"Supersavers" manages large proportion of opioid overdoses – 5-year follow-up of a regional naloxone program, Sweden

Background: With Sweden having one of the highest proportions of drug related deaths in EU, broad scale overdose prevention education and naloxone distribution (OPEND) an important tool in managing an acute situation as it may contribute to reduced number of victims to overdose mortality and morbidity. Therefore, a multi-site naloxone program was implemented in Skåne County, population of 1.4 million, in 2018. Five years into the program, more than 50 units had been included in the program offering multi-site OPEND. 
To this date, naloxone may only be prescribed to a person at risk of opioid overdose, according to Swedish regulations. Within Skåne County Naloxone program patients were given a kit containing two doses of intranasal naloxone at the end of brief training-session, free of charge. Upon patients return for naloxone refill staff asked what had happened to the previous dose(s). 
Methods: Basic baseline data (age, city, facility, and date for training participation or trained previously) was collected for all OPEND patients. Follow-up data was collected upon return for refill, where previous kit was noted as used on someone else, used on oneself, lost, given, stolen, not known, or expired. Further investigation into naloxone usage records showed 74 cases of individuals having used naloxone for overdose reversal on three occasions or more, of which 50 could be traced throughout the entire period, thus eliminating cases for those who may have reported three or more overdose reversals at multiple sites. Data was collected between June 2018 – June 2023. The study was approved by the Regional Ethics Board, Lund (file no. 2020-05176).
Results: In this 5-year follow up, 2685 participants were provided with OPEND, 29% women and with a mean age of 39.5 (men 39.9; range 18-74, women 38.4; range 18-73). A total number of 5 900 kits were distributed of which naloxone was used for overdose reversal in 926 events, of which 69 had been used on the person whom it was prescribed for, while in 857 (93%) cases naloxone had been used on someone else, with an average of 0.3 reversals per trained individual. A small group (<2%, n=50) of “supersavers”, had reported naloxone use on three or more occasions, accounting for 32% (n=275) of all reversals on others, or 5.5 reversals per trained individual. Women made up for 40% of these “supersavers”. Mean age in this group was 39.6 years (men 41.5; range 25-73, women 36.5; range 22-54).
Conclusions: To date, this has been a rather unexplored territory, more research is needed to explore this core group of “supersavers”. This rather small group of individuals who shoulders a large share of the social responsibility of overdose reversals in the community. More in-depth analysis and further investigation into their situation and specific needs to assure that these individuals are provided with easily accessed and needed support to maintain sustainable conditions enabling them to continue their important work.