No naloxone available? No excuse.
No excuse either for drug agencies failing to formally lend their support for naloxone distribution to users, families, and friends.
Getting naloxone into the community was recommended by the World Health Organisation, and some countries like the USA, Australia, Scotland, Wales have made excellent progress. In 2009 I was involved evaluating the naloxone take home scheme rolled out in Wales, but since my arrival in New Zealand in 2011, it has been difficult to get naloxone on the drug policy agenda, let alone into the community, despite the fact that Coroner data indicates that every week someone dies of an opioid overdose in New Zealand.
Why should this be so difficult when naloxone has no abuse potential, is relatively cheap, easy to administer and is so effective at reversing overdose? Unfortunately, the failure to deliver a humane and effective drug policy has little to do with a lack of evidence, understanding or science, but much more to do with a lack of interest, care or regard for people who use illicit drugs, and people who inject drugs (PWID) tend to be the most marginalized. Naloxone distribution is a vital life-saving service for PWID.
Numerous opportunities have existed in New Zealand to ensure naloxone is available to users, families and friends. In August 2013 sixty-seven agencies were represented at an invitation-only National Drug Policy Think Tank Event, led and coordinated by the New Zealand Drug Foundation. After two days debating priorities, values and strategy, to shape the future of drug policy in Aotearoa, the NZ Drug Foundation produced a 12,000-word vision statement, that became known as the Wellington Declaration – but surprisingly in this comprehensive document outlining drug policy priorities naloxone didn’t even get a mention.
A year later in August 2014 in its Matters of Substance Magazine, rather than present a robust case for naloxone distribution in New Zealand, the NZ Drug Foundation Magazine framed Naloxone take-home as a contestable issue, open to debate. They offered arguments for and against naloxone. This included some spurious arguments against naloxone distribution including “there could be an unintended consequence from widening availability of naloxone” and “people could become less cautious about their drug use because they know life-saving treatment is close at hand”.
In October 2014 after a new government was elected the NZ Drug Foundation prepared a twenty-page Briefing Paper to Parliament which was designed to identify key drug policy priorities to enable ‘opportunities to make real reductions in drug-related harm‘ (p.3). The document emphasised the need to secure New Zealand representation at the United Nations international meetings (see below), and specifically highlighted the need to tackle deaths caused by huffing solvents, but astonishingly made no reference or representation to the new government concerning fatal opioid overdoses nor did it mention the need to distribute naloxone to users, families and friends.
With this lack of formal commitment to naloxone distribution from the lead NGO organisation for drug users/drug agencies in New Zealand, it was hardly surprising that when the new government eventually rolled out its five-year Drug Policy Strategy 2015-2020 on 28th August 2015, the policy document made no mention of naloxone whatsoever. Interestingly, the new drug policy did, as promoted in the NZ Drug Foundation Briefing Paper, prioritise a commitment to ensure New Zealand would be represented at international UNGASS meetings (p.22).
Belatedly, Matters of Substance published a better informed and considered magazine feature on Naloxone after the embarrassing ‘for or against’ debate, the Foundation produced a stand-alone Naloxone Background Paper. However, while this discussion paper includes some excellent sources and appeared to offer a robust argument for reducing overdose, it also undermined the campaign with some odd statements and inclusions, such as “Due to the controversial nature of drug harm reduction and naloxone access”, and it confusingly recommends consideration for an option to: “legal protection from arrest for drug possession and/or the act of injecting someone for people who administer naloxone in an emergency situation”, [my highlight in red], as well as recommending “reclassifying naloxone as restricted medication” rather than pharmacy only, largely it seems, to ensure that anyone who accesses naloxone must receive training. The briefing paper also offered some odd arguments against naloxone: “There may also be views that wider access is not necessary with naloxone already available in hospitals and with advanced paramedics” and then further posited the view that “[naloxone] will lead to greater risk taking behaviour”.
There are other disconcerting aspects buried within what might otherwise give the impression of a solid report arguing for greater naloxone distribution, such as the omission of data concerning the high percentage of overdose deaths that occur before the medics arrive, for example, a London study by Hickman et al (2007:320) found that when an ambulance was called the person who overdosed was already dead before the arrival of the ambulance in 85% of cases. Had this information been understood and included in the NZ Drug Foundation background paper they would surely have given greater emphasis to ensuring naloxone is in the hands of People Who Inject Drugs (PWID), their friends and family, but the report seems to prioritise naloxone training over naloxone distribution. The recommendations in the paper also include loopholes that seem to almost invite a piecemeal approach to distributing naloxone, by suggesting various components of naloxone distribution could be seen as possible ‘separate options’ for consideration.
a London study by Hickman et al (2007:320) found that when an ambulance was called the person who overdosed was already dead before the arrival of the ambulance in 85% of cases
While this paper was primarily about the role of naloxone to reduce overdose death, it was an ideal opportunity to mention closely related strategies known to reduce OD deaths in New Zealand, such as the benefit of allowing prescribing injectable drugs in New Zealand to people who continually inject rather than restrict them to oral methadone which is then invariably injected, or the effectiveness of Drug Consumption Rooms in reducing overdose. Here’s a link to the report that includes my highlighted concerns and critique.
Despite the absence of any clear formal commitment to wider naloxone distribution, the campaigning in Aotearoa NZ must continue for naloxone take-home, and indeed for other strategies to reduce overdose and drug policy harm, including: drug checking; prescribing injectable opioids to opioid injectors; a Good Samaritan Law to end arrests for possession and manslaughter when co-users call for emergency help; end the risk of criminalisation for possession of needles and utensils in New Zealand (unless proven to be obtained from the needle exchanges); and establishing Drug Consumption Rooms.
In view of this failure to put naloxone on the formal agenda, it was somewhat incongruous see the Director of the NZ Drug Foundation on International Overdose Day showcase a persuasively well-argued newspaper article (with no sense of irony or doublespeak), asserting that ‘New Zealand must do more to tackle overdose‘ and distribute naloxone. If the New Zealand Drug Foundation had proactively promoted the need for naloxone, it may have been quite different. Arguably, it’s New Zealand Drug Foundation, in its pivotal drug policy advisory role, that needs to do more to tackle overdose and push for naloxone distribution.
It is hard to understand given the insights clearly displayed in their newspaper piece on International Overdose Day (August 2015), why the New Zealand Drug Foundation omitted naloxone from important documents (the Wellington Declaration & subsequently the Harm Reduction Briefing to Parliament), and why they haven’t campaigned when and where it matters, for naloxone take-home from the outset. Staff from the NZ Drug Foundation did, however, as promoted and prioritised in the harm reduction Briefing to Parliament, go to Vienna and New York (see here) and engage in the inertia of the UN drug control system that is committed to a ‘drug’ free world.
With an alternative emphasis on promoting evidence-based drug policy reform in New Zealand rather than international drug policy and networking, important drug policy harms could be tackled. Key drug policy issues that need tackling here in New Zealand include:
2. There is no naloxone take home.
3. There is no injectable maintenance prescribing.
4. There is no heroin prescribing.
5. There is no Good Samaritan law.
6. There are no Drug Consumption Rooms / Supervised Injection Facilities.
7. Unemployed people on state benefits are drug tested and lose benefits if they repeatedly test positive for illegal drugs.
8. People with life-limiting illnesses are criminalised if caught self-medicating with cannabis.
9. The Police and Air Force scour the countryside every year digging up millions of dollars worth of cannabis plants.
10. The Alcohol and Other Drug Treatment Courts adopted from the USA and based on an abstinence and disease model of addiction that uses scram bracelets and random alcohol and drug testing, have had their five-year ‘pilot’ extended a further three years.
11. New legislation came in force in February 2018 that gives the government powers to compulsory assess and compulsory treat someone considered to have an addiction problem.
12. The Psychoactive Substances Act 2013 extended the net of prohibition by making possession and supply of every NPS an automatic offence – unless the substance is subsequently approved by the state (none have been approved).
13. Housing NZ has fuelled an unfounded moral panic about methamphetamine contaminated houses evicting tenants and awarding over $100m to companies to supposedly decontaminate houses.
The 2016 and 2017 CND and UNGASS meetings predictably delivered no tangible positive outcomes or progress. New Zealand users, families and friends are still struggling to gain access to naloxone. Distribution has been agreed in principle, but procrastination concerning the cost and production of additional health education material to accompany the naloxone have stalled distribution.
Having failed to even mention naloxone in the weighty 2013 Wellington Drug Policy Declaration, and failed to mention it in the 2015 Briefing to Parliament, the urgent need for naloxone was finally acknowledged by the New Zealand Drug Foundation in their December 2017 Briefing to new Labour/NZF/Green Parliament, but it’s been too little and too late. On International Overdose Awareness Day 2018 users, family and friends were still waiting for access to naloxone.
While nations like New Zealand, inexcusably fail to deliver easy to implement evidence based drug policy reforms at a national level but instead invest considerable energy in high maintenance international drug policy reform gatherings, serious harms will continue. However, a growing number of drug reformers are recognising the need for genuine national policy transformation. It is time to stop talking the talk and start delivering evidence-based drug policies locally and nationally, including low threshold, easy access, naloxone take home.
In the meantime, people who use illicit drugs in New Zealand are needlessly suffering, some are dying. No naloxone take home – no excuse.
It is literally a matter of life or death.
Dr Julian Buchanan, is a retired Associate Professor, Victoria University of Wellington, Institute of Criminology
31st August 2015 on International Overdose Day. (updated 31s August 2018)