The long road

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Despite recent advances and lots of passionate campaigning, there’s still a long way to go before everyone who needs naloxone has easy access to it. DDN talks to a couple of early pioneers about the ongoing struggle provide this life-saving drug.

‘The distribution of naloxone to opiate misusers should be seriously considered for trial and evaluation. While the problem of heroin misuse grows worldwide, the problem of deaths from accidental overdose is a problem we can address today. We have the opportunity to gather great potential health gains from tools already in our hands.’

So said a BMJ editorial co-authored by Professor John Strang – exactly a quarter of a century ago. The June 1996 article covers the points – not least naloxone’s ‘negligible’ potential for misuse – that have been debated endlessly since, and concludes by saying ‘We may even wish to consider its legal status so it could be sold over the counter by community pharmacists’.

naloxone posters
A national naloxone and overdose awareness campaign is using posters of people personally affected by overdose on posters all over the country. If you spot one, take a picture and tag @TalkingDrugs and @Release_drugs and they will share it on their socials. See the full range of posters at naloxone.org.uk

Yet despite much energetic campaigning – and spiralling drug death rates – we’re still a long way from that, or even from naloxone being in the hands of everyone who needs it. First developed in the 1960s, naloxone has been used to reverse opioid overdose by emergency services for more than 40 years, and in 2005 was made available under UK law to be administered by anyone for the purpose of saving a life. Despite the ongoing battle for coverage, the recent launch of a landmark national naloxone campaign using posters of people with lived experience to spread awareness and challenge stigma (DDN, May, pages 5 and 12) is a measure of how mainstream the naloxone message is now becoming.

We’ve come a long way

Philippe Bonnet
Philippe Bonnet

‘It’s come along leaps and bounds compared to how it used to be but for some reason there’s still reluctance in some places, which I’ll never understand,’ peer support lead at the Hepatitis C Trust and longstanding naloxone champion, Philippe Bonnet, tells DDN. ‘You’ve got some housing providers who still don’t want naloxone on their premises, for example. It doesn’t make sense to me. It’s legal, so what’s the problem?’

Drug services in England and Scotland were promised a belated financial boost earlier this year (DDN, February, page 4), and although it won’t replace the money lost through years of funding reductions, some of the cash is specifically aimed at widening naloxone provision. Ultimately, however, it’s still down to individual services to persuade people to actually take the kits away with them.

‘It’s how you sell it, the same as with hep C testing and treatment,’ says Bonnet. ‘We’ve got people who are really vulnerable being told, “You don’t want naloxone do you?” and they’ll say, “Nah, I’m alright” and off they go. I think local authorities could put so much more pressure on services where there’s been a death. It needs to be investigated properly – “how could we have averted this? Did they have naloxone? Why not?” If it says ‘naloxone offer refused’ on the note and nothing else, that’s not good enough. People allergic to peanuts don’t tend to refuse EpiPens, do they?’

Something that’s always been critical is having the right local champions in place, he stresses. ‘Somebody asked me how many kits I’d given out over the years – I had to think but I reckon it’s got to be 3,000 at least, and I must have trained 10,000 staff. That’s just me, so national coverage really shouldn’t be a problem. It’s about getting the right people on board who can fight your battle.’

Early champions

Another early champion is harm reduction campaigner and former GP Judith Yates, who first came across naloxone in 2009 when David Best and others were working on an early paper. This studied around 70 people who were trained in overdose recognition and management and then followed up six months later after being given naloxone. ‘Some of my patients got the kits,’ she tells DDN. ‘I remember one lad in particular, whose friend had died in his flat – he’d called an ambulance, tried CPR, done everything right. He later came back to my surgery waving a naloxone kit, and we both realised that if he’d had it at the time his friend would still be alive.’

Following the paper’s publication – Can we prevent drug-related deaths by training opioid users to recognise and manage overdoses? – the feeling among Yates and her colleagues was that it would inevitably lead to a ‘big national roll out’, she says. ‘Nothing happened. Then in 2012 we decided that Birmingham should get going, and we got the first 1,000 kits out by the end of 2013, but still no one else was doing it. Ever since then it’s been push, shove, push, shove, which is down to stigma, I suppose.’

Could the availability of nasal naloxone make a difference in improving access? Might the fact that it doesn’t involve a needle help to overcome some of those barriers? ‘I was delighted by nasal naloxone finally getting licensed,’ she says. ‘It’s such a simple thing to just squirt it up someone’s nose and see them start breathing. With nasal naloxone I also think there’s a case for having it available over the counter, which would also help to de-stigmatise it.’

‘There are a couple of issues with it,’ says Bonnet. ‘The price is one, but the other is bioavailability – it’s definitely not the same as intramuscular. Looking at the research, with intramuscular the bioavailability is much higher and it will stay in your system for longer. Having said that, I know some people will prefer it, especially a layperson. Service users won’t care – they inject anyway – but people like hostel staff may well prefer it, so it definitely has its place.’

Game Changer

Nasal naloxone has also been a ‘game changer’ for the police, says Yates – ‘they don’t want to be waving needles around’. However, while more and more forces are now running pilots and embracing naloxone’s potential (DDN, May, page 13) the issue is not without controversy. The Police Federation has expressed concerns about officers ‘being turned into paramedics’, while chair of the West Midlands Police Federation recently told Newsnight he was worried about members ‘being subject to lengthy and stressful investigations’ if someone still dies after naloxone is administered.

‘I remember a case five or six years ago where a police officer did CPR, broke a rib and got sued, so I can understand them being wary,’ says Bonnet. ‘But if you say, “What if the guy dies?” – well, if he’s going to die he’s going to die. Don’t you want to try to prevent that?’

‘It’s only the Police Federation who tend to say these things,’ adds Yates. ‘There’s no resistance from ordinary police – they’re the ones who find themselves in a car park with somebody blue at their feet and they’ve got to start doing CPR, call an ambulance and wait there. The police here in Birmingham have embraced it fully – they can save someone’s life and they don’t have to do fatal accident reports.’

On that note, it’s often been pointed out that – even putting aside every argument about compassion – naloxone makes sense purely on financial terms. It’s far cheaper to save someone’s life than for them to die, as more and more people are doing, year-on-year.

‘In our drug-related death group meetings in Birmingham I always flag up the cases of people who’ve been found unconscious but have then died in hospital of a heroin overdose,’ says Yates. ‘All of them could still be alive today if the person who’d called the ambulance had given them naloxone. Lots of my patients over the years who I see walking down the street, they wouldn’t be here otherwise. Now they’re with their families and getting on with their lives.’

Getting past the stigma

From a GP perspective, Yates has previously been exasperated that people happy to prescribe methadone and buprenorphine still wouldn’t prescribe naloxone (DDN, July/August 2015, page 15). ‘GPs give out EpiPens hand over fist to anyone who’s got a peanut allergy, but do they give out naloxone kits to everyone at risk of opiate overdose?’ she says. ‘No, they don’t.’

So how optimistic is she that we’ll soon be able to get it into the hands of everyone who needs it? ‘You need to have it with you, so even once you get past the stigma you’re never going to get 100 per cent cover. But there’s certainly scope for getting an awful lot more out there. It’s frustrating because it’s absolutely the only medicine of its kind that saves lives so quickly and cheaply. I can only think it’s because people have mixed feelings about people who use drugs, and whether they live or die. And sadly, of course, some people who use drugs can have mixed feelings about whether they live or die as well – they can take a Russian roulette attitude. But I’ve been working in this field long enough to see people come out of that pit and get on to enjoy the second half of their lives in their 30s, 40s, 50s. So never give up.

‘There is no other medicine like naloxone,’ she states. ‘There’s nothing in the whole pharmacopeia that saves a life in two minutes with no side effects and no contraindications. If someone has a heroin overdose they don’t need to die, and yet we’re still having these conversations. We’ll just have to keep nagging.’

This article has been produced with support from Ethypharm, which has not influenced the content in any way.