In many countries, overdose is the leading preventable cause of death among problem drug users. In the European Union, drug overdose is one of the leading causes of death among young people and the top cause of death among injecting drug users (IDUs), exceeding deaths from AIDS-related illnesses. [3] Though adequate data is often not available in the countries of Central and Eastern Europe and Central Asia, overdose is likely a major cause of death there too according to a recent EHRN report. [1]  

Most overdose deaths are related to opioid use.  It is estimated that least two-thirds of opiate injectors will overdose during their lifetime. Out of 100 overdose events, approximately 4 of the total will result in death.[2]  The most common risk factors for overdose are a prior overdose, a recent period of abstinence (due to drug treatment, incarceration, or self-imposed abstinence) and concomitant use of other drugs including depressants and stimulants as well as some drugs that alter opiate metabolism such as protease inhibitors. HIV-positive status is associated with a 2-3 fold increased risk of overdose death; although the mechanism is uncertain, the dominant hypothesis is co-morbid medical disease such as liver, pulmonary, or systemic dysfunction. [4]

A number of interventions are effective in preventing overdose death including
•    making naloxone (a medicine that reverses opioid overdose) available to and ensuring adequate skills of  emergency services personnel (including ambulance staff and prison healthcare staff);
•    the distribution and training in use of naloxone  to opioid drug users and their families and  friends.  Naloxone is not a controlled substance according to the UN drug conventions but nonetheless it is often a prescription medication so program implementation requires carefully designed cooperation with prescribers and national level advocacy.  
•    training drug users in the prevention and management of overdose;
•    inclusion of overdose education in situations where drug users abstain from drugs like prison and detoxification programs (as overdose is common after periods of abstinence);
•    expansion of access to effective drug dependency treatment including opioid substitution treatment; and
•    mental health support (as  some overdoses may be suicides).

Many of these approaches are not expensive to run and can be incorporated into existing drug services, including harm reduction interventions.  Some cutting-edge programs to prevent and manage overdose have started to address the issue in our region.  In Khorog, Tajikistan, a local civil society organization convinced the city to allow to distribute naloxone to ambulances, emergency rooms and also directly to injecting drug users, their families and friends with training on how to use it.  Sharp declines in overdose deaths were noted after the program was underway showing that distribution of this medicine and skills to prevent and reverse overdose in resource-limited settings in our region is possible.  In Russia and Ukraine pilot programs on overdose prevention through low threshold services have begun. [1]

Response to overdose in our region has been very weak.  In most countries, it is not addressed in policy documents though some good practice examples exist: in Tajikistan national policy and executive documents address it; in Latvia it is likely to be addressed in the upcoming national HIV/AIDS program.  Overdose was also addressed in the EU Drug Strategy and Action Plan for 2009 - 2012, as well as and the 2003 EU Council Recommendation on the Prevention and Reduction of Health-Related Harm Associated with Drug Dependence though many countries have still not addressed it in national action plans.  In the eastern part of Europe and in Central Asia, surveillance is far weaker than in the west and this adds a challenge to advocacy efforts as it is difficult to call attention to a problem that is not visible.  Harm reduction practitioners, policy makers, donors and service providers often focus on the HIV epidemic rather than more broadly at the multiple needs of injecting drug users.  Better surveillance, development of models that work in our region and focused advocacy efforts are necessary to improve the response to overdose in the region.

[1] EHRN (2008), Overdose: A Major Cause of Preventable Death in Central and Eastern Europe and Central Asia. Eurasian Harm Reduction Network. Vilnius
[In English] [In Russian]

[2] Darke, S., R. P. Mattick, et al. (2003). "The ratio of non-fatal to fatal heroin overdose." Addiction 98(8): 1169-71.

[3] EMCDDA (2008), Annual Report on the State of the Drugs Problem in Europe. European Center for Monitoring Drugs and Drug Addiction, Lisbon
[In English]

[4] Wang, C., D. Vlahov, et al. (2005). "The effect of HIV infection on overdose mortality." Aids 19 (9): 935-42.