Naloxone rescheduling in Australia: Processes, implementation and challenges with supply of naloxone as a ‘pharmacist only’ over-the-counter medicine

Stocking and supplying naloxone: Findings from a representative sample of community pharmacies in Victoria, Australia

INTRODUCTION

Naloxone is an opioid receptor antagonist, which can rapidly reverse the effects of an opioid overdose. Community pharmacists may experience several barriers to stocking and supplying naloxone including a lack of confidence or knowledge and time constraints. The current study aimed to examine the extent to which Victorian community pharmacies stock and supply naloxone and determine specific characteristics associated with stocking naloxone.

METHODS

A representative sample of community pharmacists (n = 558) in Victoria, Australia, were contacted between October and November 2020 and invited to participate in an online survey. Data related to pharmacy- and pharmacist-related characteristics, including stocking and frequency of supplying naloxone in the past year. Multivariate logistic regression analysis was performed to examine the effect of various covariates on stocking naloxone.

RESULTS

The sample comprised 265 pharmacists (response rate 47%). Most pharmacies were located in Melbourne (the capital city of Victoria, 59.6%) and were part of a pharmacy chain (61.5%). In total, 100 (38%) pharmacies stocked naloxone, a third of whom did not supply it in the past year. Pharmacies that provided opioid agonist treatment had 2.4 times higher odds of stocking naloxone (95% confidence interval 1.425-4.136; p = 0.001).

DISCUSSION AND CONCLUSION

Less than half of Victorian community pharmacies stock naloxone, with even fewer actually supplying it in the past year. Future efforts are needed to increase the number of pharmacies that stock naloxone and the frequency in which it is supplied, while also addressing possible barriers to stocking and supplying naloxone among community pharmacists.

"It can save your life, that's all I know," barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study

Engagement in take-home naloxone (THN) programs by people receiving opioid substitution treatment (OST) in Australia is low despite methadone being a significant contributor to opioid overdose deaths. Our aim was to explore barriers and facilitators for OST patients to engage in THN. We used a descriptive qualitative design with thematic analysis to gain insight into naloxone uptake by people engaged in an OST program in regional Australia. Eleven participants were interviewed; eight had previously engaged with THN. Barriers to THN included limited knowledge and understanding, lack of information, and not personally experiencing an overdose. Facilitators included having a traumatic experience of overdose, knowledge and understanding of THN and overdose, empowerment in carrying naloxone, and expanding THN programs. Support for the expansion of THN programs is desired among participants, and widespread peer distribution is understood to be the key to success. This study found that prior traumatic experience of overdose facilitates acceptance of THN, and being offered THN was the most important factor in engagement. Less clear is how to engage people who lack a traumatic overdose experience.

A systematic review of the distribution of take-home naloxone in low- and middle-income countries and barriers to the implementation of take-home naloxone programs

BACKGROUND

Opioid overdose epidemic is hitting record highs worldwide, accounting for 76% of mortality related to substance use. Take-home naloxone (THN) strategies are being implemented in many developed countries that suffer from high opioid overdose death rates. They aim to provide overdose identification and naloxone administration training, along with THN delivery to opioid users and others likely to witness an overdose incident such as family members and peers. However, little is known about such measures in low- and middle-income countries (LMIC), where opioid use and opioid-related deaths are reportedly high. This systematic literature review aims to examine the distribution of THN in LMIC, review studies identifying barriers to the implementation of THN programs worldwide, and assess their applicability to LMIC.

METHODS

The literature was searched and analyzed for eligible studies with quality assessment.

RESULTS

Two studies were found from LMIC on THN programs with promising results, and 13 studies were found on the barriers identified in implementing THN programs worldwide. The main barriers to THN strategies were the lack of training of healthcare providers, lack of privileges, time constraints, cost, legislative/policy restrictions, stigma, fear of litigation, and some misperceptions around THN.

CONCLUSIONS

The barriers outlined in this paper are probably applicable to LMIC, but more difficult to overcome considering the differences in their response to opioid overdose, their cultural attitudes and norms, the high cost, the waivers required, the legislative differences and the severe penalties for drug-related offenses in some of these countries. The solutions suggested to counter-act these obstacles can also be more difficult to achieve in LMIC. Further research is required in this area with larger sample sizes to provide a better understanding of the obstacles to the implementation, feasibility, accessibility, and utilization of THN programs in LMIC.

"Those People Count": Naloxone Media Coverage in Mississippi

There is a movement to promote naloxone adoption by law enforcement and other stakeholders in the state of Mississippi. The purpose of this study is to understand how local media are framing the conversation about naloxone products, and to better understand how it might affect naloxone adoption among law enforcement. We searched for news articles published in Mississippi from January 2012 to July 2018 mentioning the words Narcan^® and/or naloxone. Four main themes emerged from 25 articles: (a) positive and informative discussion of naloxone, (b) full articles persuading readers to use and/or advocate the use of naloxone, (c) government or organizational effort to increase the availability and use of naloxone products, and (d) negative or misleading information about naloxone. Better efforts to disseminate correct and persuasive information about the drug will have a profound and positive effect on the opioid epidemic in Mississippi and in the United States.

Addiction stigma and the production of impediments to take-home naloxone uptake

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

Why aren't Australian pharmacists supplying naloxone? Findings from a qualitative study

BACKGROUND

Opioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists' perspectives or experiences of this change.

METHODS

Thirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016-2017 to investigate pharmacists' attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply.

RESULTS

Around half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges.

CONCLUSION

Pharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists' knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).

National Institute on Drug Abuse International Program: improving opioid use disorder treatment through international research training

PURPOSE OF REVIEW

For more than 25 years, the National Institute on Drug Abuse (NIDA) has supported research-training programs, establishing a global research network and expanding the knowledge base on substance use disorders. International research to inform approaches to opioid addiction is particularly important and relevant to the United States, where opioid misuse, addiction, and overdose constitute an emerging public health crisis. This article summarizes the NIDA International Program and illustrates its impact by reviewing recent articles about treatment approaches for opioid use disorders (OUD).

RECENT FINDINGS

Studies in several countries have demonstrated the effectiveness of physician office-based opioid substitution therapies. Other research has demonstrated the effectiveness of different formulations and doses of the opioid antagonist naltrexone, as well as different approaches to providing naloxone to treat opioid overdose. Continuing research into implementation of evidence-based treatment in international settings with limited resources is applicable to US regions that face similar structural, legal, and fiscal constraints.

SUMMARY

The current review describes international research on OUD treatment and opioid overdose, most coauthored by former NIDA fellows. The findings from outside the United States have important implications for best practices domestically and in other countries that are experiencing increases in OUD prevalence and related overdose deaths.