Providing take home naloxone needs to be improved to prevent opioid overdose deaths

An effective approach can only be achieved by a national strategy for averting opioid‐related deaths

Opioid overdose‐related deaths in Australia have steadily increased over the past 15 years to more than 1000 each year, more deaths than from motor vehicle accidents.1,2 Twenty years ago, most overdoses were in people who injected heroin, but now 70% of deaths involve opioids prescribed by doctors and dispensed by pharmacists.1,2 Our health system must respond to this growing community and public health problem. A number of strategies have been recommended,3 including better education of health professionals and opioid users; hospital opioid stewardship programs; improving access to multidisciplinary services for patients with complex pain or substance use disorders; better coordination of health care with systems such as My Health Record and prescription monitoring programs; and the expansion of take home naloxone (THN) programs.4

THN programs educate laypeople about opiate overdose and supply naloxone, a short acting opioid antagonist, for use in the event of a suspected overdose. These programs are possibly the single most effective strategy for reducing opioid‐related mortality,5 and are recommended by the World Health Organization6 and the United States Centers for Disease Control.7 They have been found to be cost‐effective in North America,8 and in Australia it has been estimated that THN interventions cost about $17 000 per life saved.9 Most THN programs have targeted people with a history of injecting opioids, being based either in public health facilities (eg, drug treatment and needle syringe programs in New South Wales and Western Australia) or community pharmacies (eg, Victoria).10

In their study published in this issue of the MJA, Tse and colleagues assessed naloxone supply to community pharmacies in Australia during 2014–2018 by analysing Pharmaceutical Benefits Scheme (PBS) prescriptions data and sales data supplied by IQVIA.11 Their findings highlight challenges in expanding THN programs. Higher levels of community pharmacy dispensing of naloxone in Victoria than in NSW or WA probably reflect different models of THN supply; naloxone dispensed by public health facilities in NSW and WA is not captured in PBS data. Despite the rescheduling of naloxone in 2016, enabling over‐the‐counter supply by community pharmacies, over‐the‐counter and prescribed supply had not increased; the only substantial rise was in prescriber bag supplies of the drug, unlikely to facilitate widespread expansion of its supply.

The study by Tse and colleagues was undertaken before several important changes during 2019 that are cause for some optimism: the introduction of an affordable and simple‐to‐use intranasal THN formulation (Nyxoid) as a Section 85 PBS item;12 and the initiation of a 15‐month trial of THN supply without cost in three states (NSW, WA, South Australia).13

A number of important enablers and barriers that need to be taken into account if the supply of THN is to be substantially increased, however, are not addressed by the current trial. Public awareness of the nature of opioid overdose is poor, particularly among patients prescribed opioids for treating pain;14 education campaigns about preventing and managing overdose are needed for patients and carers. No authoritative clinical guidelines on THN for patients prescribed opioid medications have been published in Australia, and few doctors or pharmacists have been trained in delivering THN. There are few (if any) hospital opioid stewardship programs that systematically include THN, and it is available in only a handful of emergency departments.

The diverse nature of people who experience opioid overdoses — young and old people of different cultural backgrounds, living in metropolitan, regional and rural Australia, taking illicit and prescribed opioids, and using different types of health services — means that we cannot rely on a one‐size‐fits‐all approach to THN. A model of care effective in one community (eg, targeting people who inject drugs by ensuring that THN is available at needle syringe program sites) will not be appropriate for others (eg, patients being treated for pain). A universal access model is needed, one in which THN is available and actively promoted across all levels of health care and with the engagement of patient and carer organisations, including primary and specialist health care, to all people at risk of overdose. The findings of the study by Tse and colleagues suggest that we have much to do if THN programs are to be supplied as part of routine health care.

We need a social and cultural change if the risks of overdose are to be more effectively managed. It is incumbent upon us, as health professionals who prescribe and dispense opioids, to mitigate the overdose risk for our patients. This is no less a challenge than the one we faced in preventing the spread of HIV infection 30 years ago, and it will require similar partnerships between health providers, the general public, governments, and industry groups. One problem that needs to be urgently remedied is the lack of a national strategy: the size of the challenge we face, and the multifaceted responses needed to meet it, require a coordinated approach that can only be achieved by a national strategy for reducing opioid‐related deaths.