Commentary on Madah-Amiri et al. (2019): Beyond saturation

Abstract

Improving upon current uptake rates resulting from naloxone saturation efforts requires that we look beyond existing delivery mechanisms toward novel distribution agents and venues with the greatest potential to reduce overdose (OD) morbidity and mortality.

Madah-Amiri et al.’s article is a cogent and timely evaluation of the impacts to be made through national efforts to ‘saturate’ an environment with the overdose reversal medication, naloxone [1]. Given Norway’s careful adherence to empirical estimates about how much naloxone should be provided per capita [2,3] and how to best distribute it [4,5], the study’s findings represent an important indication about what saturation looks like among those whose lives are most likely to depend upon it. In the case of Norway, 57% of participants who reported recent heroin injection were currently in possession of naloxone across six cities with take-home naloxone (THN) programs and one city that did not have a THN program. While that figure should certainly be seen as an indicator of success, it might also be viewed as a powerful provocation to imagine how to achieve a percentage much closer to 100.

Although the ability to access naloxone has greatly increased in Norway and elsewhere, there remain individual, socio-cultural and, for some, structural barriers to seeking and obtaining naloxone [6]. Even in the presence of large-scale distribution programs, a substantial proportion of people at high risk for opioid overdose (OD) do not have the resources, the ability or the wish to possess naloxone. The burden of travel to a service provider, lack of certainty about which service providers offer it and the stigma associated with carrying naloxone are all important barriers that programs should continue to address. For people experiencing homelessness and living unsheltered, a condition often co-occurring with mental health struggles, accessing low-threshold services at all is hardly a given. Further, the study’s authors make clear that ‘possessing’ naloxone can be a slippery concept, as having a reversal kit in one’s home is not the same as having a kit in one’s pocket or bag, ready to be used.

To continue the laudatory work undertaken by Norway and the study’s authors, we advocate for a continued effort to overcome some of the hurdles above and for novel approaches to maximizing naloxone uptake. An important study finding—that drug dealing is a significant predictor of naloxone possession and naloxone use—suggests a potentially efficacious OD intervention. People who sell drugs have been found to be effective syringe distributors and might productively be enlisted as naloxone distributors and OD reversal trainers [7]. Furthermore, the authors’ finding that recent heroin injection is associated with naloxone use reinforces other research indicating that people who use opioids are effective ‘first responders’ [8,9].

Building on the decentralized mobile modality referenced by the authors, communities should explore a greater range of alternative delivery models. Mobile units—typically vans operating under the authority of syringe exchange programs—have been a critical vector for outreach [10]. The expansion of novel distribution methods, such as home delivery of naloxone, can potentially reach a hidden population of people at risk, or people in close connection to others at-risk, who may or may not be involved in networks of drug use or utilize social service agencies that provide naloxone [11].

Locations frequented by people who use drugs should also be provided with naloxone that is visibly available for emergency use. Our recent research suggests that service industry employees encounter drug use, overdoses and syringes in their businesses regularly and are willing to be trained on how to identify and respond to overdoses with naloxone [12]. Standardizing a naloxone distribution system—similar to that seen with automated external defibrillators [13]—would require certain public places (such as restaurants, coffee shops, bars and parks) to be equipped with naloxone. Ideally, implementation of this strategy would begin in local OD hot-spots and quickly expand until public-access naloxone is as commonplace as defibrillators.

In summary, to take naloxone saturation seriously is to recognize that it takes more than an adequate amount of the medication itself within a nation, city or community to effectively ensure that naloxone is present and in the hands of a trained responder, wherever and whenever opioid-related overdoses occur.