Opinion

Naloxone is an opioid antagonist that has been used in emergency medicine to reverse opioid overdoses for over forty years¹. It has few other effects other than the rapid reversal of opioid effects². Typically administered through intravenous or intramuscular injection, it can also be administered subcutaneously or intranasally, and other routes of administration such as buccal administration are under investigation³.

In the 1990s, programs were established that allowed for the wider distribution of naloxone to potential overdose witnesses such as peers of people who consume opioids, their family, or other members of the community⁴. These programs typically involved some form of opioid overdose education and response training culminating in the dispensing of naloxone following successful training completion. Typically referred to as ‘take-home naloxone’ (THN) or ‘overdose education and naloxone distribution’ (OEND) these programs began to be implemented widely in a number of countries from the turn of the century⁴.

Australia’s first THN programs commenced at around the same time in 2012 in Canberra and Sydney, followed shortly thereafter by programs in the remaining jurisdictions^5,6. They typically involved extensive group-based training with injectable naloxone provided under prescription, aligned with initial program models implemented overseas⁷. Since that time, important developments have seen naloxone programs increase reach through: listing the drug on the Pharmaceutical Benefits Scheme (PBS), downscheduling allowing over the counter access⁸, state government programs providing free or subsidised access, the availability of fit-for-purpose delivery devices designed for intramuscular or intranasal administration, and new training models applying a brief intervention framework to enhance access⁹.

Most work in relation to THN in Australia has been targeted towards people with a history of injecting drug use, the group at highest risk of fatal opioid overdose¹⁰. However, there is increasing interest in improving access to THN to other groups in the community at risk of opioid overdose such as those taking opioids for chronic pain who have not only been shown to be at risk of overdose, but have also been shown to be largely unaware of this risk, and unfamiliar with signs and symptoms of opioid toxicity¹¹.

Shortly before the 2018 election, the Commonwealth announced funding for a PBS National Naloxone Pilot to be rolled out in New South Wales, South Australia and Western Australia. With a budget of $10 million, this pilot represents the biggest investment in THN in Australia to date through which THN is designed to be made available free of charge to anyone who wishes to access it under a PBS S100 special access scheme. Currently in implementation phase, the Pilot is due to be completed in early 2021, after which time a decision will be made on whether to extend it to other jurisdictions.

In spite of this important work and major new investment in THN in Australia there are still three significant gaps in THN implementation. First, unlike many states in the USA¹², there is no comprehensive Commonwealth, State or Territory legislation specific to THN and opioid overdose response. This means that there are major differences between jurisdictions on how THN is distributed and the protections afforded to individuals who use THN to respond to opioid overdose. For example, so called ‘Good Samaritan’ provisions provide protection to anyone attempting to save a life in Victoria but in some other states protection is not provided to intoxicated persons. Similarly, there are limited provisions for direct dispensing of naloxone by key groups such as needle and syringe program workers, with only a small number of states using special credentialing provisions through legal instruments that allow this. Comprehensive legislation in each Australian jurisdiction is needed to: (1) clearly describe THN as an appropriate emergency response to opioid overdose, (2) detail who can distribute THN and under what circumstances, and (3) provide clear protections for those engaging in overdose response (including using THN) in good faith.  

Second, although the use of fit-for-purpose naloxone delivery devices for THN has been a welcome development, there is still work needed to improve these devices. The ideal dose for administration of intranasal naloxone in particular has yet to be determined in real-life overdose events³. The packaging and marketing of available devices requires further development and the cost of these products is high given naloxone is very cheap to produce.

Finally, major gaps remain in terms of the settings for THN delivery. Support is needed in some jurisdictions to properly commence THN through accepted sites such as needle and syringe programs and housing support services. Prison release has long been recognised as a time of heightened risk of opioid overdose death¹³, yet THN has only recently been made available through prison health services in New South Wales and Western Australia and is only now about to commence in a pilot in Victoria. Prior non-fatal opioid overdose is a major risk factor for fatal overdose¹⁴, yet only now are paramedics being explored as potential THN providers, despite work already underway in other international jurisdictions¹⁵. Other first responders such as police and fire brigade have not yet been utilised for THN distribution. These sites for THN should be leveraged to maximise THN reach for those most at risk of opioid overdose to reduce associated mortality. 

Implementation of THN will not be complete or successful until it is widely available in fit-for-purpose products in all relevant settings to all people who may experience or witness an opioid overdose¹⁶.  Barriers such as cost, stigma, lack of knowledge and fear of reprisal must all be addressed for those receiving naloxone, and for those supplying it. There has been great progress towards this goal in specific settings in individual jurisdictions within Australia, yet there is a long way to go to achieve successful implementation nationwide.