August 2021

Take-home Naloxone: The revival roadshow dodging potholes aplenty

“I was at a mate’s place and my mate yelled out from the lounge room that Baz had dropped. He was on the phone to the ambulance. I threw him the car keys and said, ‘Grab the yellow box out of the glovie, twist it, screw the tip on and jab him in the leg.’

“Within a few minutes, Baz started to come around. It was unbelievable. The ambulance arrived and they said that if I hadn’t given him the naloxone he would have been dead.

“My mate told me later Baz was in rehab. It brought a tear to my eye.

“I don’t use opiates. I lost a mate last year – that’s why I got naloxone. I may have lost one but now I’ve saved one too.”

I lost a mate last year – that’s why I got naloxone. I may have lost one but now I’ve saved one too.

QuIHN client

Since 2019, the Commonwealth Government has been running a $10 million pilot Take-Home Naloxone trial to establish more effective methods of distributing the life-saving medication to people who are likely to witness an opioid overdose.

The trial is being conducted across New South Wales, South Australia and Western Australia. It was scheduled to finish in June but May’s federal budget allocated an additional $3.9 million to extend the program for a further 12 months.

The above experience was shared by a client with Tegan Knuckey, a Harm Reduction Coordinator at the Queensland Injectors Health Network (QuIHN). Over the past 10 months QuIHN has provided 585 doses of naloxone across the Burleigh Heads, Gold Coast, Brisbane and Sunshine Coast regions, free of charge.

Queensland is not part of the Commonwealth pilot, prompting some people to ask why the trial is being extended before it’s expanded.

“We know this works: it saves lives,” Tegan says.

We know that people may relapse five, six, seven times and we need to save people’s lives on those relapses. We want these people to survive to be able to get into recovery, if that’s what they want to do.

Tegan Knuckey

“We know that people may relapse five, six, seven times and we need to save people’s lives on those relapses. We want these people to survive to be able to get into recovery, if that’s what they want to do.

“These people are our family, our friends, our neighbours. We need to remember that. I don’t understand why we put barriers in place.”

Opioid deaths in Australia have doubled in the past decade. On average, roughly three people die from opioid overdose every day, with opioids being present in nearly two-thirds of all drug-induced deaths.

Increasing the availability of naloxone is one of the best ways we have of reducing overdose deaths.

In 60 per cent of opioid fatalities the person is not alone, and half of those who die are alive for about half an hour after overdosing, meaning there’s time for someone to intervene.

Currently, naloxone is available in various forms in all states and territories with a prescription or over the counter from a pharmacy for a fee, but the pilot aims to broaden access and remove barriers to entry, such as stigma and cost.

Learning over time

Several trials have been run in Australia since 2012, when the first was conducted in Sydney. Professor Nick Lintzeris, Addiction Medicine Specialist at The University of Sydney, who was part of that trial, describes it as a “spectacular disaster”. It worked on an “unrealistic” delivery model involving a 90-minute workshop, and over its two years, only 83 doses of naloxone were distributed.

The current pilot seeks to identify barriers to access and will be used in consideration of a national rollout of take-home naloxone.

During the pilot, anyone at risk of overdose or who might be likely to witness one can collect naloxone without prescription and without charge from pharmacies, hospitals, GPs, NSPs and non-governmental organisations working in the harm reduction space.

Briefings of 10-15 minutes are provided along with the product to help people understand how to use it in an overdose situation. Pharmacists have scripts to follow when handing out naloxone.

As the trial is ongoing, extensive access to data is restricted. However, the Commonwealth Department of Health says more than 36,500 units of naloxone have been supplied so far during the pilot.

Caroline Salom, Senior Research Fellow at the University of Queensland and head of the team evaluating the Commonwealth data, says the uptake “has been strong”.

“Very considerable amounts have gone out the door and the introduction of the nasal spray Nyxoid has been very, very positive,” Caroline says.

To establish the trial, various legal obstacles had to be overcome to enable non-medically trained staff to distribute the drug.

Naloxone is a mixed Schedule 3 and Schedule 4 drug, meaning it’s relatively tightly controlled for a product with such a high safety profile. The Commonwealth has made five naloxone medications available during the trial but only the nasal spray form (Nyxoid) and the pre-filled intramuscular syringe Prenoxad have been taken up by the participating states.

In NSW and WA, naloxone can be given to clients by ‘Approved Providers’ (APs) like GPs, hospitals and pharmacies or registered ‘Authorised Alternative Suppliers’ (AAS) like NSPs and NGOs. In South Australia, an AP or AAS issues a voucher that the client then has filled at a pharmacy.

In all states, two doses of naloxone can be dispensed at any one time and refills are unlimited.

Both the AP and AAS models have been popular, Caroline says, with a “very large number” of community-based pharmacies having registered for the trial.

We know naloxone that’s come into the hands of people as part of this pilot has been used to save lives.

Caroline Salom

“We know naloxone that’s come into the hands of people as part of this pilot has been used to save lives,” she says.

Frustrations being felt

As an NSP worker who has campaigned for broader access to naloxone for years, Tegan Knuckey says she is frustrated that Queensland has not been included in the pilot. “We’ve really been left with nothing,” she says.

QuIHN’s distribution of free naloxone was established in response to being left out of the trial and works on a similar model to that currently being piloted in NSW and WA.

Nick Lintzeris shares Tegan’s frustrations over the allocation of funding for free naloxone to some states but not others.

“Within the next six to 12 months, there really needs to be a decision around how we’re rolling out naloxone, not continuing trials that only apply in three jurisdictions and leaving us in limbo year to year,” Nick says.

Caroline Salom says the extension is partly due to the impact of COVID-19 on data collection, as well as the trial “taking a little while to ramp up and reach maturity” with healthcare providers.

While Caroline says the trial has been successful, outreach done while preparing this story suggests that uptake has been somewhat uneven across jurisdictions. Different distribution contexts appear to have played a substantial role in the amount of naloxone given out, and there’s a clear divide between pharmacies and NSPs in terms of enthusiasm for the product.

The 15–20 NSW, SA and WA pharmacies asked by The Bulletin to comment on the trial appear to know little about it and say their clients have little interest in receiving naloxone. Some even still have the original single box of naloxone issued to them at the start of the trial 18 months ago.

Dr Mary Harrod, Chief Executive Officer of the NSW Users and AIDS Association (NUAA), is part of the committee that meets monthly to oversee the progress of the pilot in NSW. She says client feedback about a lack of stock led to NUAA ringing all 260 pharmacies participating in NSW at the time, leading to the discovery that very few had a comprehensive understanding of either the trial or naloxone itself.

“Stores like Chemist Warehouse had like a bazillion outlets on the list and none of them had any idea they were part of it,” she says.

NUAA subsequently worked with the NSW Department of Health to ensure these stores had access to naloxone and their staff were properly trained in distributing it.

“The Commonwealth program is great but it’s only part of it. To actually make it accessible, there’s been a lot of work in NSW,” Mary says.

In WA, Alison Lori, Clinic Care Coordinator at HepatitisWA, agrees that lack of knowledge and/or stock in pharmacies has been an issue for some of her organisation’s clients too.

On the whole, however, Alison says the trial has been extremely well received. HepatitisWA has provided 502 units of Nyxoid through its NSP and the Deen Clinic in inner Perth.

It’s vital that naloxone continues to be provided so easily throughout the community as this is the pivoting point of saving lives.

Alison Lori

“It’s vital that naloxone continues to be provided so easily throughout the community as this is the pivoting point of saving lives,” she says.

Alison says her service has even had someone run in to get naloxone to successfully treat an overdose as it was occurring during the trial.

In contrast, Carol Holly, CNP Peer Projects Coordinator at HepatitisSA, says the SA voucher system has created “quite a few barriers to access” and a lack of participating pharmacies is making access difficult for some of her clients.

“There are a few pharmacies that are really, really on board with the pilot and always have naloxone in store, but there are many that don’t.”

In spite of this, Carol says the “numbers are good” for SA and a lot more naloxone is now in the hands of people who might need it.

Where to next?

Most of the healthcare professionals contacted for this article say the Commonwealth pilot has been very successful in allowing greater access to the drug – a welcome step up in naloxone distribution in their respective states.

The final report on the Commonwealth pilot is due to be submitted by the team at the University of Queensland in September.

The trial will continue to run until the end of June 2022 to allow people to keep accessing naloxone free of charge while the data is being evaluated.

– Jack Revell