Why is access to naloxone still a problem across New Zealand after all these years?

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 forty page report they prepared failed to mention the desperate need for naloxone. 

A year later in 2014, the WHO recommended wide distribution of naloxone, however, rather than present a robust case for naloxone distribution in New Zealand, the NZ Drug Foundation in its August 2014 Matters of Substance Magazine featured an article that presented Naloxone take-home as a contestable issue, open to debate. The Drug Foundation presented arguments for and indeed against naloxone distribution! The article included some spurious arguments against naloxone distribution including “there could be an unintended consequence from widening availability of naloxone” and further, “people could become less cautious about their drug use because they know life-saving treatment is close at hand”.

In October 2014 after the National Party was re-elected the NZ Drug Foundation prepared a twenty-page Briefing Paper to Parliament 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, and specifically highlighted the need to tackle deaths caused by huffing solvents, but astonishingly made no reference or representation concerning fatal opioid overdoses, nor did it make any mention of the need to distribute naloxone to users, families and friends.

With this lack of 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 urged by the NZ Drug Foundation Briefing Paper, prioritise a commitment to ensure New Zealand would be represented at international UNGASS meeting in New York and the UNCND meetings in Vienna (p.22).

Belatedly, in 2015 the Foundation magazine ‘Matters of Substance’ published a better informed feature on Naloxone after the embarrassing publication of a ‘for or against’ naloxone debate feature. This was then followed by a stand-alone Naloxone Background Paper (my highlights and comments in red). However, while this background paper included some excellent sources and appeared to offer a robust argument for reducing overdose, it also worryingly undermined the need for naloxone with some odd statements and inclusions, such as: “Due to the controversial nature of drug harm reduction and naloxone access”; and it ambiguously recommended consideration for an option for: “legal protection from arrest for drug possession and/or the act of injecting someone for people who administer naloxone in an emergency situation” (surely it’s both); and worryingly recommended “reclassifying naloxone as restricted medication” rather than on general sale in pharmacy as it is in the USA. There was also a questionable emphasis that people must have training before they can be issued naloxone. The briefing paper once again included some odd arguments that undermined the need for naloxone distribution: “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 opinion that “[naloxone] will lead to greater risk taking behaviour”.

There are other disconcerting aspects buried within the briefing such as the omission of data concerning the high percentage of overdose deaths that importantly 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 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:

1. Possession of needle/syringes is an offence if it can be proved they were not obtained from a Needle Exchange.
2. There is no nationwide naloxone take home for family, friends and users.
3. There is no long term 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 can lose benefits if they repeatedly test positive for illegal drugs.
8. People are criminalised if caught self-medicating with cannabis unless the can prove in court they have a medical defence.
9. 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 been rolled out further.
10. 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.
11. 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).
12. Housing NZ has fuelled an unfounded moral panic about methamphetamine contaminated houses evicting tenants and awarding over $100m to companies to supposedly decontaminate houses.

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.

The 2016 and 2017 CND and UNGASS meetings predictably delivered no tangible positive outcomes or progress for drug reform.  New Zealand users, families and friends are still struggling to gain easy access to naloxone. In 2018 naloxone distribution was agreed in principle, but two years of procrastination concerning the production of additional health education material to accompany the new naloxone product stalled distribution.

While nations like New Zealand, inexcusably fail to deliver easy to implement evidence-based harm reduction 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 nationwide low threshold, easy access, naloxone take home.

Until then, people who use illicit drugs in New Zealand are needlessly suffering, some are dying. No naloxone take home – no excuse. It is already a matter of life or death, and judging from other countries, the issue will only get worse once fentanyl is widely available. 

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TIMELINE

1996 The USA begin distributing naloxone to prevent fatal overdose.

2010 Scotland announce their Naloxone Take Home programme

2011 After a two year pilot Wales begin a National Naloxone distribution programme.

2011 After three years inquiry the NZ Law Commission deliver a comprehensive review of the Misuse of Drugs Act and recommend the Act be rescinded and replaced with new Health based legislation. They also recommend an automatic caution scheme for all personal drug possession, the legalisation of utensils and ending all imprisonment for social drug dealing. 

2012 The Australian Capital Territory (ACT) Government announced Australia’s first program to provide naloxone to trained potential overdose witnesses.

2013 New Zealand Drug Foundation set up a selective invitation-only National Drug Policy Think Tank Event. After two days debating priorities, values and strategy, to shape the future of drug policy in Aotearoa, their forty page report – fails to make any mention whatsoever of naloxone.

2014, The WHO recommends the distribution of naloxone must involve users, family, friends and associates.

2014 The NZ Drug Foundation prepare a twenty-page Briefing Paper to Parliament for the newly re-elected National Government. The Briefing is designed to identify key drug policy priorities to enable ‘opportunities to make real reductions in drug-related harm‘ – but it makes no mention whatsoever of naloxone.

2014 The Drug Foundation Magazine Matters of Substance published an article on naloxone and frames it as a contentious issue for debate and offers arguments against naloxone distribution suggesting naloxone might increase risky drug behaviour, and the number of O/D’s is too low to warrant naloxone distribution.

2015 The Drug Foundation produce a more weighty Naloxone Background Paper arguing for naloxone take home – but at the same time includes some odd statements such as: “Due to the controversial nature of drug harm reduction and naloxone access”; and it worryingly recommended “reclassifying naloxone as restricted medication”, rather than on general sale in pharmacy as it is in the USA. There was also a questionable emphasis that people must have training before they can be issued naloxone. The briefing paper also stated: “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 opinion that “[naloxone] will lead to greater risk taking behaviour”. The background paper omitted data showing a high percentage of overdose deaths crucially occur before the medics arrive Hickman et al (2007:320), which emphasises the need to get naloxone in the hands of users, family, friends and associates. 

2015 UK regulations introduced to permit naloxone to be supplied without a prescription to make naloxone more widely available across England. Wales, Northern Ireland and Scotland had already established nationwide Take Home Naloxone programmes

2015 The new National Government publish their 5yrs Drug Strategy (2015-2020) unsurprisingly it makes no mention of naloxone. However, as urged in the NZ Drug Foundation Briefing Paper above, the strategy includes a commitment to ensure delegates from New Zealand (including Drug Foundation staff) would be supported to attend the international UNGASS meeting in New York, USA and the UNCND meetings in Vienna, Austria (p.22).

December 2017 The NZ Drug Foundation Briefing Paper to Parliament for the Labour led coalition government finally recommends “Urgent action to fund and distribute naloxone emergency overdose kits to people using opioids, their families and service providers.

January 2019 The New Zealand Drug Foundation publishes a twelve page  ‘State of the Nation’ report to identify current concerns in NZ drug policy – but it makes no mention whatsoever of naloxone.

November 2019 The New Zealand Drug Foundation publishes their ‘State of the Nation’ report to identify current concerns in NZ drug policy – but it makes no mention whatsoever of naloxone.

October 2020 Ross Bell Executive Director resigns from the New Zealand Drug Foundation

December 2020 The New Zealand Drug Foundation publishes their ‘State of the Nation’ report to identify current concerns in NZ drug policy – but it makes no mention whatsoever of naloxone.

December 2020 Sarah Helm is appointed as the new Executive Director of the New Zealand Drug Foundation

August 2021 Sarah Helm in anticipation of International Overdose Day on 31st August 2021 states she was: ‘shocked to read this blog from my predecessor Ross Bell, written in 2015. So little has progressed – if anything, since it was written, things have gotten worse. The time for change is well and truly overdue.’

February 2022 State of the Nation Report finally puts naloxone back on the agenda and urges the government to distribute naloxone take home.

June 2022 Twelve people admitted to hospital from fentanyl – they thought they were purchasing methamphetamine or cocaine. Still no nationwide easy access to naloxone take home.  

Julian Buchanan

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Dr Julian Buchanan, is a retired Associate Professor, Victoria University of Wellington, Institute of Criminology

Written 31st August 2015 on International Overdose Day (updated timeline)