Side Event: High level side event on overdose management among opioid users: Prevention and treatment of opioid overdose

Organised by the Governments of Romania, Slovenia, Spain, the United Kingdom of Great Britain and Northern Ireland, and the United States of America, and the European Union (European Monitoring Centre for Drugs and Drug Addiction).

Mr Raed Arafat, MD, Secretary of State, Ministry of Internal Affairs and chief of Dept of Emergency Situations, founder of Romanian medical system.

Thank you to our embassy for organizing side event. Speakers from government, international organisations, scientific networks and civil society.

According to the World Drug Report 2018, opioids continue to case most harm. ~450000 people died as a result of drug use in 2015. Many directly associated with drug use disorders, namely overdoses. We need to fight for and with people who overdose. Fighting for removing stigma and misconceptions are also important. Addiction can easily start within a few days, average consumers are young and working class. The number of opioid users entering treatment is declining, overdose deaths are increasing. Many opioid deaths can be prevented. Naloxone is appropriate and effective, has been used in ambulances and hospitals for last 50 years. Can be used by police, peers and anyone witnessing an overdose. Many overdoses are witnessed, and bystanders can be able to act. Opioid overdose deaths can be prevented if people are empowered to administer naloxone. Take home naloxone programs have increased availability. Specialized programs put naloxone in the hands of people who use drugs.

In Romania, opioid treatment services are available at national level through NGOs and harm reduction services. In Romania, people who overdose on opioids or heroin received treatment when ambulance arrives – other countries are implementing take home naloxone programs – we are about to implement our first one for people who access needle syringe programs.

Leaving the overdose issue and looking at other trends – we see a big interest in selling opioid medications from pharmaceutical companies – we need to be very careful with this, these people are more powerful than us from the field of overdose prevention. We need to learn from the tobacco experience.

HE Cristian Istrate, Ambassador Extraordinary and Plenipotentiary, Head of the Permanent Mission of Romania to the International Organisations in Vienna

This side event illustrates the importance that the EU puts on cohesion – cohesion between MS, and European citizens. Europe is focused on goals and common values to reduce opioid consumption. No one affected by the world drug problem should be left behind. Multilateral regimes are important.

Alexis Goosdeel, European Monitoring Center for Drugs and Drug Addiction

‘Drug related deaths in the EU’

This is a public health challenge that is clearly mentioned in EU Drugs Strategy. Special plan to reduce OD deaths, and contribute to a healthier and more secure Europe.

The situation in the EU is relatively stable, but increasing in some countries. Increase in many age groups, including older groups – people who inject drugs are an aging population in Europe. Increase is sometimes in different age groups, and is sometimes due to heroin and opioids combined, and opioids and benzodiazepines combined. Huge variation in countries for drug-related deaths. Most overdoses in Estonia are due to fentanyl, however, fentanyl only represents 0.3% of drug related mortality.  Caveat to mention – under reporting occurring in other countries – Nordic countries have much better reporting systems than other EU countries.

Seizure data shows strong increase of fentanyl in Europe. We have problems with mortality after prison for people who use drugs. But this is the same as 30 years ago – we’ve known the problem and haven’t done anything about it.

Key responses in EU:

  • Developed interesting and comprehensive portfolio of interventions
  • Supervised drug consumption
  • THN programs
  • Retention in opioid substitute treatment
  • Overdose risk assessments
  • Overdose awareness
  • Outreach and low-threshold services
  • Empowering people who use drugs
  • Working with users is very important

Through-care interventions reduce mortality risks related to prison release.

We have evidence of effectiveness of drug consumption rooms. We’ve had new nasal naloxone kits since 2015 – potentially a game changer but have challenges. Access to pharmacies, legal regulatory barriers, training is a necessary component, there are also cost barriers

We need to prevent problem that occurred with access to hepatitis C treatment happening with naloxone. Need further investment, sharing the guidelines, working with people who use drugs, need more research, improve through-care prison community, need to further identify barriers to establishment of drug consumption rooms. I thank my colleagues for their help in preparing this presentation

Rear Admiral Sylvia Trent-Adams, PhD, RN, FAAN, Principal Deputy Assistant Secretary for Health

11.4 million Americans misused opioid medications or heroin last year. We are also seeing increased methamphetamine and cocaine deaths. President Trump’s Opioid Initiative introduced last year. It’s a 5 point strategy to strengthen data reporting and collection, improve access to prevention and medication based treatment, and enhance availability to overdose reversing drugs.

Our Center for Disease Control (CDC) provides funding and support to track opioid overdoses and death, and prescription drug monitoring programs. The CDC has guidelines for preventing opioid prescribing for chronic pain. Importance of widespread distribution of naloxone. Continue to provide support to first responders to prevent and respond to overdose. We have an initiative – Helping to End Addiction Long Term (HEAL).

Our programs are having an impact – naloxone prescriptions have increased by 338%, access to buprenorphine has increased. Non-fatal opioid overdoses have decreased in the last quarter. We remain committed to addressing this public health problem.

Alina Bocai, Romanian Association Against AIDS

We are fulling engaged and supportive of harm reduction – needle syringe coverage of about 25-30% in capital city. Romania adopted harm reduction measures for people who use drugs 20 years ago, however naloxone has only been available in emergency care. Once entering the EU, we lost international funding for harm reduction services, and HIV rates increased dramatically. Funding for NSP programs is crucial and we applaud the introduction of take home naloxone (THN) programs by the Romanian government.

Specialised drug treatment has been proven to have a critical role. Opioid substitute treatment (OST) contributes to reduction in overdoses and health harms. Public injecting is a problem – drug consumption rooms can reduce associated risks. Training in overdose prevention and naloxone is crucial – we respond to this issue with a health response. Scaling up OST double, changing drug laws to remove barriers to drug consumption rooms, increasing accessibility and affordability of naloxone, providing adequate funding for community responses. We need to work directly with the affected community.

Katrin Schiffer, EU Civil Society Forum on Drugs

It is very good that civil society is involved in this forum. I will focus on key interventions to reduce opioid overdose and importance of a public health approach. Situation in Europe is not as bad as North America but there are many things we can learn.

  • Most users are injecting but also smoking, inhaling, snorting
  • Health situation of people who use drugs is often weak eg HCV, HIV, TB, cirrhosis of liver
  • Lack of access to adequate services and interventions, stigma
  • Environmental factors (e.g. after prison release)

Reducing vulnerability – outreach services are essential for effective interventions, by building a relationship of trust, providing non-judgmental environments

  • Need for creating enabling environments
  • Empowerment of people who use drugs
  • Acknowledgement of people who use drugs as part of the solution rather than part of the problem – many needle syringe programs were initiatives of people who use drugs themselves, not governments
  • Overdose is a public health issue – support but don’t punish!

Drug checking is also a very effective way to reduce certain risks – promotes empowerment and provides knowledge for safer use. Involvement of people who use drugs is important in all of these interventions, and working with harm reduction workers, workers in housing services and police. Barriers with access to naloxone.

Need to work on stigma reduction, access to harm reduction services in prison, need more funding. We need it all – drug consumption rooms, naloxone and reducing stigma.

Dr Gilberto Gerra, PhD, Chief of the Drug Prevention and Health Branch, UNODC

‘An overdose of social cohesion’

Overdose risk is related to – social exclusion, discrimination, stigma, closed doors to social services.

Mentality without shame and stigma is important in reducing overdose. Contaminants of methamphetamine with fentanyl. Connections of overdose and PTSD, adverse childhood experiences, suicide epidemics

Anja Busse, UNODC

UNODC-WHO program: SOS (Stop Overdose Safely) – naloxone for all – relatives, partners, friends, social services etc.

Mateja Jandl MD and Ada Hocevar Grom MD,  National Institute for Public Health, Slovenia ‘Approaches to reducing the number of deaths due to opioid overdoses in Slovenia’

  • We’re a small country but are experiencing increase in drug related deaths, 10 deaths per million higher than European average
  • Deaths related to cocaine abuse and polydrug abuse increasing
  • Starting to pay special attention to fentanyl – national institute has produced guidelines for fentanyl
  • Slovenia best practices:
    • Accessible substitution treatment
    • Long tradition of harm reduction programs – needle syringe programs for over 28 years, funded by state and free for users, really happy with programs in relation to reducing blood borne viruses
    • Health data and monitoring
    • Early Warning System – a good national and regional network
    • Safely and effectively administering a pain relief therapy – advertising of opioid meds is prohibited by law, prescription opioids are last resort in guidelines
    • Take-home naloxone: a priority task for Slovenia

HE Leigh Turner CMG, Ambassador of the United Kingdom to Austria and Permanent Representative to the UN and other International Organisations in Vienna

Too many lives have been lost from opioid overdose. Through the 2016 UNGASS document, international community aims to reduce opioid overdose. Recognize importance of naloxone. This side event has showcased importance of access to take home naloxone in ending the world drug problem.

The UK is committed to preventing drug use in our community and recognizes importance of prevention and treatment. We’ve maintained availability of needle syringe programs and allows for distribution of foil of heroin smoking. The UK government supports OST as evidence based interventions in reduce drug use harms. Social cohesion is a very important factor, including access to training and employment.

Video shown from Romania from prison inmate who used drugs and witnessed overdose.

Questions:

Matt Southwell – Euro PUD – peer workers providing naloxone, example from Glasgow with peer workers providing more naloxone than rest of health workforce combined.

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