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Three Part Question

[In opiate addicts] does [training and prescription of naloxone for personal use] reduce [the mortality from opiate overdose]

Clinical Scenario

An ambulance arrives at the Emergency Department with a patient who is said to have suffered a heroin overdose. On arrival the patient has a GCS of 14 with no signs indicative of opiate overdose. The friend that accompanied him in the ambulance claims to have injected him with some naloxone he obtained. You wonder if there is any convincing evidence that known addicts should be given naloxone to administer to other addicts in order to prevent deaths from overdose.

Search Strategy

Ovid MEDLINE(R) 1950 to June Week 4 2008
EMBASE 1980 to 2008 Week 26


Medline:[exp NALOXONE AND ( overdose.mp OR exp overdose/) AND exp Opioid-Related Disorders}] Limit to humans, English Language.
Embase:[exp NALOXONE/ AND overdose.mp. AND exp Opiate Addiction/] LIMIT to human and english language

Search Outcome

Medline: 54 papers were found, one of which one was a review published in 2005 and two further papers reported work post dating the review. Embase: 61 papers found of which none were unique and contained relevant data. The 3 papers are summarised in the table:

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bacca CT and Grant KJ, 2005	6 papers reporting naloxone distribution programmes	Review	“Lives saved”	Over 200 plus various reports of use	Outcomes reported are unwitnessed self-reports and therefore anecdotal All reports uncontrolled
Maxwell S et al, 2006, USA	Chicago Recovery Alliance, a voluntary program, trains iv users and their close associates and prescribes naloxone. Program piloted 1998 and expanded in 2000	Observational	Peer overdose reversal reports	319	“Informal reports” of reversals only Uncontrolled Mortality data can be confounded by numerous other factors. Mortality has in fact fallen back to the 1997 rate
			Heroin overdose deaths in Cook County in:	2000=466 2001=374 2002=344 2003=324
Seal KH et al, 2005, USA	24 iv drug users (12 pairs of injection partners) Trained in CPR and naloxone administration Followed up for 6 months	Observational	Overdoses witnessed by study subjects	20	Small pilot study Uncontrolled
			CPR performed	16/20
			Naloxone administered	15/20
			Overdose survivors	20/20

Comment(s)

Much of the literature found on this topic, although reporting no data, has argued for or against take home naloxone. Some argue that the need for naloxone is greater when users fear that law enforcement agencies will be notified if emergency medical services are called. Others worry about the implementation of user naloxone prescriptions leading to more risky drug taking. Many workers in this area believe that lives will be saved with rapid, available treatment and that this treatment will only be available from peers. Despite the apparent successes reported it is important to recognise the flaws in the research and the lack of follow up for patients who have received naloxone, a drug with known complications. A properly designed trial may well be impossible in this area – but the evidence of potential harm and benefit requires careful evaluation whenever this sort of program is considered.

Clinical Bottom Line

There is a lack of sound evidence to suggest that the benefits of take home naloxone outweigh the risks. Careful evaluation of local circumstances is necessary when considering this option.

References

1. Baca CT, Grant KJ. Take-home naloxone to reduce heroin death. Addiction 2005;100:1823-31.
2. Maxwell S, Bigg D, Stanczykiewicz K et al. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addictive Dis 2006;25:89-96.
3. Seal KH, Thawley R, Gee L et al. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention. J Urban Health 2005;82:303-11.