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Emergency naloxone for heroin overdose

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7569.614 (Published 21 September 2006) Cite this as: BMJ 2006;333:614

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Naloxone is not the only opioid antagonist that can prevent lethal overdoses and good agonist treatment is also important.

Strang et al correctly state that “Naloxone is an extraordinarily effective drug”[1] presumably meaning that at adequate doses, it always reverses opioid effects. (Incidentally, why does one 400mcg ampoule cost the NHS about £5 when it sells for a small fraction of that in other European countries?) Whether it is true that “Naloxone saves lives”[1] in opioid overdose (OOD) when publicly distributed is, as they recognise, still unproved. Intuitively, it seems worth doing (and monitoring) especially if combined with educating relevant peer-groups about airways and resuscitation.

However, naloxone is not the only extraordinarily effective opioid antagonist. Apart from the possible advantages in acute OOD of nalmefene, with its longer half-life, almost complete prevention of OOD and of relapse to heroin for many months after detoxification are now demonstrably possible with long-acting naltrexone implants.[2] Since the authors note that OOD is particularly dangerous in detoxified, non-tolerant addicts and since naltrexone has negligible organ toxicity, it is equally important (and more evidence-based) to extend studies of these implants. Several NHS GPs have already observed very persuasive outcomes.[3]

Distributing naloxone is also no substitute for raising the quality of agonist prescribing programmes. As Strang himself has previously conceded, NHS doses are among the lowest in Europe. Higher doses are associated with better outcome and retention and fewer OOD deaths. If the British addiction establishment had not criticised methadone maintenance treatment (MMT) until the mid-1990s (well after most of Western Europe had accepted the evidence) numerous deaths might have been avoided. When for many years, psychosocial interventions were thus over-valued and MMT discouraged[4] is it surprising that many clinicians still feel very ambivalent about this most evidence-based of all treatments for opiate abuse?

REFERENCES.

1. Strang J. et al. Emergency naloxone for heroin overdose BMJ.2006; 333: 614-615

2. Hulse G, Tait R, Comer S. et al. Reducing hospital presentations in opioid overdose in patients treated with sustained release naltrexone implants. Drug Alc Depend. 2005 Sep 1;79(3):351-7.

3. Revill J. An audited 24-month comparison of the O’Neill 3-vial naltrexone implant with supervised methadone in a British general practice population. Paper presented at the 3rd Stapleford Berlin Conference, March 18-20th 2006. Abstract and PowerPoint slides viewable at: www.staplefordcentre.co.uk

4. Caplehorn J. Methadone maintenance treatment: Britain has been over-committed to psychological theories of drug dependence. Brit Med J 1995; 310: 463.

Competing interests:
None declared

Competing interests: No competing interests

25 September 2006
Colin Brewer
Research Director
The Stapleford Centre. 25a Eccleston St. London SW1W 9NP