Jo Neale is Reader in Qualitative and Mixed Methods Research based within the National Addiction Centre and working across the Biomedical Research Centre at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK. She is also an Adjunct Professor in the Centre for Social Research in Health at the University of New South Wales, Australia. Jo originally qualified as a social worker and has held positions at the University of Glasgow, the University of York, and more recently Oxford Brookes University UK, where she was Professor of Public Health. Jo has undertaken a range of qualitative and quantitative studies exploring topics relating to both homelessness and addiction. She is the Senior Qualitative Editor and Deputy Commissioning Editor for the international journal Addiction; a member of the editorial board of The International Journal of Drug Policy; a Trustee of the Society for the Study of Addiction; and a member of the expert committee of Action on Addiction.
Naloxone - Does over-antagonism matter? Evidence of iatrogenic harm after emergency treatment of heroin/opioid overdose
Dr Joanne Neale and Professor John Strang
Background: Better understanding of opiate users’ views and experiences of emergency naloxone is needed to support medical care and decision-making, and to inform the wider pre-supply of naloxone.
Aim: To analyze drug users’ views and experiences of naloxone during emergency resuscitation after illicit opiate overdose in order to identify: i. any evidence of harm caused by excessive naloxone dosing (‘over-antagonism’); and ii. implications for the medical administration of naloxone within contemporary emergency settings.
Methods: Re-analysis of a historic ethnographic study of non-fatal overdose funded by the Scottish Office. Data were generated from 70 face-to-face interviews conducted within a few hours of heroin/opioid overdose occurring, supplemented by observations from hospital settings and a further 130 interviews. The research took place in Glasgow and Dundee between 1997 and 1999.
Findings: Participants had limited knowledge of naloxone and its pharmacology, yet routinely described it in negative terms and were critical of its medical administration. In particular, they complained that naloxone induced acute withdrawal symptoms, causing patients to refuse treatment, become aggressive, discharge themselves from hospital, and take additional street drugs to counter the naloxone effects. Participants believed that hospital staff should administer naloxone selectively and cautiously and prescribe counter-naloxone medication if dosing precipitated withdrawals. In contrast, observational data indicated that participants did not always know that they had received naloxone and hospital doctors did not necessarily administer it incautiously.
Conclusions: Opiate users repeatedly reported harm caused by naloxone over-antagonism. The concept of contemporary legend helps to explain why naloxone had such a poor reputation amongst opiate users. Good treatment in emergency settings involves building and sustaining trust with patients and those who accompany them. Protocols are needed for titrating naloxone dose against response to prevent sudden acute withdrawal syndrome, with attendant risks of self-discharge, further drug use and even death.
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