Isabelle Giraudon

Acute recreational drug and new psychoactive substance toxicity in Europe: 12 months data collection from the European Drug Emergencies Network (Euro-DEN).

Context. Despite the potential for recreational drugs and new psychoactive substances (NPSs) to cause significant morbidity and mortality, there is limited collection of systematic data on acute drug/NPS toxicity in Europe. Objective. To report data on acute drug/NPS toxicity collected by a network of sentinel centres across Europe with a specialist clinical and research interest in the acute toxicity of recreational drugs and NPS to address this knowledge gap. Methods. Sixteen sentinel centres in 10 European countries (Denmark, Estonia, France, Germany, Ireland, Norway, Poland, Spain, Switzerland and the UK) collected data on all acute drug toxicity presentations to their Emergency Rooms (ERs) for 12 months (October 2013–September 2014); information on the drug(s) involved in the presentations was on the basis of patient self-reporting. Results. Data were collected on a total of 5529 presentations involving 8709 drugs (median (interquartile range [IQR]): 1 (1–2) drugs per presentation), a median of 0.3% of all ER attendances. Classical recreational drugs were most common (64.6%) followed by prescription drugs (26.5%) and NPS (5.6%). The ‘top five’ drugs recorded were heroin (1345 reports), cocaine (957), cannabis (904), GHB/GBL (711) and amphetamine (593). 69.5% of individuals went to hospital by ambulance (peak time between 19:00 and 02:00 at weekends); the median (IQR) age was 31 (24–39) years and 75.4% were male. Although serious clinical features were not seen in most presentations and 56.9% were medically discharged from the ER (median length of stay: 4.6 hours), a significant number (26.5%) was agitated, in 10.5% the GCS was 8 or less and 35 presented in cardiac arrest. There were 27 fatalities with opioids implicated in 13. Conclusion. The Euro-DEN dataset provides a unique insight into the drugs involved in and clinical pattern of toxicity/outcome of acute recreational drug toxicity presentations to hospitals around Europe. This is complimentary to other indicators of drug-related harm and helps to build a fuller picture of the public health implications of drug use in Europe.

Prescription opioid abuse in the UK.

The United States (US) is considered the center of prescription drug abuse. Since drug abuse is a worldwide phenomenon, it would be valuable to determine if the trend of increasing prescription opioid misuse and abuse seen in the US is developing in the United Kingdom (UK). To compare trends in deaths associated with prescription opioid drugs, mortality data was obtained online for England, Wales, and Scotland from the Office for National Statistics and the General Register Office and for the US from The National Vital Statistics System (NVSS). Mortality trends in the US show a relentless increase of deaths from unintentional drug poisoning with opioid analgesics in the last decade. In 2010, the number of deaths related to opioid analgesics was over 16,500, more than double the number of 2002 and more than twice the number of deaths from heroin and cocaine deaths combined [1]. Although the number of deaths related to drug poisoning reviewed from England and Wales is not as high as the US, the overall trends are remarkably similar (Figure 1). The prominent role of methadone in UK opioid deaths also is striking. In Scotland, methadone-related deaths increased from 71 in 2001 to 275 in 2011 [2] and they currently represent over half of all reported opioid deaths. However, this should be viewed in the context of a considerable increase in the availability of opioid substitution treatment in the UK [3]. In the US, most cases relate to opioid analgesics, and the number of oxycodone deaths slightly exceeds the number of methadone deaths. Tramadol presents interesting data in the UK: in 1996, England and Wales reported one death with the drug mentioned, but by 2011 there were 154 deaths [4]. In Scotland, tramadol-related deaths increased from 8 in 2001 to 34 deaths in 2011 [2]. The increase in tramadol-related deaths may reflect a rise in tramadol prescriptions, therefore availability, but also points to the need to monitor closely any increase in deaths caused by opioid analgesics as it may signal an emerging problem in the UK similar to the issue that is now well-established in the US. Language: en

The European Drug Emergencies Network (Euro-DEN)

1Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK 2King’s College London, London, UK 3Department of Acute Medicine, The National NBC Centre, Oslo University Hospital, Ullevaal, Oslo, Norway 4Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain 5Action on New Drugs and Epidemiology Units, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal

Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations

Abstract Background. The number of new (novel) psychoactive substances (NPS) available in the illegal market is increasing; however, current monitoring of the drug situation in Europe focuses mainly on classical drugs of abuse, with limited emphasis on clinical presentation in the emergency department (ED). The European Drug Emergencies Network (Euro-DEN) is a European Commission-funded project that aims to improve the knowledge of acute drug toxicity of both classical recreational drugs and NPS. As a baseline for this project, we performed a study to establish which data are currently being collected and reported in Europe on ED presentations with acute toxicity related to NPS and classical drugs of abuse. Methods. We used a three-pronged approach to identify any systematic collection of data on NPS toxicity in Europe by i) performing a literature search, ii) utilising an online survey of the European Monitoring Centre for Drugs and Drug Addiction Re seau Europe en d’Information sur les Drogues et les Toxicomanies national focal points and iii) exploiting the knowledge and resources of the Euro-DEN network members. Results. The literature search revealed 21 papers appropriate for assessment, but only one described a systematic collection of clinical data on NPS. Twenty-seven of thirty countries responded to the online survey. More than half of all the countries (52%) did not perform any registration at all of such data, 37% collected systematic clinical data on NPS at a national level, while 44% collected data on classical drugs. A few examples for good practice of systematic collection of clinical data on ED presentations due to acute toxicity were identified. Conclusion. The systematic collection of data on ED presentation of toxicity related to NPS and classical drugs in Europe is scarce; the existing collection is limited to single centres, single countries, groups of patients or not focused on novel drugs; the collection of data is highly variable between the different countries. Euro-DEN, a European Commission funded project, aims at closing some of these gaps.

Cocaine-Related Health Emergencies in Europe : A Review of Sources of Information, Trends and Implications for Service Development.

Background: Cocaine-related health consequences are difficult to observe. Data on drug users in health-emergency settings may be a useful source of information on consequences that are not visible via other information sources. Methods: Thirty European countries submit an annual national report on the drug situation to the EMCDDA. All reports for the period 2007–2010 were analyzed, with particular attention given to auditing cocaine-related mentions. Analysis was also performed in order to identify sources and case definitions, assess coverage, audit cases and, where possible, to identify long-term trends. Results: Considerable heterogeneity existed between countries in their approach to recording drug-related emergencies, with only Spain and the Netherlands having established formal indicators. The highest annual numbers of cocaine-related episodes were reported by the UK (3,502), Spain (2,845) and the Netherlands (1,211). A considerable (2- to 3-fold) increase in the numbers of cocaine-related episodes has been reported since the end of the 1990s in these countries; these increases peaked in Spain and England around 2007/08. Conclusions: The analysis reported here suggests the need to develop more standardized approaches to monitoring drug-related emergencies. It points to the potential value of developing effective referral links between the emergency and specialized drug services working with cocaine users.

New psychoactive substances: Current health-related practices and challenges in responding to use and harms in Europe

BACKGROUND The availability of new psychoactive substances (NPS) in Europe has rapidly increased over the last decade. Although prevalence levels of NPS use remain low in the general European population, there are serious concerns associated with more problematic forms of use and harms in particular populations and settings. It has thus become a priority to formulate and implement effective public health responses. However, considerable knowledge gaps remain on current practices as well as on the challenges and needs of European health professionals who are responding to use and harms caused by these substances. The aim of this study was to explore current health responses to NPS, and highlight key issues in order to inform planning and implementation of adequate responses. METHODS This scoping study was based on a targeted multi-source data collection exercise focusing on the provision of health and drug interventions associated with NPS use and harms, in selected intervention settings across Europe. RESULTS Findings revealed that in the absence of specific evidence, health professionals across most intervention settings rely primarily on acquired expertise with traditional drugs when addressing NPS-related harms. This study also identified a gap in the availability and access to timely and reliable information on NPS to users and health professionals. Health professionals in sexual health settings and custodial settings in contact with certain risk groups reported particular challenges in responding to NPS-related harms. CONCLUSION Immediate investments are required in expanding substance identification capabilities, competence building among professionals and dissemination of risk information among relevant stakeholders. The risks of neglecting under-served risk populations and failure to address the information needs of health professionals and users on NPS harms in a context of rapid changing drug markets in Europe may have unforeseeable consequences at societal level.

Roundtable discussion: how lessons learned from HIV can inform the global response to viral hepatitis

IntroductionBy Jeffrey V Lazarus.In the last few years, as viral hepatitis has become amore prominent issue on national and internationalhealth agendas, talk of“learning from HIV” has becomequite common. It is understandable for researchers, pol-icy-makers and activists to make this link, given the nota-ble commonalities between HIV, hepatitis B and hepatitisC. All are life-threatening blood-borne viruses that affecthundreds of millions of people worldwide. All can remainasymptomatic for many years, making it difficult to pro-mote awareness of their danger. Ignorance about all ofthe major forms of viral hepatitis, particularly B and C,understandably reminds many people who are workingto confront this issue of the early years of the AIDS epi-demic, when a combination of misinformation andunwillingness to candidly address stigmatised behavioursand social inequalities led to a widespread failure to for-mulate a cohesive public health response.Other parallels might be elucidated, and there is cer-tainly good reason to think of the global HIV, hepatitisB and hepatitis C epidemics as having similar trajectoriesin some regards. Nonetheless, the differences betweenHIV and viral hepatitis– in terms of how these varieddiseases manifest both biologically and socially– shouldmake us wary of oversimplifying the connection.As discussions about hepatitis policies and strategiesgain momentum at the national and global level, it isbecoming increasingly important to articulate the“lessons learned” from the HIV field. Pertinent issuesinclude disease preventionmeasures, testing and earlydiagnosis, the scale-up of treatment, and barriers to ser-vice uptake and retention in care. Key social and politicalfactors associated with viral hepatitis call to mind otherpossible lessons relating to the value of civil societyengagement, leadership and governance issues, resourcemobilization including innovative financing, the causesand consequences of stigma, and the role of socialscience in addressing health threats.This is clearly a rich and important realm of inquiry–and it is time to move beyond the general calls to learnfrom HIV and begin to systematically formulate specificlessons. As a preliminary step, the following roundtablepresents the insights of a range of experts who were invitedto reflect on how experiences from the global response toHIV might inform the global response to viral hepatitis.Kicking off the discussion is Jens Lundgren, a renownedHIV researcher, head of the new WHO CollaboratingCentre on HIV and Viral Hepatitis and co-founder of theHIV in Europe Initiative. His perspective is much broaderthan that of a medical doctor gazing at his own disease. Inthe next two pieces, Jordi Casabona of the EpidemiologicalCenter for HIV/AIDS/STI of Catalonia and Lucas Wies-sing of the European Monitoring Centre for Drugs andDrug Addiction (and colleagues) consider surveillance andmonitoring issues. Sounding a cautionary note about the“discourse of hope and expectation” associated with hepa-titis C treatment, Magdalena Harris, a qualitativeresearcher at the London School of Hygiene and TropicalMedicine, critically reflects on treatment as prevention.

Prescription opioid abuse in the United Kingdom

The United States (US) is considered the center of prescription drug abuse. Since drug abuse is a worldwide phenomenon, it would be valuable to determine if the trend of increasing prescription opioid misuse and abuse seen in the US is developing in the United Kingdom (UK). To compare trends in deaths associated with prescription opioid drugs, mortality data was obtained online for England, Wales, and Scotland from the Office for National Statistics and the General Register Office and for the US from The National Vital Statistics System (NVSS). Mortality trends in the US show a relentless increase of deaths from unintentional drug poisoning with opioid analgesics in the last decade. In 2010, the number of deaths related to opioid analgesics was over 16,500, more than double the number of 2002 and more than twice the number of deaths from heroin and cocaine deaths combined [1]. Although the number of deaths related to drug poisoning reviewed from England and Wales is not as high as the US, the overall trends are remarkably similar (Figure 1). The prominent role of methadone in UK opioid deaths also is striking. In Scotland, methadone-related deaths increased from 71 in 2001 to 275 in 2011 [2] and they currently represent over half of all reported opioid deaths. However, this should be viewed in the context of a considerable increase in the availability of opioid substitution treatment in the UK [3]. In the US, most cases relate to opioid analgesics, and the number of oxycodone deaths slightly exceeds the number of methadone deaths. Tramadol presents interesting data in the UK: in 1996, England and Wales reported one death with the drug mentioned, but by 2011 there were 154 deaths [4]. In Scotland, tramadol-related deaths increased from 8 in 2001 to 34 deaths in 2011 [2]. The increase in tramadol-related deaths may reflect a rise in tramadol prescriptions, therefore availability, but also points to the need to monitor closely any increase in deaths caused by opioid analgesics as it may signal an emerging problem in the UK similar to the issue that is now well-established in the US. Language: en

Intoxication by gamma hydroxybutyrate and related analogues: Clinical characteristics and comparison between pure intoxication and that combined with other substances of abuse

OBJECTIVE To study the profile of European gamma-hydroxybutyrate (GHB) and gammabutyrolactone (GBL) intoxication and analyse the differences in the clinical manifestations produced by intoxication by GHB/GBL alone and in combination with other substances of abuse. METHOD We prospectively collected data on all the patients attended in the Emergency Departments (ED) of the centres participating in the Euro-DEN network over 12 months (October 2013 to September 2014) with a primary presenting complaint of drug intoxication (excluding ethanol alone) and registered the epidemiological and clinical data and outcomes. RESULTS We included 710 cases (83% males, mean age 31 years), representing 12.6% of the total cases attended for drug intoxication. Of these, 73.5% arrived at the ED by ambulance, predominantly during weekend, and 71.7% consumed GHB/GBL in combination with other substances of abuse, the most frequent additional agents being ethanol (50%), amphetamine derivatives (36%), cocaine (12%) and cannabis (8%). Among 15 clinical features pre-defined in the project database, the 3 most frequently identified were altered behaviour (39%), reduced consciousness (34%) and anxiety (14%). The severity ranged from mild cases requiring no treatment (308 cases, 43.4%) to severe cases requiring admission to intensive care (103 cases, 14.6%) and mechanical ventilation (49 cases, 6.9%). No deaths were reported. In comparison with only GHB/GBL consumption, patients consuming GHB/GBL with co-intoxicants presented more vomiting (15% vs. 3%, p<0.001) and cardiovascular symptoms (5.3% vs. 1.5%, p<0.05), a greater need for treatment (59.8% vs. 48.3%, p<0.01) and a longer ED stay (11.3% vs. 3.6% patients with ED stay >12h, p<0.01). CONCLUSIONS The profile of the typical GHB/GBL-intoxicated European is a young male, requiring care for altered behaviour and reduced level of consciousness, mainly during the weekend. The clinical features are more severe when GHB is consumed in combination with other substances of abuse.

Review of European-Drug Emergencies Network (Euro-DEN) training package for non-specialist workers to assess acute recreational drug and new psychoactive substance toxicity in night-time economy environments

Abstract Aims: The initial management of acute recreational drug and new psychoactive substance (NPS) toxicity is often by non-specialists working in the night-time economy. The aim was as part of the European Drug Emergencies Network (Euro-DEN) project to pilot training of these workers in multiple European countries. Methods: Following evaluation of training needs, guidelines and training package were developed. Night-time economy workers in London, UK; Pärnu/Tallinn, Estonia; and Oslo, Norway participated in a 1- to 2-h interactive case-based training session. Participants completed a questionnaire pre-/post-training to assess confidence in managing acute recreational drug/NPS toxicity and evaluate the training package/guidelines. Findings: 98 (London: 42; Oslo: 39; Pärnu/Tallinn: 17) completed both pre-/post-training questionnaires. Participants felt significantly more confident in managing someone unwell following classical recreational drug use compared to NPS (5.6 ± 2.9 vs. 4.3 ± 2.7, p < 0.001); this difference persisted after the training (7.6 ± 1.9 vs. 6.9 ± 2.0, p < 0.001). 147 (London: 42; Oslo: 88; Pärnu/Tallinn: 17) completed the post-training evaluation; the training session and the guidelines were rated 8.2 ± 1.4 and 8.7 ± 1.7, respectively (out of 10). Conclusions: The guidelines and training were well received by night-time economy workers in three European countries and improved confidence in managing acute recreational drug/NPS toxicity. Appropriate national and European bodies need to look at wider dissemination of this work.