Learning from Italy’s Lead on Naloxone

In the United States, where an epidemic of overdoses from heroin and other opioids is front-page news, it is becoming more widely accepted that people who use drugs and their communities should have access to naloxone, an overdose antidote, in case of an emergency.

Indeed, by 2014, U.S. harm reduction programs—which focus on offering drug users choices that can help them protect their health—had given more than 152,000 laypeople naloxone kits, resulting in more than 26,000 overdose reversals. However, this simple harm reduction intervention has been slow to gain traction in many other countries. Obstacles include laws that prohibit ordinary people from providing injections, as well as a reluctance to put these tools directly in the hands of drug users—often over fears this will lead to riskier behavior.

That isn’t the case in Italy, however, where naloxone has been available in pharmacies without a prescription for over 20 years; in 1996, Italy’s Health Ministry officially classified naloxone as an over-the-counter medication and obliged pharmacies to carry it in sufficient supplies. Perhaps even more importantly, harm reduction services there have distributed it since the early 1990s, thanks to doctors at the public drug addiction services who saw a dramatic rise in the number of overdose deaths at the time. These doctors, at the local level and on their own volition, decided to take responsibility for allowing harm reduction staff to distribute naloxone to drug users. This history is recounted in a new report by Forum Droghe, which explores the results of this pioneering intervention.

What can the Italian experience teach us?

Having naloxone in pharmacies doesn’t necessarily mean people will buy it there.

In the report’s survey of 204 drug users from all over the country, only one person normally bought naloxone at a pharmacy, and only four had ever bought it there.

There are a few reasons for this: stigma on the part of pharmacists, the fact that not all pharmacies actually stock naloxone (despite the legal requirement), and the cost. Even at an average price of about €3.50 (US$3.80), it’s more than many drug users are willing to pay.

Making naloxone available through harm reduction programs is critical.

Drug users did, however, get naloxone from harm reduction programs. The research found that naloxone provision, in some cases, increases trust in harm reduction services and “creates an occasion for a more intense therapeutic relationship.” In Italy, harm reduction programs get naloxone from local hospitals, which purchase it through local health budgets (at an average cost of €2.07 per vial in 2016).

For other countries, this means that it is important to keep the list price of naloxone low. In the United States, where prices have increased exponentially, harm reduction programs may have trouble purchasing the naloxone they need.

There are benefits beyond saving a life.

Harm reduction workers said that naloxone provision promoted solidarity among peers, while increasing drug users’ awareness of risks and feelings of self-efficacy. People also saw naloxone as a way to protect themselves from police, who routinely turn up when emergency services are called.

Having naloxone doesn’t lead to riskier drug use.

This is a concern, often raised by critics of naloxone distribution, which has never been backed up by research. Of the Italian harm reduction programs surveyed, none that distributed naloxone reported an increase in risky behaviors among their participants who were given the medication.

Though overdose has been on the decline in Italy since the mid-1990s (with a fourfold reduction since 1999) and the overdose rate there is markedly lower than the European average, the report offers some other recommendations to further reduce overdoses, especially among young polydrug users: namely, drug checking (with kits made available to test the content of street drugs) and supervised drug consumption spaces (where health care workers teach safer drug use practices and intervene in overdose cases).

Meanwhile, advocates in other countries searching for an effective response to overdose deaths would do well to learn from Italy’s lesson: making naloxone available through pharmacies simply isn’t enough; services that provide drug users naloxone free of charge—and free of stigma—are the most successful at getting the lifesaving medicine into communities.

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La apertura e integracion de las comunidades de usuarios y el acceso a la naloxone.no el aislamiento y la criminalizacion, por que las vidas de las personas con adicciones dejen de ser estigmatizadas y explotadas es por lo que debemos buscar e imitare4e los mexicanos.

Ten's of thousands laypersons in Ontario, Canada taught all the signs of respiratory emergency (Drug OD). Then trained a protocol Naloxone, chest compressions more Naloxone more chest compressions. Empower people what they think is a life saving technique they are eager to follow instructions in the belief they are saving lives. Drug OD can mimic any breathing emergency rescue breathing ASAP their life depends on breaths Naloxone is second line defense.

My letter ‘Flaws in Toronto’s Opioid Overdose Prevention Program’ EMN 2015; 37(12):31 With hyperlinks to Public Health Ontario’s training literature.

Leece P et al ‘Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.’ CJPH 2013; 104(3)e200-4
My response Public Health article https://jgarythompson.wordpress.com/2016/07/04/response-cjph-20131043e20...

Pet eats a poison or drug Veterinarian will give rescue breathing then antidote continue rescue breathing. Not torture them with chest compression’s. Why do we allow this to our women and children??

Activists who promote use of Naloxone, should be prepared to overcoming multiple barriers and finding proper arguments talking also to users who are at risk of overdose -- on the one hand, Naloxone does save lives as it replaces opiates on receptors and then blocks them for about 30-90 minutes, but it also causes sudden withdrawal, and this is what would hardly be appreciated by people who spent money for a dose with a clear goal to get high. Also, many traditional guidelines recommend that after applying Naloxone, as a next "must" you call for an ambulance "because it is important to have trained medical professionals assess the condition of the overdose victim" -- however, it is not still clear whether the ambulance staff is obliged to report the "suspicious case" to police. The guidelines applicable in one country, may cause extra troubles in other, so for the activists it makes sense to see Naloxone distribution not as a stand-alone effort but a part of the overarching drug policy that goes far beyond increasing availability of the medication.

Living in the Pacific Rim port city of Vancouver, British Columbia in close proximity to the infamous Down Town East Side, working in special event public safety with a focus on electronic dance music centred events and with a social network comprised of varied high risk demographics, the current opioid crisis literally hits "close to home".

Many private citizens have received basic Naloxone training and have learned to carry a kit continuously in case they are called upon to render assistance as a Samaritan by circumstances.

Many young friends and acquaintances have required assistance in resuming respiration, some multiple times and in one case (a woman who relapsed after over a year of abstinence) 9 full ampoules were required to bring her back to life.

For some whose addictive behaviour may constitute a semi-conscious seeking of oblivion, or whose physical addiction is extreme (some actively seek carfentanyl or other synthetics by preference, eschewing even pure heroin for more potent formulations), the incidents requiring resuscitation are serial, with one fellow apparently having 26 incidents in something approximating one month's time.

The numbers are compelling:

The DTES is unique in Canada, due to a feedback phenomena of service provision and people with varied mental health or socioeconomic backgrounds finding it to be a haven, the concentration of at-risk individuals and front lines programs attempting to mitigate their risk of untimely demise being in it's own right a claim to fame.

The same could be said of the counter-intuitive level of community cohesion present among the low income population of the area, standing in stark contrast to the more individuated higher income people who are part of a controversial gentrification of the district that is driven by regionally inflated real estate values.

It is to be hoped that globally areas that have similarly high incidents of the trends behind the current public health crisis can actively share not only protocols that increase individual survival rates, but also sociological analysis of the conditions that predispose people to be vulnerable to what is functionally a pharmacological "Russian Roulette".

The opiate analogue crisis is here to stay, and short of the imposition of police state controls over individuals as well as all forms of commerce, a universal long term approach towards education and the cultivation of conscious decision making and self-awareness is no longer a utopian dream, but a requirement of modern social reality.

My personal kit has double ampoules, and I intend to acquire at least double that again prior to the peak of this year's summer festival season in BC that culminates with the Shambhala Music Festival and 15,000 attendees.

I will be wearing that kit as an attendee after 9 years in the event's public safety department, with my customized sticker as hopefully a conversation starter, it reads:

"Not Today, Darwin".

Hopefully that is not bravado.

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