Current Issue

Opioid overdose deaths continue to increase in Australia, most often associated with the use of prescription opioids (about two-thirds) and heroin (about one-third of cases), usually in combination with other sedatives. An effective and simple strategy to reduce opioid overdose morbidity and mortality is the provision of take-home-naloxone (THN) interventions (involving education and supply of naloxone) for potential overdose witnesses to have in the event of a suspected overdose in the community [1].

Despite efforts across different parts of Australia to increase the availability and use of THN, uptake has been limited [2]. In NSW, our early efforts to introduce THN interventions into health care settings (The Langton and Kirketon Road Centres) in South East Sydney Local Health District involved lengthy education sessions for consumers, and required doctors and pharmacists to be involved in the supply of naloxone [3]. This was an inconvenient and inefficient model for supplying THN to clients, meaning that THN was effectively only available at a handful of sites in inner Sydney.
In response, we determined to design, facilitate and evaluate the roll-out of a model of care for THN that could be effectively implemented in services in contact with people at high risk of opioid overdose - those with a history of opioid dependence and/or injecting drug use.

The Overdose Response with Take Home Naloxone (ORTHN) clinical intervention was co-designed with clinicians and consumers with the following features [4]:

The intervention targets people at risk of opioid overdose, attending alcohol and other drug (AOD) treatment, needle syringe programs (NSP), the Medically Supervised Injecting Centre, primary health and related outreach services that target people who inject drugs.
ORTHN involves a brief intervention with individual clients, taking approximately 10-30 minutes to deliver by credentialed health workers (nurses, allied health, health education officers, NSP workers), that involves client education regarding overdose prevention and responding to a suspected overdose, and provision of naloxone supplies - free of charge to clients.
Regulatory approvals from the NSW Ministry of Health enabling credentialed workers to supply naloxone under the Clinical ORTHN Protocol, without involvement of medical practitioners or pharmacists.

The project involved a mixed-methods translational research approach, incorporating a prospective longitudinal design in which the ORTHN clinical procedures, regulatory frameworks and training programs were implemented in approximately 20 participating services, with an evaluation of client and worker outcomes, practices and perspectives. The current paper by Lintzeris and colleagues [4] examines client perspectives and outcomes for the project.

Six hundred and sixteen ORTHN interventions were delivered over an eight-month period. Thirty seven percent were delivered in AOD treatment settings (including opioid treatment programs and withdrawal services); 36% in NSPs; 17% in primary health care settings; 14% at the Medically Supervised Injecting Centre and 13% in outreach settings. Clients were predominately male (63%) with a mean (± SD) age of 41.9± 9.5 years. A subsample of 145 client participants were enrolled in a prospective follow-up study examining overdose history, substance use, knowledge and attitudes immediately before and three months after the ORTHN intervention. Most (98%) had a lifetime history of injecting drugs and had previously witnessed (86%) or experienced (61%) an overdose.

Clients had high levels of knowledge regarding overdose prior to the ORTHN intervention, and knowledge was generally maintained at three-month follow-up. There were significant improvements between baseline and follow up (P <0.001) in self-efficacy regarding overdose response and THN use: “I have enough information about how to manage an overdose” (69% to 96% endorsed); “I would need more training before I can feel confident to help someone who overdosed” (54% to 22%); “If someone overdoses I would be able to inject naloxone” (85% to 99%). There was no significant change in patterns of substance use following the ORTHN intervention.

Overdoses were commonly reported by participants. Despite most being engaged in some form of treatment, 26% of participants witnessed an overdose in each of the three-month intervals prior to and after the ORTHN intervention. Overdoses occurred in six percent of participants in the three months before - and four percent in the three months after the ORTHN intervention. Heroin (69%), alcohol (38%) and benzodiazepines (38%) were the commonly used drugs in the 24 hours prior to the last overdose. The main overdose risk factor was the resumption of heroin use following a break (e.g. prison, detox or rehab).

Ten percent of participants reported administering naloxone in the three months after the ORTHN intervention, with the overdose reversed in all cases. Assuming naloxone would continue to be used beyond the three- month research follow-up, we estimate that naloxone was administered by 20% of ORTHN interventions – or 123 overdose reversals as part of the 616 interventions in the project.

The ORTHN project demonstrated that THN interventions can be feasibly delivered by a trained AOD and NSP workforce without medical practitioner and pharmacist involvement, and that the brief intervention model of care is effective in enhancing client knowledge and attitudes. The ORTHN model of care has now become generalised across all NSW Health AOD and NSP services, with moves to introduce the model into non-governmental organisations-based services in 2020. The ORTHN model now also includes both intramuscular and intranasal THN products and is available to all potential opioid overdose witnesses, including carers.

NICHOLAS LINTZERIS

Drug and Alcohol Services, South Eastern Sydney Local Health District; Discipline of Addiction Medicine, Central Clinical School, The University of Sydney; and NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia

References

Olsen A, McDonald D, Lenton S, Dietze PM. Assessing causality in drug policy analyses: How useful are the Bradford Hill criteria in analysing take-home naloxone programs? Drug Alcohol Review 2018;37:499-501.
Dwyer R, Olsen A, Fowlie C, et al. An overview of take-home naloxone programs in Australia. Drug Alcohol Review 2018;37:440-9.
Chronister KJ, Lintzeris N, Jackson A et al. Findings and lessons learnt from implementing Australia’s first health service based take-home naloxone program. Drug Alcohol Rev 2018;37:464–71.
Lintzeris N, Monds L, Bravo M,Read P, Harrod ME et al. Designing, implementing and evaluating the overdose response with take-home naloxone model of care: An evaluation of client outcomes and perspectives. Drug Alcohol Rev 2019. DOI: 10.1111/dar.13015 [Epub ahead of print]*.

*A complimentary PDF of the article is available to APSAD members by emailing This email address is being protected from spambots. You need JavaScript enabled to view it.

Current Issue

What's new on Early View?

Clinician's Corner - November 2019

Quick Links