The history of the concept of

take-home naloxone:

origins and evolution

Professor John Strang

National Addiction Centre, London, UK

Declaration (personal & institutional)

• DH, NTA, Home Office, NACD, EMCDDA, WHO, UNODC, NIDA

• NHS provider (community & in-patient); also Phoenix House, Lifeline, Clouds House, KCA (Kent Council on Addictions)

• Work with pharmaceutical companies re devrelopment of new medicines for use in the addiction treatment field, including (past 3 years) Viropharma (Auralis), Martindale (Catalent), Reckitt-Benckiser, Schering-Plough, Lundbeck, UCB, Napp/MundiPharma, Alkermes, Teva, iGen (including re naloxone products) and also discussions with Lightlake, Lanacher, Rusan, Fidelity International and Titan.

• UKDPC (UK Drug Policy Commission), SSA (Society for the Study of Addiction); and two Masters degrees (taught MSc and IPAS) and an Addictions MOOC.

• Work also with several charities (and received support) including Action on Addiction, and also with J Paul Getty Charitable Trust (JPGT) and Pilgrim Trust.

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

‘Harm Reduction: from Faith to Science’(3rd International Harm Reduction Conference)

John Strang, Melbourne, March 1992

“From the point of view of harm reduction, the case for such interventions seems incontestable. They stand as examples of virtually all benefit and virtually no cost. These surely stand as excellent vanguard projects for a harm reduction movement. And if your heart is just not in to such obvious but uncontroversial harm reduction measures, then why not give some thought to the idea of distribution of supplies of naloxone, the opiate antagonist, to opiate users who may at some later date be able to give a life-saving injection of the drug to a fellow drug user who has inadvertently overdosed.”

First serious consideration:

Strang, J., Darke, S., Hall, W., Farrell, M. & Ali, R. (1996) Heroin overdose: the case for take-home naloxone. British Medical Journal, 312: 1435.

(1996)

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

(1999)

Naloxone? - personal O/D

Treatment sample (n=142)

Community sample (n=312)

Ever overdosed? 78/142 (55%) 118/312 (38%) last personal overdose… -involved opiates -at own or friends home own home friends home -in company of others sexual partner close friends

72/78 (92%)

61/78 (78%) 43 18

66/78 (85%) 33 27

102/118 (86%)

84/118 (80%) 52 42

95/118 (81%) 32 57

(Strang, Powis, Best, Vingoe, Griffiths, Taylor, Welch and Gossop, Addiction, 1999)

Naloxone? -witnessed O/D

Treatment sample

(n=142)

Community sample

(n=312) Witnessing overdoses Ever witnessed overdose? Witnessed O/D in last year?

44/48* (92%)

13/48 (27%)

167/ 312 (52%)

81/312 (26%) last overdose witnessed…

-involved opiates -O/D by sexual partner close friend casual acq. stranger

44/44 (100%) 6

32 1 5

153/159*(96%) 18 84 53 10

* data collected from only 48 * data missing on 8 cases (Strang, Powis, Best, Vingoe, Griffiths, Taylor, Welch and Gossop, Addiction 1999)

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

When in particular excess?

• During methadone early treatment

• Post-detox/rehab

• Prison release

0

5

10

15

20

25

30

35

40

45

Up to

1

1 up to 2

2 up to 4

4 up to 8

8 up to 13

13 up to 26

26 up to 52

>=52 To

tal

Exce

ss m

ort

ality

ratio

Time since release (weeks)

Not drug-related Drug-related deaths

Singleton et al, 2002

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

The earliest naloxone providers, late 1990s and by 2001

• Chicago, USA – 1996

• Padua, Italy – 1996

• Jersey, UK – 1998

• Berlin, Germany – 1999

• (Barcelona, Spain – 2001)

• (New Mexico, USA – 2001)

• (London, UK - 2001)

(2001)

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

Obstacles

• Some easy areas (‘doctors treat patients’)(patients live with their families)

• Some challenging areas (controlled drugs; unknown recipients; lack of specific evidence-base)

• Some ‘self-inflicted’ areas (why different from insulin and glucagon, EpiPen, defibrillators, etc)

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

Carers – the overlooked intervention

workforce

102 carers attending 4 organisations

• 80% parents, 20% other relative/partner

• 96% of opiate users, 87% IDU, 57% in Tx,

• 1/3 used in presence of carer, 47% had past OD

• 20% of carers had witnessed an OD

• 5 had lost user to fatal OD (3 children 2 partners)

• 16% would ‘panic’ or ‘not know what to do’

• 83% expressed an interest OD management & N training

Evidence of potential to extend naloxone life-saving potential …

Strang, Manning, Mayet et al, (2008) Family carers and prevention of heroin overdose deaths: …… Drugs: Education, Prevention & Policy, 15: 211-218.

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

(2006)

(2008)

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

Several different types of naloxone –

all ought to / might work

Key steps in the naloxone story

• Original articulation – the application of harm reduction

• Peers as work-force – acceptability and feasibility

• Times and places of particular concern

• Early action – pioneers and campaigners

• Legal obstacles – some real, some self-inflicted

• Family as work-force (and ‘first responders’)

• The normalisation of emergency care and naloxone

• Naloxone without needles – good if reliable (and approved)

• The absence of good science – sort it out

(2013)

(2013)

Finally Twelve Scenarios

• (A1) patient commencing OST;

• (A2) patient concluding OST;

• (A3) client finishing rehab or hospital care;

• (B1) named client at syringe exchange scheme;

• (B2) named resident at hostel for homeless;

• (B3) unnamed contact of outreach worker;

• (C1) individual leaving prison;

• (C2) family member (e.g. parent) for their at-risk son/daughter/etc;

• (D1) stock supply for hostel staff or day centre;

• (D2) open availability at a syringe exchange scheme;

• (E1) to be carried by a taxi driver or non-clinical 'first responder';

• (F1) over-the-counter from a community pharmacy.

Thank you