October 2017

The NSW naloxone revolution

Frontline workers deliver cost and hassle-free naloxone in a NSW breakthrough

It happened.

In the week starting Monday 28 August Professor Nick Lintzeris actually achieved the first step on a journey that had at times seemed impossible: nurses at an NSP in South-Eastern Sydney handed at-risk opioid users free naloxone to take home with them.

“It’s gone live,” Nick says. “The first group of patients or clients received a naloxone distribution by nurses – without a doctor or a pharmacist in sight!”

This was no small thing. It’s taken almost five years to weave through and negotiate the many logistical hurdles surrounding cost-free and hassle-free naloxone distribution.

“Two years ago, we could not have done it,” Nick says.

Originally he had thought the way to attempt the trial was by asking for a suspension of standing orders, but the NSW Health Department said no. Instead, state government officials explained there was a new ‘authorised protocol’, whereby the state’s chief health officer could endorse a framework for nurses and relevant health professionals (non-doctors and non-pharmacists) to be trained in specific drug supply, instead of the usual drug administration.

The adjusted frameworks had been used twice already: for nurses in regional emergency departments to be able to supply antibiotics or minor drugs to patients, having been trained in explaining diagnosis, doses, potential complications and side effects, and so on, when a doctor may not be present; and also for school vaccinations, so that a nurse could provide injections without a doctor necessarily having to be present. Nick’s team had to work hard to train the specific NSP workers and nurses who would be involved in the trial in all these ‘out of scope’ aspects, before getting the green light.

Nick says that he believes there is potential for a national credentialing framework, which could make such work easier across Australia. It remains desperately needed, in his opinion.

“Technically, yes, it has been possible to buy naloxone over a pharmacist counter, but unfortunately there is no subsidy for over-the-counter drugs so that would cost you between $60 and $90 for Prenoxad or $40 to $60 dollars for ampoules,” Nick says.

“The other way was to go to a doctor and get a prescription, and then it would cost $6.20 to buy but that assumes finding a doctor who knows about naloxone and assuming you find one that bulk bills – and good luck with that. And it assumes you are on a health care card for the subsidy.

Naloxone has been legally available, but logistically difficult to receive.

Dr Nick Lintzeris

Professor Nick Lintzeris with Prenoxad

“So, yes, naloxone has been legally available, but logistically difficult to receive.”

Nick’s strategy, after climbing through the legalities and prevailing attitudes and wider ignorance about naloxone, was to try and deliver the potentially life-saving drug for free to high-risk clients and patients at the most obvious places.

“Our goal was one point of access, free of charge, at points where we know there are people at high risk,” he says. “As people leave drug and alcohol rehabilitation, for example. Or at the Emergency Departments. What happens now is an ambulance will take somebody after an overdose to the ED, but then you leave empty handed. The strongest indicator of an overdose in the next 12 months is having suffered an overdose in the last 12 months. So these people should be educated in naloxone and given it to take with them.”

Prison is the other place where Nick would like to see free naloxone distributed, as it is known that the two to four weeks following release from prison is an extremely high-risk time for overdoses. The problem is that, as Nick explains: “prisons simply will not play with needles.” Instead, he is hoping a much-anticipated intranasal naloxone spray gets approved and released for use in Australia within the next 12 months, to make the prison distribution much more achievable.

Nick is encouraged that the NSW trial is operational, in Murrumbidgee, and across several South-Eastern Sydney local health districts. This trial is intended to distribute 500 or so naloxone kits to “get a feel for the systems and whether it is working,” he explains. He wants to emerge from the trial knowing whether any of the various government, health and community stakeholders are unhappy and what the fiscal cost was. But every step is a step forward.

“Five years ago, we had done nothing,” he says. “We have come a long way since, yet the question remains: why have only 3000 or 4000 people taken home naloxone in five years across Australia? We’re not even close to meeting the public health need. The current dissemination strategy is not good enough.”

Nick Place