Community use of naloxone for opioid overdose with Dr Marianne Jauncey

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Naloxone is like a heroine or an opiate antidote. It needs to be given quickly because overdoses can kill people quickly, but it is an incredibly safe, effective drug and will reverse the effect and it will save someone's life if they're dying from an opiate overdose.

I'm Dhineli Perera, your host for this episode, and it's a pleasure to be speaking to Dr Marianne Jauncey today. Marianne is the medical director of the Uniting Medically Supervised Injecting Centre in Sydney and writes about the community use of naloxone for opioid overdose in the August edition of Australian Prescriber. Marianne, welcome to the program.

Hi, Dhineli, it's a real pleasure to be here.

So in February 2016 naloxone was actually made available over-the-counter and via prescription on the PBS. Why did this change actually occur at this point?

So it's been available on the PBS but not over-the-counter. People needed a script for it and we were hoping, I think, those of us in the field that have thought that this is a safe drug with no abuse potential, that should be much more widely available in the pre-hospital setting so that people aren't reliant on waiting for an ambulance to attend which can take 15 or 20 minutes. But unfortunately even though it's available over-the-counter it still is very expensive and doctors have been traditionally quite conservative and concerned about the idea of prescribing this drug. But I think now we have information not only from Australia but importantly from a number of other countries where they have radically upscaled the access to this particular drug. Indeed in a number of places in the United States for example it's routinely carried by police and other emergency services, and we know from this experience that it is a safe drug, you can quite simply train people, laypeople, in how to use it. You can train them in how to recognise an overdose so they know what to do and they're empowered, and then they can give that drug while you're waiting for the ambulance to get there and take over for you. Overdose numbers have been going up for about a decade in this country. We know that it's occurring when other people are present so we've got the potential to be able to do something about it. We also know that the picture of overdoses has changed somewhat over the last 15 or 20 years. Where there was a lot more heroin overdoses we're seeing a lot more overdoses of prescription opiates which are strong analgesic but unfortunately they are being used a lot and people are not aware of their risk of overdose. So you'll have someone for example that's been prescribed something for chronic back pain or after a knee injury and gradually over time their dose is going up and they're not aware of the risks necessarily of that drug in combination with either alcohol or other sleeping tablets.

Have we seen any changes in sort of opioid-related deaths since naloxone was made available over-the-counter in early 2016?

Not so far in Australia but we do know from overseas that when you can radically upscale the access to naloxone that you can make a difference. And we know for example in the United States they've given out over 150,000 kits, and have got about 26,000 successfully reported cases of reversal.

The US experience seems to be quite supportive of it. Is there much local experience to say yep that this is working and it's safe and effective?

So there's been some small pilot projects, the first one that began in the ACT and some smaller projects here in New South Wales. I know some stuff is happening in Victoria and in Western Australia. We do need a much more national approach is my view. At the moment it's largely something that is limited to drug and alcohol clinics, and drug and alcohol service settings, and I think if we're going to really make an impact we need to understand and accept that this is everybody's business, and this is not, you know, overdose risk is not something that's just now the domain of somebody injecting or using illicit drugs. There's actually more people dying of accidental overdose from prescription medications than from drugs like heroin.

So what are the risks of giving too much naloxone? Are there any adverse effects that we need to be aware of?

So because naloxone is a competitive antagonist, it bumps off any of the opiate which is on those receptors and reverses those actions. So if somebody is opiate dependent and you suddenly reverse the effects of those opiates, people can go into precipitated withdrawal. I think in the drug and alcohol world we've all heard stories of somebody having had a very large dose of naloxone and having had it intravenously and somebody waking up very upset and often angry. What we know however in the community distribution when you're giving a smaller dose and you're giving it via an intramuscular injection that actually reports of people waking up in acute withdrawal and being very upset or angry is extremely uncommon. It is a temporary-acting or short-acting medication so we do need to make sure that people are aware that they should still involve and call an ambulance, so we would caution people to just rely on naloxone. Please call an ambulance and then please jump in, give nalozone, give rescue breathing if you know how, and put somebody in a recovery position. And so we don't want people to forget about calling an ambulance and we also don't want people to forget that the drug will wear off and so very very occasionally there are reports of somebody overdosing again after the naloxone has worn off. That's extremely unusual

And, if it's given to someone that we're not really sure if they've overdosed on an opiate or something else, there isn't cause for concern?

No, that's one of the beautiful things about this drug. The simple line is it won't harm somebody but it might just save their life.

Okay, so you touched a little bit on the training necessary, Marianne. Can you tell us a little bit more about the training recommended for laypeople?

What we know from some of the programs that have been operating both in Australia and overseas is that you can effectively train people in a relatively short space of time. Ideally that's done by the person who's then providing the naloxone and at the moment in Australia that's largely the domain of drug and alcohol services. So you've got people coming who are known to be at risk because they're generally using illicit drugs and so in about 10 or 15 minutes we can teach people what are the risk factors for overdose, how do you identify somebody? So you need to know about somebody being slow breathing or no breathing, you need to know about them perhaps turning blue and importantly the size of their pupils going very very small, what we call pinpoint pupils. So if you see these signs of an overdose you should call an ambulance, you should give naloxone, an intramuscular injection of naloxone, either into their leg or into their upper arm, and you should do mouth-to-mouth breathing if you know what you're doing.

So Marianne, noloxone is available as both a prefilled syringe and ampules. Can you tell us a little bit about the pros and cons of each option?

So basically they contain the same drug and at the end of the day whatever you have in front of you is worthwhile giving it, but the actual available products have changed recently in Australia and it may be that they change again in the future. There are ampules, which are little glass ampules, which each contain 400 micrograms, so they're a little bit more fiddly and you have to break them open and sometimes people will cut themselves as they're doing that and certainly, if you're shaky or nervous, that can be a little bit tricky. But you break off the tip of the ampule, draw up the liquid inside and then give an intramuscular injection. And we know certainly amongst the populations of people where that's been used that's largely been very successful. We also now have product which is being imported from overseas called Prenoxad which is specifically made for an overdose situation and it's a yellow plastic container that you twist and you open it up and inside is everything ready to go. So it's got a prefilled syringe, which needs to be twisted to put together, and the tips or the needles are there ready to go on the end of it. It's got a much higher total dose of Narcan so you don't give the whole dose. And on the side of the syringe there are clearly printed 1, 2, 3, 4, 5 which are the doses, so it's for one person but it's a multiple-dose product. Overseas there's other products including nasal sprays and I think many of us are hoping that in time we will have something like that available in Australia.

So in areas where naloxone has been used more widely has it encouraged more illicit drug use?

Yeah it's a good question and I think something that people were concerned about early on and thankfully I'm pleased to say there really is no evidence of that.

And lastly I wanted to ask, Marianne, is there training available for health professionals specifically in how to facilitate the safe and effective use of naloxone?

Yeah it's a good question and I think the simple answer is no, we're not that great yet in having a really clear national database of where both individuals can go or where potential trainers can go to be skilled up, which was really part of the impetus for Susie and I to write this article for Australian Prescriber. There are a number of websites and there's some references in the article of where people can go to, and websites available that show in somebody's local district where they might go, but often it's going to be a case of going back to first principles and using some common sense for the health professionals who understand the action of opiates who, even if they haven't seen an overdose themselves, relatively simply can skill themselves up in terms of teaching someone to identify an overdose, and then again most professionals should be able to teach somebody how to respond. And one important thing is you need to have a dummy version of either the ampules or the prefilled syringe ready so that you yourself know exactly how to put it together and you can clearly show that to the person. Colleagues of mine who work in emergency medicine and see anaphylactic reactions constantly say to me the most common way I see an EpiPen is unused in the hand of the loved one as they walk in the door going “I didn't know how to use it”, so we don't want to see that happening in this situation either. An opiate overdose is a medical emergency because somebody stops breathing, you need to respond and respond quickly, and if you have this life-saving drug, you want to know that you can put the things together, put the needle on the end, and physically administer it to somebody to save their life.

Well that's unfortunately all the time we've got for this episode. Thank you so much for joining us today Marianne.

My pleasure Dhineli, it was good fun.

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Dr Jauncey’s full article is available online at nps.org.au/australian-prescriber and like our whole journal it's free. Subscribe to get the latest Australian Prescriber delivered straight to your email inbox and follow us on Twitter @AustPrescriber to get the latest updates. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Dhineli Perera and thanks for joining us on the Australian Prescriber Podcast.