Naloxone – saving lives

Kevin Ratcliffe FRPharmS (IP) FFRPSConsultant Pharmacist (Addictions)

NMP Lead (BSMHFT)

Why am I here…….?

Naloxone

• 2005 – UK Law changed

• 2012 - ACMD

Drug-related deaths in England and Wales 2008 - 2012

Source: ONS 2012

Opioids (inc heroin, methadone, codeine etc.)

3554

Cocaine 291

Amphetamine 127

MDMA / ecstacy 53

Novel psychoactive substances 78

More recent headlines:Heroin/morphine remain the substances most

commonly involved in drug poisoning deaths. 765 deaths involved heroin/morphine in 2013; a sharp rise of 32% over 2012.

There was a sharp increase of 21% in the number of drug misuse deaths in England in 2013,  with no change to the number of these deaths in Wales.

Over half (56%) of all deaths related to drug poisoning in 2013 involved an opiate drug.

The female mortality rate for deaths involving heroin/morphine has been gradually increasing since2010, and reached the highest rate on record (since 1993) in 2013

ONS Sept 2014

Overdose: a serious situationMost heroin users will witness / experience

an overdose at some point:

‘From a sample of 155 drug using clients in South London in 2000 :

46% had overdosed themselves; 82% had witnessed overdoses,43 of which were fatal.’ (Best D., Man LH., Gossop M., Noble A., Strang J., 2000)

Opiate overdose

Overdose causes respiratory depression and can lead to death….

But, most overdoses happen in the presence of other people who could potentially prevent death with the right training….

……and with naloxone

Risk Factors in OverdoseInjecting rather than smoking drugsMixing drugs – especially heroin, benzos,

alcohol, methadone etc. (all our respiratory depressants and affect breathing)

Using aloneVariable purity of street drugs, changing

dealer etc.Using in unfamiliar surroundings – not

engaging in normal drug-taking routineUsing with unfamiliar people – who may not

stick around or help in an overdose situation…..

Risky times……..Loss of tolerance

Leaving prisonRelapse after leaving detox / rehab / hospitalRisk of fatal overdose is 8x higher in first 2 weeks

of leaving prison than in following 10 weeks !!

Beginning / ending substitute medication

Difficult life events – such as bereavement, loss of contact with children, separation / divorce

How to Recognise Opiate Overdose

Person unconscious, and cannot be

woken - UNROUSABLE and does not respond to noise or touch (e.g. shoulder shake)

CYANOSIS – BLUE tinge to lips, tip of nose, eye bags, finger tips or nails

Not breathing at all or taking slow/shallow or infrequent breaths - DEEP

SNORING / RASPING sounds

PIN POINT pupils

Do not Panic! Do not run away.Do not put person in a cold bath or shower

Do not walk them around. Do not copy “Pulp Fiction’ - injecting adrenalin into the heart

Do not give stimulants, amphetamines, cocaine, black coffee.

Do not inject salt water.

Overdose myths – what not to do

But what you can do…………Phone 999

ABC + naloxoneAmbulanceBreathingreCovery position Naloxone

Stay with the casualty

Remember……..

A B C +naloxone

NaloxoneTemporarily reverses the effects of an opiate

overdoseNo effect on overdoses resulting from the use of

other drugsShort acting - can begin to wear off in 20 minsOverdose can last for 8 hours or more (especially

with methadone)Only for use with continued medical support –

still need to ring 999 (buys time)No potential for abuseNaloxone precipitates WITHDRAWAL – the

individual may want to use again straight away/ become aggressive.

Individual response to naloxoneTo emphasize: duration of effect approx. 20

minutes

Depends on:What opiate was usedHow muchAny other drugs / alcohol

Works in 2-3 minutes but wears off faster than the opiate does.

Inject into a muscleSide of thigh area or upper

arm.Hold needle 90 degree above

skinInsert needle into muscleSlowly and Steadily push

plunger as directedOK to go through clothes

How to use naloxone………

“My hands were shaking. I was really scared. But I knew that if I didn’t do something he was going to die. Now when I look at him, it makes me smile on the inside to know that I saved his life.”

Service user, Birmingham 2013

Barriers……….Current supply route = lots of

opportunities to drop outLack of awarenessSpecial circumstances (in particular,

prison)Money….??

Who do you train….??

Naloxone supply:Training package (adaptable to group or 1:1 setting)

– keep it simple and keep it inclusiveTargeted approach, but inclusiveTesting understandingPack developed that contained everything neededSupply at point of training via PGDOption for re-supply included if neededService driven at each hub by the NMP

(“champion”)Prison: training delivered by in-reach worker, but

testing and supply made on release with bridging Rx

What do patients/clients/service users think ?

My friend told me about naloxone. He hadn’t been using heroin for a few

months, but lapsed at the weekend at a mate’s house. He only used a couple of bags but went over and died. He’d

left his naloxone at home.

What do patients/clients/service users think ?

We’re not big users, just a bag or two on pay day. This time was different. Don’t know why. It was obvious to me he had overdosed. I panicked a bit. Couldn’t

remember all the stuff they said, but I got him on his side and whacked in the

naloxone. He came round a bit but then the ambulance got there. He made it, but it

scared the sh*t out of me.

Outcomes (end Mar 2014)200 kits issued in pilot phase (Feb-Mar 2013)1000 kits issued (Apr – Mar)15 known reversalsGreater awareness – clients are asking about

it.Other services now getting up to speed

Unplanned prison releases are still a challenge

Forgot to get ambulance service on-board: a big learning !!

New-ish kid on the block

Naloxone e-moduleAlready available

Free to access

Comprehensive training resource

Takes about an hour

Assessment + certificate

The future…….?

Greater availability ? – consultation

Other products licensed ?

Different delivery system ?