BC Take Home Naloxone Program – updated article

This is an updated article on reducing opioid overdoses that we ran on June 14, 2015: thischangedmypractice.com/bc-take-home-naloxone-program.

By: Erica Tsang MD (bio), Margot Kuo MPH (bio), Ashraf Amlani MPH (bio), Caroline Ferris MD CCFP FCFP (bio), Jane Buxton MBBS MHSc (bio)

Disclosures:

Dr. Buxton is the project leader for the development of the BC take home Naloxone Program (BC THN program). 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 over 350 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 we have 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 510 deaths due to illicit drug overdose in 2015, with 622 deaths this year up to October 31^st, 2016. The BC Ambulance Service paramedics administered naloxone, an opioid antagonist, an average of approximately 180/month in 2014; 250/month in 2015 (a 40% increase over 2014); and 370/month in 2016 up to Oct. 31^st, 2016 (a 50% increase over 2015). (3) This may be an underestimate as firefighters, enforcement personnel, and community members are increasingly administering naloxone as well. In April 2016, BC’s Chief Health Officer declared a public health emergency in response to the growing numbers of deaths secondary to drug overdose. 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 in BC 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 over 350 approved sites throughout BC through the BCCDC Harm Reduction program, and can also be purchased over the counter without a prescription from many pharmacies in BC (kits containing 2 doses cost about $50).

In August 2014, a formal quantitative and qualitative evaluation of the BC THN program was published in the Canadian Medical Association – Open Journal. (8) 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 their health through the training sessions, and found the program easy to implement. However, in rural settings, there are fewer health care professionals 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. (9) 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. (10)

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 attend one of the BC THN 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. The BC THN program aims to reach individuals across the province; particularly at sites that may involve those at highest risk of overdose, including emergency departments and provincial prisons.

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 may be the pivotal event that inspires someone to enter recovery. With increased media coverage about the current opioid crisis, prescribers are being implicated in over-prescribing opioids and the CPSBC has developed standards for opioid prescribing. (11) In response, some physicians have inappropriately discontinued long-term opioid prescriptions without offering alternate supports. As a result, individuals may turn to dangerous illegal street opioids, to self-medicate physical and psychological symptoms. It is imperative that physicians identify individuals who are at highest risk of OD, including those who are initiating or tapering opioid therapy (eg. methadone), and consider recommending a THN kit.

Implemented in August 2012, the BC THN program continues to grow, as of December 2016, 14,820 participants have been trained, 15,841 kits dispensed, and over 2,782 reported overdose reversals with naloxone. Further information, including helpful videos and other resources, 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 obtain 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. As of September 2016, emergency use naloxone is an unscheduled drug in BC, potentially making it available for purchase anywhere by anyone who may require it. More recently, intranasal naloxone became licensed in Canada. It is currently available through an Ontario-based distributor through an interim order by the Minister of Health, and the RCMP acquired this for their members to carry.

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:

1. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva (Switzerland): World Health Organization; 2009. (View)
2. Jafari S, Buxton JA, Joe R. Rising fentanyl-related overdose deaths in BC. CJA 2015;6(1):4-6. (View)
3. Internal Data Source: BC Emergency Health Services, Patient Care Report, 2014 – Oct. 31^st, 2016. Analyzed at the BC Centre for Disease Control. Overdose Surveillance Group.
4. 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. (View)
5. Buxton JA, Purssell R, Gibson E, Tzemiz D. Increasing access to naloxone in BC to reduce opioid overdose death. BCMJ 2012. 54(5):231. (View)
6. World Health Organization. Community management of opioid overdose. 2014. Accessed December 7, 2016. (View)
7. 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. (View)
8. 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. (View)
9. Eggertson L. Take-home naloxone kits preventing overdose deaths. CMAJ 2014;186:17. (View)
10. College of Physicians and Surgeons of British Columbia. Become familiar with the Take Home Naloxone Program. 2014. Accessed December 7, 2016. (View)
11. College of Physicians and Surgeons of British Columbia. Safe prescribing of drugs with potential for misuse/diversion. 2016. Accessed December 10, 2016. (View)

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BC Take Home Naloxone Program - updated article

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