Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7291.895 (Published 14 April 2001) Cite this as: BMJ 2001;322:895All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
EDITOR-Dettmer et al reported on the distribution of naloxone to
drug users for use in overdose emergencies . The state of New Mexico led
the United States in heroin-related induced deaths in 1996-1999. The per
capita death rate was 11.7 per 100,000 inhabitants compared to the per
capita heroin-related death rate of 5.3 deaths per 100,000 nationally
according to the Bureau of Vital Records and Health Statistics, Public
Health Division, New Mexico Department of Health, from 1993-1995. Rio
Arriba County in New Mexico has one of the highest heroin related
mortality rates in the country of 18 per 100,000.
Due to concerns over possible arrest and incarceration, observers of
heroin overdoses, who are often also heroin users, are reluctant to call
for an ambulance in overdose emergencies. In one study, an ambulance was
called for in only half of the overdose situations. A more effective
response by witnesses to life threatening overdoses would probably save
lives. Some authorities have advocated training in the use of the narcotic
antagonist naloxone and the distribution of naloxone to heroin users in
order to save lives in heroin-related overdose emergencies.3,4,5
In January of 2001, the New Mexico Department of Health began issuing
100 pre-filled syringes of naloxone to physicians in Rio Arriba County in
northern New Mexico for prescribing to heroin using patients. Since then,
in at least two cases, a family member or other witness has used naloxone
from this program to treat a heroin overdose. In both cases, the patients
required rescue breathing and were resuscitated by the naloxone. On March
27, 2001 New Mexico Governor Gary Johnson signed into law an act authoring
and releasing from liability non-medical personnel who administer opioid
antagonist in drug overdoses while acting in good faith.
We commend Dettmer et. al. for their preliminary work on take home
naloxone and believe that a study is needed of wider distribution of
naloxone to prevent needless deaths from opioid overdose.
Catherine T. Baca, MD
Center on Alcohol, Substance Abuse, and Addictions,
University of New Mexico Health Sciences Center
Michael Richards, MD, MPA
State EMS Medical Director
New Mexico Department of Health
Kenneth J. Grant, MD
Family and Community Medicine
University of New Mexico Health Sciences Center
References
1. Dettmer K, Saunders B, Strang J, BMJ
2001;322:895-896 ( 14 April )
2. Darke S, Ross J, Hall W. Overdose among heroin
users in Sydney, Australia: II.
Responses to overdose. Addiction 1996;
91(3):413-417
3. Abbasi K, Deaths from heroin overdose are
preventable. BMJ1998; 316(7128): 331
4. Darke S, Hall W. The distribution of naloxone to
heroin users. Addiction 1997;
92:1195-1199
5. Strang J, Darke S, Hall W, Farrell M, Ali R.
Heroin overdose; the case for take-home
naloxone. British Medical Journal 1996; 312:1435
Competing interests: No competing interests
EDITOR – Despite the time that has elapsed since a BMJ paper in 1992
suggested the idea[1], the two pilot schemes reported by Dettmer et al[2]
constitute, to our knowledge, the first published report on the
implementation of naloxone provision to heroin users for peer
administration in case of opioid overdose.
Several studies have previously addressed the pertinence[3 4] (based
on both naloxone properties [safety of naloxone with no significant
problems following intramuscular administration, rapid distribution to the
brain and other body tissues, etc.] and characteristics of the overdose
situations [heroin overdose often occurs in the company of other users,
reluctance to call an ambulance due to fear of police involvement, etc.]),
feasibility[4], medico-legal barriers[4] (naloxone is most likely to be
administered to or by people other than the one for whom it is prescribed)
and heroin users’ acceptability[5] of this intervention. However, the
encouraging results presented by Dettmer et al[2], within the
methodological limitations of a preliminary study, can assist in
overcoming medico-legal concern about conducting studies to evaluate the
effectiveness of this strategy.
Such concern is the major obstacle to authorizing a trial of naloxone
for peer administration in Barcelona, Spain, although overdose remains the
first cause of death among injecting drug users despite the high rate of
HIV among this group (Barcelona Information System on Drug Addiction,
unpublished report).
However, a heroin users’ organization (ASUT) has taken the
initiative: Naloxone ampoules are provided in the area of Can Tunis
through underground sources, together with a brief training in naloxone
administration and overdose management. According to anecdotal reports,
naloxone has been used successfully to help another user on 60 overdose
situations (ASUT, 2000 Annual Report, unpublished document).
The work reported by Dettmer et al[2] represents a promising first
step towards the evaluation of this innovative intervention. In addition
to further research on take home naloxone, more work is also needed on the
development, implementation and evaluation of non-pharmacological
strategies (eg education about risk factors for overdose, etc.) to reduce
overdose morbidity and mortality among heroin users.
Joan Trujols,
Clinical Psychologist
Unitat de Conductes Addictives,
Hospital de la Santa Creu i Sant Pau,
Av Sant Antoni Maria Claret 167,
08025 Barcelona, Spain
jtrujols@hsp.santpau.es
1. Strang J, Farrell M. Harm minimisation for drug misusers: when
second best may be best first. BMJ 1992;304:1127-8.
2. Dettmer K, Saunders B, Strang J. Take home naloxone and the
prevention of deaths from opiate overdose: two pilot schemes. BMJ
2001;322:895-6.
3. McGregor C, Darke S, Ali R, Christie P. Experience of non-fatal
overdose among heroin users in Adelaide, Australia: circumstances and risk
perceptions. Addiction 1998;93:701-11.
4. Lenton SR, Hargreaves KM. Should we conduct a trial of
distributing naloxone to heroin users for peer administration to prevent
fatal overdose? Med J Aust 2000;73:260-3.
5. Strang J, Powis B, Best D, Vingoe L, Griffiths P, Taylor C, et al.
Preventing opiate overdose fatalities with take-home naloxone: pre-launch
study of possible impact and acceptability. Addiction 1999;94:199-204.
Competing interests: No competing interests
Dear Editor
We read with interest the report by Dettmer et al [1] on take home
naloxone and its encouraging initial results. They also refer to training
opiate misusers in resuscitation as part of the project. In 1997 we
conducted a pilot study of cardiopulmonary resuscitation (CPR) training in
Glasgow, where the incidence of sudden death due to drug misuse is high.
Of the nine volunteers who agreed to participate (all opiate
misusers), eight had personally witnessed a drug overdose. Six described
unconsciousness and seven described cyanosis in the victims. The methods
used to stimulate the victim ranged from physical stimulation (e.g.
slapping) (6) or phone 999 (5) to inject intravenous amphetamine (1) or
use spoon to prevent tongue swallowing (1). Only one volunteer reported
attempting CPR.
All volunteers were assessed before and after a standard basic life
support teaching session using a validated scoring system [2]. The mean
penalty score of the group fell from 94 (range 25-120) to 11 (range 0-20),
p<0.001, paired T test for sample means. The two advanced life support
(ALS) instructors who did the testing and training confirmed that in the
post instruction test, all volunteers performed to the standard expected
for the Resuscitation Council (UK) ALS course.
In this pilot study the majority of drug misusers had personally
witnessed an overdose and strategies such as take home naloxone or CPR may
therefore be potentially useful in Glasgow. It is concerning that not all
the misusers called for immediate help, but other studies have suggested
that this may be due to fear of precipitating police involvement [3].
From the CPR sessions described above, it is clear that it is
possible to train this vulnerable group in basic life support to an
acceptable level. We believe that if enough drug misusers could be trained
in CPR, this could be a useful additional strategy to reduce mortality
from opiate overdose.
Yours sincerely
COLIN A GRAHAM
Specialist Registrar in Accident & Emergency Medicine
Victoria Infirmary, Glasgow.
GORDON W McNAUGHTON
Consultant in Accident & Emergency Medicine
Royal Alexandra Hospital, Paisley.
ALASTAIR J IRELAND
Consultant in Accident & Emergency Medicine
Glasgow Royal Infirmary, Glasgow.
KERRY CASSELLS
Glasgow Drug Problem Service
Woodside Health Centre, Glasgow.
References
1. Dettmer K, Saunders B, Strang J. Take home naloxone and the
prevention of deaths from opiate overdose: two pilot schemes. BMJ
2001;322:895-6.
2. Graham C A, Lewis N F. A scoring system for the assessment of basic
life support ability. Resuscitation 2000;43:111-4.
3. Darke S, Ross J, Chen J, Hall W. Overdose among heroin users in Sydney,
Australia. II. Response to overdose. Addiction 1996;91(3):913-7.
Correspondence to: Mr C A Graham
Specialist Registrar in Accident & Emergency Medicine
Victoria Infirmary
Langside Road
Glasgow
G42 9TY
Tel: 0141 201 6000
Email: ColinGraham@bigfoot.com
Competing interests: No competing interests
Editor,
Providing treatment by proxy for opiate overdose is attractive because it
may improve outcome in overdose victims while developing self-esteem in
drug using “rescuers”.
Unfortunately, in the pilot schemes reported, where ampoules of naloxone
were given to injecting drug users(1) it appears that most of the naloxone
was unaccounted for at the end of the study. It is possible that some of
the missing naloxone was used to support the practice of “flatlining”
where one drug user stands guard with naloxone while another uses opiates
in a dose that far exceeds tolerance – indeed we have come across this
practice as a consequence of naloxone being used in emergency ambulances
locally.
A further problem with opiate blockers is that they may be used as weapons
against other drug users (AJA came across this practice following
introduction of Naltrexone into prison practice). Provision of a powerful
drug to those who remain involved the illicit drug market should be done
with caution.
Naloxone is not without pharmacological dangers, indeed it is reported
that life threatening side effects may occur in up to 3% of naloxone
treatments for Heroin intoxication (2). It is unlikely that subjects would
have reported their involvement in deaths occurring in association with
their intervention.
Presumably the Jersey data could be examined further since, in an island
population, it may be possible to gather data from other sources such as
Accident and Emergency departments and Police to discover what happened to
the “missing” naloxone.
Before rushing headlong into provision of a therapy with unknown risks it
is important to discover the extent of harm caused by this intervention so
that this can be considered when assessing what are apparent benefits.
1 Dettmer K, Saunders B, Strang J, Take Home naloxone and the
prevention of deaths from opiate overdose: two pilot schemes. BMJ
2001;322:895-896
(2) Osterwalder JJ. Naloxone--for intoxications with intravenous
heroin and heroin mixtures--harmless or hazardous? A prospective clinical
study. J Toxicol Clin Toxicol 1996;34(4):409-16
Competing interests: No competing interests
To The Editor
Dettmer's et als paper (1) on 2 pilot studies has really answered
nothing.The numbers involved in these studies were tiny (29 episodes in
Berlin, 5 in Jersey). The response rate was less than 35% in both studies
with presumably serious selection bias. The results are anecdotal as far
as we can tell from the extremely limited methodology presented. The
patients were presumed to have done well if a,(possibly drug affected),
lay person said that they recovered (? length of observation, follow up,
late complications).
The 2nd case presented as anecdotal evidence of benefit raises
serious concerns. An agitated lay person runs into a clinic with
presumably trained medical staff, gets a naloxone injection made up, runs
of and then returns with the " saved victim". In the meantime what were
the medical staff in the clinic doing. Presumably they were so gobsmacked
by this bizarre scenario that they felt leaving a patient dying with
airway compromise around the corner was OK. Indeed this suggests that we
are know leaving heroin users to deal with their "own", and altering what
should have been the response e.g.1st aid, airway management, call an
ambulance and maybe naloxone.
I cannot cram into a reasonable length all the issues with this
"study".However a last thought to look at is that with response rates of
35% it is possible that 60 other uses of naloxone were not reported. It
seems reasonable to suppose that poor outcomes would be less likely to be
reported by a group that are naturally suspicious of authority, reluctant
to even call ambulances and are extremely wary of police involvement.
I am deeply concerned that this article was published in the BMJ
without any editorial comment. It is seriously flawed research which does
not illuminate this difficult area but just increases the shadows.For
those who believe that Naloxone is a benign drug I refer them to the
following article (2) where use of IV naloxone was associated with a 1.3%
(0.6-4.0% CI) adverse event rate (asystole, fits, pulmonary oedema,
violence).
Dr David Mountain MB BS FACEM Director Sir Charles Gairdner Emergency
Department Perth WA
1:BMJ 2001; 322: 895-896: Take home naloxone and the prevention of
deaths from opiate overdose: two pilot schemes
Kerstin Dettmer, Bill Saunders, and John Strang
2: J Toxicol Clin Toxicol 1996;34(4):409-16 :
Naloxone--for intoxications with intravenous heroin and heroin mixtures--
harmless or hazardous? A prospective clinical study.
Competing interests: No competing interests
The reported Jersey study ran between October 1998 for 16 months,
although Naloxone distribution to users continued afterwards. The
coroner's figures for deaths in Jersey from "dependent" drug use are
dominated by the use of opiates and benzodiazepines. There were no such
deaths in 1996, 4 in 1997, 2 in 1998, 4 in 1999, and 3 in the first 6
months of 2000. Such figures give no support to the effectiveness of take
home Naloxone.
Jersey's results may not be applicable to other settings. It is a
small island. Most drug users live within a mile of the hospital, and the
ambulance staff carry naloxone. It would have been safer if the
companions of the anecdotal case had phoned for an ambulance.
Competing interests: No competing interests
Take home naloxone: a contribution for the ongoing debate
Dear Sir,
We have read with interest the report by Dettmer et al (1) which
prompts us to make a few points for a timely discussion of its findings
and its implications for practice. Apart from the Berlin and Jersey
projects described by Dettmer et al (1), other European studies have been
carried out in recent years. In the Padova (Veneto Region, north-eastern
part of Italy) Addiction Treatment Unit, for example (a facility which
took care at the time of roughly 440 methadone clients daily), a pilot
trial which involved the distribution of two (400 micrograms) naloxone
vials to the significant people involved with the drug addict was carried
out between 1996 and 1997. In 18 months, about 150 naloxone vials were
given to the partners and/or relatives of these clients (only those
relatives who seemed more co-operative were chosen) together with a
syringe, the clinical description of the signs and symptoms of
intoxication and verbal and written instructions on how to administer
naloxone (2). This project was carried out because of the high number (on
average, 35 per year) of lethal opiate overdoses observed during the
previous years in Padova (a town with no more than 250,000 inhabitants).
After the start of the project a reduction of the total number of
overdoses was observed, but it had not been possible to relate this to
naloxone distribution. In fact, at that time, a strengthening of the
police enforcement was also planned and no reports whatsoever of the use
of naloxone was recorded. Consequently, the trial was abandoned and, due
to the lack of data to support the trial itself, in the recent Veneto
Region official guidelines for the treatment of opioid addiction the take
home naloxone as a practice was mentioned but not advised (3).
In our opinion, a few issues need to be taken into account both in
interpreting the Padova results and in considering the pros and cons of a
take-home naloxone trial.
A good proportion of the drug overdoses are not witnessed by anybody else
and in such case it is extremely unlikely that the client, whilst acutely
intoxicated, is able to inject him/herself with naloxone. However, in the
event that the addict is not 'intoxicated enough' the fear of his/her
subsequent withdrawal could prevent him/her from the use of naloxone.
Moreover, the overdose could be witnessed by someone who is (in 80% of the
cases; 3) intoxicated too. For this, in most cases it could be safer and
quicker to urgently call for an ambulance. Even provided that the witness
could be somewhat able to be of some help, there could still be the fear,
on his/her own side, that the police may trace him/her and implicate
him/her in the incident). For these reasons, only the non-drug using
clients' relatives could theoretically be entrusted. However, relatives
may witness an accidental overdose relatively infrequently (this is one of
the possible explanations for the non use of naloxone in the Padova
experience) and the clients could refuse to go to hospital after
successful resuscitation (so that serious complications such as cardiac
fibrillation, pulmonary oedema, convulsions and violence, which are
observable in 4 to 30 cases out of 1,000 naloxone administrations; 4)
would be observed in a non-clinical setting. Moreover, according to the
National Programme on Substance Abuse Deaths (np-SAD; a system run by our
department, which receives extensive notification by virtually every
Coroner involved in a drug-related death in England and Wales; 5), the so
called "opiate overdose" is in fact a multiple drugs overdose in which
very frequently both benzodiazepines and alcohol are involved. In this
sense, the naloxone challenge, per se, may not be enough and an additional
flumazenil (a benzodiazepine antagonist) administration could be
advisable.
Moreover, what about the medico-legal aspects which pertain to the
parenteral administration of a prescribed drug by a non-professional? It
is worth noting, in fact, that the legal status of naloxone in Italy
(where it is sold OTC, at a very affordable price, in any chemist) is
different from that in other European countries, including UK. Lastly,
some ethical issues also should be considered: in giving our clients
naloxone plus the syringe aren't we sending them an implicit message of
"condonment" of their injecting practice?
In our opinion, other options could be considered when one is trying
to cope for tackling the opiate overdose issues: a) information, i.e.:
distribution of leaflets to the clients describing the situation, from the
toxicological point of view, of the local drug scene. In this sense, the
early warning systems which are already in place could be further
implemented; b) teaching of the resuscitation techniques to the clients
themselves, to their relatives and to all the others involved in the care
of drug addiction.
In conclusion, we believe that the take home naloxone is a practice
which needs to be further investigated for its effectiveness and safety
before it is widely prompted into practice.
References
1) Dettmer K, Saunders B, Strang J: Take home naloxone and the
prevention of deaths from opiate overdose. British Medical Journal, 316:
426-8, 2001
2) Miconi L, Schifano F, Snenghi R, Benciolini P, Bricolo R:
Sperimentazione del naloxone come prevenzione dei decessi da overdose.
Bollettino per le Farmacodipendenze e l'Alcolismo, 19: 100-1, 1996
3) Serpelloni G, Schifano F: Linee guida per la prevenzione ed il
trattamento dell'overdose da eroina e degli effetti acuti dell'ecstasy.
Assessorato alle Politiche Sociali, Regione del Veneto, Venezia (I), 2000
4) Osterwalder JJ: Naloxone- for intoxications with intravenous heroin and
heroin mixtures- harmless or hazardous? Journal of Toxicology and Clinical
Toxicology, 34: 409-16, 1996
5) Ghodse AH, Oyefeso A, Hunt M, Lind J, Pollard M, Mehta R, Corkery J,
Burgess M: Drug-related deaths as reported by Coroners in England and
Wales. Annual Review 1999 and np-SAD surveillance. Report no. 5. Centre
for Addiction Studies, St. George's Hospital Medical School, London (UK),
2000
Competing interests: No competing interests