Harm Reduction Victoria (HRV) Position statement.
Peer-based distribution and administration of naloxone (Narcan™).
The current status of naloxone
Overdose is a leading cause of preventable death among Australian heroin users, with around one death a day attributed to opioid overdose. In Victoria, despite the dramatic decline in the number of fatalities resulting from illicit drug use including heroin since the late 1990’s, the recent increase in deaths involving prescription drugs is cause for concern.
There is, however, a safe, inexpensive, fast acting and reliable antidote for opioid overdoses: naloxone (also known by its trademark name, Narcan™). Naloxone has a long history of effective use as an opioid antagonist (i.e. it reverses the effects of opioids such as heroin, morphine and oxycontin). Naloxone has no potential for diversion or inappropriate use and side effects are limited to opioid withdrawal symptoms only.
The United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO) note that fatal opioid overdose can be prevented with the use of naloxone, which is included in the WHO Essential Medicines List. In 2012, the American Medical Association adopted policy to encourage education of opioid users and others in the use of naloxone . In early 2013, the Australian Medical Association followed suit and called for naloxone distribution to reduce opioid overdose fatalities. The United Nations Commission on Narcotic Drugs has also formally recognised the need to expand naloxone access to reduce overdose related mortality. Given the substantial body of international evidence regarding efficacy and safety, the Australian National Council on Drugs (ANCD) has asserted that further trials are no longer warranted to expand naloxone availability in Australia.
Peer distribution and administration of naloxone.
Prompt administration of naloxone is critical in an overdose scenario. The time lapse between reporting an overdose and the arrival of an ambulance and paramedics to administer naloxone can significantly increase the risk of fatality and/or brain damage. Research indicates that in many overdose cases, other people (and in particular, other people who use drugs) are present. Since the most likely person to be present at the time of an overdose is another drug user, training peers to administer naloxone can significantly reduce response times and lives can be saved.
Peer distribution of naloxone has operated internationally for a number of years without negative consequences. Initial concerns (that naloxone may be administered or stored incorrectly, that re-intoxication could result in fatalities, or that drug users may increase risky behaviour if opioids were considered less dangerous) have not been realised . Indeed research shows that appropriately trained drug users are as skilled as medical practitioners in recognizing an overdose and understanding when naloxone should be administered. Peer administration of naloxone carries even lower risks than peer administration of adrenaline for anaphylaxis, or glucagon for diabetic insulin reaction. Unexpected benefits of peer administration of naloxone have also been demonstrated: naloxone training programs have reinforced and expanded overdose prevention and overdose response capacity and participants have reported a sense of empowerment due to their ability to administer naloxone.
Harm Reduction Victoria acknowledges the wide range of stakeholders implicated in the potential expansion of naloxone availability and supports a broad-based systems approach to naloxone training and distribution across Victoria. Appropriate funding of such an approach is also warranted to ensure consistency of standards and efficient use of resources. However, HRV also highlights the centrality of the involvement of people who inject drugs (PWIDs); drug users must be regarded as the ‘front line’ and primary target group for overdose prevention and response education, including naloxone. HRV believes that unless we prioritise PWIDs’ access to naloxone and their ability to administer it, the roll-out of naloxone will have less than optimal impact.
Harm Reduction Victoria and Peer-based Overdose Education
Harm Reduction Victoria (HRV), as the peak organisation representing the concerns and rights of people who use drugs in Victoria, has over a decade of experience in providing peer education programs which focus on overdose prevention and response for people who inject drugs. HRV is eager to add naloxone distribution and training to complement other overdose prevention and response strategies covered by our current peer education programs.
HRV is compelled to highlight the central importance of the peer-based approach in training, distribution and administration of naloxone. Drug user organisations are uniquely placed to train people who use drugs to improve health outcomes. Peer trainers have physical and socio-cultural access to the drug using community which is not found in other agencies including drug and alcohol agencies due to the highly stigmatised and illegal nature of illicit drug use. Conversely there is strong evidence that non-peer led programs are not an effective or efficient use of overdose prevention resources. Where agencies replace peer education approaches with other methods, it has been shown that the provider-client model, as well as the environment for education frequently presents significant barriers to communication. Further, the peer based training model is endorsed by The National Heroin Overdose Strategy that states “It is important to engage drug users in the development of strategies as this may enhance uptake and effectiveness, and accordingly drug users and drug user organisations have an important role to play in this Strategy”.
Harm Reduction Victoria (HRV) has been funded by Victorian Department of Health for over a decade to provide peer education to our community to identify, respond to and prevent overdose. HRV’s existing Drug Overdose Prevention Education (DOPE) Project aims to reduce the incidence of both fatal and non-fatal overdose among drug users in Victoria. DOPE also provides overdose training for a broad range of community based agency staff, who work closely with PWIDs. Training targets have been consistently met and participant evaluations demonstrate the efficacy of HRV’s peer-based approach. The DOPE Program is responsive to changing trends in drug use and has incorporated new elements targeting people who use and inject methamphetamine and pharmaceutical opioids to complement the existing program. However, this approach cannot be fully optimised without enabling HRV to train peers in how to access and administer the opioid overdose antidote, naloxone.
HRV’s comprehensive DOPE Program emphasises risk factors for overdose and ways to reduce the risk of overdose. The second part of the program focuses on recognition of overdose symptoms and hands-on training in overdose response which stresses the need for respiratory support and the importance of calling an ambulance. HRV has established strong working relationships with ambulance services and police to reinforce the centrality of calling an ambulance and to reassure participants that police do not routinely attend incidents of overdoses. None of these important education elements will be compromised by the introduction of naloxone. Rather, they will be reinforced by adding the use of naloxone to existing training components.
The aims and objectives, then, will be essentially unchanged by the incorporation of naloxone into the current DOPE Program. The primary aim will continue to be the reduction of opioid overdose morbidity and mortality, through:
– Increased effectiveness of interventions in opioid overdose response (due to incorporation of naloxone);
– Provision of comprehensive hands-on overdose response training including rescue breathing, etc. in conjunction with naloxone administration;
– Provision of take-home naloxone to opioid users who attend overdose education and training;
– Close monitoring and evaluation of processes in conjunction with impact and outcome evaluation and follow-up of participants to assess results over time
– Reductions in fatal opioid overdose through enhanced overdose response education and training, including naloxone.
It is expected that additional benefits will include a reduction in costs to the Victorian health system due to reduced ambulance call outs and reduced hospitalisations resulting from opioid overdose.
There is a wealth of available information to guide the implementation of naloxone training and distribution among people who use drugs including published guidance and rationales for doctors about prescribing naloxone to drug users . However, HRV will continue to work closely with CAHMA, our sister drug user organisation in Canberra, to learn from the ACT experience of peer-based naloxone training and distribution which is already demonstrating significant success in recruiting and empowering people who inject drugs to respond more effectively to opioid overdose.
The Urgent Need for Action
Harm Reduction Victoria is well prepared and ideally positioned to ensure optimal reach and impact of efforts to reduce opioid overdose fatalities with the introduction of peer based naloxone training and distribution. It is clear that allowing people who use drugs to take their health into their own hands will save lives. The evidence which demonstrates that overdose fatalities can be safely and easily prevented by naloxone is overwhelming. HRV believes that the time for trials and tests has passed and that there is no good reason to further delay the full integration of peer-based naloxone training into our current comprehensive overdose education package. Naloxone constitutes an additional tool which can effectively decrease the devastation to our community caused by these unnecessary deaths. Harm Reduction Victoria believes that the time is right to introduce peer-based naloxone training and distribution and to enable people who use drugs to administer naloxone in the event of opioid overdose.
Funding is now urgently needed to facilitate immediate action and to enable Harm Reduction Victoria to actively respond to calls from community based organisations for naloxone training for both clients and staff. HRV has recently been contacted by a number of organisations, including drug treatment agencies, community health centres and primary healthcare services for PWIDs, primary NSPs and youth-focused agencies. Despite our eagerness to get started, HRV requires additional resourcing in order to adequately respond to these requests and to provide naloxone to both consumers and staff members who attend training. The cost of a naloxone prescription ($5.90) which is required for each individual participant signifies a substantial cost which HRV is unable to meet, without further funding. Additional resourcing is also vital to enable HRV to respond on an appropriate scale and to ensure our efforts achieve optimal impact and outcomes.
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 See for example, the recently launched Naloxone Website at Naloxoneinfo.org formed by a coalition of international organisations to promote evidence and practical guidance for the lay distribution of naloxone.
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 See for example, Public Health Agency of Canada. Responding to an Emergency: Education, Advocacy, and Community Care by a Peer-Driven Organization of Drug Users: A Case study of Vancouver. 2001.
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 For more Expanding Naloxone Availability in the ACT (ENAACT) program, please see: http://www.atoda.org.au/policy/naloxone/