The distribution of naloxone to heroin users

1
The distribution of naloxone to heroin users

• July 2008

2
Overview

• Mortality rates and morbidity of opiate OD
• Circumstances of opiate overdose
• Naloxone pharmacology adverse effects
• Possible problems with distributing naloxone
• Evidence from pilot studies
• Naloxone distribution in East Sussex

3
Mortality rates

• Opiate addicts annual mortality is 10-20 times
  that of age-matched non-addicted peers
• Between third and half excess mortality due to OD
  
• Only 12 of these ODs are suicide acts
• Mortality rates much higher for those not in
  treatment and for patients during the first 2
  weeks of MMT.

4
Mechanism of death

• Mainly respiratory depression leading to cardiac
  arrest (death occurs gradually gt1 hour)
• Minority caused by inhalation of vomit and
  non-cardiogenic pulmonary oedema

5
Morbidity (non fatal effects of OD)

• Among those who OD 20 suffer overdose related
  complications of such severity that they require
  hospital treatment.
• Complications include physical injury, burns,
  assault, peripheral neuropathy, limb paralysis,
  chest infections.

6
Prevalence of OD

• Strang et al (2000)
• 115 patients receiving MMT
• 50 had personally overdosed (average 4 occasions
  each)
• 97 had witnessed an OD (average 6 occasions
  each)
• Most common drug combination included heroin,
  benzodiazepines and alcohol

7
Overdose management

• Management by untrained witnesses is often
• inept, flawed or counterproductive.
• Examples of malpractice include
• Injecting salt
• Immersion in cold baths
• Slapping
• Walking the victim around

8
Overdose management

• Most witnesses of ODs are other heroin users
• During the last witnessed OD, most took actions
  to revive the victim
• Most are willing to keep naloxone at home
• Half are willing for a family member to keep
  naloxone at home on their behalf

9
Overdose management training

• Overdose training programs improve drug users
  ability to recognise and respond to opioid
  overdoses.
• Giving basic resuscitation buys time and will
  increase survival rates and reduce morbidity
• However, witnesses may still be reluctant to call
  999 and the victim may die whilst waiting for
  expert help to arrive.

10
Naloxone

• Pure opioid antagonist
• Route of administration (intravenous,
  intramuscular, subcutaneous, intranasal,
  endotracheal tube)
• Speed of onset lt2 min if iv
• gt2 min if im or sc
• Although im slower than iv, need to consider time
  required to obtain iv access
• Lasts 45-90mins (longer if given im)

11
Pharmacology (2)

• Shelf life of 2 years (?loss of potency beyond
  this period).
• Only contraindication is hypersensitivity
• No pharmacological activity in absence of opioids

12
Safety

• 90mg (9 times the maximum dose for opiate OD
  produces no behavioural of physiological changes)
  
• A review published in 1996 showed
• Severe adverse reactions in 6 out of 453 patients
  administered naloxone including asystole,
  pulmonary oedema, convulsions, violent behaviour.
  (Unsure whether this was caused by naloxone or
  the metabolic state of the patient)

13
Possible problems with naloxone distribution

• Legal status previously could only be prescribed
  and administered by a medical practitioner or a
  licensed paramedic. In June 2005, in the
  Medicines for Human Use Order, the UK added
  naloxone to the list of medicines that may be
  given by injection by anyone for the purpose of
  saving life in an emergency.

14
Possible problems with naloxone distribution

• Cost Only 10 of doses given. Only 3 of ODs
  result in death. 5 plus VAT (7.38 plus VAT as
  from September 2008) per minijet. However,
  cheaper than many other life saving
  interventions.
• Short half-life. Naloxone wares off patient still
  succumbs to OD. In Australian study only 0.004
  of OD fatalities occurred in patients who had
  received naloxone. Can occur after paramedics
  give naloxone.

15
Possible problems with naloxone distribution

• Encourage risky heroin use. Only 6 of patients
  say that access to naloxone would increase the
  dose of heroin they would administer. Research to
  date does not identify this as a significant
  problem.
• Naloxone could be used a a weapon.

16
Effectiveness of naloxone distribution

• Pilot studies carried out in Berlin and New
  Jersey in 1998/1999 involved 225 patients. About
  10 of distributed doses given. No adverse
  consequences, other than withdrawal symptoms,
  reported.
• Chicago. Between 2001-2006, gt3,500 doses of
  naloxone distributed to heroin users. 319 reports
  of peer overdose reversals. Death rate from
  heroin OD (which had increased fourfold between
  1996 and 2000) fell by 20 in 2001 and 10 in
  2002 and 2003.

17
Distribution of naloxone to heroin users in East
Sussex

• A Patient Group Direction (PGD) has been
  developed and ratified by Sussex Partnership
  Trust.
• East Sussex DAAT has funded a pilot for 200
  opiate users each to receive a minijet and a 10
  voucher if they attend overdose management
  training.
• Training run by staff from non-statutory service
  and Sussex Partnership Trust.