Take-Home Naloxone programs:History & perspectives

Sibella Hare Breidahl and Professor Sir John Strang

National Addiction Centre, King’s College London, UK

Declarations (personal & institutional)

John Strang:

• NHS provider (community & in-patient); also Phoenix House, Lifeline, KCA.

• Dept of Health, NTA, Home Office, NACD, EMCDDA, WHO, UNODC, NIDA.

• Dialogue and work with pharmaceutical companies re actual or potential development of new medicines for use in the addiction treatment field (incl re naloxone products), including (past 3 years) Martindale, Indivior, MundiPharma, Braeburn/Camurus; trial product supply from iGen and Camurus.

• Lecture includes preliminary findings from work with Pharma (Mundipharma).

• SSA (Society for the Study of Addiction); UKDPC (UK Drug Policy Commission), 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.

• The university (King’s College London) has registered intellectual property on a buccal naloxone formulation, and JS has been named in a patent registration by a Pharma company as inventor of a novel concentrated naloxone nasal spray.

Sib Hare Breidahl:• Medical student at the University of Adelaide• Previous research assistant at KCL; working on project with JS, co-sponsored by MundiPharma• Current WHO intern; Department of Mental Health and Substance Use

Naloxone over the years

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.

*** important achievements, but so slow, so very slow ***

(1996)

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

Total

Exc

ess

mor

talit

y ra

tio

Time since release (weeks)

Not drug-related Drug-related deaths

Singleton et al, 2002

When? Clustering in time and space

(2009-11)

(2013)

10

(2014)

http://www.emcdda.europa.eu/news/2016/1/pr

eventing-opioid-overdose-naloxone

Naloxone Monograph from EMCDDA (European Monitoring Centre on Drugs and Drug Addiction) (2016)

(2016)

Challenges

• Routes of administration

• Having it confiscated/scared of disciplinary action from law enforcement etc

• Size, portability=> carriage rate

• Losing naloxone

• Dose titration

• Best training technique

Service usersN=327

Staff N=158

FamilyN=39

Total respondents

N=524

Have been provided naloxone

65.0% (208/320)

26.0% (39/150)

52.9% (19/36)

50.8% (266/506)

Carrying naloxone at time of survey

17.2% (36/209)

23.8% (5/21)

17.8% (41/230)

Table 3. Naloxone device preference in NXP2U study (unpublished). “Amp” = Ampoule (figure 2), “PFS” = pre-filled syringe, “NS” = Nasal spray. Percentages shown with frequencies in brackets. This study received funding from MundiPharma.

Training

Figure 2: Still from the

training video - introduction

Figure 1: Still from the training

video - intranasal naloxone

demonstration

Service usersN=327

Staff N=158

FamilyN=39No missing values

Total respondentsN=524

Which device would you be willing to use in an overdose emergency?

AMP: 38.4% (118/307)

PFS: 70.4% (216/307)

NS: 68.7% (211/307)

None: 4.9%(15/307)

AMP: 28.3% (43/152)

PFS: 70.4% (107/152)

NS: 84.9%(129/152)

None: 0.7% (1/152)

AMP: 23.0% (9/39)

PFS: 61.5% (24/39)

NS: 76.9% (30/39)

None: 0.0% (0/39)

AMP: 34.1% (170/498)

PFS: 69.7% (347/498)

NS: 74.3% (370/498)

None: 3.2% (16/498)

Which device would you be most confident using?

Amp: 12.1% (35/307)

PFS: 41.2% (128/307)

NS: 66.4% (204/307)

None: 4.6% (14/307)

Amp: 5.9% (9/152)

PFS: 32.2% (49/152)

NS: 84.9% (129/152)

None: 1.3% (2/152)

Amp: 16.2% (6/37)

PFS: 37.8%(14/37)

NS: 83.8% (31/37)

None: 0.0% (0/37)

Amp: 10.0% (50/501)

PFS: 38.1% (191/501)

NS: 55.3% (277/501)

None: 3.2% (16/501)

Table 3. Naloxone device preference (unpublished). “Amp” = Ampoule (figure 2), “PFS” = pre-filled syringe, “NS” = Nasal spray. Percentages shown with frequencies in brackets. Respondents could elect more than one answer, explaining why totals are >100%. This study received funding from MundiPharma.