Take-home naloxone: while good, it is far from good enough
Authors: Catherine Maria Comiskey
Journal: The Lancet Public Health (2018)

According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), in the 20 years since its establishment, more than 140 000-drug induced deaths have been reported. In 2015 alone, there were 7585 drug-induced deaths in the European Union and, of these, 79% had opioids present.1EMCDDAPreventing opioid overdose deaths with take-home naloxone. Insights. 20. European monitoring Centre for Drugs and Drug Addiction, Lisbon2016Google Scholar With appropriate intervention, many opioid overdose deaths can be prevented through the use of take-home naloxone (THN). Naloxone is an overdose reversal drug that has been used in emergency medicine since the 1970s to reverse the respiratory depression caused by opioid overdose. Naloxone is included in WHO's list of essential medicines and widespread take home naloxone provision is recommended.2EMCDDAStatistical bulletin 2017—overdose deaths.http://www.emcdda.europa.eu/data/stats2017/drdDate: 2017Google Scholar In addressing the ongoing and increasing challenge of opioid-related deaths, the EMCDDA commissioned a review of take-home naloxone kits and their use across the world. The EMCDDA found that personal predictors of risk included gender, age, and history of use.2EMCDDAStatistical bulletin 2017—overdose deaths.http://www.emcdda.europa.eu/data/stats2017/drdDate: 2017Google Scholar Additionally, the EMCDDA also found that behavioural risks were important and these included how a person administered the drug they used, their use of other substances, their tolerance level, and whether or not they used alone.2EMCDDAStatistical bulletin 2017—overdose deaths.http://www.emcdda.europa.eu/data/stats2017/drdDate: 2017Google Scholar The level of tolerance of a person who uses drugs is important, as it has also been found that overdose deaths can occur around specific situations, including the time close to release from a prison sentence or completion of an episode of residential detoxification or recovery treatment.2EMCDDAStatistical bulletin 2017—overdose deaths.http://www.emcdda.europa.eu/data/stats2017/drdDate: 2017Google Scholar Furthermore a joint report by the EMCDDA and Europol3European Monitoring Centre for Drugs and Drug Addiction, EuropolCyclopropylfentanyl. EMCDDA–Europol Joint Report on a new psychoactive substance: N-phenyl-N-[1-(2-phenylethyl)piperidin-4-yl] cyclopropanecarboxamide (cyclopropylfentanyl). Publications Office of the European Union, Luxembourg2018Google Scholar has highlighted that, between June and October, 2017, more than 60 deaths were reported in Sweden and Norway with the new fentanyl cyclopropylfentany alone, and these deaths occurred mainly in the home. Clearly there is a need for THN, but there is also a wider need to address the wider personal, social and behavioural risks. In their study, Michael Irvine and colleagues4Irvine MA Buxton JA Otterstatter M et al.Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling study.Lancet Public Health. 2018; (published online April 17.)http://dx.doi.org/10.1016/S2468-2667(18)30044-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar provide new evidence on the importance of the provision of THN overdose prevention kits and their use specifically during an ongoing epidemic among people who use illicit synthetic opioids. By use of modelling techniques, the authors have estimated the number of deaths averted by THN and shown how this number could be further increased with earlier provision. While the key message of Irvine and colleagues' study is both clear, and indeed necessary to save lives, the role of policy and practitioners in addressing the underlying personal and behavioural risk factors identified by the EMCDDA have not been addressed. The investigators demonstrated the value of a fast and effective response, but also highlighted that multiple interventions are needed to achieve the optimal impact. It is this holistic, multifaceted approach to the care and provision for people who use substances that cannot be overlooked and cannot be solved by the, admittedly essential, quick fix of THN. Across Europe, national substance misuse policies are moving away from a criminal justice approach to a wider, health-led, human rights-based response. Within Ireland, legislation has been changed to allow for the introduction of safe injecting facilities, in line with more than 80 such facilities across Europe.5Government of IrelandMisuse of drugs (supervised injecting facilities) act 2017 (2017) (commencement) order 2017. The Stationary Office, Dublin2017Google Scholar Decriminalisation of drug use for personal use is being explored in light of the Portuguese experience.6Houses of the OireachtasJoint Committee on JusticeDefence and EqualityReport of the Committee on a harm reducing and rehabilitative approach to possession of small amounts of illegal drugs. November 2015. 31/JDAE/035. Houses of the Oireachtas, Dublin2015Google Scholar Communities where people who use drugs live are being empowered to actively contribute to drug policy development; organisations representing people who use drugs are joining government committees and having their voices heard. If the intergenerational use of drugs is to be halted, and if quality of life for people who use drugs is to be genuinely valued and aspired to, then more than THN is needed. Genuine shared care planning across services is needed, from prisons to treatment and from recovery centres to homes and communities. Prevention is essential, research on the risks and protective factors for the children of parents who use drugs is needed, and the stigma of substance use must be addressed. Progress is being made, and wider, evidenced-based health and social responses and interventions to drug problems are emerging.7EMCDDAHealth and social responses to drug problems. A European guide. European monitoring Centre for Drugs and Drug Addiction, Lisbon2017Google Scholar The current work by Irvine and colleagues4Irvine MA Buxton JA Otterstatter M et al.Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling study.Lancet Public Health. 2018; (published online April 17.)http://dx.doi.org/10.1016/S2468-2667(18)30044-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar is an example of how wider disciplines of statistical and mathematical modelling can contribute to debate and evidence on the topic of substance misuse. Although the challenges within substance misuse research are daunting, the rewards of evidence-based scientific results can be life changing for people who use drugs, their families, and their communities. I am the sole, invited academic expert member of the Implementation Committee of the Irish Government's national drug and alcohol use strategy. Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling studyThe THN programme substantially reduced the number of overdose deaths during a period of rapid increase in the number of illicit drug overdoses due to fentanyl in British Columbia. However, earlier adoption and distribution of the THN intervention might have had an even greater impact on overdose deaths. Our findings show the value of a fast and effective response at the start of a synthetic opioid epidemic. We also believe that multiple interventions are needed to achieve an optimal impact. Full-Text PDF Open AccessA public health approach to Canada's opioid crisisAn unprecedented public health crisis is confronting North America: a deadly drug overdose epidemic. Opioids (including prescription opioids and illegal opioids, such as heroin and illicitly manufactured fentanyl) are the main drivers of drug overdose deaths in the USA and Canada. The situation in the USA has been widely publicised in international media outlets. Opioids were responsible for more than 42 000 deaths in 2016 in the USA, a number five times higher than in 1999. The situation in Canada is equally devastating. Full-Text PDF Open Access