Overdose Education and Naloxone: Workshop for Family Medicine Trainees in Ireland
Overdose is the most common cause of deaths among heroin users. Our previous research has shown that the ambulances in Dublin see one overdose every day*. Naloxone is a life-saving nasal spray for reversing heroin overdose. It has no addictive properties, no potential for abuse and a low cost. In Ireland, it is currently used by ambulance and emergency care services as an injection into muscle, into the bone or under the skin.
Irish family doctors treat many heroin users users who are in the methadone treatment. This makes family doctors ideal to use naloxone themselves or to show patients how to use it. The new Clinical Practice Guideline of the Pre-hospital Emergency Council of Ireland advises that trained professionals can use intranasal naloxone.
Today, we ran a pilot workshop with doctors in training. It was designed to help trainees identify and manage opioid overdose with naloxone spray. The trainees listened to a short presentation, watched a video clip about how to use naloxone (Figure 1), and tried it themselves. However, they did not get the spray to take home with them.
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| Figure 1 Jano simulating overdose in a pilot educational video for general practice trainees |
23 young doctors from one postgraduate training scheme in Ireland participated in an hour long lunchtime workshop. We have asked them to self-assess their own knowledge of and attitudes towards naloxone using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales. They did the scales before and after the workshop. Another questionnaire measured the acceptability and satisfaction with workshop. The doctors gave us valuable feedback on the session which will be analysed and published in an academic paper.
The take home message from today is that adequate training is essential for distribution of naloxone through Family Practitioners. In future studies, the knowledge from this pilot may be used to inform a train-the-trainer model. Healthcare professionals and other front-line service providers may be trained to instruct heroin users and their families in overdose prevention and naloxone use. Today’s workshop was timed perfectly, because the deaths due to overdose in the country are peaking.
*Study by: Klimas, J., O’Reilly, M., Egan, M., Tobin, H., Bury, G. (2014) Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services. American Journal of Emergency Medicine (Online July 30) doi: 10.1016/j.ajem.2014.07.017
Urban Overdose Hotspots: New Paper out Now
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it.
Just as the presence of storks doesn’t cause the explosion in birth rates, methadone clinics don’t cause people to use and overdose on heroin at their door steps. Most overdoses in our study were within 1000 metres radius around the clinics, it means that they were not in the immediate vicinity of clinics. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Cited study: Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services http://www.ajemjournal.com/article/S0735-6757(14)00510-5/abstract
Study authors:
Received: June 6, 2014; Received in revised form: June 26, 2014; Accepted: July 2, 2014; Published Online: July 30, 2014
Publication stage: In Press Accepted Manuscript
Shooting Overdose video
Do we need another educational video about overdose prevention? No. A simple internet search reveals hundreds of these clips. However, as the saying goes “If it hasn’t been done in Ballydehob, it can’t be true.” Of course, I tweaked the saying a bit. My point is that local problems need local(-ised) solutions.
In Dublin, Ireland, ambulance services attend to an opioid overdose every day. No surprises, the third highest rate of deaths due to drugs – 70 per million – in Europe. Reasons are complex – consequences fatal. But there is a simple solution. Naloxone, a heroin antidote, can be sprayed into an overdosed person by anybody. It is safe, harmless and cheap.
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| Figure 1 Naloxone |
In USA, 10,171 lives have been saved by Naloxone which have been distributed to 53,032 persons. Naloxone saves lives. And yet, “If it hasn’t been done in Ballydehop, it can’t work.” Ballydehob is a small village on the Irish coast, very far from Dublin. We can’t show that Naloxone works there, but we can do so in the University College Dublin. And so we are, developing and piloting an educational intervention on overdose prevention and naloxone distribution by general practice trainees. Why GP trainees? Reasons are complex – consequences fatal. Plus, we need to start somewhere. Irish actors and accents will help us get a buy in from the local stakeholders who can help make naloxone fully available in Ireland.
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| Figure 2 Eric Schneiderman. Image: AP/Press association images http://jrnl.ie/1574998 |
On July 1st, the UCD Centre for Emergency MedicalScience started production of a short educational video. The video shows 3 steps of response to opioid overdose with Naloxone spray:
- Recognition
- Assembly (Figure 3)
- Administration – spraying (Figure 4)
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| Figure 3 |
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| Figure 4 |
Our work has been financed by the Irish College of General Practitioners. The college had no input into this post and the opinions aren’t theirs. They are mine.
Submitting ethics for new research: killing so many trees
Ethical principles, ethics committees and research
This has been a busy week from an ethics perspective. All research should be ethical and adhere to the ethical guidelines. The gatekeepers for the ethical principles are usually ethical committees, institutional review boards or panels. Researchers submit their proposals for approval to the committees and they decide whether the proposed research is in line with the universally accepted principles of ethical research. For example: Research carried out on humans should be in compliance with the Helsinki Declaration (http://www.wma.net/en/30publications/10policies/b3/index.html).
In Ireland, we have 25 committees/ boards who can provide ethical approval and we submitted two applications for ethical approval to two different committees this week:
1. Are psychosocial interventions for problem alcohol use effective among problem drug users in primary care (PINTA): A Controlled before-and-after feasibility study
2. Prospective audit of characteristics of opioid overdoses in an emergency ambulance service
…so many trees going to the ethics.
As usual, we submitted the ethics application on the last day of the deadline.
I wasn’t even sure if the cyclist courier would take it on a bike to the addressee, because the package had surely over 2 kilos. Fingers crossed.
Naloxone: The Welsh Experience. A presentation by Ifor Glynn, Director, Swansea Drug Project, Wales (www.drugs.ie)
The Irish group
In early 2012, The Ana Liffey Drug Project convened a ‘Naloxone Advisory Group’ with the following objectives:
- (a) to pilot provision of Naloxone in Ireland for administration by opiate service users and their families, with the aim of reversing overdose;
- (b) to evaluate provision the pilot with the aim of improving the project, and – if proven effective then – to roll out national Naloxone provision.
The group is comprised of the following individuals:
Dr Gerard Bury, UCD; Dr Austin O’Carroll, Safetynet; Dr Des Corrigan, TCD; Vivian Guerin, Probation Services; Sadie Grace, National Family Support Network; Tony Duffin, Ana Liffey Drug Project; Caroline Gardner, Progression Routes Initiative.
The Welsh experience
On 6th July 2012, I attended the meeting of the group where Ivor Glynn, Director of the Swansea Drug Project, gave a presentation entitled: Naloxone- The Welsh Experience, to the Irish Naloxone Advisory Group. You can view this video presentation below (courtesy of drugs.ie) http://drugs.ie/features/feature/naloxone_the_welsh_experience