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The problem
Opioid overdose deaths can be prevented if someone nearby recognizes the overdose, calls for help and gives naloxone, a drug that reverses the effects of opioids. Many overdoses happen at home or in public places, where the first person on the scene is a family member, friend or bystander rather than a health professional.
The intervention
Overdose education and naloxone distribution (OEND) programs give people who use opioids, their families and community workers naloxone kits, along with training to prevent, recognize and respond to an overdose: calling emergency services, rescue breathing and giving naloxone.
Evidence
Walley et al. (2013) studied 19 Massachusetts communities with at least five fatal opioid overdoses in each year from 2004 to 2006. OEND programs trained 2,912 potential bystanders, who reported 327 rescues. Compared with communities without OEND, communities with 1 to 100 enrollments per 100,000 people had a lower adjusted rate of opioid overdose deaths (rate ratio 0.73), and those with more than 100 enrollments per 100,000 had a lower rate still (0.54). Acute care use did not differ significantly. The design was an interrupted time series, which is observational, so other changes in those communities could also have contributed.
A systematic review of 22 observational studies found that take-home naloxone met all nine Bradford Hill criteria for a causal relationship, a framework used when randomized trials aren't available. Fatal outcomes still occurred in 1 in 123 overdoses in which naloxone was given (0.8%), and adverse events were rare. The authors concluded that take-home naloxone reduces overdose deaths among program participants and in the community (McDonald & Strang, 2016).
Access today
In 2023 the US Food and Drug Administration approved the first naloxone nasal spray for sale over the counter, without a prescription (US Food and Drug Administration, 2023). That removes one barrier, but cost, stigma and not knowing how to respond still stand in the way.
The public health nurse's role
| Level of prevention | Nursing actions |
|---|---|
| Primary | Teach safe storage and disposal of opioids at community events and in schools |
| Secondary | Offer OEND training and naloxone kits at syringe service programs, shelters, libraries and pharmacies; teach the signs of overdose (unresponsiveness, slow or no breathing, pinpoint pupils, blue lips) |
| Tertiary | Link people who have survived an overdose to treatment for opioid use disorder, and follow up after emergency department visits |
Nurses can also address stigma by using person-first language, partnering with people with lived experience as trainers, and making naloxone visible and routine.
Evaluation
A county program can track the number of people trained, kits distributed, reported reversals and the county's opioid overdose death rate over time, compared with neighboring counties.
Conclusion
Observational evidence consistently shows that putting naloxone in the hands of bystanders saves lives. Public health nurses are well placed to train communities and to connect survivors to ongoing care.
References
McDonald, R., & Strang, J. (2016). Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction, 111(7), 1177–1187. https://doi.org/10.1111/add.13326
US Food and Drug Administration. (2023, March 29). FDA approves first over-the-counter naloxone nasal spray [Press release]. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray
Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, Article f174. https://doi.org/10.1136/bmj.f174
