1. The Euro-Drug Emergencies Network (Euro-DEN) ED presentations with acute toxicity related to the misuse of prescription medicines
Professor Paul I Dargan
Guy’s and St Thomas’ NHS Foundation Trust and King’s College London
London, UK

2. Funding and Conflicts of Interest
Euro-DEN and Euro-DEN Plus
: Financial support from EU DPIP/ISEC Programme
2015-date: Support from EMCDDA
Prescription Medcine Misuse RADARS funding
Research grants from RADARS for prescription medicine misuse web monitoring and internet surveys; honoraria and expenses to present at RADARS scientific meetings
Personal
Member: EMCDDA Scientific Committee, GSK Global Analgesics Panel, UK Advisory Council on the Misuse of Drugs (ACMD)
Advisor: World Health Organisation (WHO), US Food and Drug Administration (FDA) and United Nations Office on Drugs and Crime (UNODC)

3. Hospital Coding Systems
Hospital admissions (discharges) coded using ICD-10
ICD-10 is reliable for routine medical / surgical conditions
Previous studies of acute illicit drug / NPS toxicity
Cases coded by clinical feature(s) and the drug(s) are often not included in the code
Only admitted cases coded: 70+% discharged from ED
Overall ~ 10-20% identifiable drug-related code
Pilot data from our group confirms this is also the case for prescription medicine misuse presentations to the ED
Therefore not possible to automate data collection on acute prescription medicine toxicity presentations

4. Other potential data sources include:
Part of the jigsaw puzzle to fill the significant public health data gap in our knowledge of acute drug toxicity in Europe
Other potential data sources include:
In vitro and animal studies
Population/subpopulation surveys, user forums
Poisons centres
Case reports/series; ambulance service data

5. Sentinel centre model
Collect data on ED presentations with acute toxicity related to the use of illicit drugs/NPS and/or misuse of prescription/OTC medicines
Specialist centres with an interest in emergency medicine and clinical toxicology
Lead centre: London; steering group: EMCDDA, Mallorca, Oslo

6. Definition of a Euro-DEN case:
“An individual who presents to the sentinel centre acute care facility with clinical features consistent with acute recreational drug toxicity and/or directly related to recreational drug use”
Recreational drug definition
"A psychoactive compound that was taken for the purpose of recreational activities rather than for medical or work purposes or as part of (deliberate) self-harm”
“Misuse of prescription and over the counter (OTC) medicines for recreational purposes” [hereafter called prescription medicine]

7. Euro-DEN Methods
All ED presentations to the sentinel centre with acute illicit drug / NPS / prescription medicine misuse toxicity
drug(s) involved: patient self-report
Exclusions
lone alcohol toxicity
cases not related to acute toxicity e.g. trauma, infection, self-harm
Euro-DEN minimum dataset (60 parameters)
collected from routine clinical records
entered onto Excel spreadsheet and data returned to London for collation

8. Euro-DEN Year 1: Oct 2013 – Sept 2014
16 sentinel centres in 10 countries
5529 presentations

9. 31 sentinel centres in 20 countries
Euro-DEN Plus
31 sentinel centres in 20 countries
2014 – 2016: 16,033 presentations

10. The Euro-Drug Emergencies Network (Euro-DEN) ED presentations with acute toxicity related to the misuse of prescription medicines
2 year Euro-DEN Plus dataset: Oct 2013-Sept 2015
Data from the 16 original sentinel centres
10,956 presentations involving 16,986 drugs

11. 10,956 presentations involving 16,986 drugs
2 year Euro-DEN Plus dataset: Oct 2013-Sept 2015
Data from the 16 original sentinel centres
10,956 presentations involving 16,986 drugs

12. ‘Top 20’ most commonly reported drugs
Classical, illicit drugs
Prescription medicines
NPS

13. Most commonly reported opioids
no hydrocodone or hydromorphone

14. Most commonly reported benzodiazepines/Z drugs

15. Prescription medicine presentations
3,139 (28.6%) presentations included at least one prescription medicine
1,426 (45.4%) of the prescription medicine presentations involved only prescription medicine(s)
13.0% of all Euro-DEN Plus presentations involved only a prescription medicine
significant geographical variation

16. Overall: 13.0% prescription medicine only cases
Prescription medicine only presentations % of total presentations to Euro-DEN Plus centres
Overall: 13.0% prescription medicine only cases
4 centres >20% prescription medicine only cases
5 centres <5% prescription medicine only cases

17. ‘Top 20’ drugs in the prescription medicine only presentations

18. Prescription medicine only cases
68.7% male, 31.3% female
Median (IQR) age 37 (28-46) years
Mode: 32 years
All Euro-DEN cases
76.0% male, 24.0% female
Median (IQR) age 31 (24-39) years
Mode: 25 years

19. Outcome Disposition from the ED Length of Stay 9 (0.6%) fatalities
53.0% medical discharged, 16.9% self-discharge from ED
16.7% medical, 8.6% critical care, 4.3% psychiatry admission
Length of Stay
Median (IQR) 6h 09m (3h 21m-14h 51m)
<12h: 70.0%, <24h: 86.3%
9 (0.6%) fatalities
3 methadone
1 oxazepam, zolpidem, baclofen, ethanol
2 fentanyl
1 no analytical data (history: benzodiazepine, ethanol)
1 buprenorphine, fentanyl, diazepam
1 morphine, codeine, ethanol

20. Conclusions Euro-DEN Plus:
Unique insight into acute illicit drug, NPS, prescription medicine misuse toxicity presentations in Europe
Over ¼ of acute recreational drug toxicity ED presentations involve misuse of a prescription medicine
13% involve only a prescription medicine
Geographical variation
Benzodiazepines and opioids are most common
Different pattern of opioids to North America
Triangulation with other datasets: greater understanding of the phenomenon and inform prevention strategies

21. Thank You