Naloxone

Related Chapters:
Overdose
Heroin

1. Naloxone As Overdose Prevention

(Note: For an excellent training video and other materials regarding Naloxone and overdose prevention, check out this resource from the Chicago Recovery Alliance, http://www.anypositivechange.o....)

"The heart of the challenge is the possibility that things could be different: overdose is a public health problem that can be solved. Unlike many of the other leading causes of death, death from opioid overdose is almost entirely preventable,21 and preventable at a low cost.22 Opioids kill by depressing respiration, a slow mode of death that leaves plenty of time for effective medical intervention.23 Overdose is rapidly reversed by the administration of a safe and inexpensive drug called naloxone. Naloxone strips clean the brain’s opioid receptors and reverses the respiratory depression causing almost immediate withdrawal.24 A growing number of harm reduction organizations in the United States are offering overdose prevention programs that provide injection drug users with resuscitation training and take-home doses of naloxone.25"

Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 277.
http://prescribetoprevent.org/...

naloxone, heroin, opiates, overdose, harm reduction, opioid antagonist
2. Benefits from Naloxone Distribution

"Naloxone distribution to heroin users would be expected to reduce mortality and be cost-effective even under markedly conservative assumptions of use, effectiveness, and cost. Although the absence of randomized trial data on naloxone distribution and reliance on epidemiologic data increase the uncertainty of results, there are few or no scenarios in which naloxone would not be expected to increase QALYs [Quality-Adjusted Life-Years] at a cost much less than the standard threshold for cost-effective health care interventions. Ecological data, in fact, suggest that naloxone distribution may have far greater benefits than those forecast in this model: Reductions in community-level overdose mortality from 37% to 90% have been seen concordant with expanded naloxone distribution in Massachusetts (7), New York City (11), Chicago (10), San Francisco (9, 67, 68), and Scotland (69). Such a result is approached in this model only by maximizing the likelihood of naloxone use or by assuming that naloxone distribution reduces the risk for any overdose. Preliminary data showing that naloxone distribution is associated with empowerment and reduced HIV risk behaviors (70, 71) suggest that future research is needed to test these hypotheses."

Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.
http://www.ncbi.nlm.nih.gov/pu...

naloxone, overdose, deaths, overdose reversal, opioid antagonist
3. Feasibility of Naloxone Distribution to Injection Drug Users (IDUs)

"This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone, Moher Downing, and Brian R. Edlin, "Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study," Journal of Urban Medicine (New York, NY: New York Academy of Medicine, 2005), Vol. 82, No. 2, p. 308.
http://www.ncbi.nlm.nih.gov/pm...

naloxone, overdose, survival, harm reduction
4. Naloxone Availability in Norway

"Naloxone is the most common antidote used for overdoses. It is normally ambulance personnel who administer naloxone in connection with opioid overdoses, and doses are administered by intramuscular or intravenous injection. It is now being discussed whether naloxone in the form of a mouth spray should be available to others as well, as first aid for someone who has overdosed
until the ambulance arrives."

Norwegian Institute for Alcohol and Drug Research, "The Drug Situation in Norway 2012: annual report to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)," (Oslo, Norway: December 2012), p. 38.
http://www.sirus.no/filestore/...

5. Rapid Effect of Naloxone

"Heroin is particularly toxic because of high lipid solubility, which allows it to cross the blood–brain barrier within seconds and achieve high brain levels.10
"Naloxone is also lipid soluble and enters the brain rapidly. Reversal of respiratory depression is evident 3–4 minutes after IV and 5–6 minutes after subcutaneous administration.11"

Etherington, Jeremy; Christenson, James; Innes, Grant; Grafstein, Eric; Pennington, Sarah; Spinelli, John J.; Gao, Min; Lahiffe, Brian; Wanger, Karen; Fernandes, Christopher, "Is early discharge safe after naloxone reversal of presumed opioid overdose?" Canadian Journal of Emergency Medicine (Ottawa, ON: Canadian Association of Emergency Physicians, July 2000), p. 160.
http://www.cjem-online.ca/site...

6. Barriers to Naloxone Access

"A more prosaic, but no less important, legal barrier to widespread naloxone access is the Food and Drug Administration’s (FDA) classification of naloxone as a prescription drug. This means that public health and harm reduction agencies cannot distribute naloxone like condoms or sterile syringes. Instead, naloxone must be prescribed by a properly licensed health care provider after an individualized evaluation of the patient. Because health care providers have to be involved, naloxone programs must deal with concerns about liability, which among doctors can be powerful even when they are not wellfounded in fact.31 The prescription status raises the cost of naloxone distribution and makes it illegal to give naloxone to lay people willing to administer the drug to others suffering an overdose."

Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 278.
http://prescribetoprevent.org/...

7. Cost-Effectiveness of Naloxone Distribution

"Naloxone distribution was cost-effective in our base-case and all sensitivity analyses, with incremental costs per QALY [Quality-Adjusted Life-Year] gained much less than $50 000 (Table 2 and Appendix Figure 3, available at www.annals.org; see Appendix Table 3, available at www.annals.org, for detailed results of selected analyses). Cost-effectiveness was similar at starting ages of 21, 31, and 41 years; the greater QALY gains of younger persons were roughly matched by higher costs. In scenarios where naloxone administration reduced reliance on EMS, naloxone distribution was cost-saving and dominated (that is, less costly and more effective than) the no-distribution comparison. Cost-effectiveness was somewhat sensitive to the efficacy of lay-administered naloxone and the cost of naloxone but was relatively insensitive to the breadth of naloxone distribution, rates of overdose and other drug-related death, rates of abstinence and relapse, utilities, or the absolute cost of medical services. Naloxone was no longer cost-effective if the relative increase in survival was less than 0.05%, if 1 distributed kit cost more than $4480, or if average emergency care costs (as a proxy for downstream health costs) exceeded $1.1 million. A worst-case scenario, in which the likelihood of an overdose being witnessed, the effectiveness of naloxone, and the likelihood of naloxone being used were minimized and the cost of naloxone was maximized, resulted in an incremental cost of $14,000 per QALY gained. A best-case scenario, in which naloxone distribution reduced the risk for overdose, was dominant."

Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.
http://www.ncbi.nlm.nih.gov/pu...

naloxone, overdose reversal, opioid antagonist, mortality, narcan
8. National Naloxone Program, Scotland

"The aim of the National Naloxone Programme is to contribute to a reduction in fatal opioid overdoses in Scotland. The rate of drug related deaths in Scotland remains higher than the UK average (9.17 drug related deaths per 100,000 population in Scotland in 2010, compared with 3.1 in the UK1). An earlier investigation into drug related deaths in Scotland and more recent information from Scotland’s national drug related deaths database has shown that the majority of these deaths are opioid related, the majority are ‘accidental overdoses’, the majority are ‘witnessed’ and 50% have been in prison (Zador et al, 20052; Graham et al, 2011 and 2012 3 4). As well as monitoring the supply of ‘take-home’ naloxone kits in Scotland, ISD Scotland were tasked by the Scottish Government to measure the impact of increased naloxone availability on the number of (opioid) drug related deaths in Scotland and, in particular, to monitor the number and percentage of these occurring within four weeks of prison release."

Scottish Government, "National Naloxone Programme Scotland Monitoring Report – naloxone kits issued in 2011/12" (Edinburgh, Scotland: Information Services Division, NHS National Services Scotland, July 31, 2012), p. 2.
http://www.isdscotland.org/Hea...

9. Providing Naloxone to Prisoners at Risk of Opioid Overdose on Release in Scotland

"SPS [Scottish Prison Service] developed an intervention to provide naloxone to prisoners at risk of opioid related overdose on release from prison, as part of the National Naloxone Programme, in recognition of the increased risk of overdose in the first four weeks following release from prison custody. The naloxone is packed in with their personal belongings, which are stored at reception, then supplied to the prisoner on release from custody.
"The supply of ‘take-home’ naloxone kits by prisons was introduced, incrementally, from February 2011 and by June 2011 all Scottish prisons were participating in the programme. Approximately 100 prison staff participated in training during the introduction and implementation phase (note: HMP Inverness, along with the Inverness area of NHS Highland, as noted earlier, commenced supply of ‘take home’ naloxone from July 2009)."

Scottish Government, "National Naloxone Programme Scotland Monitoring Report – naloxone kits issued in 2011/12" (Edinburgh, Scotland: Information Services Division, NHS National Services Scotland, July 31, 2012), p. 13.
http://www.isdscotland.org/Hea...

10. Naloxone Programs

"Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users."

Tinka Markham Piper, Sasha Rudenstine, Sharon Stancliff, Susan Sherman, Vijay Nandi1 Allan Clear and Sandro Galea. "Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City," Harm Reduction Journal (January 25, 2007).
http://www.harmreductionjourna...