First do no harm
re: Emergency naloxone for heroin overdose
Strang et al 1 provide a measured endorsement for distributing
naloxone to injecting drug users to prevent heroin overdose deaths. For
some years, these deaths have remained at unacceptably high levels in many
counties. They have been increasing in recent years in a few countries.
This makes naloxone distribution seem very attractive, especially as the
theoretical rationale for this intervention appears to be quite plausible.
However, in these days of evidence based medicine, it has to be
acknowledged that the evidence for the efficacy, safety and cost
effectiveness of naloxone distribution is weak. In addition, the efficacy
and safety (and cost effectiveness) of other measures to reduce heroin
overdose deaths, such as methadone and buprenorphine maintenance
treatment, is supported by compelling evidence. But demand for methadone
and buprenorphine treatment still far outstrips supply in almost all
countries reporting large numbers of heroin users.
The lack of strong evidence for naloxone distribution is for good
reason. Randomised control trials and other rigorous study designs seem
incapable of execution.
Therefore, policy makers (and researchers, treatment providers and
drug users) are faced with a real dilemma. Should naloxone be distributed
to injecting drug users because of the importance of reducing the large
number of heroin overdose deaths in young people and the strong
theoretical arguments, even though the empirical evidence for efficacy and
safety is weak? Or should policy makers try harder to overcome the
barriers to providing sufficient methadone and buprenorphine treatment? Or
should they do both?
These are difficult questions to answer. But the case for an informed
debate, with injecting drug users also involved, seems overwhelming. A
number of interventions for illicit drugs have been implemented over the
years because of high plausibility, despite the lack of supporting
evidence. Many of these interventions, such as oral naltrexone to treat
heroin dependence, turned out to be both ineffective and unsafe. The
history of these many false dawns suggests the need for caution. The
starting point in a debate about naloxone distribution has to be an
acknowledgement that evidence for efficacy and safety of this intervention
is unavailable at present.
Dr A Wodak,
Director, Alcohol and Drug Service
St. Vincent's Hospital,
Darlinghurst, NSW 2010,
1 John Strang, Michael Kelleher, David Best, Soraya Mayet, and
Victoria Manning. BMJ 2006 333: 614-615.
Competing interests: No competing interests