Preventing opioid overdose: from the global to the local
Opioid overdose is a major public health issue, with devastating impacts on individuals, their families and communities. Major strides have been made in developing responses to opioid overdose, ranging from effective pharmacotherapies for opioid use disorders (1) through to interventions designed to empower overdose witnesses to provide direct overdose response.(2) Nevertheless, implementation of these strategies is incomplete and much work remains to ensure adequate coverage.
At a global level, access to essential treatments for opioid use disorders including opioid agonist treatments such methadone maintenance therapy is limited by government policies and treatment structures.(3) Similarly, despite recognition of its role in overdose response, access to the overdose reversal drug naloxone is variable across countries. This variability is partly driven by limitations in access to the drug within countries but also driven by the absence of tools and guides on expanding naloxone access. In this regard there are almost no studies of take-home naloxone, an evidence-based intervention to expand naloxone access to people likely to witness opioid overdoses, outside of high-income countries.(4)
The Stop Overdose Safely Initiative, a global response to overdose
In recognition of the evidence gaps around take-home naloxone, and in response to specific United Nations resolutions around opioid overdose and response, the World Health Organization and the United Nations Office on Drugs and Crime lunched the Stop Overdose Safely (S-O-S) initiative in 2016.(5) One component of the initiative was the development of targets along the so-called ‘cascade of care’ whereby:
i) 90 per cent of the relevant target population should be trained in overdose risk and emergency management;
ii) 90 per cent of those trained will be given a supply of emergency naloxone; and
iii) 90 per cent who have been given a supply of naloxone will carry it on them or have it close at hand.
The S-O-S initiative also included the S-O-S program through which a take-home naloxone program was developed and implemented in four low-to-middle income countries: Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine.(6) Utilising a train-the-trainer approach around 4,000 potential opioid overdose witnesses were trained in overdose response and naloxone administration through the program in each country. After training, program kits containing two 400 microgram ampules of naloxone with equipment for intramuscular administration were distributed to program participants. The S-O-S program demonstrated the feasibility of rapid scale-up of take-home naloxone in the four countries, providing clear evidence that take-home naloxone can be implemented at scale in low-to-middle income countries using the S-O-S model. Importantly, an evaluation of the program we conducted with a sample of program participants and stakeholders showed that participants not only responded to overdoses that they witnessed but that their participation in the program had a range of other positive impacts, including changes attitudes towards people who use opioids and empowering them to take action to save lives.(6)
Opioid overdose in Australia
At a local level in Australia the situation regarding overdose response is mixed. Recent work by our group using SuperMIX cohort data finds that opioid overdose rates among people who inject drugs has remained relatively stable over recent years, at around 0.7 per 100 person years for fatalities (7) and 7.8 per 100 person years for non-fatal overdoses.(8) These cohort-derived data represent one of the few sources of information on opioid overdose incidence in Australia, highlighting the need for ongoing studies of people who use drugs. These findings emerge within a context of widespread access to opioid agonist therapy but the absence of a current national opioid overdose strategy; the last such strategy was written for 2001.(9) It is therefore not unsurprising that take-home naloxone programs vary considerably between Australian jurisdictions, despite a national pilot having been rolled out since 2019 in three Australian states. Here, there is considerable variation in the locations from which take-home naloxone can be obtained, the rules surrounding who can supply take-home naloxone and the protections afforded those who provide overdose response.(10)
Supervised Injecting Facilities
Another strategy for managing opioid overdose risk is to provide environments for people wo use opioids to consume their drugs under supervision.(11) Supervised injecting facilities (SIFs) are an example of such an environment where drug consumption takes place under the supervision of trained staff who can provide response in the case of opioid overdose. The Sydney Medically Supervised Injecting Centre that has been operating in Kings Cross since 2001 was joined by the Melbourne Medically Supervised Injecting Room (MSIR) in North Richmond in 2018 as the only two SIFs operating in Australia. Evaluations of both Australian SIFs have highlighted their potential in reducing opioid overdoses among people who inject drugs, in terms of overdose deaths as well as ambulance attendances outside of the facilities.(12, 13)
Recent work by our group with the SuperMIX cohort has highlighted how the MSIR attracted clients who experience significant vulnerabilities.(14) We found MSIR clients to be more likely to have experienced homelessness and more likely to report risky drug-related behaviours and poor health outcomes compared to SuperMIX cohort members who did not use the facility. Cohort members who used the facility frequently were more likely to report having been recently incarcerated. In this way the facility appears to be servicing some of those most in need of the protections that it affords.
In spite of the positive findings around the impacts of SIFs in Australia, and the recommendation of the Victorian Government to establish a second MSIR in Melbourne’s Central Business District, there are only two such facilities in Australian two biggest cities. However, recent work by our group and the Canberra Alliance for Harm Minimisation and Advocacy (CAHMA) suggests that a small SIF could feasibly be implemented in the ACT.(15) Here, in the context of rising opioid-related harms, stakeholders suggested that such a facility would be well-utilised in what is the jurisdiction where support for SIFs is highest among the general population.
The way forward
The advances in relation to opioid overdose response in recent years are encouraging but more work is needed. As indicated, in the context of continued opioid overdose incidence inconsistencies across Australian jurisdictions need to be addressed and global scale-up of effective responses is lacking. Alternative options for response including safe opioid supply in the form of injectable opioids have not yet been widely implemented, even in Australia where options for safe supply of injectable opioids have previously been explored in the 1990s (16) and 2000s.(17) Strategies are needed to help guide the development and implementation of initiatives designed to reduce the impacts of opioid overdose. Internationally, the S-O-S initiative is an example of how a collaborative multi-agency response can help guide new responses; at a national level in Australia an updated opioid overdose strategy is needed to guide policy and practice around responses to opioid overdose over the coming decade.
1. Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, et al. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction. 2011;106(1):32-51.
2. Olsen A, McDonald D, Lenton S, Dietze PM. Assessing causality in drug policy analyses: How useful are the Bradford Hill criteria in analysing take-home naloxone programs? Drug Alcohol Rev. 2018;37(4):499-501.
3. Harm Reduction International. The global state of harm reduction: 2019 updates. . Author: Available from: https://www.hri.global/global-state-of-harmreduction-2019; 2019.
4. Strang J, McDonald R, Campbell G, Degenhardt L, Nielsen S, Ritter A, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-418.
5. UNODC/WHO. Joint UNODC/WHO initiative addresses public health impact of community management of opioid overdose 2017 [Available from: https://www.unodc.org/unodc/en/frontpage/2017/March/joint-unodc-who-initiative-addresses-public-health-impact-of-community-management-of-opioid-overdose.html.
6. UNODC-WHO. Stop-Overdose-Safely (S-O-S) project implementation in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine: summary report. (License: CC BY-NC-SA 3.0 IGO). Geneva: World Health Organization and United Nations Office on Drugs and Crime; 2021.
7. Hill P, Stoove M, Agius P, Maher L, Hickman M, Kerr T, et al. Mortality in the SuperMIX cohort of people who inject drugs in Melbourne, Australia: A prospective observational study. under review.
8. Hill P, Agius P, Stoove M, Maher L, Hickman M, Kerr T, et al. The impact of health service utilisation, demographic, socio-structural and drug related factors on incidence of non-fatal opioid overdose among people who inject drugs: A prospective observational study. under review.
9. Australian Government Department of Health and Aged Care. National Heroin Overdose Strategy. Canberra: Author; 2001.
10. National Naloxone Reference Group. Naloxone access, distribution and training – AUGUST 2021. Melbourne: Centre for Research Excellence into Injecting Drug Use; 2021.
11. Moore D, Dietze P. Enabling environments and the reduction of drug-related harm: re-framing Australian policy and practice. Drug Alcohol Rev. 2005;24(3):275-84.
12. Medically Supervised INjecting Room Review Panel. Review of the Medically Supervised Injecting Room. Melbourne: State Government of Victoria; 2020.
13. MSIC Evaluation Committee. Final Report on the Evaluation of the Sydney Medically Supervised Injecting Centre. Sydney: Authors; 2003.
14. Van Den Boom W, Del Mar Quiroga M, Fetene DM, Agius PA, Higgs PG, Maher L, et al. The Melbourne Safe Injecting Room Attracted People Most in Need of Its Service. Am J Prev Med. 2021;61(2):217-24.
15. Kirwan A, Winter R, Gunn J, Djordjevic F, Curtis M, Dietze P. Final Report of the ACT Medically Supervised Injecting Facility Feasibility Study. Melbourne: Burnet Institute & Canberra Alliance for Harm Minimisation and Advocacy; 2020.
16. Bammer G. The ACT heroin trial: intellectual, practical and political challenges. Drug Alcohol Rev. 1997;16(3):287-96.
17. Hall WD, Kimber J, Mattick RP. Breaking the deadlock over an Australian trial of injectable opioid maintenance. Med J Aust. 2002;176(2):72-3.