Health Professionals’ Reflections on Take-Home Naloxone

NOTE: Quotes are presented word for word apart from minor editing for readability and clarity. Identifying details have been removed. Square brackets show text that has been added or, where ellipses (three dots) appear, removed. For example, ‘Since I actually participated in this Narcan [training], I’ve administered it to two people and it’s brought them around […] I wouldn’t think twice about [doing] it. Saving someone’s life is the main thing.’

The vast majority of the health professionals we interviewed for this website say that take-home naloxone is an important life-saving initiative. However, much like the participants whose views and experiences appear in other sections of this website, health professionals vary in their views on most aspects of naloxone provision and use.

Depending on their work context, some have professional experience with take-home naloxone, for example, through prescribing it. Others, however, only knew of it in theory or encountered it for the first time by participating in our research.

For many, again reflecting the views of others interviewed for this website, take-home naloxone seems an uncontroversial measure similar to other life-saving technologies such as the EpiPen® used for severe allergic reactions (anaphylaxis). Indeed, some health professionals passionately argue for increased support of take-home naloxone and more efforts to increase its availability and use in the community.

That said, a minority of health professionals express concerns about take-home naloxone and ask questions about how appropriate it is for their professional setting.

The health professionals interviewed for this website also discuss barriers to expanding access to it, and other potential issues. For example, a number consider the current price of take-home naloxone a barrier, while others describe hurdles they encounter trying to use it in their work.

Overall, the reflections recounted here emphasise the relevance of take-home naloxone for a range of different alcohol and other drug specialist and general health services.

Supporting and expanding a life-saving technology

The majority of the health professionals in all professional groups we covered argue passionately in favour of take-home naloxone. Some spoke positively of take-home naloxone in many different ways. Carlotta (F, GP, NSW) says take-home naloxone is a ‘good idea’. Betsy (F, pain management specialist, NSW) and Lily (F, GP, NSW) describe it as ‘fantastic’ and ‘great’, respectively. Talia (F, drug treatment worker, NSW) suggests it is ‘handy for people’ and Sadie (F, pharmacist, NSW) states that ‘it’s important that people have access to it readily’. Finally, Parker (M, GP, NSW) argues that naloxone access is part of ‘smart drug policy’. Manolis (M, pharmacist, Vic) and Huang (M, pain management specialist, Vic) position it as a ‘great step forward’ and a ‘step in the right direction’, respectively. Similarly, Oliver (M, pharmacist, Vic) and Larry (M, GP and pharmacotherapy prescriber, Vic) argue that recent increased availability is ‘excellent’. Lola (F, pharmacist, Vic) says encouraging naloxone uptake is a ‘great idea’. Finally, for Li (M, GP and pharmacotherapy prescriber, Vic) health professionals have an ‘ethical and moral imperative’ to make naloxone accessible to relevant patients.

Speculating on how to expand take-home naloxone uptake, Ursula (F, nurse practitioner and pharmacotherapy prescriber, NSW) argues that it needs to be supported by a large public health campaign.

I think we need a massive public health campaign. We need it out there on billboards, on stations, bus stations, railway stations, in carriages, you know, ‘Keep Calm and Carry Naloxone’. It should be everywhere, and [then] it will reach the people who it needs reaching. I mean, to have that pathetic anti-amphetamines [campaign] that Tony Abbott dreamed up […] and that was, you know, ‘Dob in a Dealer’ and all that […] and that was not public health. That was stupid, it was criminalising or stigmatising. So I think, you know, obviously there are ways that we can reach everybody with messages. I always say, I worked in India quite a lot, I always say, ‘[If] the postman in India can find every house in the country, there’s a way to reach people with messages’. So we just need to really bump it up and have funding for it.

Also thinking about uptake, Louise’s (F, GP, NSW) says her only concern about take-home naloxone is that it’s not accessible enough.

My concern is that [provision of take-home naloxone is] not done widely or broadly enough. Panadol is a widely available substance that kills many people every year, and nobody would question that this is a drug that we should have ready and easy access to. Naloxone does not kill anybody – it is incapable basically of causing harm – and it will do nothing to you other than save your life if you happen to need it. Yet we are fighting to find ways to make it cheap and available to people when they need it.

For Betsy (F, pain management specialist, NSW), take-home naloxone provision could become part of her ‘core business’ and may be useful in convincing her patients they need to be wary of the risks of their medication.

I think [take-home naloxone provision] would be part of core business. […] Recognising the risk of opioid overdose is core business and when there are enhancements in community management of that, then that just becomes part of core business. So if you’re an opioid prescriber, it should just become part of what we do. Obviously, there will be people who say that the time [needed] and commitment to explaining its use and providing resources for the prescription and the resources for education all take [too much] time, but I don’t see that there’s [a problem]. You’ve got a duty of care. […] We want to keep people safe. It may make people more nervous about taking an opioid. However, that is only appropriate really – like, we shouldn’t mislead people into thinking opioids are perfectly safe, because they’re not.

As does Louise (above), Graham (M, GP and pharmacotherapy prescriber, Vic) describes take-home naloxone initiatives as safe ways to save lives.

It’s a breathtakingly safe medication and it saves lives […] We’ve got defibrillators now in public places – we should have a naloxone Minijet or a naloxone syringe on the wall in areas of high use. Why not have a naloxone next to every needle/syringe container? Yeah, so it’s just going to save lives, really.

Awareness of take-home naloxone

The health professionals we interviewed had different levels of awareness of take-home naloxone. For example, those working in alcohol and other drug health settings generally have more knowledge than those working in other areas. Along with comments supporting the safety of take-home naloxone, some suggest that awareness of take-home naloxone within different professions could be improved. Some offer suggestions for how to increase awareness such as including information about naloxone in training initiatives.

Gregory (M, GP and pharmacotherapy prescriber, Vic) explains he knows more about take-home naloxone than ‘your average GP’.

Yeah, like, I think in general I know a little bit about [take-home naloxone] from the methadone and suboxone [prescribing] that I do, and I guess I know about it from the work that I do in the emergency department. I’m used to dealing with naloxone infusions, for example, with patients who come in via ambulance from heroin abuse. There’s probably not much knowledge around it outside of that for your average GP. Yeah, it’s hard to know whether every GP should be educated more on take-home naloxone or just those GPs that deal with methadone and suboxone programs.

Thinking about strategies to improve awareness, Lola (F, pharmacist, Vic) said pharmacists could benefit from reminders about dispensing take-home naloxone.

For sure [there should be more take-home naloxone training for health professionals], definitely, and even with our pharmacy guys, we’ve trained them a couple of times, but the problem is because [take-home naloxone is] not widely used at the moment, by the time someone comes in for a script for it, people have forgotten. So I think there needs to be perhaps more training and […] perhaps more resources, [just so] that you can go back and quickly remind yourself of the training again, so you don’t have to do a full training. Like a, you know, a 10-minute video to remind yourself, ‘Oh yeah, that’s what I’m supposed to be doing.’

As take-home naloxone is a relatively recent initiative, Disha (F, specialist alcohol and other drug psychiatrist and pharmacotherapy prescriber, Vic) suggests some health professionals may not be aware of it yet. She also discusses potential concerns about the initiative, concluding that some health professionals may worry that naloxone will underplay the need for other solutions to overdose.

Look, I mean, in terms of it as a medication […] it’s a medication we are extremely happy to prescribe to people. It’s very safe and [has] very few side effects, if any. I think realistically, most medical practitioners, if it’s not being prescribed more frequently, it’s really around lack of access [to] knowledge and familiarity [with] its role. Being a newer medication, too, it’s probably not something that’s been part of the core medical curriculum and teaching for any doctors [yet]. So […it] takes time to educate people about it.

But I think there’s very little concern [about take-home naloxone]. I think the only concern, if any, is that individuals might think they’re safe if they have it and it’s not the solution to everything in terms of overdose prevention. I think it highlights the need for people to attend a training session or have a face-to-face discussion with a professional around the broader use behaviours [and] that it’s not going to, you know, prevent all risk. But I think beyond that, there’s very little concern.

Organisational and institutional hurdles

Others identify and discuss a range of organisational issues that make it difficult to implement take-home naloxone initiatives and distribute the drug in their professional setting. Time constraints often emerge as do the challenges posed by adapting existing procedures to integrate take-home naloxone provision. Importantly, the majority of health professionals we interviewed argued in favour of take-home naloxone and were keen to overcome these hurdles in order to increase uptake of it.

While Li (M, GP and pharmacotherapy prescriber, Vic) positions take-home naloxone as a ‘life-saving medication’, he explains that time constraints limit his ability to prescribe it.

So, time’s always the biggest constraint. You know, we’ve got 15-minute appointments, so it’s just impossible to fit all of that in. So unless a patient is coming in just for a script and no other issues, it’s very difficult to raise [take-home naloxone with them]. For example, if we have a new patient released from jail, we need to cover all of the other issues and it’s just not possible to cover naloxone training in that consultation. I think ideally we’d like to get the patient back to discuss it as a subsequent consultation. Yeah, so time is one of the constraints.

Time constraints are also raised by Gretchen (F, pain management specialist, NSW), who suggests that prescribing take-home naloxone would be useful in that it demonstrates she has concerns about a patient’s health. However, she questions whether her service has time to explain how to administer it.

I would be happy to prescribe it for them in the initial consult, when I saw them, if I thought they were at risk. I think it would demonstrate to the patient that I had concerns about their health [and] it would demonstrate to the family that this was an issue. The only [question] is how I would go about educating the person and the family, or the loved one or partner or whoever, how to administer. Because that would take a bit of time, I think. I wouldn’t have the resources personally to do that at the time.

According to Disha (F, specialist alcohol and other drug psychiatrist and pharmacotherapy prescriber, Vic) integrating take-home naloxone in a specialist service is difficult.

I think the difficulty for us […is that] we are sort of a specialist sector and we are seeing people for one-off assessments in some cases. So trying to figure out how we integrate take-home naloxone in that context has been tricky. Also, understanding how we can incorporate someone’s, kind of, social context and enable them to have access to the medication as well has been tricky in the context of one-off assessments.

Hayley (F, pharmacist working in an opioid pharmacotherapy clinic, NSW) explains overdose issues are discussed at her workplace, but in the event of an overdose, the policy is to call an ambulance rather than respond with naloxone.

So, we don’t actually have naloxone on the premises […] There are naloxone vials that we can get from the pharmacy, but [not all the staff] are trained to use those vials. So […] we ended up deciding, like, we just can’t have it here. And then, because no one might know how to use it. I think we may actually have one pack here, but that expired and then we didn’t actually re-order it, yeah, and now the policy is just to call the ambulance if needed, yeah.

Taking into account different issues, some explain that they aren’t confident they could give reliable advice about using take-home naloxone.

Sadie (F, pharmacist, NSW) explains she worries that offering naloxone could offend some of her customers.

It doesn’t take too much time to, like, show someone and counsel them, and it would be, I’m hoping, just a one-off and then a refresher every now and again. But I do think it would probably be [an issue] from a cost perspective […] Also, I don’t know, from a patient perspective, they’d be like, ‘Do you think I actually overdose on these things [opioid medicines]?’ I guess a lot of methadone patients would be, you know, professionals working in the community, people who [do] not touch any opioids aside from their methadone, and to offer them naloxone – I don’t know if they’d feel offended or not.

Similarly, Elijah (M, pharmacist, NSW) says some of his customers may be resistant to discussing overdose and see opioids as safe medicines rather than dangerous drugs.

I’d be really surprised if any of my patients had even ever thought about [overdose as] a possibility. […] The places that I work […are] reasonably high […] socioeconomic areas [so] people there are not going to think of themselves as drug users, even if they’re using huge amounts of morphine. Even from my research as well, there’s a really fascinating effect where people who use pharmaceutical opioids – and I imagine it’s similar for other things, but specifically for opioids – they have a huge issue looking at themselves as drug users and as, like, having a problem. So they might be cripplingly dependent on pain medication, but they will see it as an issue of not having enough drugs rather than having too much […] It’s really difficult [to] approach that patient about the risks of those medications because their idea is, ‘Well, actually I don’t have enough – I need more.’ So talking to them about the risks of the drugs that they’re already taking is impossible, and then you add on the thing of being in, like, a high-socioeconomic community [where people] don’t tend to be very open to criticism […] To be honest, I think it would be much easier to have that discussion with a recreational drug user because they are approaching [opioids] as a thing which they understand has danger rather than [having the] idea that, ‘Oh, my doctor gave it to me, [so] it can’t be dangerous’.

Prescribing

A number of health professionals explain that prescribing arrangements shape their perspectives on take-home naloxone.

Rosamond (F, GP and pharmacotherapy prescriber, NSW) raises concerns about prescribing a medication that is likely to be administered to someone other than the person given the prescription. However, she argues that the safety of naloxone justifies the practice.

One of the issues for prescribing is that if I prescribe [take-home naloxone] to an individual, I prescribe knowing that it’s likely that they’re going to use it on someone else. So there is that issue around who am I prescribing it for? So that’s a bit tricky. It might be that it’s used on them by a friend, but if I’m doing the training and giving it to them, if they overdose, they’re not going to use it. They’re going to use it on someone else, so I am prescribing a medicine for someone that I don’t know, which is not entirely kosher. The way that I justify that to myself is that it’s a really safe medication and it should be [available] over the counter.

Also discussing prescribing practices, Lola (F, pharmacist, Vic) argues that naloxone should be co-prescribed with opioids.

So if you are giving a box of OxyContin, you [should have to] write a script for naloxone. […] You know, you have to get a permit once you’ve been on [an opioid drug] for eight weeks. [You should have to] tick the box ‘I haven’t offered naloxone to this patient, because …’ or something like that. It should be part of the permit. Like, you don’t get the permit unless you offer them naloxone as well. Because obviously the [patient is] at an increased risk if they are using [the OxyContin] for greater than two months.

Price

Like the other participants, the health professionals interviewed for this website raise concerns about the cost of take-home naloxone. For them, the cost of ordering naloxone for their particular setting can be an issue, as can the price for their clients.

As Edwina (F, pharmacotherapy prescriber working in a residential rehabilitation service, NSW) explains, the cost of naloxone is so high it prevents distributing it to service residents*.

We have naloxone available to staff here, and if there was an overdose on site, certainly there’s naloxone in all of our services. Because we are an [non-government organisation], we have to buy naloxone over the counter. So it’s a bit expensive for us at the moment and that means, we can’t actually hand it out when people are leaving […] I would like to be able to hand out naloxone, and that’s sort of one of my wishes for the future. But at the moment, because we’re not tied to a public facility, we can’t get the supply […] We hope that, at some point, naloxone will be made more readily available.

Like other participants, Elijah (M, pharmacist, NSW) compares the life-saving potential of take-home naloxone with EpiPens®, but suggests cost is a barrier*.

It’s still so expensive […] One day hopefully, they’re so cheap that every fit pack can have a naloxone vial inside […] If the government says, ‘Here’s a whole bunch of naloxone pens and here’s exactly how to use them and we’ll replace them for free,’ that’s a really easy [and] obvious intervention […] Yes, naloxone is expensive, but also people die without it. That seems like a pretty easy trade-off to me.

Stigma as an impediment to expansion

Drug consumption stigma is another concern shared by many of the health professionals and consumers interviewed. For some, stigma negatively impacts their ability to communicate effectively with their clients, including whether they feel comfortable offering take-home naloxone. Others suggest that stigma might impact community sentiment and reduce support for take-home naloxone. Overall, many argue that stigma is a major impediment to expanding this initiative.

Sadie (F, pharmacist, NSW) says that she wishes she knew more about take-home naloxone, but reasons that it’s a good idea overall. However, given the stigmatisation of drug consumption, she wonders whether there might be some opposition to it.

I wish I knew a bit more about it but I think take-home naloxone is a good idea. I believe there probably is stigma. I reckon there’s probably people out there that would be like, ‘Oh, why are we giving this to them?’ It just means that they can take the opioid prescription or, like, illegal [opioids], and then they can just treat themselves, and it’s just going to propagate further use […] I do know there’s probably opposition to it, yeah.

Some participants such as Parker (M, GP, NSW), wonder whether naloxone’s association with illegal drug consumption might discourage patients using opioid for pain from visiting an alcohol and other drugs service to get take-home naloxone.

[I’m thinking] especially [about] the [patients] who have proper medical needs and don’t see themselves as drug users. [From their perspective] they’re not drug users, they’re not drug dependent. They just have pain, you know. The thought of them having to mingle with the ‘dregs of society’, and […] there is a degree of reluctance and repulsion about the notion of them having to be lumped in together with ‘those people’.

Take-home naloxone products

Health professionals also offered their opinions on take-home naloxone products. Many spoke in favour of naloxone products that can be sprayed into the nose (called ‘intranasal’ products) because they are thought to be the ‘easiest’ to use. While many participants who consumed opioids also spoke about intranasal products favourably, they generally had more mixed views about which naloxone products they prefer.

Comparing different naloxone products, Amelia (F, pain management specialist, Vic) explains that intranasal devices would be best for her patients.

So the easiest […] would be intranasal, because it’s there, it’s like an EpiPen […For] a person that’s not used to injecting, [ampoules are] going to be confronting. [They might wonder,] ‘Oh my gosh, how do I break it, how do I draw it up, how much was it again?’ Because [… an overdose] is a pressure situation [and with a multi-dose syringe] you would just be tempted to give it all […] I wouldn’t be that cool-headed enough at the time. If someone’s blue in front of me and not breathing [it would be hard to remember that] I’m only supposed to push [the plunger] in a little bit.

Similarly, when the interviewer described intranasal products to Manolis (M, pharmacist, Vic) he expressed the view that they would be easier to use than others currently available,

My thinking is you need to make [take-home naloxone products] as simple [to use] as possible, so even a novice can use [them]. Some don’t have the aware[ness] of how to use the ampoules, but even with something like [the pre-filled naloxone syringes], you still need to get the syringe out and you still need to get it in there. I think [intranasal products] would be much easier generally, or as I […] mentioned earlier, an EpiPen style one, which could be very easy as well. But I wasn’t aware of [intranasal naloxone, which] I would say would be pretty good.

* In early 2019 the federal Government of Australia announced the two-year trial of a national take-home naloxone program focussed on expanding naloxone availability for people thought to be at high risk of opioid overdose. The national program may have implications for the price of take-home naloxone in the future.