From our foreign correspondent

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Chris FordIn her first international column Chris Ford looks at Ireland’s lack of naloxone provision

Noticing a number from abroad, I answered my phone. Before I could even say hello, a woman who I now know as Siobhan was telling me a story about her son Gary. Just 31 years old, he had died in the family home from a heroin overdose about three months previously.

On returning from work one evening, Siobhan had called up to Gary and getting no response she went upstairs to investigate. He appeared to be asleep and was snoring. She felt so angry as they had agreed to talk that evening about possible next steps, and instead she saw that he had injected. Seeing him lying on his side she decided to leave him to ‘sleep it off’. She returned to his room in the morning to find him cold and dead. With a mixture of sadness and anger, she told me how she’d screamed uncontrollably for what had seemed like hours. She described how she’d hugged and kissed him, willing him to come around, but knowing in her heart he was long dead.

Without pausing for breath, Siobhan said that she was to blame for his death: ‘If only I’d known that he was overdosing when I found him, I could have called for help and given him naloxone.’ But could she?

Gary’s history was sadly like too many other people’s. He’d had a problem with heroin for 12 years and had been in and out of treatment in Dublin for many of those years. After a short prison sentence, which he never wanted to repeat, he had decided to leave Dublin and return home to a small community close to Galway just over a year ago. He had relapsed about ten months previously and decided he couldn’t face drug treatment again. He also knew from friends that the Galway drug treatment clinic was over-subscribed and had a long waiting list, and that even if a place became available it would be almost impossible for him to get there on the compulsory daily basis.

This is not an unusual situation in rural parts of Ireland. With limited options, Gary had decided to try on his own, but this was not working; so what next steps could be possible was going to be the subject of the talk with his mum on that fateful evening.

Siobhan stopped talking for a second and realised I was listening intently to her tragic story. I was welling up myself imagining her pain of losing a son and from such a preventable condition. We talked, cried and hugged down the phone. Siobhan has learned a lot since Gary’s death and one day soon will join the campaign to stop these preventable deaths. Although not quite ready yet, she did want Gary’s story told to try and inform the debate and help other mothers to not have this happen to them.

So what is the situation in Ireland with naloxone at the moment? It is only available in hospitals and healthcare facilities under licence, for someone who has already overdosed. That is, it is not available to patients or carers.
There are moves towards changing this with training to staff, people who inject drugs and carers and a national roll-out programme, but this is not going to happen in Galway for sometime to come. As a friend who works in Ireland said, ‘Unfortunately, like most things in Ireland, strategies tend to remain in the planning phase and as we all know too well, “planning” has never reversed the effects of a single opioid overdose.’

One of the problems seems to be that no one is taking clinical responsibility for prescribing naloxone, to be given to a person injecting drugs or a family member. Patient group directives don’t exist in Ireland. Even in big centres like Dublin, naloxone isn’t on the formulary – so individual doctors working there can’t prescribe it.

Irish drug-related deaths (DRDs) are among the highest in Europe. Lack of effective, timely treatment including naloxone is undoubtedly a factor. The drug-induced mortality rate from overdose among adults (aged 15–64) was 70.5 deaths per million in 2011, more than four times the 2012 European average of 17.1 deaths per million. (http://www.emcdda.europa.eu/publications/country-overviews/ie#drd)

Increasing the availability and accessibility of naloxone would reduce these deaths overnight. We do know that the availability of naloxone is growing in several countries. Scotland implemented a national programme in 2010, and outcomes there have demonstrated its effectiveness in reducing drug overdose deaths. Canada and Estonia have pioneered programmes on take-home naloxone. In the United States, policymakers called for greater availability and accessibility of naloxone after opioid overdose deaths more than tripled between 2000 and 2010. In some states distribution has expanded, leading to a 70 per cent decrease in overdose deaths in some areas.

Last November, guidelines from the World Health Organization (WHO) recommended increased access to naloxone for people who use opioids themselves, as well as for their families and friends. Naloxone is also included on the WHO Essential Medicines List.

The role of naloxone in addressing opioid overdose was recognised for the first time in a high-level international resolution in March 2012. Members at the UN’s 55th CND unanimously endorsed a resolution promoting evidence-based strategies to address opioid overdose. Recently, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) published a very useful literature review of the effectiveness of take-home naloxone.

I finish this piece with deep sadness at the unnecessary loss of so many lives, all of whom are someone’s brother, friend, mother, daughter or as Gary, son. I also feel angry that there is an easy cost-effective, evidence-based medication that could be used to immediately cut these deaths and it is only bad policy and bureaucracy that is preventing it being available to all in Ireland and many other countries.

From the early results of the IDHDP survey it appears that naloxone is available in just over half the places that have completed it, but its accessibility is limited and often only available on prescription and/or to health workers. If you haven’t already, please complete our short
Global Naloxone Survey.

Let’s change this situation now! If you don’t have naloxone available in your area, ask commissioners why they are contravening WHO’s recommendations.

Dr Chris Ford is clinical director at International doctors for healthier drug policies (IDHDP), www.idhdp.com