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

Kerstin Dettmer, Bill Saunders, John Strang

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 take­home 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 Ïg 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).

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 Ïg naloxone) was provided to 101 drug misusers in contact with local drug services, with instructions on intramuscular administration and the wider principles of resuscita­ tion 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.

Comment

This is the first published report of lives saved directly by the provision of take­home 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 £3.30­6.70 per 400 Ïg. Since 10% of distributed doses were actually given, each use cost around £33­67. Even if lives were saved on only 10% of these occasions, then each would have been saved at a drug cost of £330­670. 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 membersmay 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 take­home naloxone is now required.

Kerstin Dettmer, project director, Fixpunkt e V Mobilix, 10967 Berlin

Bill Saunders director, Alcohol and Drug Service, Gloucester Lodge, St Saviour, Jersey, Channel Islands JE2 7LB

John Strang, director, National Addiction Centre, Institute of Psychiatry and the Maudsley Hospital, London SE5 8AF
Email: j.strang@iop.kcl.ac.uk


studentBMJ 2001;09:171-216 June ISSN 0966-6494

1. Strang J, Darke S, Hall W, Farrell M, Ali R. Heroin overdose: the case for take­home naloxone? BMJ 1996;312:1435.
2. Darke S, Hall W. The distribution of naloxone to heroin users. Addiction 1997;92:1195­9.
3. Strang J. Take­home naloxone: the next steps. Addiction 1999;94:207.
4. Strang J, Powis B, Best D, Vingoe L, Griffiths P, Taylor C, et al. Preventing opiate overdose fatalities with take­home naloxone: pre­launch study of possible impact and acceptability. Addiction 1999;94:199­204.
5. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous versus subcutaneous naloxone for out­of­hospital man­ agement of presumed opioid overdose. Acad Emerg Med 1999;5:293­9. (Accepted 13 December 2000)