Drink and Drugs News DDN November 2018 - Page 13

OverdOse preventiOn Does intranasal naloxone have a role in substance misuse services, asks Graham Parsons New optioNs oN NaloxoNe THE LAUNCH OF NALOXONE NASAL SPRAY in September 2018 provides substance misuse practitioners with another tool to support harm reduction. Although the premium price of £27.50 per pack plus VAT, 52 per cent more expensive than intramuscular (IM) naloxone, may restrict its supply in a sector already suffering significant cuts – including substantial buprenorphine costs associated with its recent short-supply (see page 8) – there are some advantages associated with the new formulation. This short article will try to consider both the advantages and disadvantages of intranasal (IN) naloxone and where its place in the sector might be. Naloxone is an emergency antidote drug that reverses an opioid overdose and can save a client’s life. Its distribution is supported by the Advisory Council on the Misuse of Drugs (ACMD), Public Health England (PHE), the World Health Organization (WHO) and many other national and international bodies. Under current legislation, parenteral naloxone can be provided to clients and their families, friends or carers by ‘any person employed or engaged in the provision of drug treatment services’. This has led to a number of drug treatment providers providing take-home naloxone (THN) to their clients and families, friends or carers since the legislation change in October 2015. The IN naloxone pack contains two individual nasal sprays each containing 1.8mg of naloxone in 0.1ml solution. Pharmacokinetic studies (studies investigating the drugs availability in the body after it has been given) suggest the nasal spray is equivalent to a 0.4mg dose of IM naloxone. The onset of action is slower but the IN formulation has a longer half-life (1.27hrs vs. 1.09hrs). The training material provided by the company advises that one dose of IN naloxone should be administered where opioid overdose is suspected, www.drinkanddrugsnews.com with a second dose given if there is no improvement after two to three minutes or the opioid overdose symptoms come back. The usual harm reduction advice, for example call an ambulance, is also recommended in the training material. The shelf life for the product is similar to licensed IM naloxone product (30 months compared to 36 months) and there are no special temperature storage requirements other than to protect from light and store in the original container. IN naloxone is licensed for use from the age of 14 as opposed to 18 for the licenced IM naloxone formulation. This provides a useful alternative for the 14 to 17 age group, where the use of the licensed IM naloxone formulation is off-label, ie outside the recommendations provided by the company. Pragmatically many services have supplied IM naloxone to under-18s within a defined protocol based on a risk to benefit analysis, but the availability of a licensed product in this age group is a welcome addition. IN naloxone may also be a useful addition in situations where clients and/or their carers or families have difficulties using the licenced IM formulation. This may be, for example, due to concerns around needle-stick injuries or difficulties in demonstrating a good technique with an IM formulation. Unfortunately the current legislation supporting the supply of naloxone (2015 SI 1503) only covers the distribution of parenteral (ie injectable) naloxone, not IN naloxone. In effect this means that currently it can only be supplied on a prescription to a named patient or via a patient group direction (PGD) or patient specific direction (PSD). This is an issue which I under stand is being addressed but will probably not hit the statute book until 2019. The manufacturers also warn that absorption of the drug may be affected in clients with a damaged nasal mucosa and septal defects. ‘Current legislation supporting the supply of naloxone only covers the distribution of injectable naloxone. This is clearly an issue which I understand is being addressed...’ Support for services who may want to supply IN naloxone has not been at the same level as that provided when the licensed IM naloxone product was initially launched. No face-to-face training is being offered and placebo (dummy) packs are not being provided to services. Patient Information Leaflets (PILs) are also not being provided in paper copies, with services being asked to print off copies via a dedicated website. In conclusion there does seem to be a place for IN naloxone in our substance misuse services. However, the cost and current legislative issues around the supply method may limit its role to selective groups. Graham Parsons is chief pharmacist and pharmacist prescriber at Turning Point November 2018 | drinkanddrugsnews | 13