Home > Take-home naloxone.

Cannon, Aoife (2016) Take-home naloxone. Drugnet Ireland , Issue 57, Spring 2016 , pp. 22-23.

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This article describes some of the findings of a report Preventing opioid overdose deaths with take-home naloxone,1 recently published by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Opioid users are 10 times more likely to die of an overdose than their age- and gender-matched peers.2

 

Data presented in the EMCDDA report  indicates that between 6,000 and 8,000 drug-related deaths occur every year in Europe and that opioids account for the majority of these deaths.1 In Ireland in 2013 , there were 203 deaths in which opioids were implicated .4 Of these 203 individuals, 93 (46%) were not alone at the time of death, suggesting that an early intervention, such as the administration of naloxone, may act to prevent opioid-induced deaths in Ireland.4

 

Opioids and naloxone

Opioids are highly addictive compounds that reduce pain by binding to their receptors in the brain and body, and by reducing the intensity of pain signals reaching the brain. A side-effect of opioid use is reduced breathing capacity, i.e. respiratory depression.

 

Naloxone is a semi-synthetic drug, which prevents opioids from binding to opioid receptors in the brain and body, and reverses respiratory depression . Naloxone is capable of reversing respiratory depression within one to two minutes if administered intravenously; with intramuscular or subcutaneous delivery, the effect takes longer, typically three to four minutes. In order to make naloxone use more user-friendly for non-medically trained individuals, alternative routes of administration have been explored. Intranasal (in the nose) preparations and buccal (in the mouth, against the cheek) are being assessed for their efficacy and may be more suitable for naloxone use in a non-clinical setting.

 

Risk of overdose

People with an opioid dependency are the group most likely to experience an overdose. Risk factors for opioid overdose include:

  • injecting opioids,
  • loss of tolerance,
  • using opioids in combination with sedatives,
  • recent release from prison,
  • discharge from a residential rehab/detox, and
  • using alone. 

History of naloxone use

Since its discovery in the 1970s naloxone has been widely used in hospitals to reverse the effects of opioids. In the 1990s, paramedics in the US were trained to use naloxone in suspected opioid overdoses outside of the clinic, in a bid to decrease opioid-associated deaths in the community. In one urban setting, a study revealed that 90-94 per cent of the 487 individuals who received paramedic-delivered naloxone treatment responded rapidly, indicating that naloxone was a quick and effective treatment for opioid overdose in the community.  

 

Despite the fact that there have been over 40 years of data and experience on naloxone use in a medical setting, the concept of take-home naloxone is relatively new. An increase in opioid-induced deaths in Chicago in the early to mid- 1990s spurred the Chicago Recovery Alliance (CRA) to commence an informal take-home naloxone programme in 1996. This is the first known established provision of take-home naloxone. The CRA trained service users in overdose prevention and provided them with take-home naloxone kits. Owing to the demand for the service, in 2001 CRA formalised the programme and standardised the training. Similar programmes were set up in Germany, Italy and the UK in the late 1990s .

 

Training for take-home naloxone

Data from a report published by the WHO in 2014 showed that many opioid overdoses occurred in the presence of other people. Based on this, three target groups for training in administering take-home naloxone were identified: (1) opioid users, (2) close family and friends and (3) services that interact with opioid users. Opioid users were the primary focus of many training programmes owing to the fact that they have a 50-70 per cent lifetime risk of having an overdose and also because they are likely to be a bystander at an overdose.3

 

International research has found high levels of support among opioid users for take-home naloxone. However, opioid users have also expressed several concerns. These include questions about competency when administering naloxone in the event of an overdose, the legal repercussions regarding the carrying and use of naloxone, and anxieties about either those they have treated or they themselves experiencing withdrawal symptoms. The authors of the EMCDDA take-home naloxone report recommend that concerns should be addressed when establishing take-home naloxone programmes.

 

Overall, data in the EMCDDA report  suggest that opioid users and their families are receptive to participating in take-home naloxone programmes.

 

Legal issues

The legality of administering naloxone to someone other than the person it was prescribed for has been a dominating issue. Both professionals and servicer users have expressed concern about the risk of civil or criminal prosecution.  The United States, Germany, the Netherlands, Luxembourg and the UK have passed versions of ‘Good Samaritan’ law, which absolve the person in the event of administering naloxone to save a life.  In Italy, naloxone is available over the counter so is not subject to legislation regarding prescription.

 

Take-home naloxone in Europe and in Ireland

In 2014 the EMCDDA carried out a Europe-wide assessment on the availability of naloxone.  5 Among the 24 member states who responded, naloxone was available on medical prescription in 13 and limited to hospital-only prescription in a further 11 countries. None of the 24 responding countries currently had a national take-home naloxone programme. However, programmes existed in cities or regions across Europe, including Denmark, Germany, Ireland, Italy, Norway, Spain and the UK, and data from these studies are expected to prompt nation-wide programmes in some countries. Outside Europe, there are take-home naloxone programmes available in the USA, Australia, Canada and Russia. 

 

In Ireland in May 2015, the Health Service Executive (HSE) established a take-home naloxone project that will assess the efficacy of take-home naloxone in preventing drug-induced deaths, with an initial target of 600 participating opioid users. Participants are required to learn by video-training about overdose signs, risk factors, administration of naloxone, and basic life support. If knowledge of these can be shown, the participant is given a take-home naloxone kit.

 

The authors of the EMCDDA report strongly recommend that take-home naloxone programmes and the rate of associated overdose mortality be rigorously monitored in order to adequately evaluate its success, sustainability and cost effectiveness. No evaluation data relating to the HSE’s project are available yet.6 

1 EMCDDA (2016 )   Preventing opioid overdose deaths with take-home naloxone. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/25045/1/Naloxone.pdf

2 EMCDDA (2015) European drug report 2015: Trends and developments. Luxembourg: Publications Office of the European Union.

3 Health Research Board (2015) Drug Related Deaths and death amongst drug users in Ireland 2013.

4 Warner-Smith M, Darke S, Lynskey M and Hall W (2001) Heroin overdose: causes and consequences Addiction (96):  1113–1125.

5 Hughes, B. (2014), Distribution and use of naloxone: legal issues: Publications Office of the European Union.

6 For more information on the HSE take-home naloxone project, visit http://www.drugs.ie/resources/naloxone

Item Type:Article
Issue Title:Issue 57, Spring 2016
Date:May 2016
Page Range:pp. 22-23
Publisher:Health Research Board
Volume:Issue 57, Spring 2016
EndNote:View
Subjects:B Substances > Opioids (opiates)
B Substances > Opioids (opiates) > Opioid product > Naloxone
G Health and disease > Substance use disorder > Drug use > Drug intoxication > Poisoning (overdose)
P Demography, epidemiology, and history > Population dynamics > Substance related mortality / death
VA Geographic area > Europe > Ireland

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