Papers

Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes

Kerstin Dettmer, project director ^a, Bill Saunders, director ^b, John Strang, director ^c. 

^a Fixpunkt e V Mobilix, 10967 Berlin, Germany, ^b Alcohol and Drug Service, Gloucester Lodge, St Saviour, Jersey, Channel Islands JE2 7LB, ^c National Addiction Centre, Institute of Psychiatry and the Maudsley Hospital, London SE5 8AF

Correspondence to J Strang j.strang{at}iop.kcl.ac.uk

Doctors routinely give naloxone during emergency resuscitation after opiate overdose. The distribution of naloxone to opiate addicts has recently been addressed,^1-4 and a survey of drug users shows extensive support for the provision of supplies to take away.⁴ We present the preliminary results of two pilot schemes to provide take home naloxone to opiate users.

	Methods and results

Top Methods and results Comment References

The Berlin project
In January 1999 drug users in Berlin were given naloxone to take home. Opiate misusers attending a healthcare project (operating from a mobile van or ambulance) were offered training in emergency resuscitation after overdose, provided with naloxone (two 400 µg ampoules), needles, syringes, an emergency handbook, and information on naloxone. They were asked to report on any use of the drug. After 16 months, 124 opiate misusers had received training in resuscitation and were provided with supplies of naloxone to take away; 40 reported back, with 22 having given emergency naloxone (two on two occasions, one on three, and one on four).

The Jersey project
From October 1998 over the next 16 months naloxone (one minijet ready filled with 800 µg naloxone) was provided to 101 drug misusers in contact with local drug services, with instructions on intramuscular administration and the wider principles of resuscitation from overdose and recovery. Five instances of resuscitation using naloxone were reported, and all fully recovered. No adverse consequences, other than withdrawal symptoms, were reported.

	Comment

Top Methods and results Comment References

This is the first published report of lives saved directly by the provision of take home naloxone. The drug was generally used appropriately. In only one case out of 34 was its use inappropriate, with two of doubtful benefit. No unexpected adverse effects were reported.

Ready prepared syringes of naloxone typically cost £3.30-6.70 per 400 µg. Since 10% of distributed doses were actually given, each use cost around £33-67. Even if lives were saved on only 10% of these occasions, then each would have been saved at a drug cost of £330-670.

The range of doses given raises the possibility that naloxone was being titrated to effect resuscitation without provoking withdrawal. If so, recovery needs monitoring to avoid subsequent relapse into overdose. Some casualty departments and ambulance services now recommend giving naloxone intramuscularly or subcutaneously rather than intravenously because it can be given more quickly and results in less violent recovery.⁵ The same advice may apply to administration by peers. In future, family members may be trained to give emergency naloxone,³ for whom non-intravenous administration would be more realistic.

Early reports are encouraging. No adverse effects have been reported, and 10% of distributed naloxone has saved lives. A study of the wider distribution of take home naloxone is now required.

	Acknowledgments

KD is author on behalf of Ines Loska, Astrid Leicht, Johannes Korporal, Eckhart Holthaus, and Michael de Ridder. BS is author on behalf of colleagues at the drugs services at St Helier.

Contributors: JS originally proposed the distribution of naloxone as a strategy for overdose prevention and brought together the authors. KD and BS were responsible for the collection of the data. All three authors contributed to the final manuscript. KD and BS will act as guarantors for their respective data in the paper.

	Footnotes

Colleagues in the Berlin project are listed at the end of the paper

Competing interests: None declared.

	References

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1.	Strang J, Darke S, Hall W, Farrell M, Ali R. Heroin overdose: the case for take-home naloxone? BMJ 1996; 312: 1435[Free Full Text].
2.	Darke S, Hall W. The distribution of naloxone to heroin users. Addiction 1997; 92: 1195-1199[CrossRef][Medline].
3.	Strang J. Take-home naloxone: the next steps. Addiction 1999; 94: 207.
4.	Strang J, Powis B, Best D, Vingoe L, Griffiths P, Taylor C, et al. Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability. Addiction 1999; 94: 199-204[CrossRef][Medline].
5.	Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous versus subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1999; 5: 293-299[Medline].

(Accepted 13 December 2000)