The Nova Scotia Take Home Naloxone Program Amanda Hudson-Frigault, MA NS THN Coordinator Amanda.Hudson@nshealth.ca nsnaloxone@nshealth.ca
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Background The misuse of opioids has become a leading health and safety concern in Nova Scotia, Canada and in other developed nations. Opioid misuse poses risks, harms and injuries to individuals, families and communities including increased risk for overdose and death. The rate of acute opioid toxicity mortality in the province has remained relatively stable at approximately 60 deaths per year (rate ~6 deaths/100,000 population, closed cases) 1. Between the years 2011-2015, there have been 303 acute opioid toxicity deaths in Nova Scotia. 1 There were 53 confirmed acute opioid toxicity deaths in 2016. There have been 39 confirmed and 11 probable opioid toxicity deaths in 2017 (as of the end of October 2017.) 1 * 1. NS Medical Examiner Service *Important-Numbers are subject to change as probable cases are confirmed or excluded and cases are added; many case investigations are ongoing).
Background In September 2015, DHW approved one-time grants to fund two opioid overdose prevention demonstration projects. The first is led by Direction 180, in partnership with Mainline Needle Exchange, and targets people at risk for opioid overdose in the HRM. The second is led by NSHA s Mental Health and Addictions, in partnership with the Ally Centre of Cape Breton, and targets people at risk for opioid overdose in the Cape Breton area. 4 staff from the demonstration project sites travelled to Toronto to The Point Program for training. The demonstration project sites adapted The Point s medical directive and training materials (with permission) for the Nova Scotia context.
Background The demonstration projects were scheduled to end in September 2016. MHA decided to fund an extension of the two demonstration projects until March 31, 2017 to allow time to explore a provincial framework and sustainable funding for opioid overdose prevention. As of September 2017, over 1500 kits have been disseminated in communities and there have been at least 60 reported opioid overdose reversals, as a result of this project.
Pharmacy Program In September 2017, the Community Pharmacy phase of the program was launched Opioid overdose prevention training and take home Naloxone kits became available without a prescription, free of charge, for those participants who are eligible. As of November 2017, 259 pharmacies are participating in the program.
Evidence to Support THN Programs Over the last 16 years, international evidence shows that provision of Take Home Naloxone (THN) programs, with appropriate training (to peers, family members and outreach workers) was remarkably safe with few, if any, adverse effects. None of the major concerns about THN have been borne out to date. 1 (such as unsafe naloxone administration, problems with re-intoxication when longer-acting opioids have been used, harm to overdose victims or those around them) There has been no evidence of THN leading to more drug use. In fact, participants in THN programs have reported a reduction in their drug use. 2,3 Two recent systematic reviews of the evidence from non-randomized studies, show that bystanders when properly trained can and will use naloxone to reverse opioid overdoses. 4,5 Training is effective in increasing the knowledge of, and positive attitudes towards, the correct use of naloxone, and overdose management. 6
Other THN Programs Take Home Naloxone Programs exist in several provinces, such as British Columbia, Alberta, Manitoba, Ontario, Quebec, Newfoundland and Labrador and Yukon. In Saskatchewan, New Brunswick and Prince Edward Islandnaloxone kits are available at pharmacies NS THN Program has adapted materials from Toronto s The Point Program, BC s Toward the Heart Program and Alberta Health Services Take Home Naloxone Program
Who should Receive a Naloxone Kit? Naloxone should only be provided to participants for whom naloxone is indicated, such as individuals who meet the following four criteria: 1) a) are at risk for opioid overdose; or b) are likely to witness and respond to an overdose such as family, friends and those who work with individuals who are at risk of opioid overdose 2) Have no known contraindications to naloxone as described in product monograph (Naloxone is contraindicated in patients known to be hypersensitive to it.) 3) Have provided informed consent to receive a THN kit (Consent to provision of THN kit is achieved expressly or implicitly when the Participant finishes the Program s training and willfully accepts their THN kit). 4) Have completed the Program s opioid overdose prevention/naloxone administration training.
Priority Populations. NS s THN program will prioritize the following high risk groups: Individuals who may have a opioid use disorder and who are not in treatment, including those who are on wait lists for treatment or not actively seeking treatment; Individuals who use opioids, including methadone, with known or suspected use of alcohol or benzodiazepines, or other drugs known to increase overdose risk; Higher-risk patients on opioid agonist therapy including patients who are about to start methadone or buprenorphine/naloxone treatment for opioid use disorder or in the first two months of treatment; Individuals with previous opioid-associated overdose including those with one or more previous: unintentional overdoses involving opioids (accidental overdoses) or intentional overdoses involving opioids (suicide attempts by overdose); and Individuals who have stopped using opioids, but are at high risk for relapse*.
What is in a THN Kit?
5 Overdose Response Steps: Step 1. Stimulation (Shake at shoulders & Shout their name). Step 2. Call 911. Place phone on speaker to receive additional support and instructions. Step 3. Inject Naloxone. 1 ampoule (0.4mg/ml) into muscle (upper arm or upper thigh). Step 4. Start Chest Compressions or full CPR and/or rescue breathing as trained. Use AED if one is available. Step 5. Is it Working-If there is no improvement in 3-5 minutes repeat steps 3 & 4. Stay! Stick around until EHS arrives. Note: Participants are shown how to perform chest compressions and how to use the one-way breathing barrier. Upon completion of the training, the instructor will assess and ensure the participant s understanding through verbal recall and accurate demonstration of their competency in naloxone administration. *These five steps have been adapted from the POINT program, Toronto.
Good Samaritan Act for Drug Overdose In May 2017, a new law was passed in Canada: It provides protection for both the drug overdose victim and the person phoning 911 from: 1. Simple possession 2. Parole violations 3. Pre-trial conditions 4. Probation orders 5. Conditional sentences Full Act can be found at; https://www.canada.ca/en/health-canada/services/substanceabuse/prescription-drug-abuse/opioids/about-good-samaritan-drug-overdose-act.html
THN Program Website www.nsnaloxone.com
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References 1. Enteen L, Bauer J, McLean R, et al. Overdose Prevention and Naloxone Prescription for Opioid Users in San Francisco. J Urban Heal. 2010;87(6):931-941. doi:10.1007/s11524-010-9495-8. 2. Maxwell S. Distributing Naloxone... Because Dead Addicts Never Recover. In: Australian Drugs Conference. Melbourne; 2010:1-30. 3. Seal KH, Thawley R, Gee L, et al. Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study. J Urban Heal. 2005;82(2):303-311. doi:10.1093/jurban/jti053. 4. Clark AK, Wilder CM, Winstanley EL. A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs. J Addict Med. 2014;8(3):153-163. doi:10.1097/adm.0000000000000034. 5. European Monitoring Centre for Drugs and Drug Addiction. Preventing Fatal Overdoses: A Systematic Review of the Effectiveness of Take-Home Naloxone.; 2015. 6. Walley AY, Xuan Z, Hackman HH, et al. Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: Interrupted Time Series Analysis. BMJ. 2013;346:f174. doi:10.1136/bmj.f174.