Podcast: Take-home naloxone kits for opioid overdose
Transcript
Ken Flegel: In Canada's current opioid epidemic, take-home naloxone kits are an integral part of the harm reduction strategy. The kits are now available without a prescription and can be used by health professionals and the general public as a potentially life saving treatment for opioid overdose. I'm Dr. Ken Flegel, senior editor for CMAJ. Today I'm speaking with two emergency medicine physicians who have co-authored a practice article in CMAJ called "Five things to know about...Take-home naloxone." Dr. Thara Kumar is an emergency medicine resident in her fifth and final year of training at the University of Ottawa, with a Global Health Certificate from Johns Hopkins University. Dr. Hans Rosenberg an emergency physician at the Ottawa Hospital and an assistant professor in the Faculty of Medicine at the University of Ottawa. They are joining me today to discuss take-home naloxone kits. Hello, Dr. Kumar.
Thara Kumar: Hi, Dr. Flegel. Thank you for having me.
Ken Flegel: Hello, Dr. Rosenberg.
Hans Rosenberg: Hello. And also thank you very much for having me and Thara here today.
Ken Flegel: Dr. Kumar, how available are naloxone kits in Canada at this point?
Thara Kumar: So they're becoming more and more widely available. And each province has slightly different guidelines and locations where you can access these kits. But generally speaking, they're being made available from specific pharmacies, community health centers, some provincial correctional facilities, and even walk-in clinics and emergency departments. Even on the Government of Canada website for naloxone, you can actually look province by province and specifically what locations within each city are offering these kits.
Ken Flegel: Do you need a prescription? How much do they cost?
Thara Kumar: So the cost of a typical kit again varies slightly from province to province because they're individually packaged by each distributor, but roughly $35 per kit. However, the vast majority of centers are distributing kits without prescription and without cost, as long as you meet some very general and broad criteria. And those general criteria are basically just that you are either a current opioid or past opioid user at risk of using again, or a family friend or any person who might be in a position to help an opioid user at some point. So the criteria are very broad designed to typically apply to almost anybody. And with that criteria, you can generally access these kits for free from those distribution centers.
Ken Flegel: Dr. Rosenberg, what is in the take-home kit?
Hans Rosenberg: Although there's some slight variability in what's in the kits, the main components are as follows. There's two ampules of naloxone, each one containing point four milligrams per vial. There are two safety-engineered syringes, two ampule-opening devices, alcohol swabs, nonlatex gloves, a rescue breathing barrier and instructions. Now the instructions may vary from one area to the next. But in essence, they tend to include a way to try to rouse the patient, ensuring to call 911 and then the instructions on how to administer the naloxone and reassess your patient.
Ken Flegel: How does naloxone work?
Thara Kumar: The naloxone is effectively a competitive opioid antagonist. So it works at mu kappa and delta receptors, and it actually displaces receptor bound opioids causing an immediate reversal of opioid effects. It has no morphine-like agonistic properties at the receptors. So it just reverses the effects of the opioid. The duration of action is about 20 to 90 minutes, which is notably shorter than the duration and action of multiple opioids themselves. And it can be administered through many different routes intravenous intramuscular subcuticular, intraosseous, and even through an endotracheal tube in a hospital setting. The onset of action is typically about three to five minutes through any one of those routes. The only route that naloxone does not work well through is oral intake. So it is a poor oral assumption.
Ken Flegel: So when should one use the contents of this kit?
Hans Rosenberg: Well, the main indication for using an alloxan kit is respiratory depression. Now as clinicians, we tend to think of that as a respiratory rate of less than 12 or if the patient is hypoxic, which as we all know, is a very late clinical effect of respiratory depression. However, for the lay person that's using a take-home naloxone kit, it'll probably be a combination of decreased level of consciousness to the point that they cannot wake up the patient in addition to respiratory depression. It is important though that when we are giving out these naloxone kits that we tell the patients or their family members, whoever is with them, that simply decreased level of consciousness on its own is not an indication for naloxone. Unless it's a very rare case of example, something like a pediatric opioid ingestion, where in that case, you you would be okay using just the naloxone.
Ken Flegel: So Dr. Rosenberg, if it were someone's mother giving it to her son, a lay person, I'm presuming that the intramuscular route is the easiest thing to do?
Hans Rosenberg: Absolutely. So in most of the instruction kids, they essentially try to keep things as simple as possible. So they tell you to drop the one mil of naloxone, so that's your point four milligrams, and you injected intramuscularly, you're either gonna go deltoid, lateral thigh, or buttocks. Now, as you mentioned, if it's some patient's mother, they may not be that handy with syringes. But in a bit of irony, and I guess, useful irony, a lot of the patients and the people who are going to be using the take-home naloxone kits will actually be quite familiar with the use of syringes and needles. So this process tends to be relatively easy for them.
Ken Flegel: Is there any preference to giving it in the upper versus the lower body such as there is, say, with insulin?
Hans Rosenberg: There doesn't appear to be from any of the literature that we've looked at. So as long as it's a big muscle, that's really what the teaching is, with the needles, they should be able to get down to the muscle, whether it's the buttocks, the lateral thigh, or the shoulder, and the absorption should be pretty much the same.
Ken Flegel: Okay. And there's no difference by gender in the use of the drug, I presume?
Hans Rosenberg: Not that we know of at all, it should be equal, male, female, doesn't matter.
Ken Flegel: What about body mass?
Hans Rosenberg: Body mass may come into play when we're really talking about the pediatric population. If you're, again, if it's a pediatric ingestion, then at that point, you're sort of going with dosing that 0.01 milligrams per kilogram. But once we get to adults, because the kits do have the the two doses, you can actually essentially go with your point four. And then if you need more, do the second dose. The one very good thing about naloxone is it has very, very few adverse side effects. So even if it is a very thin individual, you're still going to be at a safe at a safe medication dose, if you're using the point four milligrams.
Ken Flegel: Is there any risk with recurrent use of developing allergy?
Hans Rosenberg: That's a good question, as far as I've looked at in any of the literature, and I could make sure with Dr. Kumar, who's reviewed this extensively, I do not know of any, or commonly reported allergy with repeat use of the medication.
Thara Kumar: That's correct. So as far as I'm aware, there's no allergy associated with use, or any reduction in the efficacy of the drug with repeated use over time. And I also just emphasize for the pediatric population, that the risk of using too much naloxone or using a bigger dose of naloxone than needed is really minimal. If there's too much naloxone on board, it just may not have an effect beyond a certain point. But the only real danger of overdosing the naloxone is pushing a patient into withdrawal. So if a patient is is dependent on opioids, then you may induce a withdrawal syndrome by giving naloxone and in the pediatric population we generally don't have as many patients who are opioid dependent, it's usually an accidental overdose. So actually, in that population, we're often giving larger initial doses of naloxone than we give in the adult population, because that risk of withdrawal is not there.
Ken Flegel: Dr. Kumar, does naloxone always work in someone who stopped breathing and clearly has an opioid overdose?
Thara Kumar: Yeah, so that's a difficult question. In theory, naloxone is entirely effective at reversing opioid overdoses. So if you have an infinite supply of naloxone, it would be expected to be nearly 100% effective at reversing an opioid overdose. So in a health care setting in particular, once you're getting to really big doses, like 10 or 15 milligrams of Naloxone with no clinical effects. At that point, I would start considering that maybe the patient's clinical state is due to some other cause rather than due to an opioid overdose. In the setting of the doses we're talking about in the take-home naloxone kits, which is two 0.4 milligram doses, I think the best you could say is that it's very likely to be effective, and will likely create at least enough reversal of the overdose to restore respirations and buy enough time for an ambulance crew to arrive and to get the patient to definitive care. And I think that's really the main goal. It's not necessarily to completely reverse the overdose, but it's to restore respirations, in that keep that patient alive until they can get to definitive care. And I think that's where it's really important to emphasize that even if naloxone is given EMS still should be called to the scene. And that basic life support principles are essential as an adjunct to giving naloxone.
So so to come back to that poor mother. While she's busy fumbling with a syringe, he can be calling for other family members. And when they come to begin administering some sort of respiratory assistance to the patient, would you say?
Exactly, yeah, so what we really want to emphasize as these kits are being distributed and made more public, as part of that training, want to emphasize that the first step should always be to call 911. So any person who's found an overdose setting, a call to 911, to get EMS on route is an essential first step even before the kit is open. And that's also reinforced in the instruction kits included with their take-home naloxone. And once that's done, then they can proceed with trying to administer the naloxone to the patient. But things like CPR in a patient without a pulse, and giving respirations if the provider is adequately trained to do that are definitely essential adjuncts to giving naloxone to try to tide that patient over until EMS arrival.
Ken Flegel: Dr. Rosenberg for health care workers who would like to receive training or get additional information, what sort of resources are available?
Hans Rosenberg: Well, there are a number of resources available. But two that I would strongly suggest or one is if you actually go to canada.ca, and then just search Naloxone or Google Canada and Naloxone, one of the first hits you'll get will be links to resources regarding take-home naloxone for each province. Within each provincial site, there's also information on what we talked about already today, but also locations, that so specific locations within an area, within a municipality where the kits are available, where resources are available, where you know, community services are going to be available for patients or family members, who would either like to obtain a take-home naloxone kit, or learn more about them. The other site that I really like, is towardtheheart.com. This is from the BC Centre for Disease Control. It's a website focused on harm reduction, and it contains an entire section including the video actually, that shows patients and their family members how to actually administer the naloxone. So it's a nice little training, it's about 12 minutes this video, and it's very well done very clear. And then that way, if you ever have to use it, I think you'd be quite comfortable.
Thara Kumar: One additional resources that could be useful is the META:PHI initiative based out of the Toronto Women's College Hospital. META:PHI stands for mentoring, education and clinical tools for addiction, primary care hospital integration. And it's an initiative that provides resources for physicians, nurses, pharmacists and patients regarding opioids and other forms of addiction. And the website is quite intuitive and useful. And it includes free online module regarding how to approach opioid use disorder, how to initiate those difficult conversations, and how to introduce various treatment options.
Ken Flegel: So I'd like to come to the end of our interview with a with a general question. And I'd like to start with Dr. Kumar. I'm going to ask you each this question, how complete an approach is the use of naloxone to our problem of opioid-induced death?
Thara Kumar: I think that's a really good question. And I think that been a big part of the discussion around take-home naloxone kits. I think we can't make the mistake of thinking this is a solution to the opioid epidemic. Take-home naloxone kits are very much a band aid service solution to try to keep these patients alive while we sort out this broader epidemic. And I think it's going to be a long time before we have a solution to the overall epidemic. But take-home naloxone kits, while they are essential at keeping these patients alive and safe, are just one of many harm reduction strategies that are needed to be able to address the opioid epidemic in a complete way. And along with that, I think we need to have a bit of a cultural change in terms of how we perceive drug addiction and treat drug addiction in Canada. And all of that together is what's really going to address the opioid epidemic.
Ken Flegel: Dr. Rosenberg?
Hans Rosenberg: So, if I may, I think as thorough as already mentioned, this is, you know, very much a harm reduction strategy as such, there are mostly positives, at least in my mind. But there are some negatives with any harm reduction strategies such as people being more comfortable with the fact that if they do overdose, for example, that they do have the naloxone kit there. And there have been some studies that showed that a very, very small percentage of opioid users actually feel more comfortable doing higher doses unfortunately if they have take-home naloxone. So it is simply not the answer, its part of the answer. I think a couple of important things that we all need to do as health practitioners is one, if you're prescribing opioids in general, you need to keep unnecessary opioid prescriptions off the street. So if the patient does not require opioids, simply do not make that prescription. Discuss the risk of addiction with patients whenever you do prescribe opioids. For all my patients in the emergency department, it's one of the first things I let them know if I'm going to be prescribing an opioid after say, a fracture. I'll let them know, please be aware that opioids are very addictive, and therefore they must be used appropriately and as prescribed. The next part is that for patients who are on chronic opioids, you always want to reassess if the dose that they're using is that necessary or can we go lower or can it actually be stopped? And then the last part again, and these are for people when I'm prescribing opioids in general, is to counsel the patients regarding the dangers of opioids, especially when they're mixed with other medications or illegal substances. Now, a second part to this is then that discussion that you might have with the actual opioid user. So what are the things that I would suggest to my colleagues. I'd say, make sure that you tell them to keep the prescription safely stored away from children, away from teens. Don't mix drugs, don't take them with alcohol, don't use opioids alone. If you are going to use them have somebody with you have somebody who knows how to use a take-home naloxone kit. Also, as a practitioner, I think it's really important for me to know what resources are available in my community so that I can make a referral when it is appropriate. And one of the other things and I think this is really important, again, to the to our patients who are opioid users is you should let them know that just recently, in 2016, the Good Samaritan Drug Overdose Act passed. Now this is an act that actually provides an exemption from charges of simple possession of a controlled substance from charges concerning a pretrial release, probation order, conditional sentence or parole violations related to simple possession for people who call 911 themselves for another person suffering of an overdose. And this is key because the data clearly shows that people have a fear of oh, calling 911 because they know that police will show up. And often they are involved in illegal activities. And then the last part, and I think Dr. Kumar already touched on this, but I think it's so important is we have to be clear about our messaging to patients and to our colleagues, that the addiction that is at the root of the crisis needs to be treated as any disease like any other without blame or judgment. We're here to help them and we're here to ideally stop the addiction and help them with that.
Thara Kumar: So I'll just add to what Dr. Rosenberg said, with regards to treating pain as a clinician, I think clinicians often feel a bit between a rock and a hard place in terms of how to treat pain effectively in their patients, while being cautious of the opioid epidemic in front of us. And there are a couple of new guidelines that have come out recently to help clinicians. In 2017, the College of Family Physicians of Canada released the Canadian guidelines for opioids in chronic noncancer pain. And the Ontario chapter of the CFpO also released consensus guidelines on opioid prescribing from the emergency department. So I think that those are potentially really useful resources for clinicians to see how they can continue to manage pain effectively, while being cautious. And also, I just want to emphasize that setting up this opioid epidemic, it's really important as clinicians that we look for those signs of opioid dependence and development of opioid use disorder. I think there exists in both physician culture as well as in society in general, a bit of a stigma and a stereotype of what quote unquote, addict looks like. And I think it's really important to be aware that those stigmas are not necessarily true. And we need to really break those down and understand that anyone is potentially susceptible to addiction. And that opioid use disorder is a disease like any other that can happen in a wide variety of patients from different backgrounds. And that's really important. We be vigilant about the signs of opioid use disorder, and support our patients through treatment and identify those problems in our population.
Ken Flegel: Colleagues, thank you for doing this interview.
Hans Rosenberg: Thank you very much for having us.
Thara Kumar: Thank you so much for having us.
Ken Flegel: I've been speaking with Dr. Thara Kumar, our emergency medicine resident at the University of Ottawa and Dr. Hans Rosenberg, an emergency physician at the Ottawa Hospital. They have co-authored a CMAJ practice article titled, "Five things to know about...Take-home naloxone." To read the article they co-authored, visit cmaj.ca. If you've been listening to our CMAJ podcasts, let us know how we're doing. Please give us a rating on iTunes or give us your feedback on Soundcloud or on any of our social media channels.