BMJ  2006;333:754 (7 October), doi:10.1136/bmj.333.7571.754

Letter

Emergency naloxone for heroin overdose

Over the counter availability needs careful consideration

EDITOR—In their support for making naloxone freely available, Strang et al state that naloxone saves lives,¹ yet it can also be dangerous, even lethal.² Many other reports of adverse reactions are from use in health care, so more harm is likely in the hands of untrained people, especially as some may be intoxicated themselves when the drug is used. This needs to be carefully balanced by the likely benefits and other viable alternatives to address mortality from overdose, given finite budgets and workforce.

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Why Strang et al dwell on the wording of existing local prohibitions is unclear. As with injecting centres, a community naloxone trial would require indemnifying legislation. A localised pilot study in a high risk town might use other towns as controls.

Apart from theoretical endorsement on pharmacological grounds, the only reference Strang et al give supporting community naloxone is an unpublished communication (D Bigg, Chicago). There is no indication how adverse events, including deaths, were monitored, or whether there was any misuse of the naloxone—for example, as currency, weapon, etc. Neither are we told of the experience with community naloxone in Italy.

Unlike data on delayed ambulance presentations, experience from medical injecting centres indicates that early overdoses only infrequently require naloxone injection.³ As with heart and other emergencies, breathing assistance is always recommended for hypoventilation and cyanosis, regardless of the cause.

Strang et al also do not discuss the mode of administration of the naloxone and whether they advise a strict protocol or flexible arrangements.

Methadone treatment substantially reduces the occurrence of overdose. Strang with other colleagues wrote on overdoses and naloxone 10 years ago.⁴ To my knowledge, no senior author has yet published a realistic strategy to address the abysmal average quality of methadone prescription in England (average dose under 40 mg, low retention rates, poor supervision).⁵

75 Redfern Street, Redfern, NSW 2016, Australia ajbyrne{at}ozemail.com.au

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Competing interests: AB charges a fee for dispensing drugs for addiction treatments and is also a member of the Sydney Medically Supervised Injecting Centre Community Liaison Committee.

References

1. Strang J, Kelleher M, Best D, Mayet S, Manning V. Emergency naloxone for heroin overdose. BMJ 2006;333: 614-5. (23 September.)[Free Full Text]
2. Andree RA. Sudden death following naloxone administration. Anesth Analg 1980;59: 782-4.[Free Full Text]
3. Van Beek I, Kimber J, Dakin A, Gilmour S. The Sydney Medically Supervised Injecting Centre: reducing the harm associated with heroin overdose. Crit Pub Health 2004;14: 391-406.
4. 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]
5. Strang J, Sheridan J, Hunt C, Kerr B, Gerada C, Pringle M. The prescribing of methadone and other opioids to addicts: national survey of GPs in England and Wales. Br J Gen Practice 2005;55: 444-51.[ISI][Medline]

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