31 Aвгуст – Меѓународен ден за подигање на свеста од предозирање со дроги

Ever since 2001, August 31st has been celebrated as the International Overdose Awareness Day. The day is dedicated to people who have passed away from overdose and the message sent to public on this day is: tragic consequences and death caused by overdose can be prevented.

What is overdose?

Overdose occurs when a toxic amount of drug or combination of drugs and alcohol overwhelms the body. People overdose on alcohol, opioids or a mixture of drugs combined with alcohol. There are numerous signs and symptoms suggesting an overdose, depending on the type of medicine/alcohol/drugs they used.


In 2011, somewhere between 102,000 and 247,000 people in the world died as a result of an overdose. In Europe, in the first decade of the 21st century, 70,000 lives were lost to overdose. Only in 2013, 6,500 people died. In Eastern Europe and Central Asia, including Macedonia, it is estimated that around 3,274,000 people inject drugs. At least two thirds report that they have overdosed, while 4 out of 100 cases ended fatally, according to the research conducted by the Euroasian Harm Reduction Network. The overdose mortality rate in 2014 for Europe is estimated to be 18.3 death cases for a population of 1 million, aged 15 to 64. More than 40 death cases for a population of 1 million were registered in 8 European countries, the highest rate among them being Estonia (113 for 1 million population), Sweden (93 for 1 million population) and Ireland (71 for 1 million population).
Statistics on Macedonia

In the Republic of Macedonia there is no modern and efficient system to register opiate overdose cases, hence it is impossible to conduct proper monitoring and make an analysis to serve as a basis for planning future internventions.
Only in Skopje, the Medical Emergency Service at the Health Institution Skopje and the Toxicology Clinic performed 865 interventions caused by opioid overdose and 18 overdose death cases from 2009 to 2012. In the first six months of 2013, the total number of death cases for 2012 increased, amounting to 19.
Most common reasons for opiate or opioid overdose:
  • Most overdose death cases are related to use of opiates and opioids. There is an increased level of risk connected to abuse of certain medicines (benzodiazepines), opioid anelgetics.
  • A large number of overdose death cases are caused by mixing heroin in combination with other depressants of the central nervous system, such as alcohol and benzodiazepines.
  • Risk from overdose is greater after a period of abstinence when opioid tolerance significantly drops. Substance tolerance is developed by frequent drug use, meaning a larger dose is needed to achieve the same effect. This is the reason why groups at high risk from overdose are primarily people released from prison or people who have been detoxificated or rehabilitated.
  • Changes in the way opiates or opioids are administered - a frequent cause for overdose is the first time a user changes the manner of use (inhalation/intravenous). If applied intravenously, the same dose has a quicker and stronger effect which can lead to an overdose.
  • Variations in the strength of street heroin. Heroin and other opioids sold on the black market vary in quality (different supplements are added like flour, plaster etc.), and consequently vary in effect. A certain dose sometimes might not be sufficient, at times it might, and at times it might be too strong, whereupon heroin  purity might lead to an overdose.
  • Lacking prompt reaction or improper interventions conducted by the people who have witnessed the overdose, as a result of insufficient knowledge in first aid, can also lead to death caused by opiates or opioid overdose.
  • Medication, such as naloxone, used in opiate overdose cases, is not broadely available in Macedonia. Naloxone is not formally registered in Macedonia and is procured solely with intervention import.
  • Fear from reporting the case due to legal consequences. In many countries people who use drugs are afraid to call an ambulance in cases of a drug overdose.
Naloxone: Magic cure preventing harmful effects of opiate or opioid overdose

Naloxone (Narcan®) is an opioid antagonist used throughout the world in emergency medical care in cases of respiratory depression casued by opioid overdose. The WHO lists Naloxone as an essential medicine, available in the form of injections (intramuscular and intravenous) or intranasal spray. The efficiency of concentrated intranasal naloxone proved to be similar to that of intramuscular naloxone used as overdose treatment. Still, even though the medication cannot be used as a drug or be abused, it is very rarely available, contrary to WHO’s requests for broad availability for people who use drugs, members of their families and people working with drug users.

Is naloxone sufficiently available in Macedonia?

For years, all research has been pointing to the limitied availability of naloxone in the Republic of Macedonia which has led to frequent overdose death cases. In terms of the state’s positive obligation, it is necessary to adopt a legal framework which will provide continuous availability and easy access to naloxone as a blocker of opioid or opiate overdose.
Naloxone in Macedonia is available only in some health institutions:
  • Services for prevention and treatment of drug abuse,
  • Services for medical emergencies and home visits,
  • Toxicology and urgent intern medicine,
  • Emergincy wards in general hospitals in Macedonia.
Supervised injection sites

Safe injecting rooms are professional health services where drug users can inject drugs in safer and hygienic surrounding. The first safe injecting room was opened in Bern, Switzerland, in 1986. Today there are over 90 suprevised injection sites in: the Netherlands, Germany, Switzerland, Spain, Australia, Canada, Norway, Luxemburg and Danmark. France is in the process of opening the first supervised injection site in Paris. The last and, at present, the largest supervised injecting site called H-17 was opened in August, 2016 in Copenhagen.      

Good examples in Macedonia

In some emergency units in Macedonia, naloxone has been available for years now and has been used in overdose cases, saving many lives. Such is the example with the Emergency Service in Kavadarci.


Establishing coordination and cooperation among decision makers, health institutions competent for opioid overdose and civil society organizations working with drus users.

Introducing advanced and efficient track record system for cases of opioid overdose wihch would allow proper monitoring, analysis and planning of future interventions.

Naloxone, an inexpensive and safe medication, should be broadely available in services for medical emergencies and home visits, competent wards in hospitals, addiction treatment centres and harm reduction centres.

Finding solutions for naloxone distribution to drug users through harm reduction programs implemented by civil society organizations working in this field.

All concerned parties should have active roles in decreasing the stigma and discrimination towards drug users and their families.

Considering the poosiblity for opening programs for supervised injection sites. Supervised injection sites are professional health institutions where drug users can inject drugs in safe and hygienic surrounding.

Irena Jovanovska

The author has a Master’s Degree in Biology from Lund University in Sweden. She has been working on public relations and is a menager of social media at HOPS – Healthy Options Project Skopje since 2015. Irena Jovanovska is a photographer and a human rights activist for marginalized communities.