The BMJ Editorial: Take-home emergency naloxone to prevent deaths from heroin overdose

Time to save lives

A paradigm shift is occurring in the treatment of heroin overdose. On 5 November the World Health Organization launched guidelines on the community management of heroin and opioid overdose and emergency administration of naloxone by people who are not medically trained.1 Historically, naloxone has been used only in hospitals and by ambulance workers to reverse the effects of an opioid overdose. Today, several countries are providing emergency naloxone to patients, their families, and other potential non-medical first responders.

This is important because these overdoses contribute substantially to drug related deaths worldwide, with an estimated 69 000 people dying from opioid overdose each year. Of nearly 3000 drug related deaths registered in England and Wales in 2013, more than half (56%) involved opioids. Last month Scotland (the first country to introduce a national programme to provide naloxone) released results from the first three years of its naloxone programme. The proportion of deaths from opioid overdose among people just released from prison (a particularly high risk group) was down substantially from 9.8% (193/1970) in 2006-10 to 6.3% (76/1212) during 2011-13.

Providing emergency naloxone to take home was first seriously mooted in 1996. Since then policy and practice implications have been explored, with studies of acceptability and feasibility, reports of implementation, and observational studies on the training of staff (medical, nursing and drug workers), at risk populations, family members, and non-medical personnel such as hostel workers and police officers (see web appendix for references). Several countries have clarified that members of the general public may lawfully administer an injection of naloxone for the purpose of saving life. About 10% of dispensed naloxone is used at overdoses (sometimes for the person prescribed the drug but mostly for someone else), and reports of lives saved are plentiful. However, research on its impact on the number of deaths from overdose is scarce.

In 2012, a United Nations resolution identified the need for more effective prevention of drug overdose, including the use of naloxone. The same year, the first large scale randomised trial of take-home naloxone (N-ALIVE) started its pilot phase, providing naloxone to former heroin injecting prisoners on their release (1500 released prisoners had been randomised by October 2014).

The new WHO guidelines recommend training first responders in critical interim management of an opioid overdose, including intramuscular injection of naloxone. Importantly, these guidelines are for non-medical as well as medical first responders. They cover the risk of overdose among people working towards recovery in drug-free programmes, people released from prison, and those taking opiate substitutes (such as methadone or buprenorphine) as well as among people out of contact with treatment services.

Schemes to make naloxone available are being implemented around the world. Scotland’s national take-home naloxone programme began in 2011, and Wales’s scheme started the same year. City and state schemes have recently started in parts of north America, Europe, and Australia. Various countries have clarified the legal status of resuscitation actions by members of the public, including administration of naloxone, with the intention of saving life.

Naloxone’s potential for harm must also be considered, even though mild in comparison with the risk of imminent death. No deaths occurred in the 12 hours after naloxone resuscitation among 998 heroin users in San Diego who discharged themselves against advice from ambulance care, although three deaths in Copenhagen were probably attributable to post-discharge rebound overdose toxicity in a study of 2241 people with opioid overdose who had recovered with naloxone and were then discharged at the scene. Anecdotally, no increase has been observed in the level of risk taking.

Read the full article here.

John Strang, professor, National Addiction Centre (Institute of Psychiatry and The Maudsley), King’s College London, London SE5 8AF, UK / Sheila M Bird, professor, MRC Biostatistics Unit, Cambridge CB2 0SR, UK / Paul Dietze, professor, Burnet Institute, Melbourne, Australia / Gilberto Gerra, chief, Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, Vienna, Austria /A Thomas McLellan, chairman of the board, Treatment Research Institute, Philadelphia, PA 19106, USA

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