Optimizing Overdose Response in the Emergency Department: New challenges and initiatives in Scotland

With 1,051 drug-related deaths (DRDs) registered in 2022, Scotland's mortality rate remains the highest in Europe. Since 2011, the Scottish take-home naloxone (THN) program has been a cornerstone of drug policy, focusing on broad-scale community-based naloxone distribution to people who use drugs, their peers and family members, and first responders.
Recent changes in drug markets and use are concerning, as opioid overdose cases in Scotland show increasing clinical complexity. Benzodiazepines, mostly from illicit sources, are involved in the majority of DRDs. In late May 2024, the National Crime Agency reported 47 DRDs in Scotland that were linked to nitazenes — potent synthetic opioids mixed into street drugs, such as heroin, benzodiazepines, and amphetamines.
In mid-June 2024, U.S. government agencies reported that among overdose survivors, 1 in 6 individuals experienced another nonfatal overdose, and 1 in 100 died of an overdose within a 12-month follow-up period. At international level, there is thus an urgent need for evidence to inform health policy and practice to support high-risk individuals.
In recent years, U.S. emergency departments (ED) have started piloting the initiation of overdose patients onto buprenorphine treatment and providing them with THN kits on discharge. The feasibility of such interventions in the Scottish and wider European contexts has yet to be established. Monitoring data suggests that ED-based distribution only accounts for a small proportion of distributed THN kits in Scotland to date. 
In this abstract, we outline current research initiatives in Scotland focused on novel ED-based interventions targeting overdose patients to prevent further loss of life. 
As part of the RUFUS project, a randomized controlled trial will explore the safety and efficacy of ED-based intramuscular flumazenil administration, assessing breathing, seizures, agitation, sedation, and pharmacokinetics/pharmacodynamics in patients with suspected benzodiazepine overdose. LGC will be able to detect the presence novel synthetic opioids including nitazenes.  
Nested within the RUFUS project, qualitative research will explore overdose circumstances and intervention perceptions among patients and healthcare professionals to understand how overdose treatments can be optimized in emergency care. 
Conclusion: This abstract aims to generate discussion and potential international collaborations to identify solutions to prevent overdose deaths in rapidly changing illicit drug environments.