1. Recommendations on the Management of Opioid Overdose Ruth Birgin

2. The proposed package Essential health sector interventions 1.Comprehensive condom and lubricant programmes 2.Harm reduction interventions for substance use –needle and syringe programmes & opioid substitution therapy –community distribution of naloxone 3.Behavioural interventions 4.HIV testing and counselling 5.HIV treatment and care 6.Sexual and reproductive health interventions 7.Prevention and management of co-infection and other co-morbidities including viral hepatitis, tuberculosis and mental health conditions. Essential strategies for an enabling environment 1.Supportive legislation, policy and financial commitment, – including decriminalization of behaviors of key populations 2.Addressing stigma and discrimination 3.Community empowerment 4.Addressing violence against people from key populations

3. Opioid overdose Significant mortality globally Main cause of death for people living with HIV who inject drugs While sedation occurs within seconds, there is time to revere the effects, resuscitate and prevent death (1-3 hrs)

4. Risk factors Higher –history of opioid dependence –post detoxification released from prison first two weeks of methadone treatment –taking other sedatives (valium, alcohol etc) –unknown purity/dose Lower –in opioid maintenance treatment –not injecting opioids

5. Naloxone Reverses opioid overdose within minutes Recommended by WHO – on WHO list of essential medicines 60% of fatal overdoses are witnessed Peer use of naloxone –widespread in US, UK, RF, Thailand, Australia US treated > 10.000 overdoses people who use drugs proficient responders able to administer and in immediate vicinity –Experience in challenging environments eg Vietnam

6. Mini-jet naloxone 400 micrograms per 1 ml Pre-filled syringe 1 mg per ml, 2 ml syringe Different preparations

7. WHO opioid overdose guidelines Process of rigorous systematic reviews: evidence values and preferences costs and benefits potential harms

8. Recommendation One People likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of suspected opioid overdose.

9. Recommendation Two Naloxone is effective when delivered by IV,IM, IN and SC, routes of administration. Persons using naloxone should select a route of administration based on the formulation available, their skills in administration, the setting and local context.

10. Recommendation Three In suspected opioid overdose, first responders should focus on airway maintenance, assisting ventilation and giving naloxone.

11. Recommendation Four After successful resuscitation following the administration of naloxone the affected person should wherever possible have their level of consciousness and breathing closely observed until they have fully recovered.

12. Key findings from community consultation 1.Naloxone is a cheap, safe, easy-to-use, life- saving drug 2.Community distribution of naloxone should be added as an element of the comprehensive harm reduction package 3.Pre-loaded syringes or nasal spray are preferred 4.The importance of rescue breathing must be emphasized along with distribution of naloxone.

13. “There’s something so symbolic about naloxone. It’s a life-saving intervention. If you say community distribution is not worth [doing], it’s a value judgment on our lives.” (a peer respondent)

14. Structural barriers Current limited availability –including in health care settings and in ambulances Scheduling –prescription limitations –medical personnel only Policy obstacles –criminalization of drug use –police interference

15. Next steps Increase awareness and access –PUD community involvement essential Improve enabling environment –Review of laws, legislation and decriminalisation Regulatory issues of naloxone –Work with criminal justice Community engagement, empowerment –national adaptation of these guidelines –develop practical implementation tools –eg NSP, DUIT