Naloxone Distribution for Canada’s Opioid Overdose Epidemic – Does it save lives?

Naloxone-Kit

Lots of people have been prescribed an opioid at some point in their lives – in fact, Canada is the second-largest per capita consumer of prescribed opioids [1]. And about 99 000 Canadians used opioids recreationally in 2012 [2] (although the real number is probably higher. If Statistics Canada called you up one day for a survey, would you honestly tell them you take OxyContin for fun from time to time?).

With these high rates of both prescribed and non-prescribed usage, both Canada and the United States have seen huge increases in opioid-related overdose deaths in the past few years. Part of the problem has to do with how many opioids are prescribed, because that means there are more opioids to go around to both those with and without a prescription. As Dowell, Kunins, & Farley (2013) put it:

From 1999 to 2010 the number of people in the United States dying annually from opioid analgesic–related overdoses quadrupled, from 4030 to 16 651. Patients’ predisposition to overdose could not have changed substantially in that time; what has changed substantially is their exposure to opioids. During this same time, the amount of opioids prescribed also quadrupled [3].

Similar prescription increases have been reported in Canada. While rates can differ a lot between provinces, high-dose opioid prescriptions went up by 23% between 2006 and 2011 [4]. Many people who die of opioid overdoses held an active prescription in the weeks preceding their deaths [5, 6], and geographical studies show that where more opioids are prescribed, more overdose deaths occur [7].

Prescribed drugs are a main source for those who use opioids recreationally: drug diversion occurs via theft, prescription forgery, and ‘Dr Shopping’ [8]. One American study found that in 2010, 60% of abused opioids were obtained directly or indirectly through a doctor’s prescription [9].  In Canada, a study of youth in grades 7-12 in Ontario found that 14% had used prescription opioids recreationally in the past year, and most (67%) of them had obtained the opioids from someone within the home; those students also ranked opioids as the fourth easiest drug to obtain (following alcohol, cigarettes, and cannabis) [10].  A Toronto study of opioid users entering detox treatment found that 37% obtained their drugs through doctor’s prescriptions, 26% from both a prescription and street dealings, and 21% from street sources only [11].

The links between physician-prescribing of opioids and increased overdoses has led many to argue that we need to start prescribing less and monitor more. Many voices, both within and outside the medical community, are suggesting we start limiting opioid prescriptions by basing prescriptions on physical functionality rather than reported pain levels and emphasizing alternative forms of chronic pain management, or that we increase opioid-safety by screening patients for high-risk of dependency or co-prescribing naloxone with opioids [12, 13].

In an effort to reduce the harm of this opioid explosion, organizations have started distributing naloxone to people who use these drugs. Naloxone is an antagonist that blocks the effects of opiates and reverses the effects of an overdose. Through these programs, naloxone vials are given to opioid users and their friends or family members so that they have it on hand in case of an overdose emergency. Think of it as the opioid-EpiPen: upon injection, it quickly bumps opioids out of their neural receptors for about 45 minutes, giving the person time to regain consciousness and access medical care. The earliest program started in Edmonton in 2005, and since then many other provinces and municipalities have launched their own.

However, opioid users who don’t hold a valid prescription are often hesitant to call 911 in the event of an overdose for fear of legal repercussions [14]. The institution of ‘Good Samaritan’ laws – which grant immunity from possession charges to people calling emergency services in the case of an overdose – could potentially quell these fears and help save lives [15].

If you use opioids, would you carry naloxone around in case of emergency? Would you call 911? The Government of Canada [16], the World Health Organization [17], and the United Nations [18] have argued for the expansion of such initiatives. But naloxone distribution could be more effective if it was bolstered by supportive changes to prescribing practices to curtail opioid availability, as well as changes to drug laws that would protect those who use them without a prescription from persecution in the event of an emergency.

 

References

[1] International Narcotics Control Board. (2013). Annual Report. Retrieved from: https://www.incb.org/incb/en/publications/annual-reports/annual-report.html

[2] The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) (2013). Health Canada. Retrieved from: http://healthycanadians.gc.ca/science-research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013-eng.php

[3] Dowell, Deborah, Kunins, Hillary V., & Farley, Thomas A. (2013). Opioid Analgesics—Risky Drugs, Not Risky Patients. JAMA, 309(21): 2219-2220. doi:10.1001/jama.2013.5794.

[4] Gomes, Tara (2014). Trends in high-dose opioid prescribing in Canada. Canadian Family Physician, 60(9): 826-832.

[5] Fischer, B., De Leo, J.A., Allard, C., Firestone-Cruz,M., Patra, J., & Rehm, J. (2009). Exploring drug sourcing among regular prescription opioid users in Canada: Data from Toronto and Victoria. Canadian Journal of Criminology and Criminal Justice, 51: 55–72.

[6] Gladstone, E.J., Smolina, K., Weymann, D., Rutherford, K., & Morgan, S.G. (2015). Geographic Variations in Prescription Opioid Dispensations and Deaths Among Women and Men in British Columbia, Canada. Medical Care, 53(11): 954-959.

[7] Fischer, B., Jones, W., & Rehm, J. (2013). High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005 – 2009. Pharmacoepidemiology and Drug Safety, 22(4): 438-442.

[8] El-Aneed, A., Alaghehbandan, R., Gladney, N.,Collins, K., MacDonald, D., & Fischer, B. (2009). Prescription drug abuse and methods of diversion: The potential role of a pharmacy network. Journal of Substance Use, 14: 75–83.

[9] Lembke A. (2012). Why doctors prescribe opioids to known opioid abusers. N Engl J Med., 367:1580-1581.

[10] Paglia-Boak, A., Adlaf, E.M., & Mann, R.E. (2011). Drug use among Ontario students, 1977-2011: Detailed OSDUHS findings (CAMH Research Document Series No. 32). Toronto, ON: Centre for Addiction and Mental Health.

 [11] Sproule, B., Brands, B., Li, S., & Catz-Biro, L. (2009). Changing patterns in opioid addiction. Canadian Family Physician, 55: 68–69. 

[12] Albert, S., Brason II, F.W., Sanford, C.K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project  Lazarus: Community-based overdose prevention in rural North Carolina. Pain Medicine, 12: S77–S85.

[13] Coffin, P., & Banta-Green, C. (2014).The dueling obligations of opioid stewardship. Annals of Internal Medicine, 160, 207–208.

[14] Banjo, O., Tzemis, D., Al-Qutub, D., Amlani, A., Kesselring, S., Buxton, J.A. (2014). A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open, 2(3): E153–E161.

[15] Davis, C., Webb, D., & Burris, S. (2013). Changing law from barrier to facilitator of opioid overdose prevention. Journal of Law, Medicine & Ethics, Spring, 33–36.

[16] Ambrose, R. (2014). Government response: Second report of the Standing Committee on Health, Government’s Role in Addressing Prescription Drug Abuse”. June 16. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6676682&Language=E&Mod

[17] World Health Organization (2014). Community management of Opioid Overdose. Retrieved from: http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/

[18] United Nations Commission on Narcotic Drugs. (2012). Resolution 55/7: promoting measures to prevent drug overdose, in particular opioid overdose. United Nations Economic and Social Council: Vienna, March 16.

 

Comments are closed.

Blog authors are solely responsible for the content of the blogs listed in the directory. Neither the content of these blogs, nor the links to other web sites, are screened, approved, reviewed or endorsed by McGill University. The text and other material on these blogs are the opinion of the specific author and are not statements of advice, opinion, or information of McGill.