SUBLIMAZE: From Painkiller to Plain Killer

 

Here is a link to a story published on Storify a few weeks back. It traces the growth of Fentanyl from inception to present day. Fentanyl itself is an amazing medicinal breakthrough and the benefits when used in the right set and setting are numerous, however, when it breaks bad and begins a separate journey in the illicit world of criminal gangs and cartels, being reproduced in clandestine laboratories globally it’s a completely different story. This is the first installment and the second will follow shortly. Please spread the word or warning among your networks.

 

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[View the story “Sublimaze: From Painkiller to Plain ‘Killer'” on Storify]

(Are) The United Nations on Drugs

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 United Nations have exerted a unique element of drug control globally since 1909. So what has that ‘control’ really achieved over  that century+

In an extension to the World Drug Report (chapter 2) a paper entitled ‘A CENTURY OF INTERNATIONAL DRUG CONTROL’ the opening statement read…..

 

“For those who doubt the effectiveness of drug control, consider this. In 1906, 25 million people were using opium in the world (1.5% of the world population) compared with 16.5 opiate users today (0.25% of the world population). In 1906/07, the world produced around 41,000 tons of opium – five times the global level of illicit opium production in 2008. While opium used to be produced in a huge belt, stretching from China to Indochina, Burma, India, Persia, Turkey and the Balkan countries, the illegal production of opium is now concentrated in Afghanistan (92%)”

 

The illegal production of opium is indeed concentrated in Afghanistan a country and no longer overseen by the Taliban who regulated and exerted extreme measures to ensure quality control and a consistency in supply. Instead it is now regulated by the US of A.  No more quality control, no reduction in supply, other than a complete drought during take over which resulted in a sharp spike in drug related deaths during 2008-9, and obviously no respect for HR principles in that not one ounce of sense passed over under tupe law to ensure consistency.

 

Oh yeah, they were meant to be ending the war on drugs silly me?

 

Obviously the new contract / agenda, (not available via Freedom Of Information Act for some unknown reason) had a radical ‘hidden’ agenda,’Operation Blatantly Obvious’ based loosely on the 1996 Nicaraguan agenda and legislation but without the ‘Contra’versial partnership for a more complex service provision that covers all angles.  As it stands nothing changed. It still rages on ‘under new management’

 

In 1906, the ‘huge’ belt that is mentioned including China, who incidentally were responsible for the first anti-opium edict. Emperor Yung Ching, imposed severe punishment on any sellers or opium business traders back in 1729. Prohibition proving itself a dismal failure even back then it would seem. Yes China, were, unwillingly, subcontracted to India due to the increased demand for opium. Which incidentally, or coincidently, increased significantly when the British occupied India, isn’t history such a wonderful thing?

Quote from the ‘Opium Monopoly’ – ‘’China was powerless to protect herself from this menace, either by protests or prohibition. And as more and more of the drug was smuggled in, and more and more of the people became victims of the habit, the Chinese finally had a tea-party, very much like our Boston Tea Party, but less successful in outcome. In 1839, in spite of the fact that opium smoking is an easy habit to acquire and had been extensively encouraged, the British traders found themselves with 20,000 chests of unsold opium on their store-ships, just below Canton. The Chinese had repeatedly appealed to the British Government to stop these imports, but the British Government had turned a persistently deaf ear. Therefore the Emperor determined to deal with the matter on his own account. He sent a powerful official named Lin to attend to it, and Lin had a sort of Boston Tea Party, as we have said, and destroyed some twenty thousand chests of opium in a very drastic way. Mr. H. Wells Williams describes it thus: “The opium was destroyed in the most thorough manner, by mixing it in parcels Of 200 chests, in trenches, with lime and salt water, and then drawing off the contents into an adjacent creek at low tide.”

This off course pissed our British contingent off and again, coincidently,  as with all envoys in this kind of interaction, poor Lin was found two weeks later propped up against a tree with his favourite book and a  gunshot to the back of the head,  8cal, in his hand was a 9mm. The obvious analysis was suicide, so, so,  sad.  Or was it a 1ml in his hand and over  1gal of opiates in his system, I forget……

…..and digress…..

Anyway this was to be the start of the biggest Opium war to date, led by, and indeed won by our proud little firm of international dealers, sorry, British merchant bank, er sorry,  sailors  who steamed up the Yangtse, demanding the Chinese give them their gear back and compensation for the damaged goods. At the same time opening up the shipping ports to continue trading as per usual. God save the Queen?

 

 

India at this point just kicked back and ensured production was consistent and steady to meet demands, to supply, to meet demands.

Then, 15 years later,  as sales and demand again grew, more outlets were needed so our good old sales people put in the proverbial boot , (no pun intended) resulting in a second war, smothered under religion….”Great Britain, the first Christian power, really waged this war against the pagan monarch who had only endeavoured to put down a vice harmful to his people. The war was looked upon in this light by the Chinese; it will always be so looked upon by the candid historian, and known as the Opium War.” (Middle Kingdom)

In 1917, China was practically free from the native-grown drug, and foreign importation had practically ended. The final years of native-grown poppy indulgence was enjoyed only be upper classes while the lower working classes were subject to sever punishment.

So back to the initial statement in the original topic. Restriction to India of the restriction of opium growth was a natural occurrence, and restriction in production and sales was because the Chinese were no longer needed to smuggle or market the substance. The ports along the Yangtse were now operating under International law and manned by concessions in each port of  German, Austrian, British, French, Russian, mainly but not exclusively.  The United Nations were still an unfertilized egg waiting for some wanker to spawn them with a one off, lucky? shot.

 

My last edition to this prequel to the actual birth and report to follow is quite basic and, in my opinion blatantly obvious.  The declaration that there are far less opioid uses globally, do we really need to put our answers on a postcard here? I personally, am going to go out on a limb here and take a wild guess that it could have something to do with the elements of control, or numerous different attempts at control,  exerted over the last 110 years, by enforcers who feel the need to control in the first place. Yep, think I’m safe in saying the numbers are decreasing because….

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WE ARE DYING OUT HERE?….Just saying…….But hey I could be wrong?

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Implementing local Take Home Naloxone Programs (UK)

On 19th February, Public Health England released guidelines aimed at local authorities for Take Home Naloxone programs. This is aimed at following the recommendations in the letter from Department of Health (Jane Ellison) to Advisory Council for the Misuse of Drugs chair Les Iverson where there was a date for the National implementation for Naloxone programs, and recommendations into the preparation for the programs to be initiated on 1st October, 2015. Although the general consensus around this date is that it is too far in the future and leaves to much scope for a further increase in drug related deaths, this date is the one that NAG (Naloxone Action Group) England are now holding providers to as a set deadline. Here are a few ways in which you can inform / support your local authorities to ensure that this is being implemented locally in time to meet the 2015 deadline.

Follow hyperlink for copy of guidelines: http://www.nta.nhs.uk/uploads/take-home-naloxone-for-opioid-overdose-feb-2015.pdf

THE GUIDELINES INCLUDE CLARITY ROUND UK LAW SURROUNDING NALOXONE

UK Law.

Like all medicines in the UK, naloxone sale and supply is regulated under the Medicines Act of 1968. This act brought together most of the previous legislation on the regulation of medicines but also introduced some new legal provisions for the control of medicines. When thinking about the regulation of medicines, it’s important to recognise that medicines (broadly) fall into one of four categories;

• GSL. General Sales List Medicines sold or supplied direct to the public in an unopened manufacturer’s pack from any lockable premises
• P. Pharmacy Medicines sold or supplied from registered premises by, or under the supervision of a pharmacist
• POM. Prescription Only Medicines sold or supplied to named patients by prescription. Applies to all injectable preparations, including Naloxone
• POM (CD). Controlled Drugs

As stated above, injectable naloxone is a POM and can therefore only be SUPPLIED to a person identified as ‘at risk’ of potential future opiate related overdose. It can be supplied to the friends/loved ones of those identified as at risk, but only with the written consent from the person for whom it’s to be supplied.

Who can administer naloxone?

Anyone can administer naloxone for the purpose of saving a life. In November 2005 naloxone was added to the list of injectable drugs in Article 7 of the Medicines Act, this is the part of the act that covers drugs like insulin for diabetics (and adrenaline, atropine, snake anti-venom etc).

Who can supply naloxone?

Naloxone can be prescribed by any medical doctor, but can also be prescribed by some other registered medical staff using a Patient Group Direction (PGD). This means that naloxone can be given out via drug projects that don’t necessarily have a doctor on their staff.

(Taken from Scottish drugs forum Naloxone: http://www.naloxone.org.uk/)

This would mean that in order to get Naloxone out into the community there needs to be a prescription given to an individual who has been ‘catagorised’ as high risk. This could mean treatment naive community members, those still in treatment, those leaving treatment, including residential rehab, prison leavers, in light, anyone receiving any kind of opioid medication, on prescription.

At this particular moment in time, following a freedom of information request carried out by National Needle Exchange Forum, Release and NAG Engand members, the evidence would suggest that 1 out of every 3 Health and Wellbeing boards are supplying naloxone. Considering the high level of drug related deaths Nationally in 2013. This seems to be a small amount for such a major public health issue.

In light of this information, there are a number of things you can do locally to help push this program forward and to make sure that it is firmly on the agenda in your area in line with the guidelines.

• Identify local champions: Local authorities will be looking to identify local champions. This could be you, or it could be someone who is sympathetic to the need for Take Home Naloxone programs. If your local MP signed the Early day motion 445 – NALOXONE AVAILABILITY – UK then you may well have you local champion there, sympathetic GP’s, Pharmacists, local recovery / harm reduction groups, etc. Identify who your champion is and encourage them to engage with Naloxone Action Group (NAG) This can be done via the NAG England website or via the facebook forum page. This will enure that they have all the support they may need when engaging with any local authority agents on any level.

website: https://nagengland.wordpress.com/

facebook: https://www.facebook.com/groups/1455313511394512/?fref=ts

• Organise an initial ‘informing the managers’ or ‘train the trainer’ session: While this is being done by local authorities, you could be raising awareness of your plan of action to disseminate information into your community. If you are planning local train the trainer sessions or have been asked by your local authorities who might be delivering the training, but are unsure how to go about it, please contact me at drugactivist@gmail.com and I will direct you to your area representative. You can then pass relevant information over to local authorities and support them in initiating the training.

• Consider who will receive Naloxone supplies, and how, users and carers, hostels and pharmacies, etc: The aim here is to have Naloxone freely available in all providers that come in contact with high risk individuals, and eventually, being ambitious, over the counter. However, the first step would be identifying key areas where there are high risk individuals, treatment services, hostels and prisons, might be a good start. The local authorities should be more that aware of where there is an immediate need. You may have to prioritise here as a first step and decide where there is the most benefit to be had. Needle exchange programs, would be an ideal starting point.

• Consider who will pay for Naloxone supplies in different areas: Commissioning for such programs sits firmly with Department of Health as the overseers of Public Health but on a local level responsibility sits with the CCG (clinical commissioning groups) following a transfer of responsibilities through localism. To find out your local CCG contact details: NHS England » CCG Directory Also as a matter of interest here Frontier Medical Group are now the official distributor of Prenoxad / Naloxone kits for Martindale Pharma so they will be the single point of contact for provision of supplies.

• Agree how you will re-supply people when Naloxone is used or it expires, and who will pay. Will you have a system that flags up appraoching expiry dates to keyworkers, pharmacies, etc: As with any form of medication there needs to be a medication management database for monitoring purposes. This would need to monitor all needs and results pertaining to Naloxone provision. How many kits were given, when given, adverse effects of medication, etc. Once the basics for this are done then it would need to be reviewed to see how to monitor a case by case study of each individual involved in the program. All input would need to be evidence based and precise in it’s records. Medication regimens for every naloxone reciever need to be monitored and also all different naloxone products of there is to be intranasal available as well as injectable, etc. Most of this should be in place for already existing medications in the community and it would simply be a matter of adding Naloxone to the list of medications already monitored. Another thing that may need to be discussed here is the need to expand the monitoring to co-morbid conditions and socioeconomic status, substance use, homelessness, chronic health conditions, employment status, etc. As already stated there should already be a monitoring system in pace which could provide the basis on which to ad the information needed regarding Naloxone provision. This action lay with local authorities primarily so does not hold any weight on what you might be forming as a part of your action plan to offer support locally.

• Hold regular meetings for Naloxone champions – including people who use drugs – to encourage progress, discuss barriers of concerns, and learn from each other: This is already happening in a number of areas so it is simply a matter of inviting the local authorities to come along and join the already existing platform that you have provided. If there is no platform locally, you can create one in the form of a local Harm Reduction Cafe where local provision and action plans can be discussed and implimented. All you need to set one up is available on the website. This should be publicised and openly supported / attended by all providers who deal in the care of those considered at risk in the community. Also as stated attended by local service user reps, groups, and people who are currently using substances.

• Explore the products and prices available, speaking to the local pharmaceutical representative,  and decide together with local providers which to purchase: At this moment in time in the UK there is only one licensed product available and that is Prenoxad Injection This sight gives you all the relevant information around this particular product. The main suppliers of this product as stated before are Frontier Medical Group A kit costs £18 and there is an agreement in the contract with the pharmaceutical company that this price will stand unchanged for at least the first three years of the contract. It has been advised that two kits are complimentary to the needs of those who would be accessing services for it. One to carry on their person and one to leave in home environment. So if you can find out the local statistics pertaining to injecting drug users then you will effectively be able to get a rough estimate of how much is needed to ensure enough kits are bought in to meet the needs of your user community. There may be an online needs assessment for local IV users on your local authority webpage that can help you with this.

• Complete the paperwork and processes of a PGD, working with the local CCG and director of public health as appropriate:A PGD is a written agreement that in the case of naloxone allows nurses or pharmacists to distribute the drug to people at risk of overdose. It’s important to note that a PGD is only related to the supply of the drug and has nothing to do with administration (as we’ve stated above anyone can legally administer naloxone to save a life). A PGD should contain the following information:
  • The name of the business to which the direction applies
  • The date the PGD comes into force and the date it expires
  • A description of the medicine(s) to which the direction applies
  • The class of health professionals able to supply or administer the medicine (as named individuals)
  • Signature of a doctor or dentist, as appropriate, and a pharmacist
  • Signature by a representative of an appropriate health organisation
  • The clinical condition to which the direction applies
  • A description of those patients excluded from treatment under the direction (if applicable)
  • A description of the circumstances in which further advice should be sought from a doctor and the arrangements for referral
  • Details of the appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered. Legal status of the drug should also be indicated
  • Relevant warnings, including potential adverse reactions
  • Details of any necessary follow-up action and the circumstances
  • A statement of records to be kept for audit purposes

Sample PGD: http://www.naloxone.org.uk/images/pdf/pgd%20naloxone%20approved%20apr%202011.pdf

• Inform and liaise with police, local coroners, ambulance service lead, hostel managers and pharmacies: This one is also something that is best coming from local authorities as experience tells us that correspondence is less than positive when coming from action groups. However if you have been identified as local champion then it might be possible to be cc-d in on any local correspondence or contact to keep you up to date with progress and to put you in a position to inform the local action group of that progress. By all accounts local police should be trained and equipped and it is surprising how many police do not know what Naloxone is, following a number of ‘stop and question’ scenarios I was asked a number of questions surrounding the medication but when I suggested training options they never came to anything. Lcal coroners could be a valuable asset with regards to them being able to give first hand statistical data on causes of death, although this is jaded as cause of death isn’t always recorded correctly. This is for the benefit of the family afterwards. And also there are times when the actual cause of death cannot be attributed to one single underlying cause. This can at times work in favour of some research but in this particular case it does not. Local ambulance crews should be aware of the fact that naloxone is locally available and also on a national scale this needs to be addressed as when you call in a situation, at present, the best way to get a response is to not mention drugs at all and if you do mention that you are equipped and trained you are told under no circumstances to administer. Hostel managers should be a priority with regards to involvement in the program as they are involved in the care and support of some of the more vulnerable in the community. There are number of areas where hostels were approached first for training in preparation. This can also be something that can be carried out by local action groups in support.

• Purchase the naloxone kits and make the necessary arrangements for stocking and distributing them, and for re-supply when naloxone has been used or expired:  The arrangements for re-supply should be straight forward, all services in possession of naloxone should encourage those who lose, use or have a kit that expires to come in to get a kit  replaced. The ideal place for distribution would be Needle exchanges, pharmacies and prison healthcare. Any other places that you may consider should be suggested at any meetings with local authorities.

• Provide training for all drug keyworkers, all opioid substitution therapy (OST) prescriber’s locally, dispensing pharmacists, local service user groups, all of whom can contribute to the onward dissemination of information:   This target has already been partially reached in a number of places and training has or is being done already. This is where local service user groups come into their own and provide an invaluable part of the localised agenda. If you have been on point with the call to arms then you will already have been trained locally and can then put yourself or your group forward to disseminate the training and relevant information around naloxone, basic life support and administration, individual certificated training can be done online at SMMGP – Substance Misuse Management in General Practice website. There are also local reps strategically placed nationally to deliver training, if you contact me at drugactivist@gmail.com then I can direct you towards your local train the trainer.

• Arrange for training to be provided to people who use drugs, patients and clients, and their families and friends, Consider who is best placed to deliver this training. Offer this training to as many people as possible:  It stands to reason that those who are in the best position to cascade the training out to their communities are those out there on the frontline, this again would fall into the responsibilities of the local service users groups. If your group is not trained then then I wold suggest that you look into arranging training and put this in place. It may hold up the process or put the partnership options that are presenting into the hands of someone else. Once trained you are then in a position to offer yourselves as local trainers and pass this onto everyone you meet who has an interest. And id you are anything like me, even even those that don’t.

• Consider whether and how you will record the numbers of kits dispensed, and report the number of times naloxone was used: Part of the initial training and something that is also advocated for in an overdose situation is that an ambulance is always called. This is to reduce risk of the individual slipping back into an overdose as the naloxone wears off after 20-40 minutes. The research around this does state that the effects of street heroin is not much more but the risk is still relevant as due to prohibitive laws surrounding illicit heroin there is no quality control, etc.   There are however times when they may not be called,  a formula may need to be discussed as to how to monitor this, The number of kits dispensed should be easily monitored and most uses, hopefully, recorded by ambulance call outs, etc. This message is something that you can carry out into your communities. We have fought long and hard to get this far, in order for it to stay as part of service provision then we need to ensure that we are responsible, sensible and accountable for our part in the program which includes carrying the message that supports those who support us in maintaining the program at a local level.

ALL IN ALL WE HAVE PUSHED TO GET THIS TO THE LEVEL IT HAS NOW REACHED, THE JOB LAID OUT FOR LOCAL AUTHORITIES IN THESE GUIDELINES IS NOT SIMPLE ONE AND IT IS A TURNING POINT OF THE CAMPAIGN, YOUR NEXT STEPS SHOULD BE TO OFFER SUPPORT TO YOUR LOCAL AUTHORITIES TO ENSURE THAT THIS IS SUSTAINABLE. YOU DEMANDED NALOXONE, NOW YOUR ROLE SHOULD BE TO SUPPORT THE LOCAL AUTHORITIES TO GIVE YOU IT.

We could instantly reduce the number of overdose deaths if this medicine were more widely available

Please circulate where approriate, help us to save lives.

Naloxone Action Group - England

What do we do with a medicine that prevents certain death for people with a particular condition—and is safe, cheap, and easy to administer?

1. Immediately make it accessible to those who can administer it when such a life-or-death situation arises.
2. Make it available to no one except doctors and emergency room workers.
3. Endlessly debate the particulars of how and when it should be widely introduced.

If you picked number one, that would seem to be a reasonable choice. Unfortunately, it would also be incorrect. With few exceptions, answers two or three apply in the vast majority of the world when it comes to the medicine naloxone.

Overdose remains a leading cause of death among people who use drugs, particularly those who inject. Increasing the availability and accessibility of naloxone would reduce these deaths overnight.

View original post 443 more words

TEMPLATE LETTER FOR TAKE HOME NALOXONE PROGRAM CAMPAIGN (NAG ENGLAND)

(To whom it may concern),

I am contacting you in relation to a current national campaign to reduce drug related deaths in England. In light of the recent 32% rise in drug related deaths bringing the statistical data of those dying from overdose involving opioid substances in 2013 to a staggering 765 deaths, each one preventable.

Please find attached below a brief timeline of Naloxone from it’s inception up until present .

https://futuremoves.wordpress.com/2015/01/07/a-brief-timeline-of-naloxone-for-reference/

As you will see there are a number of periods where there has been open endorsement from a number of sources here in the UK. These endorsements have been made by:

Professor John Strang in the British Medical Journal (1996).
ACMD (Advisory Council for the Misuse of Drugs) (2000) (2012)
UK Clinical Guidelines (2007)
NTA (National Treatment Agency) (2007) (2009)
MRC (Medical Research Council) (2008)

The department of health chairperson Jane Ellison sent a letter, in July of last year, to the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015….

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf

This letter lays out a clear and direct plan of action which advocates for training and any other preparations to be supported ‘prior’ to the date given for roll out and was a direct result of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

I feel that a delay until October 2015 is irrational given the evidence of support given and believe that this delay warrants a judicial review based on the evidence collated globally and also from the National programs in both Scotland and Wales where take home programs have had a positive effect on th statistics surrounding drug related deaths. I also feel that this delay is a serious breach of human rights in that every human being has the right to access life saving medication and the right to live. This delay has the potential to interfere with the right to life and also the right to a family life.

Given the case that I hereby put forward for direct and immediate action towards implementation of Take Home Naloxone programs nationally. I would be grateful if you could reply to my concerns by:

A: Informing of what is currently happening locally to put this program in place
and
B: Informing me of the reasons for delay in implementing a local program.

I look forward to further correspondence with you regarding this issue.

Yours sincerely,

A BRIEF TIMELINE OF NALOXONE FOR REFERENCE

 1961:  Naloxone was first cited by Jack Fishman and researched by Harold Blumberg in 1961. The synthesis stated that although naloxone was not the first and only opioid antagonist it was however the first that did not produce analgesic qualities. The synthesis also explained other qualities of naloxone stating that it was indeed a medical breakthrough with regards to the reversal of respiratory depression in all synthetic and natural opioid related substances. It was also useful in coma situations where the cause was of unknown origin to eliminate whether there was opioid presence that had induced the coma like state. It was used on new born babies following the administration of opioid related medication to mothers during pregnancy. Nalorphine preceded Naloxone but after further research was found to cause analgesia and in higher doses hallucinations. Naloxone was found to be the ideal balance between agonist and antagonist and prove to be the only pure agonist which made it the more effective and preferred of all previous researched chemicals.

1962: The previous mentioned document was an abstract in Federation proceedings and the first full report was later released by a group working for Sankyo company in Japan in the Science citation index. Sankyo applied for the British patent for Naloxone in March 1962 and it was awarded in October 1963. The early delays in patent were attributed to the fact that Naloxone was of more interest in the academic field than it was in the commercial one in the earlier years of it’s beginnings. Also at this time the main interest of researchers and scientists was to research and produce analgesics.

1966: Blumberg released a full paper on the qualities and uses of Naloxone which was later to become the centre of the field of endogenous opioids where Naloxone became one of the key components and was heavily relied on for its qualities. Throughout the early 1970’s both Fishman and Blumberg’s research and related work on and around Naloxone focused primarily on the clinical applications of the medicine as did most of those involved in the researching and practice of medical compounds.

1971: The FDA (Food and Drug Administration) in the USA licenced Naloxone stating that access to naloxone would require a prescription from an authorized health care provider. Some physicians were reluctant to prescribe the medication to suspected opioid-misusing patients. At least one legal analysis, by Burris et al, concluded that health care providers ”do not act outside state and federal regulations in prescribing naloxone to their at-risk patients and the risks of liability are low and commensurate with those generally associated with providing health care” The Good Samaritan laws in a number of states in America provides legal protection to physicians for prescribing the medication and also to those in the community carrying and administering the medication.

1973: A patent was issued in 1973 for an analgesic combination which comprised of an orally inactive dose of naloxone and an orally active strong analgesic. Naloxone was also found to reduce obesity in further studies on animals, this research is still ongoing to date. Towards the end of the 1970’s the importance of Naloxone as one of the most relevant medicinal breakthroughs in the research of endogenous opioids and further qualities within the medical world was beginning to gain recognition.

1982: Jack Fishman and Harold Blumberg were awarded the John Scott award for their synthesis and investigations on Naloxone.  The John Scott award is awarded to those most deserving for inventions that contribute to the ”comfort, welfare and happiness of mankind” John Scott was a pharmacist in Edinburgh, Scotland whose interest were in awarding ”ingenious men or women who make useful inventions” Other individuals who were awarded the John Scott Award included Marie Curie, Thomas Edison and the Wright Brothers.

1996: Professor John Strang made a proposal for Take Home Naloxone via report in the British Medical Journal (BMJ). This report stated the case for community Naloxone and went on to say.…

Home based supplies of naloxone would save lives.

Non-fatal overdose is an occupational risk of heroin misuse1 and fatal overdose is a common cause of premature death in heroin users.2 3 4 One of the major contributors to a fatal outcome is the inadequacy of heroin users’ responses to the overdoses of their peers. They may delay calling an ambulance for fear of the police arriving, and their efforts to revive comatose users are often ineffective. The distribution of naloxone to opiate users was first mooted in 19925 as an intervention that would be life saving in such situations.6 With a rising toll of deaths from heroin overdose it is time to take the suggestion seriously.

  This study also concluded that at least 80% of those in an overdose situations were witnessed by peers. This posed the question as to why so many fatalities were found alone and on further investigation it revealed that there was even more reason to further investigate and promote the need for community provision of naloxone distribution by peers and significant others .

1996 also saw pilot programs started in 15 American states and the district of Columbia. All results from these pilots were positive. Chicago Recovery Alliance became one of the first providers of Naloxone to peers and the first Take Home Naloxone program went live in the USA. In the following link Dan Bigg talks about this groundbreaking achievment…. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/naloxone-program-case-studies/chicago-recovery-alliance/

1998: Other areas that followed suit with initiating THN programs were Bologna, Padua and Turin in Italy and Jersey in the UK pioneering peer led take home Naloxone programs.

1999: Australian studies found that Naloxone provision was ”not only feasible but acceptable in the community with regards to the target population” The report eventually materialised in December of 2011 in the form of the ACT program…. http://www.atoda.org.au/policy/naloxone/

2000: The ACMD (Advisory Council of Misuse of Drugs) released a report entitled ”Reducing drug related deaths” This document recommended further exploration of the efficacy of Take Home Naloxone programs. This report stated that ”Attempts are needed actively to involve drug users themselves in responsibility for reducing drug-related deaths” The full report can be read here… http://www.drugsandalcohol.ie/5017/1/Home_Office_Reducing_drug_related_deaths_2000.pdf

This year also saw the release of a report from Australia stating that based on the earlier studies in 1999 the ‘feasibility’ of the THN program had met with substantial legal challenges.

2001: San Fransisco and New Mexico began ‘distributing naloxone hydrochloride to heroin users as a simple, inexpensive measure with the potential to reduce mortality from heroin overdose’ There were again legal aspects that caused restrictive supply due to the ‘uncertainty about its legality or the risk of malpractice suits’ Naloxone was seen as a politically charged topic. This fear and uncertainty slowed the process of further provision in other states and around the world. Despite the evidence already being insurmountable as to it’s effectiveness as a life saving medication…. http://www.fixpunkt-berlin.de/fileadmin/user_upload/PDF/Notfall/Artikel_burris_naloxone.pdf.

This year also saw the the beginning of a Take Home Naloxone program in the UK in South London. The original Chicago program became the trusted format for Take Home Naloxone programs globally.

2002: This year saw the first ever reports of lives saved through the community provision of Naloxone and was reported in the BMJ (British Medical Journal) by Chicago Recovery Alliance. This report stated that there had been 52 successful reversals to date since the inception of their take home Naloxone program…. http://www.bmj.com/rapid-response/2011/10/28/chicago-experience-take-away-naloxone

2003: A report was released which has been cited in numerous other publications stating that the high risk period following release from prison, more prominently among females needed to be addressed and looked at with regards to naloxone being provided to those leaving the prison population. The first two weeks following release from this environment are particularly high risk with regards to overdose being prevalent for obvious reasons, tolerance, etc. Further studies took the research into the 12 week period where the findings can be found here…. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955973/#b22

Also in 2003 there was a further report aimed at the community use of naloxone. This report was aimed at highlighting the reports of risk of overdose following administration of naloxone. The results of this study, which included 998 case studies, showed that after a period of 12 hours following naloxone being given in the field, and further support being refused there were no listed fatalities. This challenged the commonly used reasoning against community provision of the risk of overdose after naloxone wears off, 20 minutes later. 12 hours allowed for this short acting period, and also for the fact that after being administered naloxone the withdrawals would require redosing of opioid for relief. This report was reviewed by dates, times, age, sex, location, and ethnicity when available.

2005: The first report on THN programs was released in USA showing that there was unsurmountable evidence to support the program. The pilot study was carried out in 2001 and released here in 2005. http://www.ncbi.nlm.nih.gov/pubmed/15872192

This year also saw the UK law changed to permit the the use of naloxone by any member of the general public for the purpose of saving a life. http://www.naloxone.org.uk/index.php/lawpolicy/law/uklaw1

2007: The 2007 UK Clinical Guidelines supported the use of naloxone as a means of preventing fatal overdoses and reducing drug related fatalities.

This year also saw the NTA (National Treatment Agency) initiate training for families, carers and users following a survey that identified the need for take home programs to reduce the fatalities.

2008: Both the USA and the UK released an impact paper showing the effectiveness of training in overdose awareness and Naoxone administration to families, carers and users. This showed the potential positive impact that Naloxone in the community could and indeed was having.  http://www.biomedcentral.com/content/pdf/1477-7517-4-3.pdf?origin=publication_detail The release of this report highlighted a number of potential barriers including. Political climate and prescription laws.

The MRC (Medical Research Council) approved the N-Alive program. This was a randomised controlled trial aimed at research within the prison community. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx fronted up by Professor John Strang, (This is still ongoing, The randomised trial period ended in December 2014 and the follow up of those involved in the trial will commence in March, 2015) Results from a similar study can be found back in 2003, follow the link to NCBI (National Centre for Biotechnology Information)

2009: In 2009 the NTA (National Treatment Agency) funded 16 pilot trials all over England. These pilots set out to train the carers and significant others in all matters relating to Naloxone. Information on the product, basic life support and overdose awareness, including administration. Overall the project was found to promote the reduction of fatalities induced by opioid related overdose. There was difficulty and resistance reported in finding individuals to train but 495 carers were trained and evidence relating to the training showed that, in reality, the training would be better served in a peer to peer environment.

This was also the year that Wales launched it’s first pilot program as well…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en The full data and evaluation report around the 34 areas where this spanned out to can be found here in a report stored on the Welsh Harm Reduction database…. http://www.wales.nhs.uk/sites3/documents/457/Naloxone%20report%202013%20FINAL.pdf 2130 kits were issued between 2009 and 2013 the full statistical data has been reproduced in the report.  

2010: Scotland launched the National Naloxone program. This progress started in 1996 when the BMJ (British Medical Journal) proposal by Prof John Strang was released, see earlier comments from 1996. This move followed a number of pilot schemes and the end result was that pre-filled syringes of naloxone are now provided to everyone considered at risk of overdose, this is after comprehensive training is given. The lord advocate endorsed the program and the National program is fully funded by the Scottish government. The Lord Advocate guidelines can be found here…. http://sdf.org.uk/sdf/files/LordAdvocatesGuidelines.pdf There are numerous reports from Scotland around the provision of Naloxone and the success of the National program. NHS Highlands also now provide nasal naloxone as well as the prefilled syringe.

2011: The Assembly Government in Wales announced their plans to make take-home naloxone available alongside training. This decision followed the evaluation report that was submitted which is here…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en

2012: The CDC (Centre for Disease Control and Prevention) and the FDA (Food and Drug Administration) hosted a workshop that hosted a large number of presentations including topics such as populations at risk, public health interventions, criminal overview, ethical and regulatory considerations, expanded considerations, and lots more. The full details and presentations an be found here…. http://www.fda.gov/Drugs/NewsEvents/ucm277119.htm

The UNDOC resolution 55/7 clearly recognised that the high number of opioid related deaths demanded immediate assessment and action, this statement was based on the world drug report 2011, https://www.unodc.org/unodc/en/data-and-analysis/WDR-2011.html This report clearly stated that opioid overdose treatment, ”including the provision of opioid receptor antagonists such as naloxone, is part of a comprehensive approach to services for drug users and can reverse the effects of opioids and prevent mortality” This report also recognised that there were a number of public health inequalities that also contributed to addictions and overdose including, polyuse, mental health, etc. The full resolution can be read here…. https://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-7.pdf

The N-ALive (NAloxone InVEstigation) trial went live. A full understanding of the content of this investigation and the different stages which include the pilot trial and then the full trial, the reasons the trial was randomised and how the final results will be used can be found here…. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx As stated earlier the randomised period of this investigation finished in December 2014 and the follow up to this will commence in March 2015.

The ACMD also released a report recommending that the department of health make naloxone more widely available and also that the prescription only status be reviewed. The full report from the ACMD ”Consideration of Naloxone” went as follows…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/119120/consideration-of-naloxone.pdf

Over in the USA in 2012 the AMA (American Medical Association) adopted a policy to endorse THN, The endorsement read….

Promoting Prevention of Fatal Opioid Overdose

Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. Naloxone is a drug that can be used to reverse the effects of opioid overdose. The AMA today adopted policy to support further implementation of community-based programs that offer naloxone and other opioid overdose prevention services. The policy also encourages education of health care workers and opioid users about the use of naloxone in preventing opioid overdose fatalities. “Fatalities caused by opioid overdose can devastate families and communities, and we must do more to prevent these deaths,” said Dr. Harris. “Educating both physicians and patients about the availability of naloxone and supporting the accessibility of this lifesaving drug will help to prevent unnecessary deaths”

Full list of other indorsements can be found here for general interest…. http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-new-policies.page

2013: The AMA (Australian Medical Association) closely followed the lead of it’s American counterparts and also endorsed THN programs. http://www.anex.org.au/ama-and-its-naloxone-policy-position/

Coffin et al released a paper showing the cost effectiveness of naloxone programs…. http://www.ncbi.nlm.nih.gov/pubmed/23277895 this report was cited in a further report on naloxoneinfo.org…. http://naloxoneinfo.org/sites/default/files/Cost%20Effectiveness%20Summary_EN.pdf

A further report in 2013 looking at yet another myth that states that naloxone promotes increased opioid use as released…. http://www.biomedcentral.com/1471-2458/14/297

Also in this year Victoria department of health fully funded naloxone programs to coincide with already existing overdose prevention programs…. http://hrvic.org.au/naloxone-position-statement/

Martindale Pharmaceutical company releases the only licenced product for community use in the UK…. http://www.prnewswire.co.uk/news-releases/martindale-pharma-launches-prenoxad-injection-for-the-emergency-treatment-of-opioid-overdose-205920351.html

2014: The department of health chairperson Jane Ellison sent a letter the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf This letter laid out a clear and direct plan of action which advocated for training and any other preparations to be supported prior to the date given for roll out and was adirect relut of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

N.A.G. (National Action Group) England was founded to address resistance and cut through the red tape with regards to the THN program nationally. The group is made up of representatives from IDHDP, IDPC, NNEF, DRUGSCOPE, PHE, MORPH, SUSSED, SCUFF, HIT, and also a few other independant representatives. To compliment this Action group a forum was also set up on social media which has members from all areas covered by Health and wellbeing boards nationally and information sharing promotes action in all respective areas.

The World Heath Organisation released new guidelines endorsing THN… http://www.who.int/features/2014/naloxone/en/

HOPEFULLY THIS WILL HELP ANYONE OUT THERE CAMPAIGNING FOR TAKE HOME NALOXONE PROGRAMS AND AID IN RESEARCH FOR INFORMATION REGARDING KEY ELEMENTS OF THE INCEPTION OF NALOXONE SINCE ITS BIRTH. AND TO END THIS IN RESPECT OF THE MAN WHO GAVE US THE PRODUCT JACK FISHMAN WHO SADLY DIED IN 2013, WE THANK YOU FROM THE BOTTOM OF OUR HEARTS FOR THE LIVES YOU HAVE SAVED BY GIVING US THIS AMAZING PRODUCT. WHAT A LEGACY YOU LEFT US.

http://www.nytimes.com/2013/12/15/business/jack-fishman-who-helped-develop-a-drug-to-treat-overdoses-dies-at-83.html?_r=0

THE PARADOX OF DRUG POLICY REFORM.

  There have been many individuals, organisations, NGO’s, etc,  that have stood up, and indeed still do, for the civil and human rights of people who use drugs (PUD’s) many have made significant and positive change happen, many still fight to reduce the risks and harms to PUD’s under dangerous and destructive policy and procedure. Raising awareness of the stigmatising and discriminatory practices that serve no purpose other than to demonise an already vilified and vulnerable group.

   In some countries illegal importing, exporting, sale, or possession of drugs constitute capital offences that can result in the death penalty. 33 countries and territories that retain death penalty for drug offences, including 13 in which the sentence is mandatory. These countries include, Afghanistan. Bangladesh, Brunei, China, Egypt, India, Indonesia, Iran, Malaysia, Morocco, Pakistan. Saudi Arabia, Thailand. United Arab Emirates, Syria, Vietnam. Even in the USA the United States Supreme Court in Kennedy v. Louisiana struck down capital punishment for crimes that do not result in the death of a victim, but left open the possibility for “offenses against the State” – including crimes such as “drug kingpin activity” including very large quantities or mixtures of heroin, cocaine, ecgonine, phencyclidine (PCP), lysergic acid diethylamide (LSD), marijuana, or methamphetamine.

 In China and southeast Asia, PUD’s are detained compulsorily in government run centres tht declare they are there to enhance “treatment” or “rehabilitation”. There is no element of treatment or rehabilitation in these facilities and PUD’s are held without the due process protections and less rights than those locked in prisons, no access to legal repressentation, no right to appeal, and no judicial oversight of detention. Some are detained for years without ever receiving any form of evidence-based drug dependency treatment,  in isolation cells, forced to work, and abused by those who should be there to provide care and support. Some forms of torture that are used in these centres incude electrical shocks and many in the care of these centres are sexually abused. There is no process to determine drug dependence either cinical or otherwise.

  These centres also lock up the homeless, street children, and those living with mental illnesses. None of those who are held in these centres are given any kind of health care even in it’s most forms. There may be contact with health proffesionals but this is usually in the form of mandatory HIV testing, forced blood donations, scientific research, (mostly involuntarily) and a number of other inhumane practices.

  Investigations into issues such as risk factors for HIV infection among injecting drug users (IDU), HIV prevalence, effectiveness of behavioural HIV/STI prevention interventions, and the efficacy of particular modalities of drug treatment have repeatedly shown that these practices are inhumane and unethical and yet these practices still continue. The practices are often described, by those who run the facilities as, training centres focusing on “physical exercise, education, information, and job training for PUD’s in the city” What is actually meant by this is that those in these centres are forced to work for at least 8 hours a day as labour therapy, they are forced to attend educational classes but denied any access to standard or recognised educational equipment, the educational content aimed at promoting the needs of the area they live in and not based on educational values or the needs of those being educated. Very basically, PUD’s and other vulnerable individuals who are held in these centres are treated worse than animals and isolated from the outside world. Completely with no civil of human rights and this treatment is indefinite spanning out years in most cases with a high number of those incarcerated dying under the conditions they are forced to live in. The surrounding communities support these ethics because it is easier to use detainees than it is to use someone who lives a ‘normal’ life when looking for employees or similar needs and it is also a lot cheaper therefore research and investigations into the running of these facilities is hard to achieve and access to the majority of them is impossible.

This and a number of other reasons make drug policy reform campaigning a matter of civil disobedience in areas where this kind of treatment is normal practice, and even in some more advanced countries. Campaigning for better programs and more humane practice in most areas is seen as controversial and can at times be dangerous to those who openly advocate for positive reform. This civil disobedience is also related to facilities such as drug consumption rooms, promotion of life saving medications, decriminalisation, equal rights for PUD’s and handing out clean equipment. Most of these actions have been carried out by passionate and dedicated individuals whose principles came before the risks they took when advocating or initiating programs that provided safer practices and safer environments for PUD”s.

It’s ironic really that in order to reduce the risks and harms of those who use substances you must put yourself at risk of harm in some cases, but for the greater good. It’s also ironic that despite this being seen as a form of civil disobedience, it is also based on insurmountable evidence that suggests, in fact proves,  that the practice advocated for is the most effective, positive and productive way to address the issues in most communities and yet many communities stance is quite the opposite in content.

There is however a paradox that presents itself when looking at policy reform. From a political angle those in power must find a solution that reduces the harms to the majority of their constituents. And this can mean economical, financial, emotional, mental, physical, etc. Now by social design that has been manufactured for years, vulnerable groups within communities have been portrayed as being less productive and at times damaging to communities with regards to crime statistics, cost on health services and such, unemployment statistics, homelessness, etc. So when looking at policy reform in any arena there is a conflict of interests when making the decisions that would be of maximum benefit. and when looking at who would be more satisfied with the outcomes of such policies there is more reason to look at the outcomes in potential for votes rather than ethical, public health outcomes.

The need to look at policy objectively, looking at socio-cultural needs, societal influence, public health issues, cost effeectiveness, etc is long overdue but is also a problem that needs to be addressed in stages with both sides of the argument being critically assessed and dissected and this might also mean that there will be recognition on both sides that some draconian policies and procedures have caused more damage than good and this might be where the delay originates from with regards to looking at the overall cost of some of these policies. Based on the evidence presented at the beginning of this article there have been a number of human rights ignored with regards to policy and agenda that have resulted in the deaths of high numbers of PUD’s and members of other vulnerable groups within communities and this would have to be held accountable if realistically taking effective and evidence based policy into account.

There lies the paradox of those who are in a position to make the changes, but even the most ignorant of those in power must know that change must occur, and to delay it any longer simply gives more space to add to the long list of fatalities and other heinous crimes that, in content, by far excede and outnumber any other casualties of war and war crimes in the course of history. The war on drugs, a war on people, needs to end and it needs to end now.

NALOXONE: THE ROLE OF USER ACTIVISM.

“It has been shown throughout history that if 3.5% of the general public stand up against social injustice and move for positive change then it will indeed happen….the last hundred years provide the evidence, sadly this is not the age for evidence based policy and therefore we need to stand taller and shout louder, but change will indeed come”

The role of user activism is clear and precise in it’s aim and objectives. Primarily the role is to raise awareness of the everyday issues experienced by those who are living on the frontline and experiencing the real effects of policies and procedures that affect them. Providing evidence base to counteract idealogical policies that neither support nor reflect the true needs of the user community.

Activists, both individually and in groups, have successfully initiated change in a number of area’s where it was sorely needed and the effects have been instrumental in supporting whole communities within communities to live positive and productive lives in the face of adversity, ignorance and discrimination. Exposing elements of fear of that which is not understood, misrepresentation, misunderstanding, scapegoating, etc, in media, politics and the medical industry to mention few.

As long term global economic trends sway towards a reduction in profit rates and the competition soars to an all time high, the pressures these put on governments, corporations and organisations, have produced a period in which fundamental issues of political and economic structure are at stake an the response is a divide-and-rule political arena to promote stability. This in turn promotes the negative outlook on specific groups of individuals by the term affectionately known as ‘the politics of scapegoating’ People who use substances are extremely vulnerable to this particular form of political escapism. This can, and does, divide communities in ways that weaken opposition to socioeconomic changes and policies and strengthens punitive and individualist ideologies. This then has the negative effect of allowing policies that maintain or increase drug-related harm to continue seeming less an ‘error’ than perhaps a rational way to defend the interests of the powerful.

This therefore, in my opinion, shows that there is indeed a desperate need to develop a political understanding between the policy makers and activist to expand the concept of ‘politics’ and take it beyond specific interest-group politics. Consideration of when and how it might be best to work with groups of individuals for social change from the bottom up, rather than the opposite way round. This political trickery is not only evident in the user community as the current display of negligence with regards to people’s hopes, fears, housing, employment, economic and financial security, becomes common practice in all aspects of the political arena. This may seem like a negative outlook, however, it also can provide the opportunity for collective action against the social-structural sources of the problems.

The term harm reduction has, of late, almost become a taboo subject that despite being firmly grounded in evidence based policy and procedure. In the current climate the harm reduction community is facing disinvestment and the health and safety of people who use substances, which should be of paramount importance, is not being seen as the priority that it should. This is having a detrimental effect on huge numbers of individuals within our communities. The harm reduction ethos is simple…

* To reduce the harms and risks to whole communities by raising the awareness of public health issues faced by people who use substances, looking at productive and positive cost effective solutions to the harms and risks to whole communities.

* To provide a platform for mutual aid support based on effective programs and past experience that has proven to promote the health and safety of all involved. A place where identity and a like-minded train of thought promotes unity and progress in the interests of all involved.

* To support others with similar issues or a vested interest in the care and support of those within the community by consulting and advocating at all levels on a global scale to increase the understanding of the risks and harms that may come with substance use on both individuals and whole communities.

The term harm reduction is ever evolving as the numbers of those involved grow bringing a different perspective and understanding to the platform. As trends and substance use changes, so does the concept and reach of its community members, but it’s core value is to always promote the health and safety of every member of the community by focusing on the individual’s wellbeing based on the above three main objectives.

User activism can take on many forms and ‘activism’ can be something as simple as writing a letter. Anything that ‘consists of efforts to promote, impede, or direct social, political, economic, or environmental change, or stasis‘ can be collated under the umbrella of activism.

The role of user activism in Naloxone provision is to raise awareness around the issues that are current in our communities with regards to drug related deaths etc. With the recent 32% rise in drug related deaths there is a dire need to provide evidence to support any kind of program that promotes reduction. It is clear that current agenda and policy does not effectively reduce the harms or risks that people who use substances face on a daily basis and based on my earlier comment around disinvestment this looks set to get even worse unless something is done about it and a return to evidence based policy and procedure can be reinstated and funded properly to secure the health and safety of the community it represents. As the evidence adds up to show that naloxone works, and the resistance loses its footing, the pressure must be applied to keep the momentum going. Activists all over the world are coming together and providing the evidence needed to support this program. With the current statistical data in UK showing that, on average, 3 individuals die every day of opioid overdose, the need for this program speaks for itself. Those living with the loss isn’t just restricted to the user community, this effects every single member of the community, emotionally, physically, mentally, financially, etc.

This can be approached by a number of ways with regards to activism and actively promoting naloxone in the community. There are a number of websites and groups that have all the information needed around naloxone, the product, the uses, the evidence, the statistics and the law to start a campaign or indeed to join an already existing one. There are also a number of groups and organisations that offer free training. Which once it has been given can be cascaded wherever needed. Lobbying local politicians, and other similar members of the community is another angle that can be taken. Petitions either hand collected or electronically collated can be used to approach health and wellbeing boards, clinical commissioning groups, service providers and other similar groups or organisations. Mutual aid groups and collectives can be set up and have proven to be successful in the form of action groups and harm reduction cafe’s where the main topic has been, but not exclusively, drug related deaths and solutions to reduce the effects this has on communities.

Making yourself available for any consultation in any arena that evolves around the topic and joining the dots in your community. As members of an already vilified and demonised community it is in the interests of everyone who has ever suffered at the hands of ideology, ignorance, discrimination and all it’s trimmings to join together and make sure that as a voice we are heard.

The substances that can induce overdose are not restricted to illicit use, in fact, the majority opioid substances that can be evident in overdose situations are prescribed medications. However due to the barriers that have risen through discrimination and socio-political design it is the illicit use that gets highlighted as the main concern and due to the afore mentioned reasons and negative media coverage the design effect is resulting in disinvestment with fatal outcomes as those who use drugs become the scapegoats of a society that has become part of the problem rather than part of the solution for many.

“HUMAN RIGHT NUMBER ONE: EVERY HUMAN BEING HAS THE RIGHT TO LIVE….”

NALOXONE AND NON FATAL OVERDOSE.

There was a recent research paper released in DDN Magazine that focused on non fatal overdoses which was carried out by a group of academics in the University of South Wales. Which can be found here….

New research on non-fatal overdoses

 Following on from this I decided to do a little non-academic research for myself to look primarily at the possible effects of a non fatal overdose on the individual, Firstly from a physical / medical perspective. In the UNODC discussion paper released in 2013, “Opioid overdose: preventing and reducing opioid overdose mortality” (http://www.unodc.org/docs/treatment/overdose.pdf) it states that….

“Non-fatal overdose can significantly contribute to morbidity, including cerebral hypoxia, pulmonary oedema, pneumonia and cardiac arrhythmia, that may result in prolonged hospitalizations and brain damage”

 Asphyxia and hypoxia lead to a redistribution of cerebral blood flow. This can result in a 25% reduction in oxygen saturation (in lambs, no human research found). Research has found that naloxone can quite significantly reverse this redistribution, this has a massive effect on the oxygen in the brain and therefore, as an opioid-mediated homeostatic mechanism, in hypoxia promotes preferential perfusion of the vital structures of the brain. During severe prolonged asphyxia there was an increase of cerebral blood flow which was more prominent in new born lambs with hypoxia. As opioids play a role in the regulation of cerebral circulation the potential in a non fatal overdose for cerebral redistribution stemmed by naloxone was proven to be significant in redistributing and therefore reducing the the hypertension, increasing the oxygen levels in the brain, reducing arterial blood pressure and reducing the risk of any longer lasting effects. Full recovery and reversal possible if naloxone is administered as soon as is possible after signs appear. For a clear understanding of the signs, symptoms of hypoxia please follow the hyper link below….

http://www.webmd.com/asthma/guide/hypoxia-hypoxemia

 Pulmonary Oedema is fluid accumulation in the air spaces and the lungs which leads to respiratory failure. There are a number of reports published around possible adverse effects of naloxone and most of these include pulmonary oedema, however, most were also highlighted in the presence of an underlying cardiorespiratory disease which has made it impossible to differentiate between what the underlying cause of the pulmonary oedema. “Many episodes of pulmonary oedema secondary to opioid toxicity have been published since it was first noted by William Osler in the 1880s and it has been suggested that naloxone simply reveals the opioid induced pulmonary oedema that had been masked by the already existing respiratory depression”

  Seizures and arrhythmias have also been recorded in pulmonary oedema but ths is more likely to be caused by hypoxia. Which in previous paragraph is reversed by naloxone. Further research around this has shown that hyperventilating patients prior to administration of naloxone could reduce the risk of sympathetic mediated adverse effects. All studies based on this and the findings from those studies were conducted in early trial periods where the main reason for research was to find out what dose of naloxone would be most effective in treatment of non fatal overdose situations to prevent them from becoming fatal. Out of 185 papers on the subject matter, studies were  only deemed to be relevant if they compared doses and routes of administration of naloxone or if they produced evidence about rates and timing of complications. This comment is a summarised account of those that were accepted. For signs and symptoms of pulmonary oedema please follow the hyper link below….

http://en.wikipedia.org/wiki/Pulmonary_edema

  Pneumonia Opioid analgesia impairs gastrointestinal motility. Enteral administration of naloxone allows selective blocking of intestinal opioid receptors caused by extensive presystemic metabolism. Therefore, the effect of enteral naloxone on the amount of gastric tube reflux, the frequency of pneumonia, Results on studies around this particular subject provided evidence that the administration of enteral opioid antagonists in ventilated patients with opioid analgesia might be a simple—and possibly preventive—treatment of increased gastric tube reflux and reduces frequency of pneumonia. This study was carried out on 84 fentanyl treated human patients and was a prospective, randomised, double blind study with 43% given a placebo. For more information on pneumonia please follow hyper link below…..

http://www.patient.co.uk/health/pneumonia-leaflet

 Cardiac arrhythmia: Administration of naloxone before a coronary artery occlusion (http://www.netdoctor.co.uk/ate/heartandblood/203287.html) reduced the incidence and severity of cardiac arrhythmias during coronary occlusion for a period of 20 minutes and reperfusion for a period of 2 hours. It also reduced the mortality. Naloxone totally wiped out the appearance of the life threatening ventricular fibrillation (http://www.patient.co.uk/doctor/ventricular-fibrillation) and ventricular tachycardia (http://www.patient.co.uk/doctor/ventricular-tachycardias) This study again was carried out on dogs, and there is no searchable research on humans. The results suggest a possible involvement of endogenous opioid peptides in arrhythmogenesis (http://medical-dictionary.thefreedictionary.com/arrhythmogenic) during coronary occlusion and reperfusion in the dog.

 Therefore the conclusion of my research is that…again…naloxone is effective in reducing the risks associated with non fatal overdose as well as reducing the risks of the overdose situation becoming fatal. Not bad for a non academic, done in the space of three hours and didn’t cost a penny.

SOMEONES DAUGHTER, SOMEONES SON.

(The title of this blog is from a poem written by a very good friend of mine who’s words resonate with me a thousands of others globally who are joining together in advocacy for the provision of naloxone in their respective communities which can be read the end of this article)

As the fatalities rise, on a global scale , and opioid related deaths tear families and whole communities apart, there is momentum growing in the debate to get naloxone out there into the hands of everyone who would be prepared to carry this lifesaving kit, PUD’s, friends of PUD’s, family members, concerned others, street pastors, dealers, community groups who may find themselves faced with an overdose situation, in fact, absolutely anyone who had a desire to carry a kit.

With Scotland (Scotland should be releasing figures following an audit internally in the prison system over the next few months to add to the evidence that this program has successfully reduced the DRD stats in those leaving incarcertion. This will directly show that although N=ALive pilot, which is still ongoing, had the right idea, it could have been done for lot cheaper and a lot quicker. And guess what it will also show that ‪#‎prenoxad‬ works, surprised?)and Wales (An Evaluation of the Take Home Naloxone Demonstration Project can be found here) leading the way, in the UK, with national programs and Ireland not far behind, (Ana Liffey Drug Project are coming through as a glowing example of best practice when it comes to saving lives in Dublin’s fair city. Statistics in Ireland have shown that almost 4,000 PUD’s exchanged 24,000 needles at drop-in centres across Ireland last year. Merchants Quay Ireland have recently shown the extent of the country’s drug problem as demand for its services soared. These statistics are shown to be closely related to poverty and hardship when looking at demographics of need in relation to specific areas. Statistical data also showed that 75% of those accessing structured service were poly drug users, with a combination of heroin, benzodiazepines and alcohol most commonly used substances, and also the most common in related overdose situations. Design has also shown that there is a current trend which is reaching out to regional areas outside of the city and the need for services outside the city is becoming increasingly evident. There are estimated 20,000 Heroin addicts in Ireland, with 10,000 men and women on Methadone programs. With this evidence coming out that clearly shows a desperate need for the expansion of services to support the growing need and funding cuts hitting where support is most needed this is a potential time bomb waiting to explode in the face of the communities where poverty and addiction are rising) it would seem that for some unknown reason England is dragging her heels with a devastating pace that is leaving its marked evidenced in the 32% rise in drug related fatalities last year. Recently, July, there was a glimmer of hope in the form of a letter from the Department of Health to Les Iverson, chair of the ,Advisory Council on the Misuse of Drugs (who first endorsed take home naloxone in 2009), stating that following a survey by the MHRA there had been a resounding call for a national take home naloxone program. Following this there was a date set for a National Take Home Naloxone (THN) Program which, and wait for it, is, October 2015? Now although this is a shimmering silver lining to those among us who have been advocating for this for quite some time now, it is still not acceptable.

As stated, in 2013 there was a huge rise in opioid related deaths, and this is just the ones that were recorded as that.

Although we do not have 2014 statistics through, my fear is that they could well show another rise, and again in 2015. I digress and hopefully misplace my fear but the truth and evidence cannot be denied here, any death that is preventable is unacceptable. So I ask you what could possibly be the hold up with getting this out there. So far there has been no solid evidence to support a delay. Well none that could possibly warrant such Negligence towards the cost of a human life….is there?

Best practice and substantial evidence to support can be found in Scotland where the Lord advocate, the chief legal officer of the Scottish Government saw fit to sign off a national program which is showing us, over time, that there is a need for such a program wherever there is a prevalence of opioid related deaths. This also showed us that, time, is something that we do not have when it comes to getting naloxone out in the community.

“In many countries, overdose is the leading preventable cause of death among people experiencing problems with drugs. Overdose prevention measures delivered in community settings are incredibly effective; the introduction and scaling up of such measures would save lives of thousands of people” (Eurasian Harm Reduction Network (EHRN))

http://www.harm-reduction.org/library/guide-developing-and-implementing-overdose-prevention-programs-eastern-europe-and-central

Naloxone has been around since the early 60’s and has, to date, given us no reason to doubt it’s efficacy. There have been no fatalities attributed to it’s use in whatever arena it has been used, there is no diversionary value, it has no long lasting side effects that overshadow it’s benefits and yet there is still a debate as to whether it should be available in the community for the purpose of saving lives. Some might say that there is an underlying issue here as to the lives that are being saved and would argue that there is more risk associated with Epinephrine autoinjector (EpiPen), and yet there are no concerns with that and there was not the same debate or delay when it was being passed through as an injectable medication.

Naloxone has the potential to help services reach out to those who may be hard to reach in the community. People who use Drugs are extremely conscious of Criminalization, Stigma and Discrimination whenever they access any kind of service, so knowing that naloxone is safe and legal could put people at ease. Naloxone programs can provide a safe starting point to engage in more open conversations about their health and choices, like seeking out and using clean needles, regardless of whether that is legal or encouraged” Not to mention staying alive in order to promote chances of making a ‘full’ recovery. There are a number of those out there who have been on the receiving end of naloxone who have stated that that second chance was indeed a turning point in their journey.

As it stands now there is an overwhelming outcry not only from Drug User Organisations, such as International Network of People Who Use Drugs (INPUD), National Users Network, and recovering community groups and structured services such as UK Recovery Walk charity, RISE Manchester, COPE Lincoln,morph – Southampton, NHS Highland, Scottish Drugs Forum, Release, Support. Don’t Punish, International Drug Policy Consortium, IDHDP, SUSSED , Bedford, Harm Reduction Coalition, SCUFF, Nottingham, World Health Organization, Criminal Justice Drugs Team, Leicester, Martindale Pharma, Department of Health (The list is endless and I am sorry if I have missed anyone out) but from Significant others (although following this hyper link it shows that in the scientific use of significant other there is still some work to be done), mothers, fathers, sons and daughters, and a number of professionals with regards to this becoming more widely available to those who may be witness to an overdose situation. For a number of reasons when faced with an overdose situation and calling the emergency services there is again fear around the already mentioned criminalization and stigma and therefore sometimes the emergency service are not called. Also the response time if there is any mention of substance use seems to take longer sometimes when thy are called. I’m not taking away the importance of calling the emergency services it makes perfect sense to me for those at the scene as and when it happens to be able to administer naloxone and potentially save a life alongside the services being called.

There are 150 Health and wellbeing boards (follow hyper link to find contact details for your local board) in England. At present, one third of them are actively rolling out programs, one third are in debate and discussion and the final third are still resistant yet unresponsive when questioned around this. So what barriers have they given us so far….

1: There is a risk due to it being an injectable medicines? (follow hyper link for guidance on safe use of injectable medicines) So is the epipen and insulin yet there was no problem when this was being put out there in order to save lives. (In fact the only recorded risk that I am aware of was an American police officer using it to ‘kill’ someones buzz?) No other recorded risk since the early 60’s when it was first marketed. There is no diversionary value….nothing. It does have the potential to cause problems with liver if liver is already compromised, as do most medications, but this is treatable whereas death is final.

2: It’s not licensed? Neither are a number of medications but they are still put out there around an off license route. And….there is a licensed product specifically for community use in the form of Prenoxad Injection

3: It’s not cost effective? (I know, ridiculous but a barrier none the less!!!) Well lets look at that, 20,000 for a basic overdose fatality when you look at the services cost, the coroner inquiry, the hospital bed, the machinery used, etc, not to mention the cost on the surrounding family members, emotionally, mentally and financially,  and community this cant be into monetary value! 400 estimated cost here naloxone was used successfully. In Bedfordshire alone during the last year there were 40 kits handed out and in the last three months 9 reversals, that’s, in monetary value, 720 cost of kits for all 40. lets say services were called on all situations, thats an average count, based on the estimated successful situation cost from Wales, of, 3600 which makes a grand total of under 5000. Savings on community budget in 9 highlighted cases? 175000!!!!! So in my humble opinion then damn straight it’s cost effective and there are still 9 individuals walking around breathing. This information cannot be used officially sadly due again to the current state of play, but there are a number of areas that are coming up with the same math and adding to the evidence to support community provision of naloxone, yet I am still waiting to here the evidence against!!!! (Cannot cover all evidence in all areas at present and have used my home town to demonstrate how a small group of user activist have managed to conduct a small pilot with the potential to save quite a significant amount of funding on the emergency services and in general on the community)

And to show the overview of cost effectiveness in rolling out naloxone programs….

http://www.medscape.com/viewarticle/777455?src=stfb

4: Political agenda? Lets take it back to the political agenda in the shape of the 2010 strategic agenda. It actually fits into that quite nicely into the full recovery setting by keeping people alive and giving them that second chance at recovering. And reducing drug related fatalities. But doesn’t fit in with the general election next year? Possibly why there is an October 2015 date?

So given this very basic but clear little picture what is missing? Other than another 32% of the opioid user community and some common sense? Yep, the evidence and reasoning to support the argument against..why? Because there is none?

So lets backtrack a little bit and look at the stages and times when naloxone has been highlighted and not adhered to in a number of areas.

One of the key directional questions in the 2011 JSNA Support pack for commissioners in section three on the first page of guidance in setting up a recovery oriented integrated service it clearly advocates for naloxone when asking the clear and direct question…..

•Is effective overdose awareness training and information
available? Where appropriate, is naloxone provided for service
users and their family/carers?

All drug users SHOULD have prompt access to:

•Interventions to prevent drug-related deaths and blood-borne
viruses.

•A range of early interventions, treatment and recovery support
appropriate to their needs, at all stages of their recovery journey.

(Sadly this need is not being fully met with regards to naloxone being the ideal intervention along with other recognised and structured interventions)

Effective integrated commissioning of services that achieve
positive outcomes for individuals, families and communities by:

•Effective partnership working between local authorities, health
(including mental health) and social care, and criminal justice.

(And effective service user input surely?)

•Operating transparently according to assessed need.

(Unless it involves explaining why naloxone is not recognised as a high priority need and why members of our communities are dying)

•Bringing providers together into cost-efficient delivery systems.

(Naloxone is a blatant evidenced based cost effective medicine with regards to savings on emergency services and communities on the whole with regards to emotional and mental wellbeing cost)

•Fully involving local communities.

(Providing they are in agreement with the way the agenda has been adopted and don’t put the value of human life first)

A seering indictment to the lack of support and attention to this issue from those that have the power to make the relevant changes can be found here in a blog by John Jolly Blenheim CDP who clearly calls out the English shame and highlights that People are dying because of a lack of harm reduction and again in another excellent article here…

http://recoveryreview.net/2014/09/enforced-recovery-unethical/

 As User Activists and supporters have pushed as far as they can in their respective areas, some more successful than others, Nottingham and Birmingham proving that this works and is effective, to mention two early adopters of programs. Where is Englands equivalent of the Lord Advocate? With great emphasis on the medications in recovery report, surely this should include naloxone? And although I am possibly a little dubious with regards to the review of the Orange Guidelines that is currently in progress, I find comfort in the fact that naloxone has been highlighted for discussion in that review, but fear that in other aspects there will be a price to pay.

(The following poem has been reproduced with kind permission from Lee Collingham. Nottingham rep….)

“SOMEONES DAUGHTER SOMEONES SON”

Why do we do the things we do,
Well it’s not for money that bits true,
For personal gain usually not,
It’ for what, most have forgot.

Our dream is everyone will have naloxone,
Somewhere safe in their home.
We don’t look upon ourselves as saviours,
We just think of it more we’re doing life a favour,
For someone’s daughter for someone’s son,
For their fathers and for their mum.

Is it not human nature to help someone?
Especially when all their Hope has gone,
And for those who moan about round here,
Try spending 6 months in Crimea.

See most only strive for what they can’t get,
They’re close minded and often forget,
But for the grace of God go they,
Who knows maybe it will be one day.

Our dream is everyone will have naloxone,
Somewhere safe in their home.
We don’t look upon ourselves as saviours,
We think of it more we’re doing life a favour,
For someone’s daughter for someone’s son,
for their fathers and for their mum
(c)lrcpublications

‘WE CALL ON THE ‪GOVERNMENT‬ TO HONOUR THEIR COMMITMENT TO ‪SOCIAL JUSTICE‬ AND RESPECT THE BASIC HUMAN RIGHT TO LIVE, AND MAINTAIN SERVICES THAT PROTECT THE MOST ‪VULNERABLE‬ MEN AND WOMEN IN OUR COMMUNITIES, OUR VIEW IS THAT IF YOU ARE NOT PART OF OUR SOLUTION THEN YOU ARE INDEED PART OF OUR PROBLEM”