ReviewTwenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids—Conception and maturation
Introduction
Over the past two decades, take-home naloxone (THN) has moved from its initial conceptualization as harm reduction measure for preventing opioid overdose deaths to becoming an evidence-based public health strategy with organized implementation (UNODC/WHO, 2013). Strong advocacy by local early adopters has enabled emergence of THN initiatives around the world. In Italy, a harm reduction service on the outskirts of Turin reportedly provided naloxone access to clients as early as 1991 (ForumDroghe, 2016). Today, formal THN programs exist in Australia, Canada, at least nine European countries (EMCDDA, 2016), and the US; as well as pilots in low- and middle-income countries, including Afghanistan, China, India, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Thailand, Ukraine, and Vietnam (UNODC/WHO, 2013). The World Health Organization issued new guidelines for community-based overdose management, suggesting that “[p]eople likely to witness an opioid overdose should have access to naloxone and be instructed in its administration” (WHO, 2014).
Despite these recent advances, dissemination of THN remains remarkably slow. THN was first proposed in 1996, and it was not until the late 2000s that serious consideration of THN implementation at state or national level began.
Opioid overdose continues to account for approximately 68,000–104,000 annual deaths worldwide (UNODC, 2016b), with sharp increases reported for the UK (ISD, 2016, ONS, 2016) and US (CDC, 2016). Many of these deaths could be prevented if THN was available: A recent analysis of the time course of opiate metabolites post-mortem found that survival times post-injecting exceeded 20–30 min in the majority of heroin overdose deaths (Darke and Duflou, 2016), suggesting that there is indeed sufficient time to intervene (Darke and Duflou, 2016, Tas and McDonald, 2016). However, adequate intervention is only possible where witnesses recognize the opioid overdose. In addition to naloxone supply, it is thus essential for THN programs to teach awareness of overdose risk factors (e.g., using alone, street injection), crisis detection (e.g., snoring following opioid use may signal overdose), interim emergency care aid, and need for continued care (McAuley et al., 2010, Seal et al., 2005, Strang et al., 2008a).
This brief history chronicles major milestones and events in the emergence and evolution of THN.
Section snippets
Literature search
The first author (RM) searched Medline and PsycINFO for THN-related peer-reviewed literature published between January 1990 and December 2016 using the Boolean queries: 1) “naloxone OR Narcan”; 2) “(opioid OR opiate) AND overdose AND prevention”. Specialist websites and databases of Public Health England, the European Monitoring Centre for Drugs and Drug Addiction, US National Institute on Drug Abuse, and United Nations agencies were also searched for THN-related entries. Additional materials
Results
We present results in four sections which discuss the following themes. Firstly, we examine formal articulation of the need for THN, along with preliminary testing and implementation (1996–2001; Section 3.1). We then document early THN schemes and challenges (2001–06; Section 3.2). We then explore new national or state-level naloxone programs made possible through the identification and response to legal concerns (2006–11; Section 3.3). Finally, we review the emergence of research studies
Strengths and limitations
This narrative review represents the first peer-reviewed attempt to reconstruct the development of THN from its conception to present.
To allow for the wide scope of this review, a broad search strategy was applied. While the search strategy was not limited to English-language entries, we cannot rule out that relevant international sources (published in other languages) may have been overlooked. Similarly, it is possible that the chronological timeline (see also Table 2) may include inaccuracies.
Conclusion
Twenty years ago, the very idea of THN was a radical speculative proposal to extend harm reduction beyond needle and syringe exchange. Today THN is increasingly accepted as an effective public health strategy to reduce overdose fatalities and is increasingly being considered as part of routine care and possibly a required standard of care. Nonetheless, THN lags behind its full potential, with only modest distribution of THN relative to the evident (and growing) clinical need. To date, THN
Contributors
JS, NC and RM drafted the manuscript. RM conducted the literature search. All authors approved of the final draft of the manuscript.
Role of funding source
No specific funding was sought or secured for the review reported in this paper.
Conflict of interest
JS declares that he is a researcher and clinician who has worked with a range of types of treatment and rehabilitation service-providers. JS is an NIHR Senior Investigator and is also supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London. He has also worked with a range of governmental and non-governmental organizations, and with pharmaceutical companies to seek to
References (179)
America embraces treatment for opioid drug overdose
Lancet
(2014)- et al.
Prison-based prescriptions aid scotland's national naloxone programme
Lancet
(2017) - et al.
Legal aspects of providing naloxone to heroin users in the United States
Int. J. Drug Policy
(2001) - et al.
Major increases in opioid analgesic abuse in the United States: concerns and strategies
Drug Alcohol Depend.
(2006) - et al.
State legal innovations to encourage naloxone dispensing
J. Am. Pharm. Assoc.
(2017) - et al.
Pharmacists' role in opioid overdose: kentucky pharmacists' willingness to participate in naloxone dispensing
J. Am. Pharm. Assoc.
(2017) - et al.
Factors associated with participation in an Emergency Department–based take-home naloxone program for at-risk opioid users
Ann. Emerg. Med.
(2017) Prescription opioid addiction and chronic pain: more than a feeling
Drug Alcohol Depend.
(2017)- et al.
Rapid widespread distribution of intranasal naloxone for overdose prevention
Drug Alcohol Depend.
(2017) Reducing Drug-related Deaths
(2000)