Guidelines call for injections, nasal spray in naloxone kits

Take-home naloxone kits for treating opioid overdoses should, where possible, offer intramuscular and intranasal formulations of the life-saving drug, according to new guidance.

The document also requires trained operators to provide rescue breathing as part of the emergency response. Finally, she recommends packaging take-home naloxone kits with a recognizable case, a respirator mask, non-latex gloves, instructions on how to administer naloxone, naloxone, and supplies for administering naloxone. Kits should contain three or more vials or vials of 0.4 mg/mL naloxone, depending on the community’s need to address illicitly produced fentanyl and other potent synthetic opioids.

The new guidelines were published online on August 28 in Journal of the Canadian Medical Association.

Deaths from toxicity are on the rise

A total of 7,328 deaths from apparent opioid toxicity occurred in Canada last year, with an average of 20 deaths per day, according to the Public Health Agency of Canada. Before the COVID-19 pandemic, the average number of deaths per day was 10.

Dr. Jane Buxton

Since 2016, the amount of fentanyl and other substances like benzodiazepines in the unregulated drug market has increased, said guideline author Jane Buxton, MBBS, former harm reduction officer at the British Columbia Center for Disease Control. Medscape Medical News. People are often unaware that the drugs they are buying contain these compounds, which puts them at greater risk of harm. “It’s just awful how toxic these substances have become,” she said.

With funding from the Canadian Institutes of Health Research, the Naloxone Guidance Development Group has produced a national guide for people who develop, fund, or supervise take-home naloxone programs. The paper may also be of interest to public health care providers, distribution sites and community overdose responders, the authors write.

In addition to public health professionals, academics and physicians, the naloxone guide development team included people with experience in drug use and overdose response. The panel conducted systematic reviews to identify and consider published evidence in all types of literature. It also considered community expertise in drafting its recommendations. The group sought feedback on its draft recommendations through an external review committee and input from the public.

The recommendations of the new guidelines on equipment kits and rescue breathing have been classified as “strong”, meaning that they can be adapted as policy in most situations or regions.

But the recommendation to provide both spray and injectable naloxone was considered “conditional” in the sense that the authors predict that its adoption “would require substantial debate” among many interested groups.

The authors note that the high cost of naloxone spray may be an obstacle to its inclusion in take-home kits. During their research, they found that the cost of the spray could be 10 times that of the equivalent intramuscular formulation. Therefore, it may not always be financially feasible to offer both forms of naloxone, the authors write.

Real-world experience

Many authors strongly prefer intramuscular naloxone due to concerns about withdrawal caused by the intranasal formulation. Participants also noted drawbacks associated with naloxone injections, including concerns about being cut due to broken vials or vials while administering the drug. Yet most people who use opioids prefer to give naloxone intranasally.

According to the guide, people living in poverty have sometimes lost fingers and even hands to infections resulting from contaminated drug supplies or frostbite, making it difficult for them to administer injections.

The cold also poses other challenges. For example, needles may not be able to penetrate through layers of clothing and it may be difficult or dangerous to remove them. “Participants in the consultation session reported that their hands become numb to cold, making intramuscular dosing difficult,” according to the guide.

These kinds of first-hand insights into naloxone have been instrumental in developing recommendations, Buxton said. In evaluating the use of naloxone, researchers cannot look at the results of studies routinely conducted in other fields of medicine.

Conducting a clinical field trial to compare patient responses to naloxone injections and nasal sprays is not feasible, he said. “There’s not much in the literature that actually shows what the thousands of people who have been doing this have experienced over the last 10 years or so.”

A medical problem

Commenting on the guide for Medscape, S. Monty Ghosh, MD, MPH, an addiction specialist at the University of Alberta in Edmonton, said that its publication in a leading journal like CMJ extension sends a strong message about the need to provide naloxone to people suffering from opioid overdose. “It frames it as a medical issue, not a moral issue,” she said. Ghosh was not involved in writing the guide.

Ghosh helped establish Calgary’s Rapid Access Addiction Medicine Program, the first and largest comprehensive outpatient addiction treatment program in the province.

He applauded the approach taken in developing the guidelines.

“They recognize that the vast majority of our overdose response with naloxone is not actually done by doctors,” Ghosh said. “It’s done by community members and people who use substances.”

The Canadian Institutes of Health Research (CIHR) for the Canadian Research Initiative in the Substance Abuse Implementation Science Program on Opioid Interventions and Services funded the guide. Buxton received a grant from CIHR to the Canadian Research Initiative in Substance Misuse for work supervised and managed by the Center for Addictions and Mental Health in support of driving. Ghosh did not disclose any relevant financial dealings.

CMJ extension. Published online August 28, 2023. Full text

Kerry Dooley Young is a freelance journalist based in Washington, DC. Follow her on Mastodon and Threads as @kerrydooleyyoung and on BlueSky

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