Take-home naloxone programs and calls to emergency services

Updated advice to be given by Triple Zero call-takers is being developed

In May 2012, Australia’s first take-home naloxone program for opioid overdose prevention commenced in the Australian Capital Territory1; it was soon followed by programs in other jurisdictions. Current Australian naloxone training programs cover calling an ambulance, administering naloxone and giving cardiopulmonary resuscitation (CPR). Some training programs are as short as 10 minutes, and others are as long as 2 hours, so capacity to present practical emergency management scenarios, including calls to emergency services, varies.

We are involved in the National Naloxone Reference Group (NNRG), which is run under the auspices of the Centre for Research Excellence into Injecting Drug Use. The NNRG brings together representatives involved in take-home naloxone programs from all states and territories. Currently, all programs recommend that opioid overdose responders initially call Triple Zero (000) for ambulance assistance to ensure adequate post-resuscitation care and further assessment and treatment if needed. In evaluating take-home naloxone programs, we have identified conflicts between advice given in training and advice received from emergency services. In this article, we explore the decision-making process for calling emergency services while administering life support measures and (potentially) naloxone to reverse an opioid overdose, and advice of call-takers. Our discussion includes recommendations on appropriate action in a generalised overdose scenario that we sought from NNRG members and other researchers.

In most Australian jurisdictions, calls to Triple Zero may result in individuals being given advice which is contrary to that provided during current naloxone training programs. Triple Zero calls are diverted to emergency call centres which, in all jurisdictions other than the ACT, use Medical Priority Dispatch System (MPDS) software to guide call-takers through assessment scripts. These scripts, developed through extensive research and consultation, are designed to consistently help callers manage risks, but may not reflect the needs of population subgroups or be responsive to new practices, such as take-home naloxone programs.

Although there are no specific MPDS scripts for opioid overdose, there is a generalised overdose script, which may be activated when someone reports an opioid overdose. Opioid overdoses present in a variety of ways depending on the severity of the overdose. Clinical signs of opioid overdose include (but are not limited to) shallow breathing, clamminess, pallor, cyanosis, decreasing level of consciousness and seizures, progressing to complete cessation of breathing and loss of consciousness, followed by cardiac arrest and death if resuscitation procedures are not commenced.2 Should the opioid overdose sufferer be unconscious and not breathing, the call will most likely activate the cardiac arrest script (the highest priority script) rather than the overdose script, which advises CPR until emergency services arrive. These instructions are supported by evidence showing that decreases in the number, rate and quality of chest compressions delay return of spontaneous circulation3,4 and reduce survival rates.5,6 Under this script, no caller would be instructed to delay or stop CPR to administer naloxone, even after reporting training and naloxone availability. When other scripts (eg, the overdose script) are activated, callers might be instructed to administer a medication in accordance with the patient’s own doctor’s instructions, although typically only if the patient is conscious.

Hence, the advice of call-takers can directly contradict naloxone training and first-aid response to opioid overdose. This means that those trained in administering naloxone who are present at an overdose must decide whether to ignore the call-taker’s advice and administer naloxone as trained; if they do, they must also decide when to administer it vis-a-vis CPR. As trainees may already be reluctant to call an ambulance during an opioid overdose (it is estimated that only about 50% of opioid overdoses involve an ambulance service call7,8), due to concern that police will attend,9-11 or concern that ambulance attendance will attract unwanted attention from public housing or child protection officials,12 contradictory and seemingly unhelpful messages from call-takers are another disincentive.

Key stakeholders suggest that a short-term solution is to provide instructions based on whether the overdose witness is alone (apart from the victim) at the scene. If another person is present, then the call-taker’s CPR instructions can be followed and naloxone administered simultaneously; otherwise, stakeholders suggest that naloxone be given just before or while calling Triple Zero.

A flowchart describing when to administer naloxone, based on overdose witness numbers, is being developed for naloxone training while new MPDS scripts are being developed. MPDS scripts must query whether naloxone is available and whether it has been administered. Emergency call-takers should be trained about naloxone and responding appropriately. NNRG members have been engaging with ambulance authorities nationwide and contributing to MPDS scripts that incorporate take-home naloxone principles, and will continue raising public awareness of community naloxone programs through a range of activities, including community advocacy and publications.