Elsevier

Drug and Alcohol Dependence

Volume 178, 1 September 2017, Pages 176-187
Drug and Alcohol Dependence

Review
Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids—Conception and maturation

https://doi.org/10.1016/j.drugalcdep.2017.05.001Get rights and content

Highlights

  • Deaths from opioid overdose can be prevented by prompt administration of naloxone.

  • It has been 20 years since take-home naloxone provision was first proposed.

  • Take-home naloxone programs have recently overcome legal barriers in many countries.

  • Take-home naloxone provision remains low compared to evident growing clinical need.

  • The ‘opt-out’ model of required pre-provision may achieve wider naloxone coverage.

Abstract

Background

Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy.

Method

Medline and PsycINFO were searched for peer-reviewed literature (1990–2016) using Boolean queries: 1) “naloxone OR Narcan”; 2) “(opioid OR opiate) AND overdose AND prevention”. Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline.

Results

Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001–2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006–2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016.

Conclusions

Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.

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)

  • ACMD

    Consideration of Naloxone

    (2012)
  • ACMD

    Reducing Opioid-Related Deaths in the UK

    (2016)
  • D. AIDS-Hilfe

    Leben Retten Mit Naloxon

    (2013)
  • AMA

    AMA Adopts New Policies at Annual Meeting

    (2012)
  • S. Albert et al.

    Project Lazarus: community-based overdose prevention in rural North Carolina

    Pain Med.

    (2011)
  • Anex

    AMA and Its Naloxone Policy Position

    (2013)
  • E. Angiolini

    Lord Advocate's Guidelines on Allowing the Supply of Naloxone to Extend to Staff Working for Services in Contact with People at Risk of Opiate Overdoses

    (2011)
  • A.J. Ashworth

    Emergency naloxone for heroin overdose: beware of naloxone's other characteristics

    BMJ

    (2006)
  • C.T. Baca et al.

    Take-home naloxone to reduce heroin death

    Addiction

    (2005)
  • C.J. Banta-Green et al.

    Police officers’ and paramedics’ experiences with overdose and their knowledge and opinions of Washington State’s drug overdose–naloxone–good Samaritan law

    J. Urban Health

    (2013)
  • T. Barry et al.

    Opiate addiction and overdose: experiences attitudes, and appetite for community naloxone provision

    Br. J. Gen. Pract.

    (2017)
  • E. Behar et al.

    Primary care patient experience with naloxone prescription

    Ann. Fam. Med.

    (2016)
  • L. Beletsky et al.

    Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities

    J. Urban Health

    (2007)
  • G.A. Bennett et al.

    Accidental overdose among injecting drug users in Dorset, UK

    Addiction

    (1999)
  • T. Bennett et al.

    Evaluation of the Take Home Naloxone Demonstration Project

    (2011)
  • T. Bennett et al.

    The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN Project in Wales

    Drugs: Education, Prevention, and Policy

    (2012)
  • D. Best et al.

    Peer overdose resuscitation: multiple intervention strategies and time to response by drug users who witness overdose

    Drug Alcohol Rev.

    (2002)
  • D. Bigg

    Overdose Management Training with Naloxone. Paper Presented at Preventing Heroin Overdose: Pragmatic Approaches. 13–14 January

    (2000)
  • D. Bigg

    Data on take home naloxone are unclear but not condemnatory

    BMJ

    (2002)
  • I.A. Binswanger et al.

    Overdose education and naloxone for patients prescribed opioids in primary care: a qualitative study of primary care staff

    J. Gen. Intern. Med.

    (2015)
  • S.M. Bird et al.

    Male drugs-related deaths in the fortnight after release from prison: scotland, 1996–99

    Addiction

    (2003)
  • S.M. Bird et al.

    Take-home naloxone to prevent fatalities from opiate-overdose: protocol for Scotland's public health policy evaluation, and a new measure to assess impact

    Drugs: Education, Prevention, and Policy

    (2015)
  • S.M. Bird et al.

    Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006–10) versus after (2011–13) comparison

    Addiction

    (2016)
  • H. Blumberg et al.

    N-allylnoroxymorphine: a potent narcotic antagonist

    Fed. Proc.

    (1961)
  • A. Byrne

    Emergency naloxone for heroin overdose: over the counter availability needs careful consideration

    BMJ

    (2006)
  • J.R.M. Caplehorn et al.

    Mortality associated with new south wales methadone programs in 1994: lives lost and saved

    Med. J. Aust.

    (1999)
  • CCBCnews

    Health Canada OK's Non-prescription Nasal Spray Overdose Antidote

    (2016)
  • CCSA

    CCENDU Bulletin − The Availability of Take-Home Naloxone in Canada

    (2016)
  • CDC

    Community-based opioid overdose prevention programs providing naloxone-United States, 2010

    MMWR Morb. Mort. Wkly. Rep.

    (2012)
  • CDC

    Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014

    (2015)
  • CDC

    MMWR: Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014

    (2016)
  • J.R.M. Caplehorn

    Deaths in the first two weeks of maintenance treatment in NSW in 1994: Identifying cases of iatrogenic methadone toxicity

    Drug Alcohol Rev.

    (1998)
  • T.J. Cicero et al.

    The changing face of heroin use in the United States: a retrospective analysis of the past 50 years

    JAMA Psychiatry

    (2014)
  • A.K. Clark et al.

    A systematic review of community opioid overdose prevention and naloxone distribution programs

    J. Addict. Med.

    (2014)
  • C. Coffin P.O., Fuller et al.

    Preliminary evidence of health care provider support for naloxone prescription as overdose fatality prevention strategy in New York City

    J. Urban Health

    (2003)
  • Coffin P.O et al.

    Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal

    Ann. Intern. Med.

    (2013)
  • P.O. Coffin et al.

    Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities

    J. Med. Econ.

    (2013)
  • P.O. Coffin et al.

    Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain − naloxone coprescribing in primary care clinics

    Ann. Intern. Med.

    (2016)
  • W.M. Compton et al.

    Expanded access to opioid overdose intervention Research, practice, and policy needs

    Ann. Intern. Med.

    (2013)
  • CRA

    CRA Annual Report, 2014

    (2014)
  • Cited by (0)

    View full text