Take-home naloxone kits for treating opioid overdoses should, where possible, offer intramuscular and intranasal formulations of the lifesaving drug, according to a new guidance.
The document also calls for trained responders to provide rescue breathing as part of the response to the emergency. Finally, it recommends packaging take-home naloxone kits with a recognizable carrying case, breathing mask, non-latex gloves, instructions on how to administer naloxone, naloxone, and supplies to administer naloxone. Kits should contain three or more 0.4-mg/mL naloxone ampoules or vials, it says, depending on the community’s need to address illicitly manufactured fentanyl and other potent synthetic opioids.
The new guidelines were published online August 28 in the Canadian Medical Association Journal.
Toxicity Deaths Increased
A total of 7328 apparent opioid toxicity deaths occurred in Canada last year, which comes to an average of 20 deaths per day, according to the Public Health Agency of Canada. Before the COVID-19 pandemic, the average number of deaths per day was 10.
Dr Jane Buxton
Since 2016, the amount of fentanyl and other substances such as benzodiazepines in the unregulated drug market has increased, guideline author Jane Buxton, MBBS, former harm reduction lead at the British Columbia Centre for Disease Control, told Medscape Medical News. People are often unaware that the drugs they are purchasing contain these compounds, which put them at greater risk for harm. “It’s just horrific how toxic these substances have become,” she said.
With funding from the Canadian Institutes of Health Research, the Naloxone Guidance Development Group drafted national guidance for people who develop, fund, or oversee take-home naloxone programs. The document may also be of interest to public health workers, distribution sites, and community overdose responders, the authors write.
In addition to public health professionals, academics, and clinicians, the Naloxone Guidance Development Group included people with experience in drug use and response to overdose. The group conducted systematic reviews to identify and consider evidence published in all types of literature. It also considered community expertise as it drafted its recommendations. The group requested feedback on its draft recommendations through an external review committee and public input.
The new guidelines’ recommendations on kit equipment and rescue breathing were classified as “strong,” meaning that they can be adapted as policy in most situations or regions.
But the recommendation about providing both naloxone spray and injection was deemed “conditional,” meaning that the authors anticipate that its adoption would “require substantial debate” among many interested groups.
The authors note that the high cost of naloxone spray may be a barrier to its inclusion in take-home kits. During their research, they found that the cost of the spray could be 10 times the cost of the equivalent intramuscular formulation. Thus, it may not always be financially feasible to offer both forms of naloxone, the authors write.
Real-World Experience
Several of the authors strongly prefer intramuscular naloxone because of concerns about withdrawal precipitated by the intranasal formulation. Participants also noted drawbacks to naloxone injections, including concerns about being cut by broken vials or ampoules while administering the drug. Yet most people who use opioids prefer to administer intranasal naloxone.
People who live in poverty sometimes have lost fingers and even hands to infections arising from contamination of drug supply or frostbite, making it difficult for them to administer shots, according to the guidance.
Cold weather poses other challenges as well. For example, needles may not be able to penetrate through layers of clothing, and it may be difficult or unsafe to remove layers. “Consultation-session participants reported that their hands become numb in the cold, making intramuscular administration difficult,” according to the guidance.
These kinds of firsthand insights about naloxone were critical to developing recommendations, said Buxton. In assessing naloxone use, researchers can’t look at the results of studies that are conducted routinely in other fields of medicine.
Conducting a clinical trial in the field to compare patients’ responses to naloxone injections and nasal spray is not feasible, she said. “There’s not much in the literature that actually shows what the thousands of people who have been doing this for the last 10 or so years have experienced.”
A Medical Problem
Commenting on the guidance for Medscape, S. Monty Ghosh, MD, MPH, an addiction specialist at the University of Alberta in Edmonton, said that its publication in a prominent journal such as CMAJ sends a strong message about the need to provide naloxone for people experiencing opioid overdoses. “It frames it as a medical problem, not as a moral problem,” he said. Ghosh was not involved in drafting the guidance.
Ghosh helped establish Calgary’s Rapid Access Addiction Medicine program, the province’s largest and first comprehensive outpatient addiction treatment program.
He applauded the approach taken in developing the guidelines.
“They recognize that the vast majority of our overdose response using naloxone is not actually done by clinicians,” Ghosh said. “It’s done by community members and people who use substances.”
The Canadian Institutes of Health Research (CIHR) for the Canadian Research Initiative in Substance Misuse Implementation Science Program on Opioid Interventions and Services funded the guidance. Buxton received a CIHR grant to the Canadian Research Initiative in Substance Misuse for the work overseen and managed by the Centre for Addictions and Mental Health in support of the guidance. Ghosh has disclosed no relevant financial relationships.
CMAJ. Published online August 28, 2023. Full text
Kerry Dooley Young is a freelance journalist based in Washington, DC. Follow her on Mastodon and Threads as @kerrydooleyyoung and at BlueSky @kdooleyyoung.bsky.social.
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