Nasal naloxone for overdose prevention in Norway: results from the first four years
Opioid overdose (OD) deaths are the most serious consequence of drug use. With an annual rate of around 70 deaths per million, Norway is among the most affected countries in Europe. Factors known to contribute to the high OD mortality are injecting opioids as the preferred route and the large extent of mixing opioids with other drugs. In 2014, the Norwegian Department of Health launched a National Overdose Prevention Strategy, which included a widespread naloxone distribution program. An important feature of naloxone distribution to people who inject drugs (PWID) was the provision of nasal spray as a needle free device. After four years, the interim nasal spray (2 mg naloxone per 2 ml prefilled syringe, with atomizer attached) that the Norwegian Medicines Agency accepted for use in the project was exchanged with regularly marketed spray in June 2018.
The oral presentation will report detailed findings from the first four years of the National naloxone distribution program, whereas preliminary results are given in approximated numbers below.
The naloxone project includes over 60 locations, hundreds of staff, and several municipalities. Naloxone distribution started in the two cities with the highest OD death burden (Oslo and Bergen). It was then expanded annually to cover the majority of affected municipalities. Staff from existing facilities were trained to be overdose prevention trainers in order to include established infrastructures and thus a variety of key stakeholders. The main outcomes were a) naloxone coverage as number of sprays distributed in the communities at risk, b) self-reported reversal rates from individuals returning for replenishment of naloxone and c) OD mortality rates.
In the first four years of the project, around 8000 naloxone sprays were distributed in total. The estimated coverage rate of 100 distributed sprays per 100 000 population was achieved during the first year after project start. During the first three years alone, naloxone sprays were replenished about 2500 times and we are currently analysing data to achieve complete four year figures including updated numbers of reported reversals. Self-report on reversals from the first 2,5 years points to a success rate of 95 % among around 600 sprays used on overdose victims. Overdose mortality has continued at a high rate in Norway, however, the latest numbers for the year 2017 may indicate a downward trend. Moreover, heroin overdose deaths comprise a significantly smaller proportion in 2017, whereas there is an upward trend for OD deaths caused by prescription opioids.
Nasal naloxone distribution in Norway was implemented successfully with high coverage rates among PWID and feedback indicating successful reversals in the majority of cases. However, a significant impact on overdose mortality has not yet been achieved. Naloxone distribution needs to be expanded to at risk populations other than PWID such as patients receiving opioid maintenance treatment or drug-involved inmates. We also need to reach out to prescription opioid users and individuals using opioids irregularly or by accident.