By: Dr. Jane Buxton MBBS MHSc (bio), Erica Tsang (bio), Ashraf Amlani MPH (bio), Dr. Caroline Ferris MD CCFP FCFP (bio)
Disclosures:
Dr. Buxton and Ashraf Amlani are the project leaders for the development of the BC take home Naloxone Program (BC THN program). Erica Tsang is a fourth year medical student working with Dr. Jane Buxton (physician epidemiologist) at the BC Center for Disease Control. The BC Take Home Naloxone program is a provincial initiative aimed at reducing opioid overdoses. This program trains individuals who use opioids (prescription or illicit) in overdose recognition and response, and provides free naloxone kits. The kits are currently being distributed at 72 sites across BC.The THN kits are distributed and covered by the BCCDC, at no cost to patients. If naloxone is prescribed directly (separate from the THN kit), it is not currently covered by Pharmacare. However, naloxone is covered by most third party insurance plans.
Mitigating Potential Bias:
Recommendations are consistent with current practice patterns
What care gaps have we noticed
Opioid overdose is a major cause of morbidity and mortality worldwide, and constitutes a serious public health issue. (1) Throughout British Columbia (BC), the landscape of opioid overdose has evolved, first with oxycodone and more recently, illicit fentanyl. The potency of these opioids, the practice of cutting heroin and other drugs with more potent agents, and recent trends in illicit opioid availability, such as fentanyl being sold as fake oxycodone, has resulted in a sharp increase in overdose deaths. (2) In BC alone, there were more than 330 deaths due to illicit drug overdose in 2013, and the BC Ambulance Service administered naloxone, an opioid antagonist, in over 2000 calls to reverse opioid-related respiratory depression. (3)Opioid overdose knows no socioeconomic bounds; individuals who use prescription or illicit opioids are at risk of an overdose. Certain populations are considered to be at higher risk of experiencing opioid overdose, including those with previous overdose, recent discharge from prison or drug treatment (i.e. reduced tolerance), high-dose opioid prescription, opioid use with co-morbidities (eg. respiratory, hepatic, renal disease), and concurrent treatment with antidepressants or benzodiazepines. (4) Accidental opioid overdose deaths are preventable with education and community naloxone. Until August 2012, access to naloxone was only through primary care, hospital, and ambulance settings. (5)
Data that answers these questions or gaps
Naloxone is part of the World Health Organization (WHO) Model List of Essential Medicines, and is effective in reversing opioid-related respiratory depression. Naloxone cannot be abused, and has no pharmacological activity in the absence of opioids.
In its recent guidelines on Community Management of Opioid Overdose, WHO recommended that: “People likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of suspected opioid overdose.” (6) Take-home naloxone (THN) programs have been in existence in Europe, Australia, and in the United States to address opioid overdose. (7) In August 2012, the BC Centre for Disease Control (BCCDC) launched the BC THN program to educate and train individuals to recognize and respond to opioid overdose with naloxone. Naloxone kits are provided to an individual who uses opioids, whether prescription or illicit, and who has received appropriate training. In an emergency situation, an individual can administer their naloxone to another person who is overdosing. Naloxone kits are distributed from approved sites throughout BC through the BCCDC Harm Reduction program.
In August 2014, a formal quantitative and qualitative evaluation of the BC THN program was published in the Canadian Medical Association – Open Journal. (7) Clients described feeling empowered by learning skills that could potentially save a life. Service providers from urban and rural areas across BC reported increased client engagement about health through the training sessions, and found the program easy to implement. However, in rural settings, there are fewer physicians who work within a harm reduction model and they often do not have additional support to assist with the administration and training required for the BC THN program. Despite these constraints, the program and its mandate have been declared a priority. (10)The program works closely with the Ministry of Health, regional health authorities, and allied health professional colleagues to develop strategies to provide support for this program, particularly in rural communities. One of the most active naloxone prescribers in the BC THN program speaks of hearing “heartwarming stories of how ordinary people have been able to save lives with a simple injection” after years of watching with dismay the evolving prescription opioid epidemic in her community and the associated sharp increase in overdose deaths.
The College of Physicians and Surgeons of British Columbia has endorsed the program and recommends that all physicians learn about the BC THN program. (8)
What we recommend (practice tip)
We recommend that physicians consider whether their patients taking opioids are at risk of an overdose. Through the BC THN program, physicians now have a tool to turn the tide of overdose – a simple kit for users and their friends to save a life when someone stops breathing with an unintentional overdose. Patients should be educated about overdose prevention, recognition and appropriate response, including calling 911 when suspecting an overdose. If patients and their family members are interested in receiving opioid overdose training they can be referred to one of the Take Home Naloxone sites (http://towardtheheart.com/site-locator). If physicians are interested in implementing a Take Home Naloxone program at their clinic, a program implementation guide, video, and new site registration form is available at http://towardtheheart.com/naloxone. In addition, the BC THN program has worked with other health care disciplines to facilitate naloxone dispensing and administration. Nurse practitioners are able to prescribe naloxone, and the BC THN program has collaborated with the College of Registered Nurses of British Columbia (CRNBC) to develop decision support tools for nurses to dispense naloxone to persons at risk of opiate overdose. When dispensing naloxone, Registered Nurses are required to meet the expectations for dispensing set out in CRNBC’s Dispensing Medications Practice Standard and follow employer policy. Further information is available here: http://www.bccdc.ca/prevention/HarmReduction/default.htm.
Physicians should know that the availability of naloxone does not cause people to use higher doses of their drugs. The last thing a user wants is to waste his money by having his high reversed, and to experience the pain of sudden withdrawal. But witnessing or surviving an overdose is often the pivotal event that inspires someone to enter recovery. And that is what harm reduction is all about: having people survive long enough to get treatment.
At 30 months since implementation, the BC THN program continues to grow, with 72 sites across the province, 2500 participants trained, 1500 kits dispensed, and over 200 reported overdose reversals with naloxone. Further information about the BC THN program can be found at http://towardtheheart.com.
Despite the growth of this initiative, naloxone is not limited to the BC THN program. We recommend that physicians who prescribe methadone or high dose opioids consider if their patients should also receive a prescription for naloxone, and to educate patients and their families about signs of opioid overdose and naloxone administration. Naloxone is not currently covered by BC Pharmacare, but most third party private insurance companies will reimburse patients for their naloxone prescription. The BCCDC is working with the College of Physicians and Surgeons of BC to develop appropriate education materials in the coming months. Prescription or illicit opioid overdose deaths are preventable with education and naloxone. We recommend that all physicians be familiar with naloxone and the BC THN program.
References
- Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva (Switzerland): World Health Organization; 2009. Free full text
- Jafari S, Buxton JA, Joe R. Rising fentanyl-related overdose deaths in BC. CJA 2015;6(1):4-6. Free full text
- BC Ambulance Service, personal communication, June 26, 2014.
- Dasgupta N, Brason FW, Albert S, et al. Project Lazarus: Overdose prevention and responsible pain management. North Carolina Medical Board Forum 2008;1:8-12. Free full text
- Buxton JA, Purssell R, Gibson E, Tzemiz D. Increasing access to naloxone in BC to reduce opioid overdose death. BCMJ 2012. 54(5):231. Free full text
- World Health Organization. Community management of opioid overdose. Available at: http://apps.who.int/iris/bitstream/10665/137462/1/9789241548816_eng.pdf?ua=1&ua=1 [Accessed December 11, 2014]. Free full text
- Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone – United States, 2010. MMWR Morb Mortal Wkly Rep 2012;61:101-105.
Free full text - Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S, Buxton JA. A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open 2014. 2(3):E153-61. Free full text
- College of Physicians and Surgeons of British Columbia. Become familiar with the Take Home Naloxone Program. Available at: https://www.cpsbc.ca/for-physicians/college-connector/2014-V02-02/06 [Accessed December 9, 2014].
- Eggertson L. Take-home naloxone kits preventing overdose deaths. CMAJ 2014;186:17. Free full text
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chief barrier to further program implementation is lack of facilities to have clients view the video and complete training – need dedicated service agencies to provide this – not available in all communities
Policy does not encourage provision of kits to front line street level workers, who are very likely to encounter such situations – 2 OD reversals in Maple Ridge occurred when workers used a kit from a client who happened to be close
This sounds like an excellent harm reduction intervention.
In my rural area of practice we have had no opioid overdose deaths that I can recall and have had a few occasions of elderly patients taking too much of their prescribed medication and requiring naloxone, however they presented to the hospital with plenty of time to be treated. It therefore seems to be unnecessary to carry it here, however I am happy to be aware of this for possible future use.
We are fortunate to have a community pharmacist that initiated and manages the THN program for our clinic. I think that the utilization of the THN program within our community will grow as a result of a few practices initiating the program.
We have been distributing these kits through our ED in Kamloops, thanks to the dedication of Dr. Ian Mitchell and Kirstin Mclaughlin MSN.
The program has been well received by our patients and it opens the door for non-judgemental conversation regarding drug use and/or rehab.