Policy Interventions to Address Fatal Opioid Overdose:
A Regional Menu
Leo Beletsky
Introduction
Despite its devastating impact in many communities and its emergent
epidemic proportions, fatal opioid overdose (OOD) has gotten far too little
attention from public health authorities, academics, and the media in many
settings. The causes behind OOD are complex. They include fluctuations in drug
quality and purity, lack of awareness among drug users and healthcare
providers, and poor infrastructure for drug treatment and emergency response.
Problems associated with the distribution, administration, and legal status of
naloxone also form barriers to effective intervention to prevent overdose events
from turning deadly. Stigmatization of drug use and users underlies many of
these causes. It also helps to explain the general lack of attention or resources
dedicated to combat OOD in many countries.
Nonetheless, thanks to dedicated advocacy by community members and
progressive healthcare providers, a number of countries, states or provinces, and
cities have implemented policy reforms to address OOD. Shaped by the specific
legal environment, resources, and other factors, these efforts focused on the
following three major areas:
1.
2.
3.
Improving the naloxone supply chain on national, regional, local,
and institutional levels,
Ensuring effective emergency response to OOD by governmental
institutions and healthcare providers,
Facilitating OOD prevention by NGOs and individuals.
Although more scientific evaluation is needed to document the overall public
health impact of these initiatives, it is clear that policy reforms can facilitate OOD
prevention efforts. In this brief, we will summarize the various kinds of reforms
that have been implemented (or could be implemented) in this realm, providing
examples of existing efforts where appropriate. Each country, and each individual
program, should consider this menu of options when determining its advocacy
and other action priorities.
The Landscape for Policy and Legal Interventions
1. Improving the Naloxone Supply Chain
Naloxone is a cheap, effective opioid agent whose sole purpose is to block the
effect of other opioids, like heroin. It is the standard of care for reversing opioidinduced respiratory depression in the emergency medical setting. It is available in
liquid form, used for injection and intranasal administration, as well as sublingual
administration reportedly available in China. The acceptance and availability of
naloxone as the standard medical agent to reverse OOD is widespread, but not
universal.
As a prescription pharmaceutical medication that is not a controlled
substance, the legal supply of naloxone is predicated on the official approval of
the drug to that country. In others, the drug may be approved, but is not available
for distribution. The flow of naloxone supply to the points of its sale, distribution,
or utilization in emergencies may be a complicated process, fraught with legal,
logistical, and economic problems. The following policy processes may be helpful
in addressing these issues:
A. Inclusion of naloxone into the national registry of medical drugs that are
approved for use and sale in the country,
B. Inclusion of naloxone into the national list of essential medicines for the
country,
NATIONAL FORMULARY OF REGISTERED
C. Inclusion of naloxone among the
DRUGS, KAZAKHSTAN (2002)
standard formulary of drugs available
LISTS INJECTIBLE FORMULATION OF
at key institutions, including
NALOXONE AS A DRUG THAT IS APPROVED
pharmacies, outpatient medical clinics,
FOR DISTRIBUTION, SALE, AND USE
drug treatment (and methadone
maintenance treatment) centers,
ambulances, hospital emergency departments, and correctional settings,
D. Long-term commercial contractual agreement or government mandate
assuring steady and cheap supply from a reliable manufacturer and
supported through a donor agency, foundation or government.
Although it may be possible to conduct pilot OOD activities involving naloxone
without undertaking the last four of these efforts, sustained and appropriately
scaled operations require attention to supply chain management. Securing these
policy shifts requires coordinated national-level or institutional-level advocacy,
including members of the community, naloxone manufacturers, public health and
medical professionals, and domestic and international legal experts. Drug
manufacturers should be recruited to carry the brunt of the costs associated with
improving supply chains.
2. Ensuring Effective Emergency Response by Healthcare Providers
The deterioration and failure to reform the governance, financing, and supply
chain management of healthcare systems has created serious problems in the
delivery of emergency care in many regional settings. In the context of OOD
reversal, this includes the provision of effective, timely aid to overdose victims in
emergency rooms and by ambulance staff. Research suggests healthcare
providers may have low knowledge of OOD and its treatment; their actions may
also be shaped by poor attitudes toward drug using populations. Among the
policy reforms that may be useful in addressing these problems are:
A. Ensure effective overdose care by healthcare providers in emergency
situations by improving knowledge and incentive structures:
2
o Amend formal medical “standards of care” and protocols for
hospitals, ambulance workers, and other medical providers who
may respond to OOD to include the provision of naloxone,
o Change policies to ensure that procedures that are necessary to
provide effective OOD
PRIKAZ NO140, MOH, RUSSIA
response are included among
1. DEFINES AND CLASSIFIES OOD FOR
services billable (and actually
MEDICAL PROFESSIONALS AND
reimbursed) by the third party
EMERGENCY RESPONDERS
payers (national or other
2. DESCRIBES DIAGNOSTIC PROCEDURES
health insurance schemes),
AND PROTOCOLS
o Change policies or curriculum
3. STIPULATES USE OF NALOXONE TO
to recommend or mandate
REVERSE OOD
overdose prevention and
response training for medical
students, emergency medical technicians (EMTs) and active key
medical personnel in areas with heightened population rates of
OOD.
B. Ensure the stocking of naloxone by key response institutions:
o Change policies to require the inclusion of naloxone in the
formulary of drugs that are stocked by the specific hospital, clinic,
treatment organization, correctional institution, or ambulance
service,
o Change policies to monitor the actual inclusion of naloxone in key
response settings.
C. Facilitate timely emergency medical response:
o Change policies to shield OOD victims and witnesses who call for
help from criminal prosecution for drug possession or related
charges,
o Change policies to exclude police escorts from accompanying
ambulances responding to OOD calls.
o In some areas certain classes
OOD PREVENTION LAW,
of EMTs may not be authorized
US STATE OF NEW MEXICO
to administer naloxone (or other
1. LIMITS CRIMINAL LIABILITY FOR DRUG
prescription medications), even
POSESSION FOR VICTIM AND
if it is available and legally
WITNESSES OF OOD WHO CONTACT
possessed by the victim;
EMERGECY RESPONSE SERVICES
allowing low-level EMTs to
2. LIMITS THE USE OF EVIDENCE THAT
administer naloxone could be
EMERGES FROM EMERGECY CALLS
an additional policy directive.
ABOUT OOD IN CRIMINAL CASES
In addition to the above interventions, programs may also consider wider
activities to facilitate the improvement of ambulance and other emergency
services in the community, including working with governmental and donor
organizations on training, infrastructure, and funding of these services. Efforts to
boost general provider knowledge, attitudes, and practices related to drug user
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health can facilitate more effective OOD response. Engaging medical providers
and their organizations is key to the success of efforts in this realm.
3. Facilitating OOD Prevention by NGOs and Individuals
In view of the supply chain and government
PRESCRIPTION DRUG FORMULARY,
response failures, harm reduction NGOs in the
REPUBLIC OF GEORGIA
region have responded to the crisis by instituting
NALOXONE IS NOT INCLUDED
training and naloxone distribution programs. This
AMONG THE LIST OF PRESCRIPTION
has included initiatives that distribute naloxone
DRUGS, MAKING IT AVAILABLE
directly to the users, those that provide
OVER-THE-COUNTER
prescriptions to outreach workers who, in turn,
distribute the drug, and those that refer users to
government clinics or pharmacies for purchase or dispensation of free doses of
naloxone. The specific program design is often shaped by the legal and policy
environment. Factors complicating efforts to improve peer access to naloxone
includes naloxone’s prescription status, facility licensing for naloxone storage and
dispensation, police interference, along with many others. The interventions
listed below can help to improve the impact and facilitate the scale-up of these
programs:
A. Improve lay lifesaver access to naloxone:
o Change professional or commercial policies to mandate the
inclusion of naloxone in pharmacy inventory, including working with
pharmacy chains,
o Change in prescription status of naloxone by excluding it from the
list of drugs available only by prescription (List B in most countries),
o Provide for anonymous prescription or standing orders for
prescription of naloxone,
PRIKAZ NO327, MOH, RUSSIA (1999)
reducing the need to involve
1. ALLOWS ANONYMOUS TREATMENT OF
medical providers in naloxone
DRUG USERS
distribution.
2. SETS UP A FRAMEWORK FOR
B. Facilitate NGO program operations:
ANONYMOUS PRESCRIPTION OF
o Procure licensing for NGO
MEDICINES (NALOXONE) USING BLANK
programs to purchase, store, and
PRESCRIPTION CARDS TO BE FILLED
dispense naloxone,
OUT BY ALLIED MEDICAL STAFF
o Change licensing laws to
(OUTREACH WORKERS)
eliminate or substantially lessen
requirements for NGOs to obtain
licensing to purchase, store, and dispense naloxone,
o Change laws and operational police policies related to naloxone
dispensation to reduce police interference with naloxone
distribution programs,
o Change policies to recommend or mandate police training on laws
and operational procedures related to naloxone distribution.
C. Encourage the use of naloxone by lay lifesavers in the community,
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o Create or modify good Samaritan legislation (shielding from
criminal and civil
POLICE FIELD OPERATIONS MANUAL, NEW
responsibility for any
YORK CITY POLICE DEPARTMENT
negative consequences),
1. DESCRIBES OOD PROGRAMS
o
Change institutional policies
2. DESCRIBES THE LAW RELATED TO
to recommend or mandate
NALXONE POSSESSION AND USE
drug user training in
3. OUTLINES PROCEDURES RELATED TO
naloxone use, first aid, and
CONTACT WITH A TRAINEE OF OOD
other OOD prevention
PREVENTION PROGRAMS
techniques, especially in key
4. DESIGNED TO ACCOMPANY TRAINING
settings such as drug
FOR CADETS AND OTHER OFFICERS ON
treatment and corrections.
OOD
o Change laws or operational
police policies related to naloxone possession or administration to
reduce police interference with lay lifesaver activities.
o Create policies recommending or mandating police training on
policies and procedures related to lay lifesaver activities.
o Incorporate overdose response in broader health education
initiatives aimed at the general population.
D. Encourage providers to participate in OOD prevention, including
prescribing naloxone
o Create legal protection to prescribers to facilitate participation in
OOD prevention programs, including laws shielding them from
criminal or civil responsibility from lay lifesaver activities,
o Change reimbursement schemes to make screening for overdose
risk, naloxone prescription, OOD education, and refills and followup care billable services,
o Amend formal medical “standards of care” and protocols for
hospitals, drug treatment clinics,
MEDICAL BOARD POSITION STATEMENT, US
correctional institutions, and other
STATE OF NORTH CAROLINA
key settings where naloxone
1. RECOGNIZES NALOXONE
prescription and dispensation is
PRESCRIPTION AS AN ACCEPTED
feasible to cover these activities,
MEDICAL SERVICE TO PREVENT OOD
o Change professional licensing or
2. RECOMMENDS NALOXONE
education policies to mandate or
PRESCRIPTION TO KNOWN AND
recommend provider training on
SUSPECTED OPIOID USERS
naloxone prescription as a way to
prevent OOD.
o Provide funding for development and dissemination of continuing
medical education (CME) credits on naloxone-based overdose
prevention for clinician accreditation.
Prevention of OOD in the community requires a holistic approach, including
improving medical infrastructure, supply chain for naloxone, and broader
awareness and capacity in the community to respond to OOD events. National,
regional, and institutional policy reform can help facilitate these efforts and
5
improve the impact of existing OOD prevention initiatives. Most importantly it has
to be a key aspect of the strategic planning process in expanding and scaling-up
pilot programs.
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