Expanding Naloxone Availability in the ACT

ACT Chief Minister and Minister for Health Ms Katy Gallagher launched the ACT program on 16 December 2011 at the ACT Legislative Assembly. Speakers included:

• Ms Nicole Wiggins, Canberra Alliance for Harm Minimisation and Advocacy
• Associate Professor Paul Dietze, Burnet Institute

Download the launch flyer

For further information about the Implementing Expanded Naloxone Availability in the ACT (I-ENAACT) please see the program description (August 2012  V4.2)

An independent evaluation of the program will assess the implementation of the program and participants’ experiences of the program. It will contribute significantly to new knowledge about the implementation of expanded naloxone availability in the ACT context.The Chief Investigators are Associate Professor Paul Dietze, Burnet Institute and Professor Simon Lenton, National Drug Research Institute.
For further information about the evaluation see the Implementing Expanded Naloxone Availability in the ACT (I-ENAACT) program description.

An interim findings report, released on 13 February 2014 has been written by the independent evaluators Dr Anna Olsen, David McDonald, Simon Lenton and Paul Dietze.
The report found that the program is progressing well, with 23 successful overdose reversals, and the 160 program participants were found to be better trained to respond to overdose and displayed a good knowledge of how to administer naloxone.
For further information about the report, see the Key Interim Findings – Independent evaluation of the ‘Implementing Expanding Naloxone Availability in the ACT (I-ENAACT)’ Program, 2011-2013

The Final Report, released on 31 August 2015 has also been written by the independent evaluators Dr Anna Olsen, David McDonald, Simon Lenton and Paul Dietze.
The Evaluation shows that the ACT THN program has achieved its objectives in relation to recruitment and training of participants in overdose response, and participants can be trained to administer THN in appropriate circumstances. Furthermore, we documented 57 separate episodes of programissued naloxone being used without adverse events. A positive unintended consequence of the program was participants reporting a sense of empowerment, and positive emotional impacts associated with program participation. Both program participants and key stakeholders support the continuation of the program. The I-ENAACT program represents one delivery model of THN programs. Alongside international evidence on the effectiveness of various models of THN programs, the findings of this report are evidence of the feasibility of naloxone programs in Australia and could be used in the consideration of a variety of THN delivery models in the community.
For further information about the report, see the Independent  Evaluation of the ‘Implementing Expanded Naloxone Availability in the ACT (I-ENAACT) Program’ 2011 – 2014

The purpose of the Committee is to provide expert guidance and support to and develop a program to expand naloxone availability in the ACT.  For further information about the Committee, including 2011 terms of reference and membership, please download the Committee’s 2011 terms of reference.

For further information contact Carrie Fowlie, ENAACT Chair, on carrie@atoda.org.au or (02) 6249 6358

This Question and Answer document was developed by Professor Simon Lenton, National Drug Research Institute, Curtin University (s.lenton@curtin.edu.au), as a member of, and for use by, the ENAACT Committee.  It is hoped that this document will raise awareness and support stakeholder engagement in this important program.

Download the Expanding Naloxone Availability in the ACT Q&A (December 2011)

Naloxone: long history as safe, reliable and effective medication

For over 40 years naloxone has been used in medicine to reverse the effects of heroin and other opioids. In this capacity it has been shown to be safe, reliable and effective. Naloxone is an opioid antagonist. It does not produce any intoxication and has no effect on people who don’t have opioids in their body.  In Australia, as elsewhere, naloxone is widely used in hospital emergency departments and most ambulance services as a key response to opioid overdose.

In 1992 Professor John Strang from Kings College London argued for the wider distribution of naloxone to those who come into contact with people who inject drugs in order to help prevent overdose mortality and morbidity. This argument was subsequently endorsed by Australian researchers and academics from the mid-1990s. In 2009, the case for the wider distribution of naloxone was reiterated on the basis of findings emerging from (primarily ‘peer’) naloxone distribution programs running overseas.

The argument for the wider distribution of naloxone stems from findings that show that:

• People who inject drugs commonly experience overdose;
• Overdoses are often witnessed by people who can respond;
• Peers, family members and others can successfully respond to assist in the management of overdoses among people who inject drugs; and,
• Peers and family members are keen to respond to overdoses if they occur.

Adapted from a resource produced by Associate Professor Paul Dietze, Burnet Institute and Professor Simon Lenton, National Drug Research Institute (December 2010). Read The Case for the Wider Distribution of Naloxone in Australia.

Evaluation of the WA Peer Naloxone Project – Final Report (August 2016)

Implementing Expanded Naloxone Availability: Public Status Report (August 2013)

Summary of Interim Findings summary for release (February 2013)

Key Interim Findings – Independent evaluation of the ‘Implementing Expanding Naloxone Availability in the ACT (I-ENAACT)’ Program, 2011-2013

ACT Naloxone Program Launch Media Briefing (December 2011)

This Media Briefing includes comments from professionals related to expanding naloxone availability in the ACT and Australia, including:

• Professor Simon Lenton, National Drug Research Institute
• Dr Ingrid Van Beek AM, Founding Medical Director, Sydney Medically Supervised Injecting Centre
• Mr Michael Moore, Chief Executive Officer, Public Health Association of Australia
• Mr Tony Trimingham OAM, Founder and CEO of Family Drug Support
• Carrie Fowlie, Executive Officer, ATODA

Download the Media Briefing.

Recent media reports:

Evaluation shows WA drug users can save lives with naloxone (National Drug Research Institute, 31 August 2016)

Calls for trailblazing ACT drug overdose reversal program to be rolled our nation-wide (ABC News, 31 August 2015)

Drug trial praised for saving more than 50 Canberrans from overdoses (Canberra Times, 30 August 2015)

Drug overdose deaths among ex-prisoners fall (The Scotsman, 5 June 2014)

Report findings confirm Naloxone Program saves lives (ACT Government, 13 February 2014)

Saving lives for just $40 (WA Sunday Times; 26 January 2014)

Positive results for ACT trial of drug overdose treatment (ABC News, 13 February 2014)

Naloxone overdose drug is a lifesaver : ACT report (Canberra Times, 14 February 2014)

Naloxone drug overdose treatment program saves lives (Canberra Times, 13 February 2014)

Life-saving program to cure drug and alcohol addicts under scrutiny (Canberra Times, 13 March 2014)

Saving lives for just $40 (WA Sunday Times, 26 January 2014)

Dr Jack Fishman is the man who originally developed Naloxone (Narcan). He passed away on 7 December 2013 at the age of 83.
Dr Jack Fishman’s obituary. (The New York Times, 12 December 2013)
‘How do I say goodbye to a man who not only changed my world, but the whole world?’ (TotemTamers, 9 December 2013)

Nose spray Narcan reverses overdoses in Mass. town at high rate. (CBS News; 21 July 2013)

Overdose antidote trial begins in Canberra (ABC News; 19 December 2011)

Overdose antidote training (AM with Tony Eastley, ABC News; 17 December 2011)

Capital addicts get help at home (The Canberra Times; 17 December 2011)

Cover Page: Overdose Packs for Capital’s Addicts (The Canberra Times; 17 December 2011)

Australian first Overdose Management Program launched at Alcohol, Tobacco and Other Drug Awards (Katy Gallager MLA, Media Release; 16 December 2011)

Radio Interview with Dr Ingrid van Beek about Australia’s first overdose program to provide naloxone (2CC Drive Show with Mike Welsh; 15 December 2011)

Overdose Antidote to be Trialed in Canberra (ABC News; 24 June 2011)

Interview with Associate Professor Paul Dietze on Naloxone (Radio National, ABC News; 24 June 2011)

Bid to Curb ACT Drug Overdoses
19 June 2011: The Canberra Times
“It is in the interests of the ACT Government and the community to implement strategies to reduce opioid overdoses now so preventative interventions can be evaluated and refined before the number of overdoses increases further.” The association [ATODA] has renewed the 15-year campaign for access to the lifesaving drug naloxone. Download the Bid to Curb ACT Drug Overdoses Article.

Overdose Antidote Scheme ‘Could Save Lives’ (ABC News; 1 December 2011)
1 December 2010: ABC News
The ACT Government has expressed interest in a scheme to help friends and relatives of drug users to resuscitate them from overdoses.
 The Alcohol Tobacco and Other Drug Association (ATODA) has proposed an ACT trial where associates of heroin and opiate users would be permitted to administer the anti-overdose drug Narcan….
”[Narcan] is already widely used in Australia and internationally by paramedics and emergency room staff in suspected cases of opioid overdoes and it’s usually administered intramuscularly so a shot to the leg or in the bottom,” said ATODA executive officer Carrie Fowlie.
”

666 ABC Radio Naloxone Program Interviews (666 ABC Radio: 1 December 2010)
Two interviews were conducted by Ross Solly on 666 ABC Radio related to Naloxone with Health Minister Ms Katy Gallagher, MLA and Ms Carrie Fowlie, Executive Officer, ATODA.
Download the interview with Ms Carrie Fowlie, Executive Officer, ATODA.
Download the interview with Ms Katy Gallagher, MLA.

Overdose Antidote Scheme Proposed (The Canberra Times; 1 December 2010)
1 December 2010
: The Canberra Times
ACT Health is investigating a trial program that would allow the families and friends of heroin and opiate users to resuscitate them in the event of an overdose….
The proposal, which would be an Australian first, was put to ACT Health by the Alcohol Tobacco and Other Drug Association….
If the association’s proposal succeeds, an opiate user would be prescribed Narcan to be administered by a third party such as a housemate, partner or family member. That third party would be trained to administer the drug in the event of overdose….
ACT Health spokeswoman Hasnah Scheding said the organisation was investigating whether there were legal barriers to introducing a pilot program and whether it had the support of local medical practitioners.
“Preliminary advice is that it is something that could potentially save lives and, if targeted well and supported by key groups locally, it may be a valuable addition to current drug overdose prevention interventions in the ACT,” she said.

Call for Public Access to Overdose Treatment (ABC News; 25 October 2010)

25 October 2010: ABC News
“Groups dealing with narcotics users and their families are pushing for greater public access to a drug that can reverse overdoses.”

The needle and the damage done (The Canberra Times; 24 October 2010)
24 October 2010: The Canberra Times
“Academic reviews suggested making naloxone available in the heroin-using community could help reduce the number of killer overdoses.”

Intranasal Naloxone (ABC Radio National; 13 October 2008)

In November 2011, Carrie Fowlie, Executive Officer, ATODA, visited three services in New York City that provide naloxone on prescription as part of their overdose management programs.  The programs were:

• Harm Reduction Coalition (Manhattan, NYC)
• The Corner Project (Washington Heights, NYC)
• St Ann’s Corner for Harm Reduction (The Bronx, NYC)

ATODA would like to express its gratitude to these programs and their staff for sharing their expertise and experiences to support the development of a program in the ACT to expand naloxone availability.

Dr. Sharon Stancliff, Medical Director, Harm Reduction Coalition & Carrie Fowlie, ATODA

The Harm Reduction Coalition is a national advocacy and capacity-building organisation that promotes the health and dignity of individuals and communities impacted by drug use. HRC advances policies and programs that help people address the adverse effects of drug use including overdose, HIV, hepatitis C, addiction, and incarceration.

Dr Sharon Stancliff, Medical Director, Harm Reduction Coalition (East), has been a leader in promoting and providing naloxone as part of overdose prevention programs.  Dr Stancliff visited the ACT in December 2010 as part of the Australasian Professional Society on Alcohol and Drugs Conference.  For further information see:

Paper 280 – Symposium – Policy and Practice – Increasing Community Access to Naloxone to Prevent Opioid Overdose Deaths: Lessons for Australia. Drug and Alcohol Review. V29. December 2010

Get The SKOOP Kit, Harm Reduction Coalition (Manhattan, NYC)

Skills and Knowledge on Overdose Prevention Project (SKOOP) trains heroin users and their associates to utilise naloxone kits and to provide introductions to overdose prevention, training of trainers and technical assistance for staff of local services. For more information about when the project began (2006) see this powerpoint.

Some of the dedicated staff from The Corner Project (Washington Heights, NYC)

The Corner Project’s mission is to significantly decrease behaviors among drug users that put them at the highest risk for HIV and hepatitis transmission. They provide  participants with safer-injection and safer-sex supplies, harm reduction education and literature, as well as case management and referrals, supportive counseling, wellness evaluations, crisis intervention, and other crucial health and social services.

Example of harm reduction kits from The Corner Project (Washington Heights, NYC)

Find out more about what they do through their youtube video (2009)

Some of the dedicated staff from St Ann’s Corner of Harm Reduction (The Bronx, NYC)

St. Ann’s Corner of Harm Reduction (SACHR) has been meeting drug users where they are: on the streets and actively engaged in high-risk lifestyles or within the center, where they seek an individualized and comprehensive cluster of healing services.

Demonstration of GP assessing and prescribing naloxone to a patient (The Bronx, NYC)

This is an example of the assertive outreach services provided by the Harm Reduction Coalition in partnership with the St Ann’s Corner of Harm Reduction.  Other concurrent street-based outreach services being provided included safe sex kits and information; needle and syringe packs and information; peer support; and referrals.

Carrie Fowlie, ATODA & Bill Matthews, Harm Reduction Coalition (The Bronx, NYC)

ATODA’s submission to the 2011/2012 ACT Budget included a proposal for a program with the aim of reducing and preventing opioid overdoses in the ACT, which includes Naloxone.

A tool to reverse overdose (Canberra Times, 8 March 2015)

A systematic review of community opioid overdose prevention and naloxone distribution programs (Journal of Addiction Medicine, Volume 8, No. 3, p.153-63)

America embraces treatment for opioid drug overdose (The Lancet, Volume 383, Issue 9933, p.1957-58)

Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users (International Journal of Drug Policy 2013)

The Network for Public Health Law (2012), Legal intervention to reduce overdose mortality: Naloxone access and overdose Good Samaritan Laws. Ideas, Experience. Practical answer, October 2012.

AMA backs naloxone overdose prevention rollout (Anex bulletin Feb 2013, Vol 11, edition 4)

Expanding Naloxone Availibility (ANCD Position Statement; September 2012)
A substantial body of evidence shows that expanding naloxone availability and training potential overdose witnesses to administer naloxone is a remarkably safe and effective intervention for preventing opioid overdose fatalities, with the potential to prevent opioid overdose related injury

Government Considered Overdose Antidote, Naloxone, to Fight Prescription Drug Misuse (Time Magazine; 27 April 2012)
The U.S. Food and Drug Administration (FDA) has for the first time advocated considering the distribution of the naloxone, an overdose antidote, as a way to curb the rising toll of overdose deaths in America.

Australia’s First Naloxone Overdose Management Program in the ACT (2/52 Update, Fortnightly update of the ACT Medicare Local; Volume 9, 21 December 2011)

Community naloxone gets green light in the ACT (Medical Observer; 12 December 2011)

Wider naloxone access to cut heroin deaths (Medical Observer; 6 December 2011)

Hero heroin – a solution to overdoses? (Medical Observer; 15 November 2011)

Moving toward wider availability of Naloxone – Professor Simon Lenton, National Drug Research Institute (Drug Info, Newsletter of the Australian Drug Foundation’s DrugInfo Service; Vol 9, No 3, September 2011)
Despite the “heroin shortage”, about one Australian a day still dies from an overdose, most involving heroin.  For about 20 years there have been calls to make naloxone more available to people who use opioids, their friends, family members and other potential overdose witnesses to help prevent overdose deaths.

I’m the Evidence. Naloxone Works (Harm Reduction Coalition)
I’m the Evidence uses video advocacy to give a face and a voice to overdose stories happening all over the world. It provides an outlet for these stories as a way to mobilize the drug using community and harm reduction advocates around the promotion of naloxone availability and use.

Fueled by Growing Painkiller Use, Overdose Deaths and Child Poisonings Are on the Rise (Time Magazine; 19 September 2011)

Naloxone Program (Nicole Wiggins, Manager, Canberra Alliance for Harm Minimisation and Advocacy (CAHMA) Junkmail 14, AVIL; August 2011)

Update on Expanding Naloxone Availibility in the ACT (Mental Health, Justice Health and Alcohol and Drug Services Update; July – August 2011)

When a friend drops: The push to distribute potential-lifesaving naloxone (Dietze, P. 2011, Of Substance; Vol 9. No 2.)

Of Substance is a free, triannual magazine of the Australian National Council on Drugs that addresses alcohol, tobacco and other drug (ATOD) issues and problems in Australia today.

Overdose prevention and intervention: ACT leads the way (ACTCOSS Update Newsletter; Issue 56, Winter, June 2011)
Update is the quarterly newsletter of the ACT Council of Social Service, the peak body representative body for people living with low incomes or disadvantage and for not-for-profit community organizations in the ACT.

Naloxone program, Article and Opinion Piece (p.6 AIDS Action Council of the ACT Newsletter; May-June 2011)
The Newsletter of the AIDS Action Council of the ACT. The AIDS Action Council of the ACT provides services to the ACT community, aimed at eliminating further transmission of HIV and minimising the personal and social impacts of HIV and AIDS.

Update on Expanding Naloxone Availability in the ACT (GP Action, ACT Division of General Practise; Vol 144 May 2011)
Overdose Prevention and Intervention: Naloxone Trial (GP Action, ACT Division of General Practise; Vol 143 February 2011)
GP ACTion is the quarterly newsletter of the ACT Division of General Practice, whose core focus to support general practice in delivering local health solutions.

Peer Administered Naloxone Program in the ACT (Families and Friends for Drug Law Reform (FFDLR); March 2011)
FFDLR believes that prohibition laws are more the problem than the solution; it seeks laws and policies which will eliminate the deaths and minimise the health and social harm and, amongst many things, produces a monthly newsletter.

Naloxone 101 (Griffiths, P.; Anex Bulletin; Volume 9, Issue 1, October 2010, Melbourne)
The Anex Bulletin is the Australian Needle and Syringe Program (NSP) sector’s quarterly magazine and highlights new information, research findings and emerging issues for harm reduction workers. This issue of the magazine provides information on Naloxone and its role in reviving people who are suffering from an opioid overdose.

Below are some recent conference and symposium presentations related to expanding naloxone availability.

Implementing Expanded Naloxone Availability in the ACT Training Program
Nicole Wiggins, Manager of the Canberra Alliance for Harm Minimisation & Advocacy. CREIDU Colloquium: Exploring injecting-related harms; August 2013.

Expanded naloxone availability in the ACT-barriers and enablers
Carrie Fowlie, Executive Officer of the Alcohol, Tobacco & Other Drug Association ACT. CREIDU Colloquium: Exploring injecting-related harms; August 2013.

Strategic advocacy and the ‘time lag’: Expanding naloxone availability in the ACT (ENAACT Committee Members Associate Professor Paul Dietze, Professor Simon Lenton and Carrie Fowlie at the Centre for Research Excellence in Injecting Drug Use Colloquium; 18 July 2011)

Making Naloxone Available to Potential Overdose Witnesses: evidence and policy opportunities (Simon Lenon, PhD MPsyc(clin), National Drug Research Institute at the second annual Drug Policy Modelling Program Symposium; 18 March 2011)
Simon Lenton, PhD MPsych(clin), National Drug Research Institute
Professor Simon Lenton presented on naloxone and highlighted some of the work taking place in the ACT.  For further information regarding the symposium the Symposium’s website.

International Naloxone Symposium (‘Building on the Capital’ – 30^th International Australasian Professional Society on Alcohol and other Drugs (APSAD); Conference
National Convention Centre, 28 November – 1 December 2010)
A peer-administered naloxone symposium was held at the Conference, which looked at increasing community access to naloxone to prevent opioid overdose deaths: lessons for Australia.  Presenters included experts, Paul Dietze, Simon Lenton, Nicholas Lintzeris, Sharon Stancliff, Howard Wren (ACT Ambulance Service), and Nicole Wiggins (CAHMA).

Distributing Naloxone … because dead addicts NEVER recover (Dr Sarz Maxwell, Chicago Recovery Alliance at the Australian Drug Conference; Melbourne, 25- 26 October 2010)

For research and evidence summaries about other issues see ATODA’s research eBulletin, which you can subscribe to by emailing ebulletin@atoda.org.au

More naloxone needed to cut opiate overdose deaths

The UK’s Advisory Council on the Misuse of Drugs was established under the Misuse of Drugs Act 1971 to keep under review the drugs situation in the UK and to advise government ministers. This report from the council offers advice to government on the evidence regarding the opioid antagonist naloxone and whether to make the drug more widely available to prevent overdose deaths. Naloxone rapidly, but temporarily, reverses the effects of heroin and other opioids, preventing overdose progressing to a fatality. For several years it has been distributed in emergency kits to heroin users worldwide including in England, Scotland, and Wales, and in New York State, Los Angeles and Chicago in the USA. It has also been distributed over the counter in pharmacies in Italy. International and UK research has found that naloxone provision may be effective at preventing opiate-related deaths. Wider benefits around engaging with drug users and empowering family members and carers have also been reported.

For more information: See the paper (Feb 2014)

 Opioid Related Deaths – NCIS Fact Sheet April 2013

Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. This fact sheet comprises data about opioid related deaths in Australia from 2007-2009.

For more information: See the Fact Sheet (April 2013)

Promoting Prevention of Fatal Opioid Overdose

Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. Naloxone is a drug that can be used to reverse the effects of opioid overdose. The AMA today adopted policy to support further implementation of community-based programs that offer naloxone and other opioid overdose prevention services. The policy also encourages education of health care workers and opioid users about the use of naloxone in preventing opioid overdose fatalities.

Below are some recent naloxone references, compiled by Professor Simon Lenton, National Drug Research Institute and social scientist David McDonald – most are available from the National Drugs Sector Information Service (NDSIS) at the Alcohol and Other Drug Council of Australia.

For further information also see the American Medical Association website

Anex (2010), Lifesavers: a position paper on access to Naloxone Hydrochloride for potential opioid overdose witnesses. Anex, Melbourne, Australia.

Australian National Council on Drugs (2001). Naloxone availability: A Secondary Position Paper on Heroin Related Overdoses. ANCD Position Paper. Canberra.

Centers for Disease Control and Prevention (USA, 2012). ‘Community-based opioid overdose prevention programs providing naloxone – United States, 2010’, MMWR; Morbidity and Mortality Weekly Report, vol. 61, no. 06, pp. 101-5.

Darke, S 2014, ‘Opioid overdose and the power of old myths: what we thought we knew, what we do know and why it matters’, Drug and Alcohol Review, vol. 33, no. 2, pp. 109-14.

The current issue of the journal Drug and Alcohol Review has a valuable editorial by Professor Shane Darke from the National Drug and Alcohol Research Centre with the title ‘Opioid overdose and the power of old myths: what we thought we knew, what we do know and why it matters’. Darke identifies four powerful myths about who is dying and how they are dying:

Myth 1. It is the young, inexperienced user who overdoses
Myth 2. It is variation in the purity of illicit opioids that is the major cause of overdose
Myth 3. It is the opioid that is crucial in overdose, not other drugs
Myth 4. Impurities in illicit opioids are the major cause of overdose.

The research evidence that debunks each of these myths is presented. The author emphasises that opioid overdose is not an unpredictable, random event. Rather, it is concentrated in ‘older, very experienced polydrug users who die from multiple drug toxicity’. Furthermore, these deaths can be prevented through enrolling many more long-term opioid users in treatment, better overdose response including the provision of naloxone, focussing on the high-risk period when tolerance is reduced (immediately after detoxification and the first weeks after release from prison), and educating users about the risks of polydrug use—especially combining alcohol and/or benzodiazepines with opioids.

Darke concludes: ‘Drug use patterns, however, are never static and the opioids are no exception. New trends in the demography of opioid use are emerging, most prominently the use of pharmaceutical opioids such as oxycodone, which will require new interventions. At least we now know these events are not random. The fact that we can now identify who is likely to overdose and why substantially increases our chances of successful intervention to reduce the considerable harm attributable to overdose. In terms of overdose, the past few decades of research have been crucial’.

Davis, C, Webb, D & Burris, S 2013, ‘Changing law from barrier to facilitator of opioid overdose prevention’, The Journal of Law, Medicine & Ethics, vol. 41, no. s1, pp. 33-6.

Opioid overdose is the leading cause of accidental injury death in the United States, taking the lives of over 16,000 Americans every year. Many of those deaths are preventable through the timely provision of naloxone, a drug that reliably and effectively reverses opioid overdose. However, that drug is often not available where and when it is needed, due in large part to laws that pre-date the overdose epidemic. Preliminary evidence suggests that amending those laws to encourage the prescription and use of naloxone will reduce opioid overdose deaths, and a number of states have done so in the past several years. Since legal amendments designed to facilitate naloxone access have no documented negative effects, can be implemented at little or no cost, and have the potential to save both lives and resources, states that have not passed them may benefit from doing so.

Enteen, L., Bauer, J., McLean, R., Wheeler, E., Huriaux, E., Kral, A., et al. (2010). Overdose Prevention and Naloxone Prescription for Opioid Users in San Francisco. Journal of Urban Health, 1-11.

Opiate overdose is a significant cause of mortality among injection drug users (IDUs) in the United States (US). Opiate overdose can be reversed by administering naloxone, an opiate antagonist. Among IDUs, prevalence of witnessing overdose events is high, and the provision of take-home naloxone to IDUs can be an important intervention to reduce the number of overdose fatalities. The Drug Overdose Prevention and Education (DOPE) Project was the first naloxone prescription program (NPP) established in partnership with a county health department (San Francisco Department of Public Health), and is one of the longest running NPPs in the USA. From September 2003 to December 2009, 1,942 individuals were trained and prescribed naloxone through the DOPE Project, of whom 24% returned to receive a naloxone refill, and 11% reported using naloxone during an overdose event. Of 399 overdose events where naloxone was used, participants reported that 89% were reversed. In addition, 83% of participants who reported overdose reversal attributed the reversal to their administration of naloxone, and fewer than 1% reported serious adverse effects. Findings from the DOPE Project add to a growing body of research that suggests that IDUs at high risk of witnessing overdose events are willing to be trained on overdose response strategies and use take-home naloxone during overdose events to prevent deaths.

Jones, JD, Roux, P, Stancliff, S, Matthews, W & Comer, SD ‘Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users’, International Journal of Drug Policy, http://www.sciencedirect.com/science/article/pii/S0955395913000807 

Background: In an effort to increase effective intervention following opioid overdose, the New York State Department of Health (NYSDOH) has implemented programs where bystanders are given brief education in recognizing the signs of opioid overdose and how to provide intervention, including the use of naloxone. The current study sought to assess the ability of NYSDOH training to increase accurate identification of opioid and non-opioid overdose, and naloxone use among heroin users.

Methods: Eighty-four participants completed a test on overdose knowledge comprised of 16 putative overdose scenarios. Forty-four individuals completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n = 40), who opted out of training, completed the questionnaire just once.

Results Overdose training significantly increased participants’ ability to accurately identify opioid overdose (p<0.05), and scenarios where naloxone administration was indicated (p<0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered.

Conclusions: The data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.

Kinner, SA, Preen, DB, Kariminia, A, Butler, T, Andrews, JY, Stoové, M & Law, M (2011), ‘Counting the cost: estimating the number of deaths among recently released prisoners in Australia’, Medical Journal of Australia, vol. 195, no. 2, pp. 64-8.

How many ex-prisoners die soon after release from prison, and what do they die from?

Research reported in the Medical Journal of Australia reveals that ‘The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community’. The researchers estimate that ‘between 380 and 527 people released from prison in 2007–08 died within 1 year of release, with a disproportionate number dying in the first 4 weeks’.

They found that ‘a large proportion of deaths in both cohorts [NSW and WA] was drug-related, highlighting the ongoing need to develop and implement evidence-based strategies to reduce drug-related death among ex-prisoners. One such strategy is opiate substitution therapy, which has been associated with reduced mortality, reincarceration and hepatitis C infection in ex-prisoners. Yet, despite unambiguous endorsement of opiate substitution therapy in the National Corrections Drug Strategy 2006–2009, its provision in Australian prisons remains inconsistent. Another suggested approach is the provision of naloxone for peer administration. A clinical trial of naloxone provision to those at risk of overdose on release from prison has been proposed but not yet conducted’.

However, ‘Although drug overdose is a leading cause of death for recently released prisoners, more than 50% of deaths in this study were not drug-related, and at least two-thirds of deaths in the first year occurred more than 1 month after release. These findings underscore the importance of moving beyond simplistic messages about reduced drug tolerance and overdose risk in the first few weeks of release’.

Lancaster, K. & Ritter, A. (2014). Making change happen: A case study of the successful establishment of a peer-administered nalaxone program in one Australian jurisdiction. The International Journal of Drug Policy, In Press.

Leece, P., Orkin, A. (2013). Opioid Overdose Fatality Prevention. Journal of American Medical Association, vol. 309, no. 9, pp. 873-874.

Lenton, S. (2013). Endnote output of Naloxone References as at 27 March 2013.

Mayet, S, Manning, V, Williams, A, Loaring, J & Strang, J (2011). Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging. International Journal of Drug Policy, vol. 22, no. 1, pp. 9-15.

Naloxone-based overdose prevention training spread slowly in England
After being initiated in London, training for addiction treatment staff in managing opiate overdose using naloxone cascaded to other staff and to patients at a disappointingly slow pace; on average each clinician trainee trained one drug user every 11 months. Is this a sign of the low priority given to overdose prevention?

McAuley, A. (2011). The impact of drug-related death on staff who have experienced it as part of their caseload: An exploratory study. Journal of Substance Use, 16(1), 68-78.

BACKGROUND: Opioid overdose has a high mortality, but is often reversible with appropriate overdose management and naloxone (opioid antagonist). Training in these skills has been successfully trialled internationally with opioid users themselves. Healthcare professionals working in substance misuse are in a prime position to deliver overdose prevention training to drug users and may themselves witness opioid overdoses. The best method of training dissemination has not been identified. The study assessed post-training change in clinician knowledge for managing an opioid overdose and administering naloxone, evaluated the ‘cascade method’ for disseminating training, and identified barriers to implementation.
METHODS: A repeated-measures design evaluated knowledge pre-and-post training. A sub-set of clinicians were interviewed to identify barriers to implementation. Clinicians from addiction services across England received training. Participants self-completed a structured questionnaire recording overdose knowledge, confidence and barriers to implementation.
RESULTS: One hundred clinicians were trained initially, who trained a further 119 clinicians (n=219) and thereafter trained 239 drug users. The mean composite score for opioid overdose risk signs and actions to be taken was 18.3/26 (+/-3.8) which increased to 21.2/26 (+/-4.1) after training, demonstrating a significant improvement in knowledge (Z=9.2, p<0.001). The proportion of clinicians willing to use naloxone in an opioid overdose rose from 77% to 99% after training. Barriers to implementing training were clinician time and confidence, service resources, client willingness and naloxone formulation.
CONCLUSIONS: Training clinicians how to manage an opioid overdose and administer naloxone was effective. However the ‘cascade method’ was only modestly successful for disseminating training to a large clinician workforce, with a range of clinician and service perceived obstacles. Drug policy changes and improvements to educational programmes for drug services would be important to ensure successful implementation of overdose training internationally.

McAuley, A George, L, Woods, M & Louttit, D (2010), ‘Responsible management and use of a personal take-home naloxone supply: A pilot project’, Drugs: Education, Prevention, and Policy Jul 2010, Vol. 17, No. 4: 388–399.

Responsible management and use of a personal take-home naloxone supply: A pilot project
The results of this project suggest that Scottish drug users can be trained to identify and respond to an opiate overdose utilizing basic life support and naloxone administration skills similar to their counterparts from other parts of the world. Moreover these results suggest that a majority of opiate users can responsibly manage their own personal take-home naloxone supply when trained appropriately.

N-ALIVE team. (2011). Prison-based Naloxone-on-release pilot randomised controlled prevention trial Summary V1.4, 1.2.11. London.

National Treatment Agency for Substance Misuse (2011) The NTA overdose and naloxone training programme for families and carers. London.

Naloxone empowers carers to save lives of overdosing heroin users
Up to 18 lives were known (and more perhaps unrecorded) to have been saved after the National Treatment Agency in England piloted training for the carers of opiate users on how to administer the overdose-reversing drug naloxone. But how does catering for relapse in this way square with the optimism of the recovery movement?

Open Society Foundations (2011) Stopping overdose: peer-based distribution of naloxone. Open Society Foundations Public Health Program. New York.

Overdose is a major and often overlooked cause of death among people who inject heroin or other opioids. Yet there is a safe and effective treatment: the medication naloxone.
This public health fact sheet describes how naloxone is successfully being used to reverse overdose around the world with no side effects beyond opiate withdrawal. It provides real-life examples of programs that have trained drug users, their families and friends to efficiently identify the signs of overdose, administer naloxone, and often, save lives. And, it explains in-depth why naloxone is an invaluable tool for empowering communities to protect their health.

Sherman, S. G., Gann, D. S., Tobin, K. E., Latkin, C. A., Welsh, C., & Bielenson, P. (2009). “The life they save may be mine”: Diffusion of overdose prevention information from a city sponsored programme. International Journal of Drug Policy, 20, 137-142.

Tobin, K. E., Sherman, S. G., Beilenson, P., Welsh, C., & Latkin, C. A. (2009). Evaluation of the Staying Alive programme: Training injection drug users to properly administer Naloxone and save lives. International Journal of Drug Policy, 20, 131-136.

United Nations Office on Drugs and Crime & World Health Organization 2013, Opioid overdose: preventing and reducing opioid overdose mortality, discussion paper, contribution of the United Nations Office on Drugs and Crime and the World Health Organization to improving responses by Member States to the increasing problem of opioid overdose  deaths, United Nations Office on Drugs and Crime and the World Health Organization.

Wagner, KD, Davidson, PJ, Iverson, E, Washburn, R, Burke, E, Kral, AH, McNeeley, M, Bloom, JJ & Lankenau, SE ‘“I felt like a superhero”: the experience of responding to drug overdose among individuals trained in overdose prevention’, International Journal of Drug Policy, online ahead of print.

Background Overdose prevention programs (OPPs) train people who inject drugs and other community members to prevent, recognise and respond to opioid overdose. However, little is known about the experience of taking up the role of an “overdose responder” for the participants.
Methods We present findings from qualitative interviews with 30 participants from two OPPs in Los Angeles, CA, USA from 2010 to 2011 who had responded to at least one overdose since being trained in overdose prevention and response.
Results Being trained by an OPP and responding to overdoses had both positive and negative effects for trained “responders”. Positive effects include an increased sense of control and confidence, feelings of heroism and pride, and a recognition and appreciation of one’s expertise. Negative effects include a sense of burden, regret, fear, and anger, which sometimes led to cutting social ties, but might also be mitigated by the increased empowerment associated with the positive effects.
Conclusion Findings suggest that becoming an overdose responder can involve taking up a new social role that has positive effects, but also confers some stress that may require additional support. OPPs should provide flexible opportunities for social support to individuals making the transition to this new and critical social role. Equipping individuals with the skills, technology, and support they need to respond to drug overdose has the potential to confer both individual and community-wide benefits.

Walley, AY, et al. 2013, ‘Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis’, BMJ: British Medical Journal, vol. 346, no. 7894, p. f174.

A US study evaluated the impact of state-supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. The program was implemented among opioid users at risk of overdose, social service agencies’ staff, and families and friends of opioid users in nineteen Massachusetts communities where there had been at least five fatal opioid overdoses in each of the years 2004 to 2006. OEND programs trained 2,912 potential bystanders who reported 327 rescues. ‘Of 327 rescue attempts using naloxone reported by 212 individuals, 87% (286/327) were reported by users. Most rescue attempts occurred in private settings. The rescuer and the person who overdosed were usually friends. Naloxone was successful in 98% (150/153) of the rescues attempts. For the three rescue attempts where naloxone was not successful, the people who overdosed received care from the emergency medical system and survived.’

‘Compared with no implementation, both low and high implementation of OEND were associated with lower rates of opioid related deaths from overdose, when adjusted for demographics, utilization of addiction treatment, and doctor shopping…Rates of opioid related visits to an emergency department and admission to hospital were not significantly different in communities with low or high implementation of OEND.’

The researchers concluded that ‘This study provides strong support for the public health agency policy and community based organisation practice to implement and expand OEND programs as a key way to address the opioid overdose epidemic. Two features of the Massachusetts OEND programs that supported broad implementation include the use of an nasal naloxone delivery device and the use of a standing order issued by the health department, which allowed non-medical personnel to deliver OEND. These features may enable broader implementation with greater impact as more communities implement OEND.’

Walley A Y, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A (2012). Opiod overdose prevention with intranasal naloxone among people who take methadone. Journal of Substance Abuse Treatment

Overdose education and naloxone distribution (OEND) is an intervention that addresses overdose, but has not been studied among people who take methadone, a drug involved in increasing numbers of overdoses. This study describes the implementation of OEND among people taking methadone in the previous 30days in various settings in Massachusetts. From 2008 to 2010, 1553 participants received OEND who had taken methadone in the past 30days. Settings included inpatient detoxification (47%), HIV prevention programs (25%), methadone maintenance treatment programs (MMTP) (17%), and other settings (11%). Previous overdose, recent inpatient detoxification and incarceration, and polysubstance use were overdose risks factors common among all groups. Participants reported 92 overdose rescues. OEND programs are public health interventions that address overdose risk among people who take methadone and their social networks. OEND programs can be implemented in MMTPs, detoxification programs, and HIV prevention programs.

Walley, AY, Xuan, Z, Hackman, HH, Quinn, E, Doe-Simkins, M, Sorensen-Alawad, A, Ruiz, S & Ozonoff, A 2013, ‘Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis’, BMJ: British Medical Journal, vol. 346, p. f174, http://www.bmj.com/content/346/bmj.f174 free full text online.

OBJECTIVE: To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.
DESIGN: Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.
SETTING: 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS: OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users.
INTERVENTION: OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.
MAIN OUTCOME MEASURES: Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.
RESULTS: Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100 000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100 000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.
CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. (2011). No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. Jul-Sep;15(3):320-4.

INTRODUCTION: Naloxone is widely used in the treatment and reversal of opioid overdose. Most emergency medical services (EMS) systems administer naloxone by standing order, and titrate only to reverse respiratory depression without fully reversing sedation. Some EMS systems routinely administer sufficient naloxone to fully reverse the effects of opioid overdose. Frequently patients refuse further medical evaluation or intervention, including transport.
OBJECTIVES: The purpose of this study was to evaluate the safety of this practice and determine whether increased mortality is associated with full reversal of opioids. As a component of a comprehensive quality assurance initiative, we assessed mortality during the 48 hours after patients received naloxone to reverse opioid overdose followed by patient-initiated refusal of transportation.
METHODS: The setting was a large urban fire-based EMS system. Investigators provided the Bexar County Medical Examiner’s Office (MEO) with a list of patients who were treated by the San Antonio Fire Department with naloxone, and not transported. Inclusion criteria were administration of naloxone and patient-initiated refusal. Patient dispositions also included aid only, referral to the MEO, or referral to law enforcement. The list was then compared with the MEO database. A chart review was completed on all patients treated and subsequently presented to the MEO within two days. A secondary time period of 30 days was also assessed.
RESULTS: The list identified 592 patients treated with naloxone and not transported to the emergency department. Five-hundred fifty-two patients received naloxone and refused transport or were not transported. The remaining 40 patients all presented to EMS in cardiac arrest, naloxone was administered during the course of resuscitation, and subsequent efforts were terminated in the field. None of the patients receiving naloxone with a subsequent patient-initiated refusal were examined at the MEO within the two-day end point. The 30-day assessment revealed that nine individuals were treated with naloxone and subsequently died, but the shortest time interval between date of service and date of death was four days.
CONCLUSION: The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

Wermeling, D. P. (2010). Opioid harm reduction strategies: Focus on expanded access to intranasal Naloxone. Pharmacotherapy, 30(7), 627-631.