Naloxone shortage uncovers nagging problems

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This article was published 14/06/2023 (860 days ago), so information in it may no longer be current.

There is always a story behind every big news story. When community groups went public last week with concerns about a naloxone shortage in Winnipeg, the story behind the story took the form of a rather startling statistic.

Community groups that administer the life-saving medication to people who have overdosed on opioids reported it was taking, on average, seven doses of naloxone to bring some back from the verge of death.

Harm reduction groups that help administer these drugs attributed the increased dosage as a sign that the types and formulations of street opioids were growing in toxicity. Thus, the need for more naloxone was behind the shortage.

However, that same statistic raised other red flags with public health officials who oversee the program of distributing the naloxone kits to those groups and to the public.

Two concerns in particular rose to the surface: first, that community groups or members of the public who administer naloxone may be rushing to administer too many doses in too short a time; and second, that they don’t always call 911 and seek medical assistance, even in cases where someone’s life is at stake.

“If we hear from an incident report that seven doses of naloxone have been administered and we arrive 10 minutes after the call to 911, then we know that they are not waiting long enough between doses,” said Cory Guest, the public education co-ordinator for the Winnipeg Fire and Paramedic Service.

“I know for a fact that people are not waiting long enough. They give a dose and then when there isn’t an immediate reaction, they give another dose right away. You have to leave a bit of time for the medication to work.”

Guest said it takes between three and five minutes for a single dose of naloxone to take effect. However, for someone who is not a medical professional, it’s very hard to wait that long if the person’s condition doesn’t immediately improve.

In some instances, additional doses are being administered because the person providing the naloxone believes they have to continue until someone completely regains consciousness, and not just starts breathing again.

As a result of these factors, and the incredible stress that comes from having to provide life-saving treatment, people err on the side of action and administer more doses.

Unfortunately, while there is little doubt opioids are increasing in toxicity, street-level opioids are really cocktails of all kinds of different drugs, some that respond to naloxone and some that don’t.

Recently, there has been a trend in which opioids (morphine, heroin, codeine, oxycodone, hydrocodone and fentanyl) have been cut with sedatives such as benzodiazepines that do not respond to naloxone, Guest said. In those instances, there is no way for community support personnel to know that naloxone will not help, he said.

It adds up to a situation that is too complex for the average person to assess, Guest said. “We are not criticising the decision making that’s going on here,” he said. “There is just no way for someone who is not fully trained to recognize all the different factors that are at play.”

The other major problem that public health officials have flagged is a reluctance to call 911.

Shelley Marshall, a clinical nurse specialist with Manitoba Health and the Winnipeg Regional Health Authority, said the naloxone kits were only intended as an interim tool to support someone experiencing “drug toxicity” while awaiting emergency medical responders.

However, for a variety of reasons, calls for medical attention are not being made. Marshall said the overdose victims, or their friends and family who are trying to help them, do not want paramedics or a fire truck responding to their residence out of fear of embarrassment, or because it may jeopardize their residency if they are in a rental apartment. Provincial data shows that 911 was not contacted in 50 per cent of incidents where take-home naloxone kits were used, she added.

In other cases, there is a “systemic distrust” about calling for emergency services when someone is overdosing on illegal street drugs, she added. “This is not exclusive to Manitoba,” Marshall said. “In every province, we’ve seen a continued reluctance to call 911 when there is an overdose.”

Guest and Marshall agree the time is right for updated training and education about naloxone.

Guest said he is about to launch a deep dive into incidents in the Winnipeg library service, where naloxone — in its nasal spray form — is frequently administered by city staff. Guest said he hopes to dig more deeply into individual incidents and interview staff about their experiences administering the medication.

The result, he said, will be new insight into the pressures faced by non-medical personnel during a medical emergency.

“One of the things I recognized when these kits were sent out to the community is that there is no formal training or certification required. I understand that they wanted to promote the distribution, but I’ve been concerned that there hasn’t been enough training and education.”

dan.lett@winnipegfreepress.com