Naloxone for opioid toxicity and overdose

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Hi, I'm Jo Cheah. And this is the Australian Prescriber Podcast. Joining me today is Dr Marianne Jauncey, who's a medical director and has written an editorial titled, Naloxone for opioid toxicity and overdose in the community. Thank you Marianne for joining us.

My pleasure, Jo.

It's great to have you. So to begin, could you tell us about naloxone and how it works to reverse opioid toxicity?

This is a drug that will save someone's life, who might otherwise die of opiate overdose. So, the reason it's so essential for everyone to know about this drug is because you can do no harm, but you might save a life. So, you can do no harm, but you might just save a life. Opiates, all opiates, whether we're talking about OxyContin, morphine, Endone, Kapanol, or we're talking about illicit opiates, such as heroin, the way they work is they connect to a particular receptor. And when that receptor is on, the effects of opiates are apparent, and one of those is a reduced drive to breathe. So we get a reduced respiratory rate, we get a reduced depth of respiration and frequency of respiration. And if there's too much of the opiate, or there's other substances on board that act to increase the effects of that opiate, it can be enough to kill you. Even if it doesn't kill you, it can be enough to harm you. So we all know that every minute of hypoxia is important and needs to be reversed as soon as possible.

That's where naloxone comes on board, because you really don't need to have any particular medical skills or first aid skills. If you give someone Narcan, and the reason that they're not breathing is because of opiate toxicity, you can save them.

So, what happens if naloxone is not readily available in the instance of an opiate overdose?

An opiate overdose or toxicity is when somebody has had so much that their drive to breathe is reduced and puts their life at risk. Somebody will have pinpoint pupils and a reduced respiratory rate, and/or depth of breathing. And if nobody's around to recognise that, or nobody knows what to do, that person can die. It is a simple as that. And every year in Australia we’re getting worse at this. More and more people are dying of opiate toxicity and opiate overdose every year. We’ve now got more than 1000 deaths a year, Jo. Think about that. That’s more than 3 deaths a day. And the important thing is these are preventable deaths.

Who is the target patient group of naloxone? And are there certain factors that may increase a person's risk of overdosing?

People who are using heroin as well as other illicit substances that may have opiates involved are very much a target group to know about and have access to naloxone. Two-thirds of the deaths these days is not heroin, but it's prescription opiates. So I think a really crucial factor that we need to acknowledge is that twice as many people are dying from an overdose on their prescription opiate medication, as are dying of heroin overdose. And I don't think that population are nearly as well informed or aware about the benefits of naloxone and how they might access naloxone. I think the patient group is not as aware, I think their family members and support groups and carers are not as aware. And actually, I think sometimes GPs and pharmacists are not as aware. If we've got 650-odd overdose deaths every year in this country that are prescription opiates, and half amount again that are heroin deaths, we really have to be doing something different.

And what we would say is one of the things that we need to be doing differently is really talking to our patients about the dangers of opiates. There are benefits, as with any medication, there are also dangers and there can be side effects and toxicity. People need to know how to recognise that and what some of the risk factors are. And certainly we know that using alcohol, using other central-nervous-system depressants such as benzodiazepines, are both significant risk factors for having an overdose. The longer someone has been on, and the higher dose of an opiate that they're on is also a potential risk factor. So I think as healthcare providers, we've just got to stop a minute, step back, take off our blinkers and remember that all opiates kill, and all opiates can cause overdose, not just the illegal ones.

What sort of counselling points would you recommend, and specifically what are the signs and symptoms of opiate toxicity?

So I think opiate toxicity is not too hard to recognise. The key things that we're looking for is somebody who is less rousable, is more drowsy, is less responsive, look at their pupils and see if the black bit on their pupil is very very small, which is what we call pinpoint pupils. Those are the key things we're looking out for.

And would there be any other, I guess, general counselling points that you think other health professionals would benefit from, I guess learning about from the podcast today?

Reminding people that suffering toxicity or something going wrong is not good or bad, or right or wrong. We care about it because we care about you. All of us are concerned about one thing and that's making sure that our patients and people around us and those that we care about survive. So it's all about safety at the end of the day. And then say to them, "Look, there are places that you can go and get this medication." I would encourage all GPs and pharmacists to have access to naloxone, have access to some dummy kits where you can show them both the intranasal product and the intramuscular product.

Could you go through, I guess the dosages of each dosage form? And yeah, any other administration instructions that we haven't already talked about?

So, in Australia there's largely two particular products. And the main reason they're different is how they are given to somebody, or the route of administration. So the first is a nasal spray. It comes in a box and there's two little contraptions that you take out. And each of those has a single dose. It's a single metered spray that goes up somebody's nose. And it's basically the equivalent of 400 micrograms of intramuscular. It's a higher dose because it's a nasal spray, and so it's 1.8 mg, but most people know naloxone in terms of an intramuscular dose calculation. So it's a relatively small dose. And once you've given it once and you've clicked through, then that device is finished and there's no more in there. And then you take the other one out of the box and give that into the alternate nostril if the person needs another dose.

The other product is a intramuscular route of administration. It's in a box that you squeeze and turn and it will open up, and there's a preloaded syringe. The total dose in the syringe is 2 mg. So it's much higher. And what you have is, down the side of the syringe, are numbers that go one, two, three, four, five, with each one of those being the equivalent of one dose. So the equivalent of one dose of the nasal spray. If you're using the intramuscular dose, you click it open, you have to then screw on the needle tip which is in there, that's the one part of the contraption which hasn't been put together. So you'd take the lid off and screw on the needle cap. And then you would either enter somebody's shoulder muscle, where we typically think of getting a vaccine, or into somebody's thigh muscle. And that can go through clothing if you need to, because time is of the essence, you would give someone a dose. You would just depress the needle initially to the number one, then the number two, because each of those is a dose. And anybody can be given repeat doses every couple of minutes.

If something happens and you give a bit more than normal, again, this is a safe drug. You will not harm someone, and you might just save a life. The worst that can happen is that you don't give it, not that you give too much.

Mm-hmm (affirmative). Sure. And if someone did administer either the nasal spray or the injectable form, would that person also call for an ambulance at the same time?

Yes. Ambulances, like all of us are just concerned in safety, so that does not result in an immediate call to the police. People should not be concerned that an ambulance is going to notify police. The only reason police should come as if they're concerned about the safety of the ambulance officers. So we would always recommend that people still call an ambulance. If you call an ambulance and you're talking to them over the phone before they arrive, they can potentially give you additional information and support as you're managing the person in front of you. And you can say to the ambulance officer on the phone, "I think this person might've taken too much of dot, dot, dot, whatever that is. I have some naloxone and this is what I've done."

Can you take us through the various steps that led to naloxone being available to purchase over the counter?

In 2013, the PBS began subsidising naloxone. And then a couple of years later, it was rescheduled to be available over-the-counter. However, when something is purchased over-the-counter without a script, it doesn't attract the PBS subsidy, and so it can be very expensive. Unfortunately, the PBS subsidy wasn't then being able to be used when it was rescheduled and was over-the-counter. So in 2019, a couple of years ago, the Federal Government funded a pilot program in three states, in New South Wales, Western Australia, and South Australia, that provides naloxone completely free, no questions asked, don't even need to give your full name if you don't want to, at participating pharmacies, and a small number of other services, but largely at participating pharmacies. And so what that means is not only those people themselves at risk of overdose, but others involved in their care, so families and friends and carers, can go to participating pharmacies and get one or either, or both of these particular products.

The pharmacist will be able to instruct them about what to look out for and how to use it. And again, they can go to some simple online videos for further information to make sure that they feel confident in both recognising an overdose and then responding appropriately.

So the federal pilot has been extended at this point until June of this year, so June 2021. We don't at the moment have any data about that pilot. We don't yet know exactly what's going to happen. My hope as somebody that cares about unnecessary deaths is that this will be able to be extended in both time and geography.

Other than the pilot, do you have any other current data on naloxone use in the community?

No. Other than what we know, as I said, both the PBS subsidy and then the rescheduling were positive steps, most of the naloxone in the community is not getting out via that way, it's still coming as a Prescriber Bag item. So it's not actually going out. It wasn't actually going out over-the-counter. I absolutely think when somebody is writing out that repeat prescription for any kind of an opiate, that is the time you need to be going, "Hang on," prompt reminder, "Hang on, what was that thing I learned on the podcast? Yes, yes, I need to remember about Narcan." And any doctor can write a script for naloxone for that patient and explain to them, plus or minus obviously their family members or friends who might be around and in a position to respond, so that they know what to do and how to do it.

What sorts of policies or changes in practice would you like to see in the future in regards to naloxone use?

I would like to see every GP thinking about naloxone every time they write a script for opiates. I would like to see every pharmacist having a conversation about the signs of toxicity and the risks of opiate toxicity with anyone that comes in with a script for opiates, whether that is prescription opiates for pain, opiates for opiate dependence, whatever it's for, all opiates act and kill in the same way. I would like to see other setting-based responses where community healthcare centres, other settings where there might be people who are at risk of overdose, for example some homeless shelters with a number of people with drug and alcohol conditions or addictions, that all of those places consider having naloxone and training their staff. If we continue to see the increase in overdoses continue at the rate it is, I think we need to consider other emergency services personnel have access and use naloxone.

But are there any other preventative measures that are currently in place or that you would like to see in regards to reducing opiate-related overdoses, especially since a lot of toxicities or overdoses are due to prescription drugs?

I think if we could do one thing, it would be start having the conversations, for a couple of reasons. One, I think having a conversation with anybody about their medications and/or their other substances that they're using helps remind us that we don't always know everything about our patients. It reminds patients that we're interested and concerned for them. And it also manages to reduce stigma. If you are routine in asking everybody about what they use, how they use it, including licit and illicit substances, and talking about the side effects of all of their medicines, whether that is their antihypertensives, their anti-cholesterol drugs, their antidepressants, whatever, and their opiate medications, it makes it a lot easier for people to start having open and honest conversations. And it's those open and honest conversations, and reducing the stigma associated, both with illicit opiates and for a lot of people with opiates for pain, people can feel very threatened, I think, about the views that some people may have.

And I think that healthcare workers, be they doctors, nurses, pharmacists, anyone that's involved in the care of somebody, we should never be frightened about having an open and honest conversation because we can remind people at all times, we have one thing at the forefront of our mind and that is their safety.

So, that is all the time we have for today's episode. Thank you again for your time. It's been really insightful and I've definitely learned a lot.

It has been my pleasure, Jo. As you know, I could probably talk under concrete, so you've done very well to keep this to time.

So, Marianne's editorial is available online at nps.org.au/australianprescriber. I'm Jo Cheah. And thanks again for listening to the Australian Prescriber Podcast.

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The views of the host and the guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise.