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.
|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
|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.
|Figure 2 Eric Schneiderman. Image: AP/Press association images
- Assembly (Figure 3)
- Administration – spraying (Figure 4)
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.
The Irish group
- (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 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