Why people who inject drugs are crucial to naloxone access programs
Naloxone, known commercially in Australia as Narcan is currently utilised by paramedics to reverse the overdose effects of opiates like heroin. A chief factor in the effectiveness of naloxone is that it needs to be administered quickly. A brain deprived of oxygen for even a couple of minutes starts to accrue damage. Quick administration of naloxone, reversing the sedating effects of an opiate like heroin can be crucial in preventing brain damage and potential death. By ensuring that the family, friends and peers of people who use opiates have access to this life saving medication and are legally protected when administering it, response times can be improved, ensuring that potentially fatal overdoses are prevented.
On the 31st of August 2012 (International Overdose Awareness Day 2012) the Victorian state government announced it would consider providing greater access to naloxone to be administered by people who were not medically trained, to address opioid overdose. The Victorian Government has since signalled via an alcohol and other drugs policy framework released in January 2013 that it would:
“… assess and implement targeted interventions to widen the use and availability of naloxone as an emergency response to opioid overdose, including reviewing evidence from trials in Australia and other countries, and taking steps to encourage prescribing its use for family members, carers or nominated peers within current rules.”
(State of Victoria 2012)
As we move, oh so slowly towards realising programs that enable greater access to naloxone in Victoria, I thought it might be timely to highlight the very real need to ensure that people who inject drugs are included in the development and implementation of any such initiative in Victoria.
There are gaps in how we respond to opioid overdose currently
Preliminary data regarding accidental opioid induced deaths (overdoses) suggests that approximately 500 people died in 2010 as a result of an opioid overdose across Australia (Roxburgh, & Burns, 2012)
According to the Illicit Drug Reporting Survey (IDRS) conducted in 2012 nearly half (41%) of the national sample of people who reported using heroin, had experienced a heroin overdose in their lifetime. Of those who had ever overdosed on heroin, 20% reported overdosing in the last year and two percent in the last month. On average participants in the survey reported overdosing on two occasions. (Stafford & Burns 2013)
Stafford and Burns (2012) also asked about the treatment they received at the time of a recent heroin overdose (in the past year; N=74). The survey found that:
- 18% of those who overdosed on heroin in the last year reported not receiving any treatment,
- 53% reported receiving Narcan®.
- 57% had an ambulance attend,
- 27% reported receiving cardiopulmonary resuscitation (CPR) from a friend/partner,
- 18% attended the hospital emergency department,
- 18% received oxygen
- 12% received CPR from a health professional.
Perhaps most disappointingly however:
“87% of respondents, reported that they did not receive any information or treatment after the recent overdose,6% received information from a drug health service, 2% from a counsellor or user group/organisation. “
(Stafford & Burns 2013)
It is obvious from the data collected in this report that there remains significant gaps in the way that we address heroin overdose within our community. Providing formal opportunities to address overdose for people who inject drugs not only provides them with the tools to address another person’s overdose, but also provides an additional avenue for people, who themselves are at potential risk of overdose to receive accurate and helpful information that may prevent overdose.
People who inject drugs are likely to witness an overdose
Examining the more local context, In the Melbourne metropolitan area between 1st June 2009 and 30th June 2010, Ambulance services attended 1188 heroin overdoses where naloxone was administered by ambulance personnel. This equates to an average of 3.25 incidents per day. (Lloyd 2011) In 59% of instances the overdose occurred in a public space, with the overwhelming majority of them occurring outdoors. These figures do not include responses to overdose experienced due to other opioids such as methadone, fentanyl or oxycodone, nor does it include instances where ambulance personnel did not administer naloxone.
The environmental context in which a large number of heroin overdoses are occurring (e.g. in public spaces) is a telling factor in planning where to strategically place naloxone resources in order to get the greatest impact. The fact that the majority of overdoses occur in public space suggests that in many instances people experiencing heroin overdose are more likely to be discovered by a peer than say a family member. This is not an argument for the exclusion of family members from naloxone programs, but does highlight the importance of ensuring that any naloxone training programs are widely promoted and offered to people who inject drugs. This idea is further reinforced when we consider Lloyd’s findings regarding the geographic spread of heroin overdose occurrence across the Melbourne metropolitan area. The 10 local government areas recording the highest incidence of heroin overdose either encompass or are adjacent to known ‘drug hotspots’ where identified street markets for heroin exist. One can extrapolate that since these areas are frequented by people seeking to purchase for heroin for injecting and that since much of the injecting occurs in public spaces, there is an increased likelihood that people who inject drugs are more likely to witness an overdose.
This is not new news. Kerr et.al 2008 (citing Darke et.al 1996, Strang et.al 1999, McGregor et.al 1998, Darke et.al 2000), assert that, ‘Injecting drug users (IDUs) are frequently present at overdoses of others, with most having witnessed at least one heroin overdose.’
People who inject drugs want to be involved
Face to face interviews conducted with 99 injecting drug users conducted by Kerr et.al in 2007 showed that:
“The large majority of the sample reported positive attitudes toward peer naloxone distribution (good to very good idea: 89%). Further, 92% said they were willing to participate in a related training program if made available. Reported reasons for these attitudes included beliefs that peer naloxone distribution may reduce morbidity and mortality by reducing delays to treatment, preservation of ambulance services for other medical emergencies, avoidance of authority involvement, improved
response to heroin overdose with additional resuscitation training, empowerment of heroin users to help others, and reduction of the long-standing physical and psychological impact of personal and witnessed overdose.”
(Kerr et.al 2008)
Training people who inject drugs to administer naloxone provides other benefits
According to a fact sheet compiles by the Open Society Foundation, training people who inject drugs to administer naloxone can provide other benefits too. These benefits as identified in a range of studies regarding peer naloxone programs, include:
- An increased sense of empowerment and self-efficacy amongst people who inject drugs
- Provides opportunities for peers to discuss other overdose information (that presumably could lead to a lessening of risk behaviours)
Conclusion
The provision of training on how to administer naloxone, appears to be appealing to people who inject drugs. The attitudes expressed in the study conducted by Kerr and colleagues, flies in the face of the prevailing stigmatising stereotypes that abound regarding the ‘typical’ injecting drug user. The obvious willingness of many people who inject drugs to contribute to their community also challenges previously patronising and paternalistic approaches to substance use issues within our society. We know that people who inject drugs often witness overdose, and that they want to be empowered to do something about it. What is left to do is ensure that they have a very real voice in the development and implementation of future naloxone access programs in Victoria.
References
Department of Health (2012) ‘Reducing the alcohol and drug toll Victoria’s plan 2013–2017’
State Government of Victoria, Melbourne Australia
Kerr, D., Dietze, P., Kelly, A & Jolley, D. (2008) ‘Attitudes of Australian Heroin Users to Peer Distribution of Naloxone for Heroin Overdose: Perspectives on Intranasal Administration’ in Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 85, No. 3
Lloyd, B. (2011) ‘Trends in alcohol and drug related ambulance attendances in Melbourne 2009-10.’ Fitzroy, Victoria: Turning Point Alcohol and Drug Centre
Open Society Foundation, ‘Stopping Overdose: Peer-Based Distribution of Naloxone’ Open Society Foundation website http://www.opensocietyfoundations.org/publications/stopping-overdose accessed 9th August 2013
Roxburgh, A. and Burns,L.(2012). ‘Accidental drug-induced deaths due to opioids in Australia, 2008.’ Sydney: National Drug and Alcohol Research Centre.
Stafford, J. and Burns, L. (2013). ‘Australian Drug Trends 2012. Findings from the Illicit Drug Reporting System (IDRS). Australian Drug Trend Series No. 91.’ Sydney, National Drug and Alcohol Research Centre, University of New South Wales.
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Stonetree Harm Reduction 
What is crucial but not explicitly stated in this fantastic article is that drug user organisations, who in there very nature employ and involve people who use drugs should be the ones funded to provide Naloxone training and distribution rather than a Gov dept. or AOD nurse. if you look at the Australian experience where half the states now have Naloxone distribution, the one that is the most successful is the ACT model, delivered and designed by the ACT drug user org, although a few others would/do like to take credit.
If Victoria goes down the road of starting a Naloxone program if they really are serious about preventing deaths and rapidly expanding Naloxone into the hands and homes of those who need it (i.e. drug users ) then a drug user org must be given absolute permission and the resources to design and implement this program.
Couldn’t agree with you more Sam. I would be hard pressed to name any organisation or group of organisations outside of the drug user orgs that have as solid links with the drug using community combined with a very intimate understanding of the complexities (e.g. Legal, community attitudes, as well as the physiological and environmental realities) of overdose. Thanks for your very constructive comments. Cheers Matt