Vol. 6 Nasal naloxone, spectroscopes, interim OAT and not going to the doctor.

This week I am trying a little experiment with a quick and dirty 4x100 which I think could be a regular format. Four new papers and around 100 words on each. Of course, that means I can only give the briefest of overviews so dive into the full paper¹ for the details. 

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Comparison of intranasal and intramuscular naloxone in opioid overdoses managed by ambulance staff: a double-dummy, randomised, controlled trial. Skulberg AK, et al. Addiction. https://doi.org/10.1111/add.15806

IM or nasal naloxone? This Norwegian study was about resuscitating people who have gone over. They looked at 201 overdoses (almost all heroin) and found that 97.2% returned to spontaneous respirations in 10 minutes with a single dose of 0.8mg IM naloxone and 79.6% in the intranasal group who got 1.4mg/0.1ml. There are subtleties here to unpick. Bear in mind this important point: ideally, naloxone is titrated up to avoid over-reversal and triggering withdrawal. The near 100% reversal with 0.8mg IM suggests it is perhaps too potent. Good for a one and done approach but, arguably, the intranasal is better for professional staff who can give a further dose as needed.

Rapid and accurate etizolam detection using surface-enhanced Raman spectroscopy for community drug checking. Gozdzialski L, et al International Journal of Drug Policy. https://doi.org/10.1016/j.drugpo.2022.103611

Etizolam is a problem benzo but how the hell do we spot it without drug checking services? There is a huge safety concern here - if people knew what they were taking they'd be less likely to suffer overdoses and deaths. Read McAuley, Matheson and Robertson’s excellent report for more on etizolam and other benzos in Scotland. Here, they found etizolam in opioid samples with a specificity of 86% and a sensitivity of 90%. Decent. I'm not expecting spectroscopes to suddenly get dropped into UK services - but we need some kind of drug checking services if we want to get serious on reducing harm. 

Interim opioid agonist treatment for opioid addiction: a systematic review. Samsó Jofra L et al. Harm Reduction Journal. https://doi.org/10.1186/s12954-022-00592-x

'Interim' opioid agonist treatment (OAT) is used when systems can't manage the demand to provide OAT in regular services. Rather than making people wait they bang them on a script - it's often known as low-threshold treatment. This systematic review included six studies - five of which were RCTs. They found that interim OAT didn't differ from standard treatment when looking at retention, reductions in heroin and cocaine use, and reduction in criminal activities. It is a salutary lesson that any kind of access to opiate substitution therapy does a damn good job at helping people. And, raises slight concerns about why 'standard treatment' isn't markedly better… 

Healthcare seeking among Swedish patients in opioid substitution treatment – a mixed methods study on barriers and facilitators. Troberg K et al, Substance Abuse Treatment, Prevention, and Policy. https://doi.org/10.1186/s13011-022-00434-w

This was a mixed methods study with data from 209 Swedish people on OST with an in-depth qualitative element with 11 of those. Why didn't they seek healthcare? Most commonly, because they deprioritised healthcare. They were concerned about their health but when they were actively using there were too many other priorities to consider. It just got pushed down the list. The next four themes: they feared being labelled a junky [sic]; they were afraid of being treated badly; they had tried without success; and they were simply resigned to it all. Stigma, stigma, prejudice, despair. All depressingly familiar. 

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In the pipeline

More of these 4x100s are planned. I also have some longer essays in draft form - one around the myth of methadone rotting teeth is well advanced and I’m teeing up some good ol’ fashioned rants. The syphilitic chancre that is competitive tendering and re-tendering of drug services in England is high on the polemic list. But, to be fair, that particular list is lengthy and, each week, I seem to get angrier and more gets added to it. 😀

Take care and look after yourselves.

1. I am using my own citation style. Title of paper, first author and the journal. I'll then offer the full DOI link. This is the best URL as it will always point to the most up-to-date version of a paper as it progresses through online first/early view versions and you also have the DOI if you need to search manually. Let me know if you have difficulty accessing a link/paper.