Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes

Doctors routinely give naloxone during emergency resuscitation after opiate overdose. The distribution of naloxone to opiate addicts has recently been addressed,^1–4 and a survey of drug users shows extensive support for the provision of supplies to take away.⁴ We present the preliminary results of two pilot schemes to provide take home naloxone to opiate users.

Methods and results

The Berlin project

In January 1999 drug users in Berlin were given naloxone to take home. Opiate misusers attending a healthcare project (operating from a mobile van or ambulance) were offered training in emergency resuscitation after overdose, provided with naloxone (two 400 μg ampoules), needles, syringes, an emergency handbook, and information on naloxone. They were asked to report on any use of the drug. After 16 months, 124 opiate misusers had received training in resuscitation and were provided with supplies of naloxone to take away; 40 reported back, with 22 having given emergency naloxone (two on two occasions, one on three, and one on four).

Case 1 (Berlin)

“Three days ago, I was walking along the canal with a friend of mine. We saw a guy lying on the ground, with two people trying to help him—they were trying to help him breathe by mouth to mouth. When we ran over to them, we could tell it wasn't really working. The guy was blue in the face and hardly breathing any more. I could barely feel his pulse. Right away I gave him one ampoule of naloxone—I didn't think I could find a vein so I just shot it real slow into his upper arm. We tried to give him CPR and we called 911. Then the guy started to wake up and he started to breathe and shake a little bit. He was so thankful, he wanted to give me 50 Marks, but I wouldn't take it. When the medics came I told them I had given him the naloxone. The medics said ‘Wow! So you guys have even got naloxone now?’ But he thought it was great. He said we had probably just saved the guy's life.” The ambulance staff then took the overdose victim to hospital for further observation.

The methods of administration were diverse. Resuscitation occurred both at home (17; 59%) and outdoors (parks, public restrooms) (11; 38%). In 10 instances the individual was unknown to the person resuscitating him or her (35%). Naloxone was given intramuscularly (14 instances; 48%), intravenously (13; 45%), and subcutaneously (2; 7%). One ampoule was the usual dose given (22; 76%). Half an ampoule was given to four people (14%) and both ampoules to three (10%). In 10 (34%) instances naloxone provoked a sudden onset of opiate withdrawal; no other side effects were reported. An ambulance was called for nine (31%). All 29 people recovered. Naloxone was judged appropriate in 26 (90%) cases, of uncertain benefit (no life threatening situation) in two (7%), and pointless in one (cocaine overdose). More risky consumption as a result of the availability of naloxone was not reported.

The Jersey project

From October 1998 over the next 16 months naloxone (one minijet ready filled with 800 μg naloxone) was provided to 101 drug misusers in contact with local drug services, with instructions on intramuscular administration and the wider principles of resuscitation from overdose and recovery. Five instances of resuscitation using naloxone were reported, and all fully recovered. No adverse consequences, other than withdrawal symptoms, were reported.

Case 2 (Jersey)

A known drug user rushed into the drug clinic demanding that he was immediately given a naloxone minijet to take away. Although agitated, he was resourceful enough to request that the minijet was assembled for him, and he then departed in haste. Some 20 minutes later he returned, accompanied by a shaken overdose victim who had some 15 minutes earlier been comatose and blue. “I was very nervous putting a big needle in him. I didn't know what would happen, what the result would be, but once I did it there was an immediate result that was a good one. He was dead. He came back to life.” The overdose victim was then taken by ambulance to the local accident and emergency department where he was observed and made a full recovery.

Comment

This is the first published report of lives saved directly by the provision of take home naloxone. The drug was generally used appropriately. In only one case out of 34 was its use inappropriate, with two of doubtful benefit. No unexpected adverse effects were reported.

Ready prepared syringes of naloxone typically cost £3.30-6.70 per 400 μg. Since 10% of distributed doses were actually given, each use cost around £33-67. Even if lives were saved on only 10% of these occasions, then each would have been saved at a drug cost of £330-670.

The range of doses given raises the possibility that naloxone was being titrated to effect resuscitation without provoking withdrawal. If so, recovery needs monitoring to avoid subsequent relapse into overdose. Some casualty departments and ambulance services now recommend giving naloxone intramuscularly or subcutaneously rather than intravenously because it can be given more quickly and results in less violent recovery.⁵ The same advice may apply to administration by peers. In future, family members may be trained to give emergency naloxone,³ for whom non-intravenous administration would be more realistic.

Early reports are encouraging. No adverse effects have been reported, and 10% of distributed naloxone has saved lives. A study of the wider distribution of take home naloxone is now required.