In the midst of a national opioid crisis, take-home naloxone programs have expanded rapidly, with Ontario’s Minister of Health and Long-Term Care Dr. Eric Hoskins recently announcing that naloxone kits will be provided to fire and police departments across the province.
University of Toronto researchers are questioning whether naloxone distribution might distance people from health-care services or worsen health inequities.
“Having naloxone on hand saves lives. It also brings power back into the hands of people who need it most, including people at risk of opioid poisoning or overdose,” says Dr. Daniel Buchman, a bioethicist at the U of T Joint Centre for Bioethics and one of the lead authors of an article published on Feb. 3 in Public Health Ethics.
“We also wonder whether naloxone distribution will improve health equity or if it might unintentionally keep people from accessing the health care they need and deserve.”
Buchman and co-authors explore the history of take-home naloxone, showing that the intervention was developed to avoid the stigma of opioid addiction and overdose. They argue that sidestepping stigma and marginalization doesn’t always overcome those problems.
“People are dying from opioid overdose in part because the health-care system has failed to serve them. Handing out naloxone doesn’t fix that on its own,” says Dr. Aaron Orkin, an emergency and public health physician and clinical public health fellow at the Dalla Lana School of Public Health.
"We need a seamless and inviting system of care. A system where 911 and paramedicine, hospitals, clinics and emergency departments are the safest, most open and destigmatizing environments for everyone to get care, especially for people who use drugs."
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Take-home naloxone programs have expanded quickly in Canada since the opioid antidote became available without a prescription in 2016. In Ontario, naloxone is available for free at many retail pharmacies. Public health units and authors agree that it is an important part of the response to the opioid crisis. It may, however, be considered a Band-Aid solution because the intervention is reactive rather than preventing emergencies, but there are so few interventions that health-care providers can deploy to reduce opioid-related deaths.
“We know that communities where naloxone distribution is commonplace have had fewer opioid-related deaths than communities with less distribution, so that's a pretty amazing Band-Aid,” said Orkin.
The trouble is why naloxone distribution is necessary in the first place – because people who use drugs often cannot access emergency-care systems, for many reasons, including fear of arrest and stigma. Unless naloxone distribution programs are carefully implemented, authors argue that they might reinforce barriers to care experienced by people who use drugs and the resulting health inequities.
“We want to make sure that people have naloxone and the skills to use it,” said Orkin. “At the same time, it would be tragic if take-home naloxone programs sent the message that overdose is not a real emergency health-care problem or that people who overdose don't deserve to get care from capable and empathetic providers.”
Drs. Buchman and Orkin were co-authors on the paper with Professors Carol Strike and Ross Upshur from the Dalla Lana School of Public Health.
Research for the article was supported by the Canadian Institutes of Health Research, the Schwartz/Reisman Emergency Medicine Institute and the University of Toronto department of family and community medicine.