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gerard bury
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In 2011 more people died in Ireland from opiate overdose (211)1 than in road accidents (186)2. Neither toll is acceptable and both figures conceal great sadness and loss. However, a key difference between them is that while road safety has rightly become a national and societal priority for action, virtually nothing is being done about deaths from opiate overdose.
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Overdose prevention can be attempted in many ways including overdose education for users, their friends and families; sheltered drug using sites; better access to opiate substitution therapy or planned prison releases. ‘Take home naloxone’ is a further option and has reasonable evidence to suggest that it has value3. Naloxone is an effective opiate antagonist with an excellent safety profile; it works rapidly to reverse the respiratory depression which generally is the immediate cause of death – but it must therefore be given within minutes of the overdose. Naloxone is widely used by health and emergency services in Ireland to good effect4 but is not currently available for use by lay people. Community based schemes to provide naloxone training and kits have been established throughout the US since the mid-90s and more recently in Wales, Scotland and elsewhere.
Naloxone is given by intravenous, intramuscular or subcutaneous routes by health care professionals; internationally, most community schemes have provided kits for intramuscular injection by drug users or other lay rescuers. The recent use of intranasal naloxone is increasingly recognised as an alternative to the parenteral route, with important advantages – it is needleless, simple to use and has been shown to reduce deaths at a population level5. Intranasal nalaoxone is given using the parenteral preparation administered through a nozzle-shaped Mucosal Atomiser Device. Legal (prescription-only medicine) and pharmaceutical (parenteral preparation used by intranasal route) concerns exist and have been addressed in 10 US states and several other countries to enable this medicine to be held and used by lay people6. A customised nasal spray is reportedly in development by at least one pharmaceutical company.
What’s happening in Ireland to address the genuine crisis of almost two deaths from opiate overdose every three days? Very little, at least in official circles. A HSE working group reviewed opioid overdose issues in 2013; the report has been submitted but not published. The Department of Health says that it is examining the issue, consulting with stakeholders and was to publish its plans by the end of 20147. In the meantime, it indicates that its regulations are not compatible with ‘Take Home Naloxone’ schemes, whether they involve parenteral or intranasal naloxone. The Pre-Hospital Emergency Care Council has published a Clinical Practice Guideline enabling lay people qualified in basic life support to use intranasal naloxone, if trained – however this cannot be implemented until prescribing regulations are changed by the Department of Health.
The voluntary sector and individual clinicians and agencies are working hard to help those at highest risk; Safety net, the Merchant’s Quay Project and the Ana Liffey Drug Project are excellent examples. However in the absence of straightforward regulatory change by the Department of Health, little can happen to enable trials of schemes to provide Take Home Naloxone to drug-users, their families or to the many lay people who provide support services.
Here is an excellent opportunity for focused, high-level action to save lives, at very little cost. Are the leaders of our health system sufficiently interested in a marginalised group to take action?
G Bury
Academic General Practice, SMMS, UCD
References
1. Drug related deaths and deaths among drug users in Ireland. 2011 figures from the NDRDI. Health Research Board, 2014.
2. 2011 road death and injury statistics. Road Safety Authority, 2012. http://www.rsa.ie/Documents/Road%20Safety/Road_deaths_2011.pdf
3. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict med 2014;8:153-63.
4. Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010. Centre for Disease Control. MMWR 2012;61:101-105.
5. Klimas J, O'Reilly M, Egan M,Tobin H, Bury G. Urban overdose hotspots: a 12-month prospective study in Dublin ambulance services. Am J Emerg Med. 2014 Jul 31 (epub).
6. Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ.2013 Jan 30;346.
7. Hewlett L, Wermeling DP. Survey of naloxone legal status in opioid overdose prevention and treatment. J Opioid Manag. 2013 Sep-Oct;9(5):369-77.
8. Sunday Times, 21st September 2014.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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