Tools for Practice


#243 Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths


CLINICAL QUESTION
Does population-based or programmatic provision of naloxone kits decrease the risk of opioid- related deaths in people who use opioids?


BOTTOM LINE
Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).



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EVIDENCE
Randomized controlled trial:  
  • 1676 inmates being released from prison were randomized to kit with single dose naloxone versus no naloxone.1,2 After 3 months: 
    • Opioid-related deaths: 0.7% naloxone versus 0.4% no naloxone arm, not statistically different. 
    • Limitations: Trial stopped early as ~66% of naloxone used on others, thus limiting individual patient analysis. 
Observational studies: pre/post naloxone program initiation: 
  • Naloxone kits and overdose education provided to people who use opioids, friends/family, and social agency staff, in Massachesettes.3 After one year: 
    • Opioid-related deaths in community (per 100,000): 11.6 with program, 19.0 without program. 
    • Opioid-related hospital visits: unchanged. 
  • Other studies found naloxone kits provided to Scottish prisoners (pre-release) or to patients attending Catalonia harm reduction centers decreased opioid-related deaths.4,5 Evidence limited by:  
    • Improper or unknown “denominators” (number of prisoners released or Catalonian program participants). 
  • Limitations: observational studies results may be influenced by other interventions (example: opioid agonist therapy prescribing). 
Context: 
  • Every day, 2 Albertans and 11 Canadians die of an opioid-related death.6,7 
  • Those at higher risk of opioid-related death include:  
    • Previous opioid overdose.8 
    • Discharge themselves from drug treatment programs.8,9 
    • Recently released from prison.8,10 
    • Use higher doses of prescribed opioids.8,11 
    • Co-ingest benzodiazepines and/or anti-psychotics.8,11,12,13 
  • Patient level data supports the use of naloxone by non-medical personnel, emergency medical services, or in the emergency department.14,15 


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Author(s):

  • Dan (Lucy) Ni BMSc
  • Joey Ton PharmD
  • Michael R Kolber MD CCFP MSc

1. Parmar MB, Strang J, Choo L, et al. Addiction. 2017;112(3):502-515.

2. Meade AM, Bird SM, Strang J, et al. Drug Alcohol Rev. 2018; 37(4):487-498.

3. Walley AY, Xuan Z, Hackman HH, et al. BMJ. 2013; 346:f174.

4. Bird SM, McAuley A, Perry S, et al. Addiction. 2016; 111(5):883-91.

5. Espelt A, Bosque-Prous M, Folch C, et al. PLoS One. 2017; 12(10):e0186833.

6. Alberta Health. Quarterly report on: Opioids and Substances of Misuse Alberta Report, 2017 Q4. Retrieved from the Government of Alberta website: https://www.alberta.ca/opioid-reports.aspx. Accessed May 10, 2019. 

7. Statistic Canada. “Accidental apparent opioid-related deaths”. National Report: Apparent Opioid-related Deaths in Canada. Last updated April 2019. Available from: https://infobase.phac-aspc.gc.ca/datalab/national-surveillance-opioid-mortality.html#accidentalAORD Accessed May 10, 2019.

8. Albert S, Brason II FW, Sanford CK, et al. Pain Medicine. 2011; 12:S77-S85.

9. Cousins G, Boland F, Courtney B, et al. Addiction. 2016; 111(1):73-82.

10. Ranapurwala SI, Shanahan ME, Alexandridis AA, et al. Am J Public Health. 2018; 108(9):1207-1213.

11. Dasgupta N, Funk MJ, Proescholdbell S, et al. Pain Med. 2016; 17(1):85-98.

12. Gomes T, Mamdani MM, Dhalla IA, et al. Arch Intern Med. 2011 Apr 11;171(7):686-91.

13. Leece P, M.D., Cavacuiti C, Macdonald EM, et al. J Subst Abuse Treat. 2015; 57:30-5.

14. Lynn RR, Galinkin JL. Ther Adv Drug Saf. 2018, Vol.9(1)63-88.

15. Willman MW, Liss DB, Schwarz ES, et al. Toxicology. 2017; 55(2):81-87.

Authors do not have any conflicts of interest to declare.