 I'm happy to welcome you on board of the 16th webinar, EMCDA webinar. This time we'll talk about drug-related deaths in Europe, and I will give directly the floor to our director, Alexis Gousdil, to open the webinar. Alexis, the floor is yours. Thank you, Marika. Can you hear me? Yes. Yes, OK. Good morning, everybody. Hello, everybody. Actually, it's already the afternoon for some of you. I'm very pleased to welcome you for this last webinar of the year. Actually, it's already the second year of the series of EMCDA webinars. And we end up this year with a very important topic for us, as the prevention and the reduction of overdose and deaths from overdose is one of the three top-level public health priorities for the EMCDA as part of our strategy 2025. And today, I know Marika and the colleagues, they will introduce them, but I would like still to welcome and thank Andrew, Martin, Thomas, and Marc for sharing their experience and their vision of the situation from their perspective. I think high-risk substance use and polydrug use is still fueling drug-induced deaths in Europe. We also see that in the recent years, there was a stabilization of the drug-related deaths. No more decreases. We also observe changes in the patterns of drug use with the risk behaviors covering different age groups from teenagers in some countries, but in some other countries, those who are over 50. And then finally, we see also that we have a change in the profile but also in the risk behaviors in the substance use. And it was essentially about heroin use or opioid use frequently combined with other substances. In another meeting yesterday, I had the opportunity to highlight the importance of benzodiazepines that I frequently found together with the heroin or opioids in samples of drug-related death cases. But we also see an increasing change towards more risk behaviors that is partly associated to the economic crisis and the consequences of the COVID pandemic. And therefore, certainly, it's an indication that we should redouble our efforts and try to find better ways to implement the best practice. And here, I mentioned on purpose best practice because we are organizing this webinar in the context of the bundle, the new bundle as part of the EMCDD MIDI guide that is dedicated to drug-related death in Europe. And what we see is that certainly there is a moment for more efforts and anticipating that with the economic crisis, possible cuts in budget, we need to make sure that drug services, treatment services, harm reduction program, they keep their financing. In some countries, they need more and more stable financing because this is about the risk people are taking and facing. And it is one of the priorities of the European strategy on drugs. So I look forward to listen to the different answers you will provide to our questions. And I look forward also to listen and to read the action with the participants before the final conclusion. Thank you very much. Thank you very much, Alexis, for your inspiring opening. And I will give the floor to the chair today, Isabel Giroudon. Isabel, the floor is yours. Thank you very much, Marika. Thank you, Alexi. I'm very honored and very pleased actually to welcome our panelists. We've chosen to invite some different people, really. And as our director said, it's really the opportunity to share different visions and different perspectives. We will have speakers from part of the European region where there's really high prevalence of high risk of use and drug-related deaths. We will have visions as well on different types of responses in Austria. And of different problems in Norway. And as well, we'll have the perspective from Mark, the last panelist, who has more insights into how I'm related to prison and to prison release. So it's a really interesting panel. And I will now directly ask my colleague, Ali, to move to the first question. And I will invite the speakers in the order. I see them on the screen, which is first Andrew then Martin, then Thomas, and then Mark. And I would ask you really to address this first question. So what is the current major concern around drug-related deaths in your country? And we ask that because we thought it was really important to have a good view of the situation before you explain to us and you discuss the responses. So you will now please tell us what is exactly the situation and what is the major concern around drug-related deaths in your country? The floor is yours, Andrew. And I ask you to briefly introduce yourself before you start. Good afternoon, everyone. My name is Andrew McCauley, and I'm a reader in public health at Glasgow Caledonian University in Scotland and delighted to be here today. Next slide, please. So as Isabel has asked us to provide some context about what are the key issues facing our countries at the moment. So the first key issue for us is that we have a historically and comparatively very high drug-related death epidemic in Scotland. As you can see from the graph on the left, drug-related deaths in Scotland increased for seven years in a row between 2014 and 2020 and have risen by nearly 450% since records began in 1996. In our most recent year of data, 2020, there were 1,339 drug-related deaths recorded, all involving people aged 15 to 64 years old. By comparison, in the same year, there were 650 persons who died from COVID-19 who were aged 15 to 64. So more than double that number. And the annual number of drug-related deaths in Scotland now exceeds the annual number of alcohol-specific deaths in our country. And by comparison across Europe, if you look at the graph on the right, we sometimes have to redraw this graph and redraw the axes on this graph to include Scotland on it because our issue is so extreme. Scotland is on the far right of the graph, the large red bar, which exceeds all the other countries. And you can see that Scotland's rate of 327 deaths per million population is more than three and a half times the UK rate and more than 20 times the rate across the European Union. Next slide, please. The second main issue we face is an issue related to our toxic drug supply, which is impacting on our norm of polydrug use, people using more than one substance at a time. And in particular, the rapidly increasing role of benzodiazepines in our drug use. This is really driven what we've seen over the last six or seven years in terms of drug-related deaths increases. And you can see it is the role of a Tysolam in particular, which has driven this. When first detected in 2012, a Tysolam was involved in just one death. But in our most recent figures for deaths recorded in 2020, a Tysolam was involved in 806 deaths or 60% of all drug-related deaths in Scotland, representing a 19-fold increase in just five years. And the graph on the right describes the trends in benzodiazepine prescribing in Scotland over the last 15 years. And you can see that the environment of benzodiazepine prescribing in primary care has steadily reduced over the last 20 years. And increasingly, the illicit market supply of benzodiazepines has replaced and superseded the availability of prescribed benzodiazepines within communities. So we really have a major issue related to safe supply at the moment. Next slide, please. And the third major issue we face at the moment is in relation to health inequalities. And specifically, the widening health inequalities we see in drug-related deaths in Scotland. We know that poverty is strongly associated with drug use in related terms and people living in the most deprived communities are more likely to engage in problematic drug use and, in turn, more likely to be affected by drug-related morbidity and mortality. In the year 2000, people living in the most deprived communities in Scotland had a 10-fold greater risk of drug-related deaths than those living in the least deprived communities. By 2020, this ratio had almost doubled to an 18-fold greater risk, reflecting the widening inequalities in this epidemic. Thank you. Thank you very much, Andrew. I give the floor to Martin. So good afternoon, also from my side. My name is Martin Busch and I am from the Addiction Competence Centre of the Austrian Public Health Institute. Next slide, please. You can see here the development of the number of drug-related deaths in Austria between 2003 and 2011. The numbers were quite stable on a high level, you can say. Then there was a decrease until 2014 and now in 2019, we are hardly on the same level in history. Next slide, please. The numbers are quite looking the same, but when you look into the data, you can see an interesting development. In 2005, we had a very young population, 42% of the drug-related deaths were below 25. And when you look at the year 2019, you see that there's just 15% in this young age group. So something has changed. Please, the next slide. When you look first at the graph at the right side, this is our prevalence estimation of a problem drug use in Austria by age groups. And what you can see is that we had an increase among the 15 to 24 old people. It's the red line between 1999 and 2005. And since then, the numbers are going down. The same increase happens later in the group 25 to 34 some years later. And the same increase happened in the year 35 plus another time later. And you see it's a typical wave. We had a wave of incidents and then this wave is going into the older age groups because when people are in opioid addiction, many of them stay there because it's a chronic disease. And the consequence of this high incidence now is that we have an aging population of heroin users. You can say the good thing is that the drug users survive and get older because otherwise, we wouldn't have this number in the older group. The good thing is that less young people start opioid use. So we don't have an rising drug problem, you can say, but we have rising numbers of drug related deaths and our interpretation is that the older group has a long time of drug career and is more vulnerable to overdose deaths. I think there are different needs of older drug users. The question is, do we know about them? Then we know that more than half are in opioid substitution treatment. It's good, but it could be better. So are there ways to further improve in treatment rate? And we have to overthink if we reach older drug users, especially with drug related death prevention. So thank you. Thank you very much, Martin. I give the floor to Thomas Krozen from Norway. Thank you, Isabel. Yes, my name is Thomas Klausen. I'm from the Norwegian Center for Addiction Research at the University of Oslo in Norway. Good afternoon to all and thank you for the invitation. In Norway, so what you see on the screen now is a figure of the numbers of overdose or drug induced deaths as they've developed with time, split by men and women. And we see that we had a peak with about 400 such deaths in the year 2000 and since then we had a decline. And then a long period with a relatively stable situation and we are still considering the most recent year 2020 to be within that bracket of some sort of stability. Although we're also fearing that this is beginning of a new increase as it also might be indicated. And you see development, particularly for women, has also increased over the past year and now has a greater share, maybe of the total number of deaths. Next please. So this is not a figure with real numbers, but its point is to show some developments that we and trends that we see. So the red line are the numbers of heroin deaths and we recognize again the peak in year 2000, the 400 deaths and most of them at that time were heroin deaths. But when we look into detail, what has caused that? It has been gradually reducing over time and is now at around 50 annual deaths related with heroin. But we see the blue line, which has gradually increased from early 2000 and those are deaths related to prescription opioids such as oxycodone, tramadol, morphine, medical fentanyl, those kinds of medications. And we see they have increased gradually. And then the observed trend has been that relative stability since 2003, but we are worried that we are seeing the beginning of a second wave rising and then dominated by prescription opioids in Norway. And we are looking into these details by research now and by some months, hopefully we'll have more answers, but we know that oxycodone, tramadol and the likes are increasingly causing these drug induced deaths. And that is parallel also with quite a large and parallel increase in the use of these medications in the population and also the use of these medication for long-term treatment of chronic pain in the community. So next slide, please. When it comes to those who are receiving opioid substitution treatment in Norway on the left side of the diagram, we see the mean age of those patients and it increases by every year. As also Martin just told us, was experienced from Austria, which is on the one side, good news. People survive longer, they stay in treatment longer and it's the whole intention with the treatment. On the other hand, and on the right side of the figure, we also see the differences in drug related deaths in this population, in those who are in opioid substitution treatment. And we can see that with age, mortality rates increase and that is particularly driven by somatic causes of death. And that includes liver related diseases, cardiovascular diseases and lung related diseases. And from 50 and above, that's the dominating cause of death in this population. And this reminds us that with the patients in OST that are in treatment for decades and their age, we also need to attend to their healthcare needs other than just the substitution treatment, but also the somatic help in particular. So thank you. And that was what I plan to say for this first part. Thank you very much, Thomas. I'm not sure we've got Mark. I think maybe we had some technical problems because I can't see if Mark can join us. If not, what I suggest is that we just, maybe for just Mark to have the time to join us again, we will just move to the second question after we had this very interesting overview really of your perspective. I think it was really interesting to see both the commonalities that you see in your countries in terms of opioids being the most crazy in terms of OST being in place, but not often and not always at the optimal level. But there were some particularities and that's interesting as well. You mentioned the social circumstances around the desk. So that was really important first part to really see the situation and how it can be different in different countries. I give you now the floor again to answer the second question. What is being done to address the problem? Go again please, Andrew. The floor is yours. Thank you, Isabel. Traditionally in Scotland, the main tools to address drug-related deaths have been provision of opioid substitution treatment, mainly through methadone and since 2010 a national naloxone program. But because the situation in Scotland has become so acute over the last couple of years, we've seen more specific responses by our national government to try and address this epidemic. The first of these was the appointment of a drug death task force in 2019 with the name of identifying measures to improve health by preventing and reducing drug use, harm and related deaths. And the task force is three high level areas of focus. First of all, in relation to the emergency response and this is related to prioritising scale-up of our naloxone program through allowing police, paramedics and other lay people to have access to naloxone supplies and also creating new non-fatal overdose pathways where people who have a non-fatal overdose can be fast-tracked into treatment services. The second high level area of focus in relation to reducing risk amongst those who are already at risk of drug-related deaths and that is focused around optimising engagement in drug treatment by implementing at first new treatment standards which have been devised for Scotland aiming to allow things such as same-day prescribing and to reduce waiting times and access issues in relation to treatment. And then thirdly, a more long-term vision to reduce the vulnerability of individuals aimed at reducing stigma associated with drug use and focused on things like drug law reform so particularly exploring issues around decriminalisation and other models in relation to drug use. And the graph on the right just gives you a flavour of what our take-home naloxone program has achieved over the last 10 years since it's been in place. This data is slightly dated now. It shows that before the task force was appointed, we had supplied around 60,000 naloxone kits over that period, but since the task force has been appointed that has dramatically increased further and there have been over 100,000 naloxone kits supplied, including a number by the paramedics and also to the police who have used it on multiple occasions since they were involved in the programme. Next slide, please. And the second major development is really came about this year. Yep, that's fine. And this was announced in January of this year, just a month after the latest figures were published. The latest figures, again, were another historical high, as I said earlier, and really prompted action from government that a lot of people had been asking for for a long time. And to support the work of the task force, the government announced what's called a national mission to reduce drug-related deaths and harms. And you can see some of the aims and objectives of this are similar to those for the task force in terms of fast and appropriate access to treatment and improved drug services. But there's also specific mention of things like increasing capacity and use of residential rehabilitation and more joined up policies across sectors, so not just focusing on health, but also focusing on health, criminal justice and social care. And significantly, alongside the national mission was the largest investment in drug death prevention or indeed drug policy that has been seen in a generation. The government committed to £50 million extra funding per year for the next five years, so a total of £250 million. Much of that will address the funding that has been cut from drug policy over the last 10 years, but it is certainly welcome news and long overdue and the picture on the right is just to show you, just this week on Monday of this week, the government launched a new anti-stigma campaign really framing the drug problem in Scotland as a health issue. And again, this is the first time the government has really led on doing such a thing in terms of moving the narrative away from drug use being a criminal justice issue to being much more of a health issue and trying to move the general population with them on that. Thank you. Thank you very much, Andrew. I'll give the floor now to Martin, please. So, what is done in Austria in the field of prevention of drug-related deaths? After a long period of lobbying and discussion now, we managed to introduce some Pia Naloxone projects. At the moment we have three projects in nine provinces, but Vienna is included and Vienna is the biggest city in Austria. Then another thing is we are thinking about measures to improve in-treatment rate of opioid substitution treatment. One thing is that now we have plans for a project of opioid substitution treatment which is injectable more fine because we know that there is a group of opioid users who need injection and we would like to offer them this possibility and also the law was changed recently to make this possible. And another thing I wanted to point is due to the COVID-19 crisis, the control of prescription by the medical officers in Austria changed from personal to electronic way and this makes OST easier to integrate into daily life. Before COVID-19, they had to go each month to the medical officers to check their prescriptions and now these prescriptions are sent via electronic way and there are just some reports from experts that at the moment we see due to this change there is no increase of misuse but a new client group is reached because for some clients it was too complicated and not to integrate OST in the life with the former regime. But we have to look more into details because there is no study on that or something like this but it was very interesting that changes in the administration leads also to be more accessible for new clients group. Thank you. Thank you very much and then Thomas. Thank you. Yes, some of the interventions and policies that have been in place in Norway I'll go through some of them and in Norway the government launched National Overdose Prevention Strategy in 2014 and it's still ongoing and one feature of this is that this national strategy launched by the actually former government is now also for the time being forwarded by our new government that came in position in October so the National Overdose Strategy is surviving changing governments which is an important issue I think. What it includes is it has central government funding on the overdose prevention issue and strategy. It includes a naloxone distribution programme in Norway it's been a nasal naloxone device that's been distributed and we started in 2014 and by now there's more than 20,000 kits distributed and also as part of the strategy there's been increased access to low threshold OST around the country and these are three mentioned but there are several other elements part of this national strategy. The policy also includes the availability of safe drug consumption rooms and also this year we're starting now around Christmas a project with injectable diamorphine so an injectable heroin clinic as part of the OST programme. This will be in the two cities Oslo and Bergen the two largest cities with the most combined also overdoses. In addition to these more clinical and practical interventions there's also been funded from the central government and from the research council funding to better understand the developments regarding prescription opiates and this is ongoing and we're hopeful that we over the next months and years will know more of what's going on relating to that. For example we see that oxycodone and tramadol they are increasingly parts of overdose deaths but until now we haven't known for sure if if those who died had a prescription or not or if it was illicit medication involved and we will then use the prescription registry to link with overdose death registries and find out more of these details. So overall there's been a commitment from the government to continue and for long term both fund and have strategy plans to prevent overdose deaths. The strategy plans they are of a four-year duration and then they're renewed and revised so we're currently in the second period and hopeful that the third one will start next year and I think this is the way to go because there's not one single solution that will solve the problem with overdoses. I think we need to realize that we need a number of interventions and strategies and ideally combined as some sort of overarching national strategies that can be evaluated and adopted to the current needs in the situation. And also one thing I'd like to just remind ourselves I think it's very important with long-term commitments because over those situations they develop over time and I see no solution that will end them immediately so we would need to be consistent and persistent with the efforts and I think that's sometimes frustrating but also something that we need to be engaging in long-term commitment in developing always better interventions but then in combination with others such as provision of treatment and the provision of harm reduction measures etc. Thank you. Thank you very much Thomas and the other panelists as well. I think that's very important you mentioned the national strategies and it's interesting that we see now in many of the European countries there is really a formal group of people working on these issues and there is a strategy and the things are really moving forward. We are still having problems I'm sorry about that but we can't see or other panelists Mark so we move now to the third question and I would ask you please from your perspective what are the most pressing challenges right now and what are the implications for policy and for practice and for research as well so again I leave the floor to Andrew. Thank you very much. Thank you Isabel so I've tried to break these down into again three key pressing problems or issues that we face at the moment. I'm quite hard to do that in three slides but I'll try my best. First of all it's really the size of the population at risk we have in Scotland despite us having a high mortality rate for some time now we still have a huge number of problem drug users and our prevalence of problem drug use is higher than anybody else in the UK and probably higher than the than elsewhere in Europe. So we still have huge numbers of people at risk of drug related deaths this epidemic is still very live and not something that's able to be halted abruptly it's going to take a while to to turn around and when you have a large at-risk population of mortality you can expect to get lots of deaths unless you take radical action and that's why it's been somewhat of a relief to see some of the responses we've seen over the last 12 months after many years for people advocating for change and really the graphs on the right just illustrate the issues the time talking about in terms of the Scotland's prevalence of problem drug use being comparatively higher than in other regions across the UK or also Scotland's mortality risk being higher than in other comparative regions as well. So despite us having some progress in recent times we still have a huge population to work with here and that means that that things are still in a very dangerous position for us in terms of the sheer volume of deaths that we're trying to prevent. Next slide please. The second thing I wanted to highlight was treatment and effectiveness and I think this is this this is arguably one of the the key explanations why Scotland has done so poorly in recent years. We obviously highlighted earlier the issues related to poly drug use and benzodiazepines and inequalities in relation to poverty but treatment and effectiveness is one of the key drivers and continues to be one of the key drivers. We know from the evidence that specialist drug treatment through opioid substitution therapy is the most effective intervention we have at our disposal to reduce the risk of mortality but in Scotland we continue to have among one of the lowest proportions of treatment engagement amongst our opioid user population. Typically in Scotland it's less than 50% around 40% when comparing that with England they're around 60 to 65% and previous studies have shown Thomas may correct me on this so apologies but previous studies have shown that Norway had treatment engagement of over 80% so we were well below what we would like to see in relation to that and we know getting people into treatment is very protective. Now I think this is possibly one of the reasons why those treatment standards have been so prioritised by the task force and the national mission and those treatment standards have now been published and are designed to try and make treatment more accessible to people but also more effective for people because treatment in Scotland until very recently has been very much associated with people cycling in and out of treatment very frequently so engaging with treatment but then dropping out within a matter of weeks and there's having what we call a high number of unplanned discharges so people being discharged from a treatment service without completing a therapeutic journey of care in a planned manner in agreement with their professional and when people cycle in and out of treatment so frequently their tolerance obviously fluctuates quite markedly putting them at risk over those and other negative health outcomes so I think a real challenge for us at the moment is can these new treatment standards be implemented quickly enough for us to at least try and halt the speed of our drug related death increase which we've been observing over the last couple of years and this is certainly against a backdrop where we're still within the pandemic and the treatment landscape has changed quite markedly during the landscape during the pandemic as well so it's a very challenging environment to implement service change next slide please and then the final challenge and I deliberately avoided COVID-19 because I think people have spent a lot of time talking about COVID-19 and how it impacts on all aspects of life but including drug users and drug services as well so I haven't focused on that today but I have made reference here but I think the third challenge for us from a research perspective is identifying what works. One of I suppose the unintended consequences of all the new attention on drug related deaths in Scotland from government and from services has been a lot of new interventions that have been rolled out very very quickly and most of these interventions are generally rolled out without an evaluation plan and a lot of the evaluation of these new interventions is usually done post hoc it's not planned in any way it's a kind of retrospective evaluation which is not the way we like to do evaluation and I foresee a difficulty in over the next 12 months trying to untangle what the most effective responses have been amongst all the noise we have from all the different interventions that have been tried. Taking naloxone as an example there have been multiple different new naloxone supply routes put in place over the last 12 months and it's important for us to understand which of these is most effective that we can prioritise in the future similarly there's been a big shift moving people away from daily dispensing of medications to more take home doses up to one week and two weeks and it's very important we understand whether that's helped some people or whether that's had negative impacts for some people I suspect it's a bit of both but we have to research that and evaluate it so I think as researchers we have a responsibility to work together over the next few years involving both epidemiologists, social scientists and a whole lot of other disciplines to understand the impact of all these fairly rapid and radical changes that we've observed over the last 12 to 18 months. Thank you. Thank you very much Andy. I give the floor to Martin Busch. So what are the challenges implications and possibilities concerning the situation of drug-related deaths in Austria? Of course we should extend our pionnalexone programs to the whole of Austria. We should improve the in-treatment rate in OST for example with injectable OST or also with making the administration easier but I would also like to point to one fact which is somehow a little bit neglected to my opinion in prevention of drug-related deaths. On the graph on the right you see that the percentage of injecting drug users or the injecting heroin users in the age group over 29 is much higher than in the age group under 20 and we observe this fact since very long time and it is somehow sure that some drug users change the route of administration from snorting or from smoking in the course of the drug career to injecting and if you could avoid this change this would be a good thing to reduce drug-related deaths because the risk for drug-related deaths for injecting drug users is much higher than for the other forms of administration. So if there would be ways to avoid this change or to make a change back from injecting to smoking or to snorting I think this could help a lot and I think this would be a thing which should be investigated more because it's obvious that there is some potential for prevention so thank you very much. Thank you very much and then I would ask you Toma. Thank you again I think one of the challenges that I've also in a way highlighted previously is that we observe that those who die from odors increasingly come from diverse or heterogeneous risk populations and that speaks for of course having national and broad preventive strategies. We've seen over the past 20 years that those who have been traditionally using heroin that is not anymore the main cause of that in terms of odors is in no way it's a prescription or it's in combination so there's been a shift in the whole situation and I think we therefore also need to adjust the preventive strategies but that doesn't mean we should lose focus on those who are using heroin we should continue this broad range of interventions that the national strategy and others have been which has been put in place for a long time but we also need to develop new interventions particularly targeted towards those who use prescription opioids in a harmful way and we think that they both include pain patients who are taking their prescription medicines typically combining sleeping tablets and painkillers and maybe alcohol and that they can die from an overdose but we also know that prescription opiates may be used in non-medical ways and also cause overdoses so I think again the at-risk population is heterogeneous and we therefore need to apply policies that can meet more than only the classical heroin user and that's one of the main challenges from Norway to to actually do that shift and that shift requires knowledge of the local situation what is the situation what are people dying from now and why and what are their backgrounds so for that we need to know our local context it needs evaluations and research on what's going on where we are and then adaptation to that situation which is shifting with time so what was the valid intervention 10 years ago may not be that anymore today and to monitor and follow that we need research but so for us we need both to keep in mind the the classical illicit drug users and heroin users and now the new type of at-risk population who are primarily dying from prescription opiates and then within the treatment system OST treatment system as I've also shown we are experiencing as part of a success aging populations in this treatment but that also comes with some new challenges which includes increased health somatic health issues and that treatment system hasn't really been on top of that situation and I think improving screening and treatment for somatic conditions and lifestyle related condition is important and one example is that in Norway more than 90 percent of patients in OST they are smoking cigarettes and they've been doing so for for many years and there are very few interventions in the programs that smoke cessation and I think those are the kinds of intervention that would potentially improve the health and also survival of these patients longer I don't know do you have another slide next slide if there is one yeah and this is my final slide when I sum up the the needs in OST programs I I like to show this slide which indicates that that such a program needs to balance different dimension so one is that we need to make these programs OST easily available so in Norway we've also added low threshold OST as part of the program it should be high access to care and few people should be outside treatment but then when we manage to do that when actually we do have a large share of the population at risk in treatment we also have to make sure that that treatment is safe for those patients who are in treatment and that has to do with quality standards and how the treatment is provided and that varies within countries and between countries quite a lot and again we need to find the balance it has to be safe enough but also we cannot if it should be 100% safe then the experience availability of the treatment will be low so these these dimensions they they do interact with each other so we need to find the right balance between several dimension at the same time and since these patients are going to be in treatment for decades many of them it also has to be a treatment that patients feel is worthwhile and something that they benefit from in the long term and that requires user involvement and the attention to individually needs in treatment so again I think we need to bear in mind that that all these dimensions they are interrelated and they are part of the system and finding this right balance is not easy for any of us and it's kind of the clinical channel challenge for everyone every day but still we need to maintain that focus and make it better because the overall goal here is long term retention in treatment and where also other health and mental issues are dealt with in a good way while in treatment and again to manage this and to do this in a good way research and monitoring and adoption to changes to improve treatment outcomes is an ongoing need and requirement to make this happen and a final comment for us to keep in mind is that if we remember back in history some years about the smoking epidemic so let's say in the 50s and 60s smoking was popular in Europe but then we started to realize that smoking was not good for lung health and interventions to prevent smoking came in place but it took between 20 and 30 years before we saw that lung cancer deaths were reduced so even though we implement new interventions today we might not actually see results from them tomorrow but it may take many years before we see results therefore we need to commit for long term and we also have to make our policy makers understand this that we need long term and coherent efforts over time both with funding and with stamina in in seeing what's going on thank you thank you very much Thomas thanks Andrew and Martin as well yeah I think that was really very interesting to to have your your insights and your expertise on linking the the data the facts and and the responses I think we we will now have more time to take some questions from our audience and I will ask maybe some help from Marika from Ali because you were keeping a look and a knife on the on the chat so thank you thank you Isabel for optimal time management in spite of the fact that you have missed one of the speakers he contacted us to say that he was connecting from the countryside so he wasn't able to we have also with barco costa trying to to find a way but it didn't work there is one question for Martin directly asking if there is any difference between a different age of population in mortality rate and between people in opioid substitution treatment and not in opioid substitution treatment the second question first we don't know it exactly with our data but in the scientific literature you can find that mortality rate in opioid substitution treatment is much lower than outside what we know is that the mortality rate of our substitution treatment clients is really very low in comparison with with other countries because we made some mortality court study and we found out that our mortality rate is quite low what was the first question the other question was if you have your analysis stratified by age so if you observe difference between the older and the younger generations yeah that's I think this is not this is not so easy because you would have to put the prevalence estimation in relation to the number of drug-related tests and until now we didn't this so maybe I think it's a good idea we can try this for next year but at the moment I do not have this information on that thank you very much there is another question about the occupational histories of people dying from overdose and this is linked with the experience from the United States I suspect it is again quite a difficult question but I leave it to our guests to see I could comment on it at least and maybe the others will follow up but in Norway we've seen on the more social demographic backgrounds so those should die and we are increasingly observing two or three different groups or backgrounds so we have those who have very little history of work experience and they've typically maybe then been using heroin since the early 20s and and not ever enter the job market but at the other end of the scale we do have increasingly now people who have been part of the work market but or workforce but then now maybe they are on disability benefits we will find in treatment registries for chronic pain and and there are a higher number in this group are women so that we're seeing this group of people who have been in the workforce maybe they have disability benefits now and pain problems and then they die from overdoses and typically we find no illicit drugs in the toxicology but we find different kinds of medications so again in Norway as I've told previously also we're seeing these two different at risk populations those who primarily have been using illicit drugs and heroin and they're dominated by younger men and then a new group it's with older higher numbers of women and with pain problems and dying from prescription opiates and they have for a larger a larger part of that has been part of the workforce previously thank you it's extremely interesting thank you very much Thomas there is another question addressing all of you from Chile Nicola says that in this country there is not a big problem now but you would like to know what would be your advice to avoid having the big problem of opioid overdose for the future or drug related deaths for the future this is a little bit for for all of you I would say maybe I can give some answer I think the most the most yeah the most important thing is to have good access for people with opioid addiction to opioid substitution treatment if I could add to that as well I think an important thing is to prevent people becoming at risk in the first place so in one of my slides I highlighted the health inequalities and the role of poverty so if your country can prioritise keeping people out of poverty as much as they can prioritise a drug treatment services and stuff that's a bit further downstream then I think you can have a you can continue to keep your numbers of drug related deaths at lower levels but I think we have to look as much upstream as we have to look downstream when tackling these things I can add to that I'm missing some of the words I guess I can I can follow up I agree with both Martin and Andy here and in Norway also we see that those who end up in drug use problems and later are at risk of overdose deaths there those that we maybe could term outsiders of the mainstream society so and those who drop out from mainstream society that they are the ones who have not completed secondary school or come also from deprived parts of the country they're not part of normal afternoon activities like sports etc so again I agree with what Andy said you know the general preventive strategies in terms of reducing social inequality and health inequality are important and as Martin said provide rapid and easy access to OST for those with opioid disorders again I think one thing that we need to to remember is that situations change quickly so even though we think or experience that overdose is aren't a major concern now the situation can change fairly rapidly and therefore also having some monitoring systems where we detect change fairly quickly and then can adapt to it and address it properly is important thank you very much very important remark there is one question addressing you Thomas and it is about how difficult was if it was difficult the debate around heroin treatment in Norway you mentioned in your presentation if you can expand a little bit about this yeah well I guess it's it's been a debate for many years and there's been probably strong opposite views on it and but then also the former government they at some point decided that this this was their priority and then they they were in majority while in position so they decided and I think it's a good idea what they did they decided to do it as a trial project so they didn't implement it full scale in the beginning but they are trialing it in two cities and they also funded evaluation of it so that during the five-year trial period there will also be an evaluation and a report which is to recommend what's what's going to happen after the trial period so I support that idea but it was debate before this started but doing it this way we will also learn from the process and and the evidence base will be as good as possible in four or five years when the decision is to take in what what is going to happen with the program yeah Marika can I add to that yes please absolutely yes yeah it's just in relation to heroin assisted treatment I think the UK is an interesting example where the UK government commissioned a research into this a number of years ago so a clinical trial that people may be familiar with which was called riot and led by John Strang and that found evidence of effectiveness and cost effectiveness of heroin assisted treatment but the government refused to act upon that effectiveness evidence and wouldn't fund the rollout so what we have been left with is two small pilots in the UK one in the northeast of England and one in Glasgow actually in my home city despite the the evidence from around Europe and in other parts of the world that this is an effective response and interestingly the new UK government drug strategy was published just two days ago on Monday and I think people optimistically thought that heroin assisted treatment would be within scope of that because it was recommended by Dame Carol Black in her evidence gathering but it is one of the notable absentees from that UK government strategy that heroin assisted treatment is not within scope of that strategy so despite the evidence that exists it continues to be one of these treatment interventions that has no courage favour with governments for for whatever reason thank you very much Andrew there is one interesting question about what measures are in place for non-opioids related deaths and people using drugs I guess this is for all of you I'll just say something briefly I think Thomas highlighted this in his final slide that the drug death prevention services are very much focused on a traditional model of opioid users and certainly in my country they haven't modernised quickly enough to look at the wider range of substances that people are using now including benzodiazepines, cocaine, gabapentanoids etc which are much more prevalent in the poly drug mix now so I think we have an urgent job to modernise their approach to reflect the type of substances people use now beyond opioids but Thomas was the one who highlighted this so he maybe want to add more well I can just comment on it I think you know as we all know or at least in Europe in many places of overdose that's 80% or more are related to opioids so but then it means 20% or around that would would be from other types of drugs including stimulants which are an increase many places both cocaine and amphetamine and methamphetamine related deaths so yes I think we should not lose sight of the other ones although we maybe have the the main focus on the opioids we should also diversify the interventions to include other drugs and again I think the the basic approaches would be at least provide access to treatment so we don't have substitution types of treatment for most other drugs but at least provide drug treatment and keep awareness also on the other types of drugs there is a challenging question about do we have means to disentangle accidental or voluntary overdoses I guess this is quite a difficult question but I imagine that sometimes there is a doubt yeah I can start at least and that is a challenge I think in any country and as a general rule I would expect suicides or voluntary poisonings to be underreported in most countries in Norway at least those who are coded as violent or suicide poisonings they they have to be confirmed with a specific you know farewell letter or those kind of things to be coded as a suicide rather than an accident so I think they are underreported generally and it's difficult I don't I don't have any specific suggestions how to do it better but we need to be aware of it and again for those types of overdose deaths that are included in the main numbers the interventions are quite or should be quite different from the accidental ones because accidental ones are those that we primarily have been targeting but suicide types of poisonings and overdose deaths then we should talk more about access to mental health care and you know probably also basic services in terms of social needs so again it's the health disparities and it's access to mental health care that would be the types of intervention required thank you thank you to you Thomas any other comments by the other panelists may I continue also you this is somehow how I hidden think the suicide among the drug users in our mortality cohort study the suicide risk of drug users was five times higher than in the general population also there is this underreporting which was already mentioned so I think maybe suicide prevention should be also a thing which should be implemented in opioid substitution treatment or in other services with drug users because they have this risk and I think that the number is much higher than then we found out in our mortality cohort study it's just a minimum number and and also yeah so okay and you would you like to add something no I would agree with with the other panelists all suicides in Scotland are all suspected suicides are investigated thoroughly but the same level of investigation is not done on drug related deaths so by virtue of that it's almost certain that some drug related deaths will be under reported suicides the size and scale of that I couldn't comment on but I think it is reasonable to assume that there will be some cases of drug related deaths where the overdose was intentional unfortunately thank you very much I'm tempted to associate with an old study we made in Italy the death study where also we investigated the violent cause of death among people who use drugs there is one question that is again for everybody and what about the role of distribution of food and proper living conditions as a measure for opioid prevention so to extend the care to the condition and I invite also Isabelle if you see some question that you would like to highlight please do it in the meanwhile I see in the screen Alessandra you are sharing part of the responses guide but sorry please go ahead with the answer food and proper living conditions if I can start Marika I think it comes back to the the issue of poverty again so we talked about poverty and poverty can be income related it can be food related it can be fuel related so if people are living in unhealthy circumstances in relation to whether they can't feed themselves or whether they can't heat their homes or whether they don't have a job I think all these factors contribute to increase an individual's level of risk including our level of risk of poor physical health poor mental health and we know that some of these are markers for poor drug use outcomes as well so I think if we want to take a holistic approach to drug death prevention then we have to as I said earlier we have to look not just at the immediate kind of service level landscape but we also have to look at broader a society in reducing health inequalities because I think that that can absolutely help this agenda yes I think it's become particularly apparent during the COVID emergency any other comments as well yes please yeah I agree with Andy there and I think you know if we look historically back in in the UK and particularly and maybe Scotland as well but when the Thatcher government closed down like the coal mine and the traditional work towns and people lost their jobs some lost their houses they got severely hit their economy we saw both that alcohol use increased but also a few years later I think opioid overdoses so that but when we have social crisis and people experience painful things in their lives this is a risk and this is what we see in the United States so a lot of the overdose epidemic that they've seen there is among those socially deprived those without health care insurances and all that and and they experience painful things in their lives where opiates it being illicit or prescribed relieve that pain for some hours and and that really increases the risk of overdoses I think so and in the US as you said but when you had a large population in a very deprived situation and you get the COVID pandemic on top those who are already vulnerable they will be more vulnerable with a new crisis on top as we've seen with COVID in the United States so so I think this this overdose mortality issue is not independent of what's going on around us in the society and social inequality is an important factor thank you very much for this there are two questions that are unrelated one with the other but I would like to propose them together and the final remark it's about the role of clean syringes in the prevention of those mortality and I think it goes in the direction some of you have already said like package of interventions rather than disentangling individual interventions and the other so I say the two and then you can comment on both is about the role of stigmatization on possible voluntary overdose would like to start Marika sorry I didn't hear the question you broke up when you were talking there sorry okay the first question comes from Pakistan and this is about the role of clean syringes to prevent also overdose so probably as a package of intervention for prevention and the other asks about the role of stigmatization on the possible voluntary overdose I don't know if any of you would like these two questions suggest the idea of providing packages of interventions I can maybe start a well needle and syringe provision that there's very very strong evidence for the prevention of blood bone viruses in particular especially when used in combination with opioid substitution treatment that's when it's most effective and we know there's also evidence that people who have blood bone viruses so people who have hepatitis c or hiv are at a greater risk of drug related death so if you can prevent the blood bone virus by definition you can reduce the risk of drug related deaths so needle and syringe provision should absolutely be part of the the package of interventions that's that's that's rolled out to people at risk because they have multiple benefits and in terms of stigma I think I think it's universally accepted now that stigma is stigma does kill stigma there is that there is widespread against people who use drugs it's been well documented now and I think that's a better understood problem now than it maybe was five or ten years ago and the responses from national countries are starting to improve I gave an example of the scottish government's anti-stigma campaign that was launched this week and I think there is now a movement in certain areas to try and frame drug use as a health issue not a criminal justice issue and I think that's a key it's a key starting point to reducing stigma amongst these populations the other thing that's key to stigma is language and how we refer to people and I think that has improved in recent years we refer to them more commonly now as people we don't refer them to them as junkies or addicts or all these stigmatizing terms and again I think the narrative in that is changing not just within our own field but also within media as well and journalists have definitely started to improve in that front as well so I think I think there's a lot of work to be done in that area but it's definitely I can see improvements I'd like to add on that particularly on the provision of syringes I agree with what Andy said there's very good evidence that they prevent the spread of infectious diseases and secondary to that also reduce possibly over those deaths but one important thing around that is that the general approach to an idea of harm reduction because that discussion and debate varies a lot around the world and in some parts of the world harm reduction is not really accepted so the so on those terms needle exchange and even naloxone wouldn't be acceptable and again what I think there's good evidence for is that the provision of harm reduction measures such as clean needles does not result in increased drug use in the population so teenagers in a country would not start to use drugs because there are clean needles available there are other things that would cause them to start to use drugs but and if they do clean needles would prevent them from further harm so there's no evidence that the provision of harm reduction in being clean needles or naloxone will increase or encourage drug use in a community it's I think it's important to keep that in mind and and spread that message and I would like to add another aspect concerning this needle exchange because all this harm reduction is that sometimes it's the first possibility to get in contact with the drug users and you also could give them some talking or some counseling when they change the needle so it's it's it's part of a package and it's always it's sometimes the first point of contact with these people thank you very much indeed so we won't be able to answer all the questions it always happen is a good sign I will give the floor to our director but there is one question I would like to pick for him I'm provoking and this about how to give greater policy attention to drug related deaths this is one of the questions from our public Alexis the floor is yours thank you marica and thank you for the question so difficult to conclude actually impossible to conclude and to summarize but still a few remarks that I would like to share with you but I would like first to thank all the and also all the participants and the questions I think your your fidelity to the webinars of the mc dda your your very active participation it encourages us to continue usually there is an evaluation at the end of the webinar but I really would like to invite you even more than I do every time that you should send us requests or suggestions about how we could be even more useful for you in the future as marica and all the colleagues we prepare the program for the next wave of webinars next year but also to see how as the european drugs agency we can be more useful for customers and certainly practitioners from the field and people who are using drugs are among our top-level priority customers so the the first thing that I note while listening to the to the different discussions and presentation is the the dynamic evolution and interaction of the lecith and illicit market there was the example of benzodiazepines that that's something that we describe I think quite well as c mc dda at european level but I think sometimes people forget or do not realize that what we explain or present at your EU level is actually what is happening in a very dynamic way at national or local level so I think those are very useful examples I see also the growing importance in some countries of the impact or changes in legal prescription of opioids and and that's very important because as you most of you know this is at the origin of the biggest opioid with the last year around 90 000 people who died from overdose just so so we certainly want to avoid this to happen in the european union and its member states so something that joins our message when we presented the european drug report this year when I said that we may find ourselves just before the next perfect storm is the correlation between multiple deprivation and death from overdose and including as some of you mentioned the fact that vulnerable groups are even more exposed to the negative impact in terms of mental health of covid pandemic and the lockdown measures it certainly can be associated to the economic crisis following the covid pandemic of which in the EU we have not yet seen the biggest part of it still because the most of the governments they are still providing active financial support to the economy but the day will come that this will end and that the the most brutal impact on the economy will appear again affecting vulnerable groups which means also causing for some people maybe inducing a start in substance use but for some others also a change in substance use for instance because they would move for cheaper substances or mode of consumption and and so certainly that's that's one of the things we we we raised the awareness of decision makers because the clear message for two years from two years of webinars and all the work we did around covid or key message still is drug treatment services should not pay the bill of the covid 19 pandemic and I think this message needs to be repeated until we are sure that treatment and services will not be disrupted next time governments need to to make savings in their budget another important point which for me shows a very interesting development in the recent years is more questions about the quality of treatment also the to realize that we really need especially at local level you have shown explained very good reasons that there is a need to increase the in-treatment coverage but underlining all difficulties and and therefore certainly I think the fact that we need to associate much more systematically the clients is certainly very important one one in that sense something also very even more important today than it was already before is it's an emergent need to adapt treatment modalities and services to the needs of in some cases an aging population but in some other cases of people having problem with other substances I think about crack for instance and and and I think there are some interesting reasons from the evaluation of the DCR in France showing that apparently there is a need to establish a better link with treatment services but this can be possible only if we adapt the services to what the clients can do so it's not only a dogma that the treatment has to be in one way we need to look at what are the risks and what are the introduced much more flexibility and I think that's something that as I myself a clinical psychologist I think that 10 or 15 years ago we were not necessarily ready to consider so we certainly need consistent and evidence-based national strategies but no need to insist that your comments show that that's not granted and even with the strongest scientific evidence we are not sure always that we will get the strategy and the policy that this would support we need to continue to support an exchange on best practice on the implementation of programs such as Naloxone and I would like to insist that the MCDDA is there to provide any kind of support for practitioners and national authorities and we are lucky that we have been able to support this discussion and to push for to help for some kind of conclusion for instance in Greece recently need for more research and evaluation and again evaluation probably in the drugs treatment field is something about new relatively new as a concept but I think we we I know there are plenty of requests and needs that are put on the on the shoulders of people working in the treatment area but that's certainly one of one of the emerging emerging more important needs more than ever I would say and then to to finish with a general comment and reflection I think that what what some of you have explained in the in the very concrete terms with evidence with some diplomatic references also is that there has been an evolution in some countries at national or the recent least that has not always been positive I think what we observe in many places is that we have over specialized and fragmented responses and there is a pressure on the services in the same way that there is a pressure on the nurses working in the hospitals considering that they should stop speaking with or talking with with the patients because it's considered as a loss of time but actually this is this is part of the care this is part of the intervention and and I think the the pressure to efficacy to efficiency in some cases may have as an impact that each as illustrated by each of you we we we we should we should look more broadly not only about methadone or buprenorphine not only about the dose but what are the new needs of those clients who are in the treatment the same treatment with the same boring methadone for 20 years what what are the different needs how can we support and this leads me to to the last point is that we we we we need more inclusive policies we need we need to to push towards a comeback towards involving involving and associating the communities the communities they are part sometimes of the problem because of deprived areas socially economically deprived areas but there is no way to bring solutions if we don't involve and if they are not accepted by the communities and I'm really worried to say that in many countries when I look in the news or the languages that I understand or on the internet we have more and more discussions and sometimes conflicts about the solution that in the case even the authorities once want to implement the solution that the not in my backyard reaction makes that because there was no consultation or maybe that the people living in a socially deprived area have much many other problems that just drug use and that you cannot pretend addressing only the problem of drug users if you don't try to also bring a solution for the community as such so so and that's that's the part of our interventions that I think every 20 25 years we need to reinvent the same way that 30 years ago in some European countries we developed we discovered what was called the community approach which still had different definitions if we compared between France Italy spend in the UK for instance I think we need to come back to this because to a more fragmented society to the pressure of the economic crisis this I think will be certainly the key to maintain the existing services and to help to manage to help better people to survive and maybe to get rid of substance use and and to find a way to build or rebuild a new a new life while in any case the overall conditions remain challenging for everybody having said that I want to thank you all again and as far as I'm concerned I want to thank all the mcdd staff who is involved in the organization of all those webinars and more broadly that are also involved and contribute to create all those new mini guides but we need to be and to do better so we need your input to tell us how we can be more useful so thank you very much and looking forward to see you next year thank you very much Alexis always inspiring we don't anticipate the webinars that we have in program for next year and I'm very looking forward to suggestions from our public I would like to thank the guests including Mark Johnson who was on table but tried to connect with us Isabel who was very good in managing in spite of some of the problems and a lot of colleagues that people don't see behind the scenes some of them not in service today Marco Costa was helping us with our technical problems and Paro Oliver all the ICT colleagues communication colleagues I will just launch a quick poll for our audience to ask them how to improve our guests can go I will remain a few minutes to give people time to answer the poll and to leave thank you everybody