Organised by Australia with the support of Canada, the United Kingdom and the United States

Welcome and Opening Remarks – Celia Street, First Assistant Secretary, Population Health Division, Australian Government Department of Health and Aged Care

The Australian Government is investing $19.6 mil over four years from 2022-23 (and $4.9 mil ongoing) to deliver the National THN program. This program makes naloxone available at no costs and without a prescription to anyone who may experience or witness an opioid overdose or adverse reaction in every state and territory in Australia.

People who are at risk of an opioid overdose and their carers, friends and family members are able to access the take-home naloxone program. Approved provided of the program include community pharmacists, dispensing doctors and hospital pharmacists. Other authorised supplied include needle syringe programs, AOD treatment services and outreach services.

Naloxone is available from all participating pharmacies across Australia, and in non-pharmacy settings, is available through some: community and hospital based pharmacies, alcohol and other drug treatment services, needle and syringe programs, custodial release programs. Between July 2022 and March 2023, there were over 28,000 individual requests for naloxone, with 49,406 units supplied.

Professor Michael Farrell, Director, National Drug & Alcohol Research Centre (Australia)

The impact of opioid agonist treatment on fatal and non-fatal drug overdose, a global perspective

Key points:

There is clear evidence of opioid agonist treatment (OAT) to prevent mortality and globally. There is evidence of OAT, NSP, naloxone interventions, and higher coverage since 2007, but still not enough -there is low evidence of access globally. In Australia (NSW) well delivered OAT treatment reduces mortality by more than half. We know that during and post-release periods from incarceration are high-risk periods for overdose. At the population level, the key point is the importance of OAT coverage – high coverage and access to more than 50% of PWID is what we are aiming for.

Dr Christopher Jones, Director, National Centre for Injury Prevention & Control, Centers for Disease Control and Prevention (United States)

Epidemiological content – Overdose deaths are at historically high levels in the US. Particular drugs involved – opioids continue to play a significant role – over time, declining heroin/semi-synthetic opioids and benzos – but more recently, stimulants – methamphetamine, cocaine, and also drugs like xylazine.

Very few OD deaths involve just opioids – less than 4% of those deaths involved neither opioids or stimulants. In our mortality data, it is shown that there are many missed opportunities before someone dies – e.g. use of naloxone, awareness training at recent release from institutional setting.

Our public health response – we released an overdose prevention strategy about a year ago, which focuses on four areas:

• Primary prevention: focuses on root causes and key predictors of substance use and substance use disorder, and how to safely and effectively manage pain
• Harm reduction: focuses on reducing risks associated with substance use, including overdose and infectious disease transmission
• Evidence-based treatment: focuses on providing the most effective, evidence-base treatments without delay, stigma or other barriers
• Recovery support: focuses on funding, reimbursing, training workforces for, and developing protocols around peer, employment and housing supports

We need to continue to expand harm reduction in the US – relatively new in US – naloxone, syringe programs, raising awareness to key affected communities. Equally important to invest in upstream primary prevention.

Where to focus efforts?

• Strengthen upstream prevention with a focus on preventing adverse childhoof experiences (ACEs) and trauma
• Support harm reduction and expand the provision and use of naloxone, fentanyl test strips, and syringe programs, raise awareness about the illicit drug supply
• Expand access to and provision of treatment for SUDs, with a focus on MOUD, as well as recovery support services
• Intervene early with individuals at highest risk of overdose
• Improve detection of overdose outbreaks due to fentanyl, stimulants, NPS (e.g. fentanyl analogs), or other drugs to facilitate an effective response

Provide a range of technical assistance about overdose prevention and prescribing, working with governments and community-based organisations. These include:

• The CDC’s Linking People with Opioid Use Disorder to Medication Treatment: A Technical Package of Policy, Programs and Practices
• Opioid Response Network
• SAMHSA Opioid Overdose Prevention Toolkit
• cdc.gov
• The Providers Clinical Support System (PCSS)

Jon Shorrock, Programme Manager, Drug & Alcohol Improvement Support Team, Department of Health and Social Care (United Kingdom)

Office for Health Improvement and Disparities (previously known as Public Health England)

The leading cause of overdose in the UK has always been, and remains, opioids. Cocaine use and overdoses are rising quickly. Polydrug use is a complex picture with differences between (and within) countries. The standout is the situation in Scotland – there is a huge increase in drug related deaths – factors driving overdose levels.

In the UK we have an aging cohort of people; people using heroin are getting older. We don’t really have an issue with fentanyls, unlike other countries. However, there are increasing comorbidities, unmet needs, physical needs. Since the pandemic, health inequalities have widened. Impact of years of austerity, peoples colleagues and friends are dying, people are using alone. 2016 PHE investigation – recommendations are still valid, links to peoples BMI.

Naloxone is a prescription-only medicine in the UK. Since 2015 and 2019, legislation has enabled people employed or engaged in drug treatment to provide naloxone without prescription (this includes community pharmacies involved in OST or NSPs). National naloxone provision programmes (and funding) exist in Scotland and Wales. Financial support to local government in England, with additional drug strategy funding since 2021. DHSC consulted in 2021 on further funding extending the legislation to enable other people and other settings to provide naloxone without prescription, including:

• Outreach and day services for homeless people
• Temporary or supported accommodation services
• Police officers
• Drug treatment workers commissioned by PCCs
• Prison officers
• Probation officers
• Registered nurses
• Registered paramedics
• Registered midwives
• Pharmacists

Consultation responses were overwhelmingly supporting but making the wide range of people/settings legally watertight is proving complex. Who actually procures and supplies naloxone is also an issue to be addressed.

We held a naloxone consultation nationally – good penetration rates for OST, introduction of Buvidal, CMO round table event. Innovation fund. Naloxone is still prescription only in UK – looking at first responders to provide naloxone and advise local systems. Automatic notification is being worked on. Looking at bringing in LAIB. 1.5% of treatment of OST population is in England. Investment in overdose prevention in the UK is now rising. Stronger partnerships are developing with civil society.

In summary:

• We have a UK drug strategy with government support
• For many of the UK countries, there is greater investment for drug and alcohol services and treatment
• Overdose rates in the UK continue to rise, but there are signs that opiate deaths are slowing
• We are gaining greater depth of understanding of the multiple and complex factors that are driving overdose deaths and developing responses
• Some helpful policy and practice changes are in scope
• Stronger partnerships are developing including civil society and recovery groups

Dr Raul Martin del Campo, Planning Director of the National Institute of Psychiatry of Mexico (Mexico)

Used to be in member of the INCB, today I represent Mexican researchers. In Mexico, the problem of overdose deaths is heroin. Availability of drugs that criminal groups cannot cross to USA the second market is returning Mexican migrants – returning from the US where they started using opioids. Invisibility of problem – due to low prevalence, underreporting, stigma and discrimination, IV administration. In a study of people who use drugs, 70% have experience of overdose in past 12 months, average of 4 in their lives. Low awareness of fentanyl. Using test strips, 93% of heroin samples contained fentanyl (powder). Fentanyl also being found in meth samples, and don’t know they need naloxone. People are trying to reverse overdose by injecting saltwater.

National Death Register – but doesn’t collect all data – family can request the death not to be recorded as drug-related. Deaths have gone from 160-1240 per year. There is no census in Mexico to understand how many OAT services exist. “La Sala” is the first safe consumption site for women in Latin America. It’s an exclusive service for women but flexible for entry of partners.

Naloxone distribution is almost impossible. Naloxone is improperly classified as a psychotropic substance – we are trying o have this changed. Trying to do some work to understand how naloxone is classified in other countries. Countries should start looking to make naloxone programs available.

Closing Remarks

Andrew Arcand, International Relations, Officer of Drug Policy and Science, Controlled Substances Directorate, Health Canada

Overdose crisis continues to impact Canada. In 2022 there were 20 deaths per day – most significant public health crisis in Canada. In response – Canada continues to support harm reduction and law enforcement, and range of recovery models. Since 2017 – $800 mil for evidence based measures – drug consumption rooms (DCRs), medical supply, naloxone, training to administer it.

Emerging themes from today – importance of sustained access to treatment and care. Low barrier free access to naloxone, missed opportunities to intervene. Intersectionality – important role for understanding. Need to address the information gaps. Underreporting due to fear of reprisals. Contributing demographic shifts, including people using alone. Access to life saving naloxone. Important for policy makers to have hope that things can be done.

Q&A

Question: A key ingredient of success in Australia’s response to opioid overdose and take-home naloxone has been the centring and activating of civil society, particularly affected communities. Given this, can the panel share their reflection on how partnerships between governments and civil society can be strengthened to prevent overdose and increase the uptake of naloxone?

Answers:

Christopher (US) – Naloxone needs to be in the hands of people who need it- our approach to partner with SSPs, harm reduction, health systems – where people have a touchpoint – some people have touchpoints with community base orgs. Some partnerships done through funding – many are substantially under funded – need to make sure that they are bringing people to the table.

Jon (UK) – relationship with college of lived experience orgs (CLEARO) recovery orgs. Developing area in the UK, living and lived experience is important. Naloxone – if you’re carrying for others, better uptake.

Michael (UNSW) – need to listen to consumer orgs and hear their voices and be shaped by it.

Question: Tragically the World Drug Report tells us that over half a million people die of opioid overdose each year. A critical part of the response is raising public and affected community awareness of overdose prevention. International Overdose Awareness Day is held each year on 31 August as a strategy to mobilise and drive action. Can the panel share their reflections how government, civil society and affected communities can best work together to promote this Day?

Answers:

Christopher (US) – we’re doing our best to promote IOAD across social media channels.

Celia (Australia) – we often have an event at parliament house, we could do more like is done in the US.