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Opioid overdose and misuse pose a substantial global public health burden and are a leading cause of drug-related deaths in Australia. In 2012, Australia recorded 564 accidental opioid overdose deaths, nearly equaling the number of road accident-related deaths. Opioid-related deaths have been rising sharply, with a 21-fold increase in oxycodone-related deaths observed in Victoria from 2000 to 2009.
This surge is partly due to a 15-fold increase in opioid prescriptions dispensed through the Australian Pharmaceutical Benefits Scheme (PBS) from 1992 to 2012, with oxycodone being the main contributor, increasing from 35.3 to 89.2 per 1,000 population between March 2002 and August 2007.
Several factors contribute to the increase in opioid use. One significant factor is the increased acceptance of opioids for pain treatment, as they were once considered safe with a low risk of iatrogenic addiction. However, recent trends show that rates of iatrogenic addiction and risks associated with prescribed opioids are higher than previously believed. As early as 2001, the rate of hospitalisation due to non-heroin opioids surpassed that of heroin. Other factors contributing to this growth include efforts to increase patient satisfaction scores and strong marketing of opioids by the pharmaceutical industry.
Due to this increase in opioid use, there has also been an increase in opioid overdoses and opioid-associated deaths, as mentioned above. Research suggests that certain contributing factors, such as low socioeconomic status, male gender, concurrent use of multiple medications, recent incarceration, homelessness, and mental health conditions, increase the likelihood of opioid overdose from both prescription and illicit opioids. This trend is not limited to Australia but is being observed around the world, with the United States (US) declaring an "opioid epidemic."
In response to the increased number of accidental opioid-related deaths worldwide, there has been a global shift to improve access to take-home naloxone for administration by patients and bystanders. Naloxone is a "rescue drug" approved by the US Food and Drug Administration (FDA) in 1971 for administration by emergency medical providers. Naloxone is a mu-opioid receptor antagonist that can reverse the effects of opioids on the central nervous system and improve acute respiratory status. It is deliverable via injection or intranasal routes with similar efficacy. Patient preference and ease of administration in a non-hospital setting lean toward intramuscular or intranasal use; however, intranasal forms are not readily available in some countries, including Australia.
Opioid overdose and misuse pose a substantial global public health burden, and naloxone has emerged as a vital tool in mitigating these risks. Many countries, including various states in the US, the United Kingdom, Canada, Italy, and Australia, have made naloxone available without a prescription in the hope that those at risk of an opioid overdose or their family and friends (bystanders) can easily access this life-saving medication.
In February 2016, naloxone was down-scheduled to Schedule Three (Pharmacist Only) medicine in Australia, allowing it access without a prescription. Before this, naloxone was available as a "Prescription-Only" medicine, primarily used in emergency medical services and hospital settings.
In 2011, the "Implementing Expanded Naloxone Availability in the Australian Capital Territory" (IENAACT) program was initiated to trial an increase in naloxone availability and awareness in the ACT community.
This program demonstrated that training participants (mostly opioid users) enabled the successful administration of naloxone in overdose situations and that participants felt "positive emotional impacts." Additionally, 96 individual submissions to the Therapeutic Goods Administration (TGA) reiterated that making naloxone "over the counter" would remove a barrier to its access and is safe with no potential for misuse or abuse. The successful outcomes of the IENAACT trial, the submissions to the TGA, and a recommendation from The Advisory Committee on Medicines Scheduling (ACMS) all contributed to the final decision to down-schedule naloxone.
While policy changes like this should significantly increase access to naloxone and its community use, the uptake and outcomes of take-home naloxone programs have not been established. Furthermore, it is unknown if any specific challenges may influence the actions or opinions of stakeholders involved in take-home naloxone supply and use. Therefore, this blog aims to explore the factors that affect the use of take-home naloxone from the perspectives of different stakeholders.
In 1985, the Australian Government adopted harm minimisation as a national framework to address the range of drug and alcohol issues in society. While take-home naloxone has support from potential users in the community as a harm minimisation project, healthcare professionals have expressed concerns about its uptake, perceiving it to encourage high-risk opioid use. Similar concerns were, and still are, expressed regarding needle exchange and distribution programs implemented in Australia since the mid-1980s under the harm minimisation framework. Although there is no evidence that take-home naloxone or syringe exchange programs increased drug use, this stigma persists. Studies have shown that naloxone can potentially decrease drug use, as access to naloxone motivated and empowered patients to be more health-conscious.
To highlight the stigma associated with naloxone, a comparison can be drawn with adrenaline for anaphylaxis. Both naloxone and adrenaline are patient-administered rescue medications that save lives; however, the introduction of adrenaline faced no resistance from the community compared to other harm minimisation programs like syringe exchange or methadone. A systematic review of healthcare professionals' perspectives showed that they expressed "lowered regard, less motivation, and feelings of dissatisfaction" toward patients with substance use disorders, reinforcing this notion of stigma. As mentioned, naloxone is a life-saving medication, and a healthcare professional's decision to withhold it from patients based on stigma violates all principles of professional ethics in healthcare. Codes of ethics state that, despite conscientious objection to the supply or prescribing of a medical product, healthcare professionals must place the patient's best interests above all else and, at the very least, maintain continuity of care to all patients.
It is important to note that illicit opioid use is not the only cause of opioid overdose. Chronic pain patients are also at risk due to pharmacokinetic changes with age or confusion about dosing or instructions of use. Despite this, current studies disproportionately focus on injecting drug users and patients involved with needle exchange programs, homeless shelters, and similar facilities. This may be due to healthcare professionals' fear of offending non-illicit opioid users when discussing take-home naloxone. To mitigate this risk, healthcare professionals should be educated on how to identify "high-risk" chronic opioid-using patients and provide all of these patients with take-home naloxone. In this review, many healthcare professionals also emphasised the lack of education and training on take-home naloxone. Although codes of ethics in healthcare mandate lifelong learning for healthcare professionals, it is clear that patients are adversely affected by their lack of knowledge. Two studies showed that training lasting around an hour was sufficient to increase the understanding of homeless shelter staff and other healthcare providers. All healthcare professionals who prescribe opioids or care for patients at risk of opioid overdose should be provided with training on take-home naloxone.
A systematic review of stigma among healthcare professionals towards patients with substance use disorder highlighted the importance of training professionals to enhance their knowledge, skills, and self-efficacy when working with these patients. McArther's 1999 study identified two factors that contributed to the successful implementation of methadone in communities: high demand from drug users themselves and the eventual realisation of its effectiveness in reducing crime rates and HIV/AIDS transmission. This suggests that naloxone, like methadone, could gain community awareness and acceptance over time, demonstrating its value in a take-home setting. A 2007 article by Beletsky et al. supported this notion, concluding that physicians with more experience and awareness of patients with substance use disorders were more likely to respond positively to take-home naloxone prescriptions.
Emergency care providers, with their expertise in opioid-related overdoses, are potential critical stakeholders in the uptake of take-home naloxone. However, studies have shown that they often hold opposing views towards patients with substance use disorders, with some even perceiving take-home naloxone training as ineffective. Addressing their concerns and gaining support is crucial for successfully implementing take-home naloxone programs.
Given the high number of patients presenting to emergency departments at risk of opioid overdose and the trend of patients continuing medications prescribed in hospitals, emergency physicians are ideal candidates for further education on take-home naloxone. This can increase the dissemination of this life-saving medication into the community. Once initial uptake is established, other healthcare providers, such as general practitioners and pharmacists, will likely follow suit.
Pharmacists, as increasingly accessible healthcare professionals who may be patients' first point of contact, play a crucial role in take-home naloxone distribution. However, policy regulations, particularly in the US, can hinder pharmacists' involvement due to varying state-level legislation. While pharmacists generally have positive attitudes towards harm-reduction services, many lack confidence in their ability to educate patients on naloxone use or even stock the medication. Moreover, a lack of awareness regarding the prevalence of opioid overdose among pharmacists can hinder their uptake of take-home naloxone programs.
The paucity of information surrounding the role of pharmacists and emergency care professionals, two key stakeholders in the future of take-home naloxone, highlights the need for further research in this area.
To conclude, the Australian Government has invested $19.6 million over four years (from 2022-23) to deliver the Take-Home Naloxone (THN) program nationally. As of July 1, 2022, naloxone is available for free without a prescription to anyone who may experience or witness an opioid overdose or adverse reaction. This investment ensures access to this life-saving medication and will help people obtain naloxone when needed.
The THN program is available to:
People who are at risk of an opioid overdose or adverse reaction, their carers, friends, and family members.
Approved providers such as community pharmacists, dispensing doctors, and hospital pharmacists.
Authorised Alternative Suppliers (AAS) such as needle and syringe programs, alcohol and other drug treatment centres, and outreach services.
Naloxone is available at all participating pharmacies across Australia. In non-pharmacy settings, the availability of naloxone varies by state or territory and may include:
Community and hospital-based pharmacies
Alcohol and drug treatment centres
Needle and syringe programs
Custodial release programs
To find out where to access naloxone, please refer to the relevant state or territory health department. The Australian Government funds the THN program and oversees its delivery in collaboration with state and territory governments.
To support the program, the Australian Government has partnered with the Australasian College of Pharmacy (ACP) to develop and deliver THN program education and training resources, including:
Educational flyers
Naloxone first aid videos
Free training modules
Free training modules are available for pharmacists and other AAS services. Pharmacist training is accredited for Continuing Professional Development credits. To access the modules, you must create an account with the ACP.
Canberra Alliance for Harm Minimisation advocacy is one of the harm reduction services in Australia that provides THN and extensive training. Also, to inform you, dear readers, that August 31 is an overdose awareness day, and Canberra Alliance for Harm Minimisation Advocacy will host an overdose awareness BBQ on August 30 at Veterans Park (50 Bunda Street Canberra, ACT). So, if you're in Canberra, Australia, try to be there. There would be naloxone training and food and drinks to go around.
Be safe!
To your health,
Nwabekee.
REFERENCE
mdpi-res.com, Taylor J. Holland, Jonathan Penm, Jacinta Johnson, Maria Sarantou and Betty B. Chaar (2020).
Wow! Thanks for sharing.