If recent coverage in blogs, tweets and journals is to be believed
, it should
be full steam ahead for the widespread distribution of the opiate antagonist
naloxone. In San Francisco, recent coverage asserted that ‘naloxone saves
600th life,’ while closer to home in Wales, ‘20 lives were saved in 18 months
in Swansea’ thanks, it is claimed, to naloxone.
An expansion of naloxone distribution is very likely and judging by the
commentary to date, it is well nigh heretical to raise questions about this. I
am keen to see an expansion of any interventions that can be demonstrated
to save lives – nonetheless, there are some important practical and ethical
concerns that seem to me to have been skated over.
Many years ago, I attended a presentation by Dr Ingrid Van Beek, who set
up the drug consumption room (DCR) in Sydney. She explained the low level
Soapbox |
Kevin Flemen
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| December 2011
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of frequency with which naloxone was used to manage overdose – most
were safely managed until the arrival of paramedics by using oxygen, which
provided a safe and less violent method.
A review of overdoses in the supervised injecting facility (SIF) in
Vancouver saw oxygen used on just under 300 occasions, with naloxone
being used on less than 100. In Sydney, in the 2,000 opiate overdoses
managed between 2001 and 2007, naloxone was used on less than one in
five occasions.
I share concerns about rolling out use of naloxone, especially in settings
such as hostels. Proposed models of distribution have included trained staff
holding naloxone, so it can be used in the event of resident overdoses. A key
concern in such settings would be that ‘naloxone-happy’ staff would lead to
the perverse outcome of deterring people from using on site, so as to avoid
being ‘got’ with naloxone.
Why though, should staff become overly keen on the use of naloxone? A
key reason would be that we have yet to fully consider issues of liability.
Given a situation where staff have been trained in use of naloxone, and are
facing an overdose situation, they could feel obligated to use it, even where it
wasn’t needed. Ultimately, while the unnecessary use of naloxone merely
distresses an opiate user, the failure to use naloxone by someone trained in
its use, where the person overdosing dies, opens up scope for litigation.
All professionals owe the person overdosing a ‘duty of care’. Depending
on training and role, this could be limited to calling an ambulance. But what
are the implications where non-medical staff have been trained and
equipped with naloxone – could this be a breach of duty of care? The easiest
way for a member of staff to avoid this negligence would always be to err on
the side of caution, and administer anyway.
This increase in scope of duty of care presents other challenges. This in
part stems from the precedent set by Bolam
v
Friern Hospital (1957) which
established the principle that a professional ‘is not guilty of negligence if he
has acted in accordance with a practice accepted as proper by a reasonable
body of (medical) men skilled in that particular art’. So once trained and
equipped to administer naloxone, it seems reasonable that the standard to
which one would be held accountable would be that of paramedics.
If this is the case, then the implications for people being trained in the
use of naloxone are significant. The failure to call an ambulance, failing to
wait with a person until an ambulance came, failure to place in the recovery
position, or the use of the same needle between two overdose casualties
resulting in BBV transmission – each of these omissions or acts would fall
below the standard of ‘practice accepted as proper’ and so could be
actionable in the event of death or serious harm. In one evaluation of take-
home naloxone in Wales, out of 28 cases of naloxone being deployed,
paramedics weren’t called on 14 per cent of occasions, despite training.
We need to make more explicit to those being trained in use of naloxone
that their involvement in an overdose has potential implications. They could be
a life-saver, which is what we of course hope for. But this may not be the case.
A discussion took place a while ago, looking at a monitoring system for
pharmacy needle exchange. The revised system had a newly added field for
when the pharmacist was re-dispensing naloxone after it had been used. The
field asked the question ‘successful or unsuccessful?’ meaning did the
overdose victim live or die? What, I asked, would be the pharmacist’s
obligations if the person seeking naloxone said ‘unsuccessful’? The issue had
not been looked at in training, and the consensus was the pharmacists
would feel obliged to notify the police, and give details of the person seeking
naloxone.
This didn’t, of course, mean that the person administering naloxone had
done anything ‘wrong’. Just that they may well need to speak to police,
possibly under caution, would have to go to the inquest, could be found to
have done something illegal by the police, and may have been negligent.
I wonder how many people had that explained to them when they were
undertaking their naloxone training?
Kevin Flemen runs KFx, a service that provides an information website,
training and resources to those with an interest in drugs – www.kfx.org.uk
GETTING NARKY
OVER NALOXONE
Are we rolling out an ill-thought-out
scheme, asks Kevin Flemen