New WHO guidelines, released on 4 November 2014, aim to reduce the number of opioid-related deaths globally. The guidelines recommend expanding naloxone access to people likely to witness an overdose in their community, such as friends, family members and partners of people who use drugs, and social workers. In most countries, naloxone is currently accessible only through hospitals and ambulance crews. Globally, an estimated 69 000 people die each year from opioid overdose.
Below we reproduce the article originally published by WHO: http://www.who.int/features/2014/naloxone/en/#
Naloxone: A take-home antidote to drug overdose that saves lives
After seeing the life-saving impact of naloxone, Sharon Nedley won’t leave home without it.
Nedley, a recovering drug user, was living in a community-supported housing unit in Glasgow, Scotland. One day, while sipping her morning coffee in the communal lounge, she learned from a startled staff member that her friend was in the throes of a drug overdose upstairs.
“When we went into her flat, she was sitting on the couch. She wasn’t breathing,” Nedley recalls. “We immediately got her onto the floor. I gave her a full dose of naloxone, as I had been taught to do, while a staff member gave her CPR.”
Thanks to a training session that Nedley had followed, she knew how to safely administer naloxone, a pharmaceutical drug that rapidly reverses the harmful effects of opioids such as morphine, heroin and methadone.
“Within a couple of minutes, she sat bolt upright,” says Nedley. “She immediately opened her eyes and said, ‘I’m sorry.’ My friend is here today because I gave her naloxone.”
Wider access to naloxone
Nedley was able to access and administer naloxone as part of a government programme that aims to counter a rising trend in drug-related deaths. In 2009, there were 545 drug-related deaths in Scotland, nearly double the number recorded in 2000. By 2011, the death toll stood at 584, the highest on record.
Under the “Take Home Naloxone” programme, launched in November 2010, naloxone became accessible—after specialist training—to people at risk of an opiate overdose as well as to their circle of close friends and family.
The programme recognizes that timely treatment is critical to survival. “This is about buying time,” notes Roseanna Cunningham, Minister for Community Safety and Legal Affairs. “It doesn’t mean that you don’t have to have very serious, very fast emergency medical intervention, but it gives you the time to get that intervention into place.”
While touting the “huge importance” of the government’s naloxone programme, the Minister cautions that it is no magic bullet. “This is one aspect of a whole set of interventions that are needed if we are going to make big inroads into the drug problem in Scotland,” she says.
“I think the programme is really starting to gain momentum,” says Kirsten Horsburgh, National Naloxone Coordinator at Scottish Drugs Forum, a non-profit organization that has supported the government roll-out of “Take Home Naloxone.”
According to a new report from National Health Service (NHS) of Scotland, 6472 naloxone kits were issued in 2013/14 compared to 3878 kits in 2012/13—a nearly 70% increase. Most of the kits were distributed within communities to people at risk of an opioid overdose.
Between 2012 and 2013, the number of drug-related deaths in Scotland fell from 581 to 526. Can this dip in the death toll be attributed to the national naloxone programme? It is too early to tell, but early signs are encouraging.
Nurses in community addiction teams and pharmacists are starting to see naloxone distribution as part of “normal practice,” notes Horsburgh. This, in turn, has helped to break down barriers between health workers and people who use drugs, she says.
And there appear to be gains in the programme’s efforts to reduce drug-related deaths among people recently liberated from prison—a population at high risk of a fatal overdose. Since 2011, all Scottish prisons have provided naloxone kits to individuals on their release from custody. In 2012 and 2013, the proportion of opioid-related deaths among former inmates dropped by 50% in the four-week period following their release from prison, according to the new report from NHS Scotland.
New WHO recommendations
Globally, an estimated 69 000 people die each year from opioid overdose alone. Among people who inject drugs, opioid overdose is the second most common cause of death after HIV/AIDS.
New WHO guidelines, released on 4 November 2014, aim to reduce the number of opioid-related deaths globally. The guidelines recommend countries expand naloxone access to people likely to witness an overdose in their community, such as friends, family members, partners of people who use drugs, and social workers. In most countries, naloxone is currently accessible only through hospitals and ambulance crews who may not manage to get help to the people who need it fast enough.
Naloxone has been used in the management of opioid overdose for more than 40 years. It is a safe drug with a low risk of serious side effects. According to the guidelines, any adult capable of learning basic life support can also learn to recognize an opioid overdose, and administer naloxone in time to save lives.
- WHO Information sheet on opioid overdose
- WHO Community management of opioid overdose
- WHO Model List of Essential Medicines
Heroin-related deaths account for around 8% of all UK deaths in individuals aged 15-44. For UK prisoners, the risk of a drugs-related death is 7.5 times higher in the first fortnight after their release than at comparable other times at liberty. In 2008, the Medical Research Council approved pilot funding for the N-ALIVE (NALoxone InVEstigation) Trial, a large prison-based randomized controlled trial, designed to test the effectiveness of giving naloxone-on-release to prisoners with history of heroin use to prevent fatal opiate overdoses. (NOTE this is not the research outcomes but an overview of ongoing research)
The N-ALIVE project has two stages: the Pilot randomized trial (n=5,600) and the subsequent main randomised trial. Ultimately a total of 56,000 participants are planned to be recruited in total. (Information taken from N-ALIVE website)
The pilot was designed to randomize, equally in two prison jurisdictions, the first 10% of 56,000 prisoners (with a history of heroin injection) needed to determine if those randomized to receive Naloxone-on-release experience 30% fewer DRDs in the first 4 weeks than those randomized to the control group.
Scotland became the first country in the world to introduce a national naloxone programme in November 2010. As of 2011, the Take-home Naloxone Programme become public health policy in Scotland and Wales.
Sheila Bird is a Programme Leader within the Evidence Synthesis to Inform Health Research Programme, from the Medical Research Council Biostatistics Unit, has been involved in the pilot N-ALIVE Trial and Scotland’s monitoring of its National Naloxone Programme.
“Our group design record-linkage studies across health registers and administrative databases to ascertain key event-dates (such of hospitalization, incarceration, drug treatment, or sentencing) for national ‘virtual’ cohorts of hard-to-reach individuals. We then analyse cause-specific morbidity and mortality rates and make proposals for, or test, interventions to reduce identified major risks such as from carriage of undiagnosed Hepatitis C virus (HCV), or of overdose death soon after release from prison. The hard-to-reach populations we have focused on are caught up in addictions, criminal justice or epidemics of injection-related blood-borne viruses. We have needed to estimate how many current injectors there are by capture-recapture techniques; and to project their future drugs-related deaths. By record-linkage, we have quantified hazard-rates for ex-prisoners, HCV carriers, drug treatment clients, and ever-injectors: in the short-term (notably within 28 days of prison-release or hospital-discharge), by calendar era, and as individuals age or report misuse of alcohol. Our seminal Scottish record-linkage studies have been corroborated internationally and, in 2012, randomization began in our prison-based N-ALIVE Trial to determine if naloxone (opiate antagonist) on-release can reduce by 30% overdose-deaths soon after release from prison. In addition, our statistical work has determined the primary and secondary outcomes for how Scotland conducts 5-year before/after monitoring of whether its public health policy on take-home naloxone will have reduced opiate-related deaths when these were on an age-related increasing trajectory during the baseline period of 2006-10.”