Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria

By Rebecca McDonald and John Strang

Opioid overdose represents a major cause of premature death and accounts for the majority of deaths among injection drug users (IDUs) world-wide. Opioid overdose deaths are preventable through timely administration of naloxone, a potent mu-opiate antagonist that rapidly reverses opiate-induced respiratory depression.

In 2014, the World Health Organization (WHO) launched guidelines on the community management of opioid overdose, recommending that ‘people likely to witness an opioid overdose should have access to naloxone and be instructed in its administration’.

The community-based provision of naloxone rescue kits to opioid users (‘take-home naloxone’, THN) was first proposed in the 1990s. THN programmes typically involve training opioid users and/or their family members or peers in overdose risk awareness, overdose emergency management and naloxone administration. During the past 15 years, THN programmes have been implemented in Europe, North America, Asia and Australia. However, the vast majority of evaluations have been pilot schemes with uncontrolled study designs.

The evaluation of THN programmes is challenging: randomized controlled trials (RCTs) are often considered the gold standard of scientific study of clinical impact, but conducting such trials in this context would often be unethical and fraught with methodological difficulties, given the infrequency and unpredictability of overdose.

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