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,
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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