoses and reducing fatal outcomes when they occur.

1. Reducing drug related deaths:
London 2014
Dr Judith Yates GP Birmingham
International Doctors for Healthier Drug
Policies
IDHDP.com
SMMGP website moderator
@judithyates1
dryates@btinternet.com

2. Reducing drug related death
o National and international drug related deaths
o 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

3. Drug Related Deaths (until last month):
had been falling for last four years, from 2009-2012
Drug Misuse related Deaths England and Wales 1993-
2012
Source: Office for National Statistics 2013
2,500
2,000
1,500
1,000
500
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number of deaths
years 1993-2012

4. Shocking rise in number of deaths registered in 2013
(Office of National Statistics: 2014)
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
number of drug related deaths
Number of “drug misuse” Deaths 1993-2013
England
Wales
Scotland
350
300
250
200
150
100
50
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
number of deaths
Number of deaths from "drug misuse" in London
London

5. Heroin/Morphine deaths increased by
32% in 2013
Office of National Statistics 2014
1000
900
800
700
600
500
400
300
200
100
0
2006 2007 2008 2009 2010 2011 2012 2013
number of deahts.
heroin and morphine
methadone
tramadol
novel psychoactive
substance

6. Preventing accidental opioid overdose deaths
in Europe
o 1.3 million users of opioids in Europe
o 27 million users of opioids worldwide (0.6% world pop)
o 70,000: deaths in Europe in the first decade of the 21st century
o 6,100: deaths in Europe 2012
o 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)

8. 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)
100
90
80
70
60
50
40
30
20
10
0
drug related deaths per million popiulation

10. Number of road traffic accident
(RTA) deaths in UK 1926-2012
10,000
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Deaths in RTA UK 1920-2012
1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Number of deaths
year
https://www.gov.uk/government/collections/road-accidents-and-safety-statistics

11. 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

12. Reducing Drug Related Deaths:
A multi-pronged plan
1. What increases risk?
2. What reduces risk?

13. 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 HIV
7. Poor response to overdose
.

14. 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.

15. 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

16. 2. What Reduces Risk?
A: Prevent overdoses from happening
B: 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 happening
o 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.

17. 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)

19. What reduces risk of fatal overdose?
2. Better response to opiate overdose
and wider access to take home naloxone.

21. 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

22. 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

23. 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)

24. 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

25. 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?

26. 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

27. A multi-pronged approach