Recommendations on the Management of Opioid Overdose

Ruth Birgin

The proposed packageEssential health sector interventions1. Comprehensive condom and lubricant programmes2. Harm reduction interventions for substance use

– needle and syringe programmes & opioid substitution therapy– community distribution of naloxone

3. Behavioural interventions4. HIV testing and counselling5. HIV treatment and care6. Sexual and reproductive health interventions7. Prevention and management of co-infection and other co-morbidities

including viral hepatitis, tuberculosis and mental health conditions.

Essential strategies for an enabling environment8. Supportive legislation, policy and financial commitment,

– including decriminalization of behaviors of key populations 9. Addressing stigma and discrimination 10.Community empowerment11. Addressing violence against people from key populations

Opioid overdose

• Significant mortality globally

• Main cause of death for people living with HIV who inject drugs

• While sedation occurs within seconds, there is time to revere the effects, resuscitate and prevent death (1-3 hrs)

Risk factors• Higher

– history of opioid dependence– post detoxification

• released from prison• first two weeks of methadone treatment

– taking other sedatives (valium, alcohol etc)– unknown purity/dose

• Lower – in opioid maintenance treatment– not injecting opioids

Naloxone

• Reverses opioid overdose within minutes • Recommended by WHO

– on WHO list of essential medicines• 60% of fatal overdoses are witnessed• Peer use of naloxone

– widespread in US, UK, RF, Thailand, Australia• US treated > 10.000 overdoses • people who use drugs proficient responders able

to administer and in immediate vicinity

– Experience in challenging environments • eg Vietnam

Mini-jet naloxone400 micrograms per 1 ml

Pre-filled syringe1 mg per ml, 2 ml syringe

Different preparations

WHO opioid overdose guidelines

Process of rigorous systematic reviews:

• evidence • values and preferences • costs and benefits • potential harms

Recommendation One

People likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of suspected opioid overdose.

Recommendation Two

Naloxone is effective when delivered by IV,IM, IN and SC, routes of administration.

Persons using naloxone should select a route of administration based on the formulation available, their skills in administration, the setting and local context.

Recommendation Three

In suspected opioid overdose, first responders should focus on airway maintenance, assisting ventilation and giving naloxone.

Recommendation Four

After successful resuscitation following the administration of naloxone the affected person should wherever possible have their level of consciousness and breathing closely observed until they have fully recovered.

Key findings from community consultation

1. Naloxone is a cheap, safe, easy-to-use, life-saving drug

2. Community distribution of naloxone should be added as an element of the comprehensive harm reduction package

3. Pre-loaded syringes or nasal spray are preferred

4. The importance of rescue breathing must be emphasized along with distribution of naloxone.

“There’s something so symbolic about naloxone. It’s a life-saving

intervention. If you say community distribution is not worth [doing],

it’s a value judgment on our lives.”

(a peer respondent)

Structural barriers• Current limited availability

– including in health care settings and in ambulances

• Scheduling– prescription limitations– medical personnel only

• Policy obstacles – criminalization of drug use– police interference

Next steps

• Increase awareness and access– PUD community involvement essential

• Improve enabling environment– Review of laws, legislation and decriminalisation

• Regulatory issues of naloxone– Work with criminal justice

• Community engagement, empowerment– national adaptation of these guidelines– develop practical implementation tools – eg NSP, DUIT