Abstract
SETTING: Alberta is a prairie province located in western Canada, with a population of approximately 4.3 million. In 2016, 363 Albertans died from apparent drug overdoses related to fentanyl, an opioid 50–100 times more toxic than morphine. This surpassed the number of deaths from motor vehicle collisions and homicides combined.
INTERVENTION: Naloxone is a safe, effective, opioid antagonist that may quickly reverse an opioid overdose. In July 2015, a committee of community- based harm reduction programs in Alberta implemented a geographically restricted take-home naloxone (THN) program. The successes and limitations of this program demonstrated the need for an expanded, multi-sectoral, multi-jurisdictional response. The provincial health authority, Alberta Health Services (AHS), used previously established incident command system processes to coordinate implementation of a provincial THN program.
OUTCOMES: Alberta’s provincial THN program was implemented on December 23, 2015. This collaborative program resulted in a coordinated response across jurisdictional levels with wide geographical reach. Between December 2015 and December 2016, 953 locations, including many community pharmacies, registered to dispense THN kits, 9572 kits were distributed, and 472 reversals were reported. The provincial supply of THN kits more than tripled from 3000 to 10 000.
IMPLICATIONS: Alberta was uniquely poised to deliver a large, province-wide, multi-sectoral and multi-jurisdictional THN program as part of a comprehensive response to increasing opioid-related morbidity and mortality. The speed at which AHS was able to roll out the program was made possible by work done previously and the willingness of multiple jurisdictions to work together to build on and expand the program.
Key words: Fentanyl, take-home naloxone, harm reduction, opioid overdose
Mots Clés: fentanyl, trousse maison de naloxone, réduction des dommages, surdose d’opioïdes
Résumé
LIEU : L’Alberta, une province des Prairies de l’Ouest canadien, a une population d’environ 4,3 millions d’habitants. En 2016, 363 Albertains sont décédés de surdoses apparentes de fentanyl, un opioïde 50 à 100 fois plus toxique que la morphine. Ce chiffre a dépassé le nombre de décès par collision entre véhicules automobiles et de décès par homicide combinés.
INTERVENTION : La naloxone est un antagoniste opioïde sûr et efficace qui peut rapidement neutraliser une surdose d’opioïdes. En juillet 2015, un comité d’intervenants de programmes communautaires de réduction des méfaits de l’Alberta a mis en œuvre dans une zone géographiquement restreinte un programme de « trousses maison de naloxone » (TMN). Les réussites et les contraintes de ce programme ont démontré le besoin d’une intervention élargie, multisectorielle et intergouvemementale. L’autorité sanitaire provinciale, Alberta Health Services (AHS), s’est servie des processus établis du système de commandement en cas d’incident pour coordonner la mise en œuvre d’un programme de TMN provincial.
RÉSULTATS : Le programme de TMN provincial de l’Alberta a été mis en œuvre le 23 décembre 2015. Ce programme concerté a coordonné une intervention intergouvernementale de grande portée géographique. Entre décembre 2015 et décembre 2016, 953 établissements, dont de nombreuses pharmacies communautaires, se sont inscrits au registre pour pouvoir dispenser des TMN, 9 572 trousses ont été distribuées, et 472 surdoses neutralisées ont été déclarées. Les approvisionnements provinciaux en TMN ont plus que triplé, passant de 3 000 à 10 000.
CONSÉQUENCES : L’Alberta était singulièrement bien placée pour offrir un vaste programme de TMN multisectoriel et intergouvememental à l’échelle de la province dans le cadre d’une intervention globale face aux hausses de la morbidité et de la mortalité liées aux opioïdes. La vitesse à laquelle AHS a pu déployer le programme s’explique par le travail effectué antérieurement et par la volonté de plusieurs sphères de compétence de travailler ensemble pour renforcer et développer le programme.
Footnotes
Acknowledgements: Those who provided their input by interview: Alberta Community Council on HIV: Marliss Taylor; Alberta Health: Michelle Craig, Keely McBride; Alberta Health Services: Dianne Dyer, Alexis Mageau, Domhnall Odochartaigh, Amy Woroniuk; First Nations and Inuit Health Branch, Health Canada: Chris Sarin. Numerous other people within AH, AHS, ACCH and other organizations were instrumental in the roll-out and continued operation of the THN Program.
Conflict of Interest: None to declare.
References
- 1.Degenhardt L, Bucello C, Mathers B. Mortality among regular or dependent users of heroin and other opioids: A systematic review and meta-analysis of cohort studies. Addiction. 2011;106:32–51. doi: 10.1111/j.1360-0443.2010.03140.x. [DOI] [PubMed] [Google Scholar]
- 2.Poklis A. Fentanyl: A review for clinical and analytical toxicologists. J Toxicol Clin Toxicol. 1995;33:439–47. doi: 10.3109/15563659509013752. [DOI] [PubMed] [Google Scholar]
- 3.Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367:146–55. doi: 10.1056/NEJMra1202561. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Canadian Centre on Substance Abuse. Bulletin CCENDU. Ottawa, ON: CCSA; 2015. Deaths involving fentanyl in Canada, 2009–2014. [Google Scholar]
- 5.Alberta Health. Opioids and Substances of Misuse Alberta Report, 2016 Q4. Edmonton, AB: Alberta Health; 2017. [Google Scholar]
- 6.Canadian Centre on Substance Abuse. CCENDU Drug Alert. Ottawa, ON: CCSA; 2015. Fentanyl-related overdoses. [Google Scholar]
- 7.Johnson NB, Hayes LD, Brown K, Hoo EC, Ethier KA. CDC national health report: Leading causes of morbidity and mortality and associated behavioral risk and protective factors — United States, 2005-2013. MMWR Surveill Summ. 2014;63(Suppl4):3–27. [PubMed] [Google Scholar]
- 8.Windspeaker. 2015.
- 9.Centers for Disease ControlPrevention CDC. Community-based opioid overdose prevention programs providing naloxone — United States, 2010. MMWR Morb Mortal WklyRep. 2012;61:101–5. [PMC free article] [PubMed] [Google Scholar]
- 10.Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, et al. Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(Suppl2):S501–18. doi: 10.1161/CIR.0000000000000264. [DOI] [PubMed] [Google Scholar]
- 11.World Health Organization. Community Management of Opioid Overdose. Geneva, Switzerland: WHO; 2014. [PubMed] [Google Scholar]
- 12.Doe-Simkins M, Quinn E, Xuan Z, Sorensen-Alawa A, Hackman H, Ozonoff A, et al. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: A retrospective cohort study. BMC Public Health. 2014;14:297–308. doi: 10.1186/1471-2458-14-297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Banjo O, Tzemis D, Al-Qutub D. A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open. 2014;2:E153–61. doi: 10.9778/cmajo.20140008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Tobin KE, Sherman SG, Beilenson P. Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives. Int J Drug Policy. 2009;20:131–36. doi: 10.1016/j.drugpo.2008.03.002. [DOI] [PubMed] [Google Scholar]
- 15.Baca CT, Grant KJ. Take-home naloxone to reduce heroin death. Addiction. 2005;100:1823–31. doi: 10.1111/j.1360-0443.2005.01259.x. [DOI] [PubMed] [Google Scholar]
- 16.Dong KA, Taylor M, Wild CT, Villa-Roel C, Rose M, Salvalaggio G, et al. Community-based naloxone: A Canadian pilot program. Can J Add Med. 2012;32:4–9. [Google Scholar]
- 17.Government of Canada. Joint Statement of Action to Address the Opioid Crisis. Ottawa, ON: Government of Canada; 2016. [Google Scholar]
- 18.Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ. 2013;346:f174. doi: 10.1136/bmj.f174. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Alberta Government. Population. Economic Dashboard. Edmonton, AB: Alberta Government; 2016. [Google Scholar]
- 20.Statistics Canada. Aboriginal Peoples: Fact Sheet for Alberta. Ottawa, ON: Statistics Canada; 2016. [Google Scholar]
- 21.Alberta Health. Alberta Government. About us — AlbertaHealth. Setting Strategic Direction. Edmonton, AB: Alberta Health, Alberta Government. Available at: http://www.health.alberta.ca/about-us.html (Accessed September 28, 2016).
- 22.AlbertaJusticeSolicitor General. Overview: The Office ofthe ChiefMedical Examiner. Edmonton, AB: Alberta Justice and Solicitor General; 2016. [Google Scholar]
- 23.Tsihikssini Special Publication. Blood Tribe. Standoff, AB: Blood Tribe Administration; 2015. [Google Scholar]
- 24.Alberta Government. Latest Steps to Combat Opioids are Welcomed by Justice and Health Ministers. Edmonton, AB: Alberta Government; 2016. [Google Scholar]
- 25.Office of the Minister of Health. Ministerial Order 32/2016. Edmonton, AB: Office of the Minister of Health; 2016. [Google Scholar]
- 26.Health Canada. Notice: Prescription Drug List: Naloxone. Drugs and Health Products. Ottawa, ON: Health Canada; 2016. [Google Scholar]
- 27.Alberta College of Pharmacists. Guidance for Pharmacists and Pharmacy Technicians Dispending or Selling Naloxone as a Schedule 2 Drug. Edmonton, AB: Alberta College of Pharmacists; 2016. [Google Scholar]