Heroin overdose: the case for take-home naloxone.

Non-fatal overdose is an occupational risk of heroin misuse' and fatal overdose is a common cause of premature death in heroin users. ... One of the major contributors to a fatal outcome is the inadequacy of heroin users' responses to the overdoses of their peers. They may delay calling an ambulance for fear of the police arriving, and their efforts to revive comatose users are often ineffective. The distribution of naloxone to opiate users was first mooted in 1992s as an intervention that would be life saving in such situations. With a rising t oll of deaths from heroin overdose it is time to take the suggestion seriously. Interviews with 320 heroin users in Sydney found that two thirds had had a drug overdose, a third within the past year, and that 80% had been present at the overdose of another user. 7 In Australia the incidence of deaths from ·heroin overdose has increased over the past decade while deaths from other drug related causes have fallen. In the United Kingdom a sharp increase in the numbers of deaths among opiate users has recently been reported from Glasgow. • Naloxone has along established use in emergency resuscitation of patients with opiate overdose. 9 Such a tried and t ested product might be suitable for distribution to opiate misusers so that they could give themselves the drug after inadvertent overdose or have others give it to them. An obvious target group for naloxone would be opiate rnisusers at high risk of overdose, such as those leaving the emergency department against i:nedical advice after resuscitation with naloxone. The short duration of action of naloxone puts such people at h igh risk of re-entering· overdose. Patients could be given a dose of naloxone for self administration in the event of re-emergence of overdose in the next few hours. Another group at high risk is those re-entering the community after loss of opiate tolerance, either on release from prison or after discharge from a treatment programme. More controversial would be the distribution of naloxone to all opiate users receiving treatment, as a precaution against unexpected overdose. Even more controversial would be distribution to all opiate users through needle and syringe exchanges. All opiate users are at risk of overdosenot only those who are dependent or undergoing treatment. Indeed, a heroin user who is not undergoing treatment seems to be at even greater risk of fatal and non-fatal overdose. What concerns are raised by these proposals? Marri11da/c concludes that adverse effects tend not to be a problem with naloxone at therapeutic doses. Nausea and vomiting have occurred, with seizures reported infrequently. Individual reports of hypertension, pulmonary oedema, and cardiac arrhythmias have generally been in patients with pre-existing heart disease undergoing cardiac surgery, 10 and the role of naloxone in two reported cases of pulmonary oedema in healthy young men" 11 has since been questioned. n The National Poisons Information Service in London reported that it had hever been informed of a suspected adverse reaction to naloxone despite being contacted by about 800 cases of opioid poisoning each year." The potential for abuse of naloxone is negligible: it has virtually no agonist effects and is strongly antagonist to heroin and methadone. Removal of the deterrent effect of overdose might perhaps increase the frequency and intensity of opiate intoxication, although this seems unlikely given heroin users' dislike of the withdrawal symptoms produced by naloxone. Education about such dangers would need to accompany the introduction of naloxone and is already necessary to prevent post-resuscitation overdose as the short acting effect of naloxone wears off (th_us leaving the heroin user at potentially