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Take Home Naloxone program – who is this really aimed at helping?

take home naloxone

I’ve had a few issues with Australia’s Take Home Naloxone program, most specifically the way it has been marketed. The constant implication is that chronic pain patients on long term opioid therapy are in need of naloxone because they are overdosing left right and centre.

That is not true. 

Chronic pain patients on long term opioid therapy generally take their medicines exactly as prescribed and do so safely.  Less than 1% of chronic pain patients overdose, according to recent, large scale, well-designed studies. 

That has been the point I have been making in discussions about this program. I am not against naloxone being available free at community pharmacies and elsewhere. I believe it’s a very good initiative.

What I am against is the constant smearing of chronic pain patients on long term opioid therapy. I predicted that chronic pain patients would not need naloxone and there would not be good uptake by chronic pain patients, for the reasons stated above.   And it seems my opinion is correct.

Today I see this article in the Sydney Morning Herald titled “The free life-saving opioid antidote that remains unused”.

Or, Take Home Naloxone has been a giant waste of money.

And while this result is vindicating, it does not make me happy.   And I am still angry, because the first line of this article states:

“A free drug that can save the life of someone overdosing on prescription painkillers is remaining unused on the shelves, with advocates concerned the fear of being labelled an opioid abuser is putting people at risk.”

Firstly, WHY did the journalist single out prescription painkillers?  The vast majority of overdoses are related to illicit drugs and diverted prescriptions.  That is, people taking pharmaceutical opioids that were NOT prescribed to them. 

And which advocates are saying that people are not asking for naloxone for fear of being seen as an opioid abuser?

Addiction specialists.  

Not pain management doctors. Not GPs who treat chronic pain.  Certainly not patient advocates.  These ‘advocates’ are people who have no idea what they are talking about in relation to chronic pain patients and prescription opioids.  Yet the media publishes their opinions as expert.

Ironic that the article talks about people not accessing naloxone due to stigma, and then goes ahead and heaps a whole lot of stigma on chronic pain patients who rely on long term opioid therapy.

It is not stigma stopping people with chronic pain accessing naloxone. We simple do not need it. This program was marketed as helping people with chronic pain, it is not for us.  I’m glad it exists because I agree, death by overdose is 100% preventable, and for that reason, is doubly tragic.   I hope the Take Home Naloxone Program is saving lives.

But it’s not pain patients who are overdosing.

They instigated this program on the basis of highly inflated overdose numbers and inflated estimates of benefit. No surprise that no one is asking for naloxone.  There just aren’t as many people on long term opioid therapy overdosing as they said there were.

And the 19 million dollars’ worth of naloxone is remaining on the shelves. No surprises there.

Th article continues:

“Nearly half of NSW’s 2000 community pharmacies have signed up for the $19.6 million Naloxone Take-Home program, with only 23,000 doses distributed across the state since the program launched in July last year, an average of 11.5 doses per participating pharmacy.

Nationally, 136,776 doses have been distributed, reversing an estimated 3000 opioid overdoses, or eight adverse reactions, a day.”

Three thousand lives potentially saved is a very good thing. But apparently not good enough, because we need the scare tactics:

“Director of the King’s Cross Medically Supervised Injecting Centre Dr Marianne Jauncey said more people on prescription opioids needed to be aware of this program.

“The mechanism of death from opiates is identical to heroin. Anyone prescribed significant long-acting opioid medication should be aware of this,” she said.”

Excuse me, Dr Jauncey, we’re not ignorant. Chronic pain patients know the risk and benefits of opioids.  We take our opioids medications safely, as prescribed by our doctors, to treat pain, not addiction.  International studies show people living with chronic pain ARE NOT the people who are overdosing!   

We don’t have Australian studies, and we don’t have proper Australian statistics.  The way the data is captured means that we don’t have the granularity to know who is overdosing, on which opioids and why.

If the government cared about these deaths, they would spend some money on collecting proper statistics.  They would check when a person overdoses on a pharmaceutical opioid, whether that person has a valid script for that medicine.  That would be important data to capture.  Right now, there is no way to tell.    

It would not be difficult to find out.  It could be a lowly admin persons job to check a database, see if the deceased had a valid prescription.  It’s not hard.

Could it be they don’t want that information to be public?

Could it be that they want to continue blaming chronic pain patients and demonising people on long term opioid therapy?  What would they do if the statistics showed that chronic pain patients aren’t the ones accidentally overdosing, as the evidence shows?  What would they do if the data showed that opioids are actually very safe long term?

That’s why they don’t collect that data.

“Jauncey said doctors needed to discuss with patients the warning signs of opioid overdose, such as snoring, along with risk factors including alcohol and sleeping tablets.”

I’m sorry, SNORING is now a sign of impending overdose?  Really? JFHC.  This is ridiculous, how can a doctor say this? 

Looking at many reputable sites, sign of overdose do include “unusual gurgling sounds, or snore like sounds otherwise known as a ‘death rattle’”.

A death rattle is a far cry from snoring.

This woman is being purposefully alarmist.  And obtuse.  And providing DISinformation.   A lot of people snore. That does not mean they are overdosing.

And I am very sure that the Director of the King’s Cross Medically Supervised Injecting Centre knows nothing about chronic pain, or the treatment of chronic pain with opioids.  She is way out of her area of expertise.  But she gets media space, meanwhile chronic pain advocates on long term opioid therapy are ignored.  We have no voice in this debate.

The real problem is the way in which overdose data is captured.  Obviously, the data is available, but the way it is coded into the Australian Bureau of Statistics system means the required granularity to know who is overdosing, on which medicines and why, is lost.  Once coded, that data is gone forever.

The data separates opioids into largely meaningless categories that serve more to muddy the waters than add much of anything helpful.

Heroin and methadone each have their separate category, and that makes sense.  Obviously, heroin overdoses are illicit drug users.  Most methadone users would be people on medication assisted treatment for opioid use disorder, people in recovery.  Therefore, these would be illicit opioids users also.  

Where it goes wrong, is they then categorise the rest of the common opioids into those derived from the poppy plant and those that are synthetic, or man-made in a lab.  In truth, all opioids are made in a lab.  And whether the opioid was derived from a poppy or whether it was synthesised is an utterly meaningless distinction.  They all behave the same way in the body. 

So those opioids that come from the poppy plant are codeine, oxycodone, hydromorphone and morphine. Those that are synthetic include fentanyl, tramadol, pethidine and tapentadol.  Once coded, it is no longer possible to know which drug caused the overdose, only these categories. We can’t tell if most people overdosed on oxycodone or tapentadol or codeine, that data is lost because they are all grouped together.

It would be good to know if most people were overdosing on strong opioids, or weak opioids, but we can’t tell that either, because both categories contain both strong opioids and weak opioids.  So, no help there.

It would helpful if they categorised those opioids most commonly used for the treatment of chronic pain together.  Those would be oxycodone, morphine, and tapentadol.  But oxycodone and morphine are in the poppy category and tapentadol is in the synthetic category.  So no conclusions can be drawn there.  

Buprenorphine is commonly prescribed as opioid agonist therapy to people with opioid use disorder and is more and more commonly being prescribed for chronic pain.  Many people have been forced off their current opioid and forced to switch to buprenorphine, as it is considered safer.  But there is no way to tell if this is true, however, no way to tell if buprenorphine really IS safer, because buprenorphine is just lumped in the synthetic category.  People are being forced onto a less effective pain medicine with no evidence that is IS, in fact, any safer.

They simply do not capture the data in a way that makes any logical sense or is useful to target populations to prevent overdoses.

Additionally, the way heroin is metabolised contributes to heroin deaths being classified as morphine overdoses, depending on the time of death and how much time passes before autopsy.

From the report:

Heroin is rapidly metabolised by the body, and is converted to monoacetylmorphine (MAM) and then to morphine. The presence of MAM indicates heroin use as opposed to morphine use. At times, toxicology is not able to determine MAM, and in these cases the death is coded to T402 “Other opioids”, as only the morphine derivative can be identified.”

Therefore, the numbers of heroin deaths are likely substantially higher, and the deaths that are attributed to pharmaceutical opioids are likely substantially lower. There’s just no way to know. 

Clearly, the personnel who attend the death would be able to make an educated guess as to whether the death was from heroin or morphine, illicit or prescription. But no effort is made to capture that data.  

It serves their purposes to inflate the pharmaceutical opioid figures and reduce the heroin overdose figures.  This is how a prescription overdose crisis is manufactured.

And further, unintentional deaths are not classified as suicides unless there is a note.  Contrary to popular opinion, only a minority of suicides leave notes, somewhere between 3% and 42%.

And another, more recent study founder that more than 50% of suicides left no note.

Therefore, very likely more than 50% of unintentional overdose deaths were actually intentional suicides.

These are large numbers that would make a significant difference to the statistics.  And again, this data could be captured, with a little effort. But it is not.

Instead, we have people twisting the statistics to suit their narrative, and cherry picking the data to further their own agenda.

If the government was really interested in the ‘opioid crisis’ and the ‘overdose epidemic’ they would be capturing this data in such a way as to actually be able to tell who is overdosing, on what medications, and why.

I know that the data is captured this way because of the ICD-10 classifications, and now that ICD-11 has been around for a few years, the Australian Bureau of Statistics is finally updating to a new classification system.  They will, in the future, be capturing data on individual drugs, which will be a significant improvement. 

Change comes slowly, however, and it will be several years before we have better data. But at least it’s a big step in the right direction.

In the meantime, doctors, the media, everyone needs to stop making assumptions about the data that the data does not support, stop disparaging chronic pain patients on long term opioid therapy and stop promoting their own personal agendas.

The take home naloxone program was pitched at helping chronic pain patients. But chronic pain patients have not taken up the program. 

The assumption is that this is because of the stigma.  Chronic pain patient do not want to be seen as ‘opioid abusers’ in their local pharmacy.

I don’t believe this is the problem, however, if they really wanted to improve access to naloxone, GPs should be able to give it out, in the privacy of their consult rooms.  Then people would not be recognised branded an ‘addict’ or opioid user.  There would be no stigma.

And yes, I am aware that there is a separation of prescribing and dispensing for very good reason; so that there can be no conflict of interest. For example, if GPs were dispensing medications, they could be tempted to prescribe a medication with a higher profit margin, rather than the most appropriate medication.  The same applies for pharmacists, if pharmacists were allowed to prescribe AND dispense medicines. 

However, pharmacists now DO prescribe and dispense.  There have been pilot programs and pharmacists can now prescribe and dispense medication for a finite number of conditions.

So this rule has been bent or broken when it suits the government.

Therefore, I see no problem with GPs handing out naloxone.  GPs can ask chronic pain patients on long term opioid therapy if they would like to have some free naloxone to take home.   Most would probably take it if their GP suggested it, but never have to use it.  It would certainly make the program at least LOOK like it was worthwhile.

So it’s a win-win, right?

Not for the pharmacists.  Because then the pharmacists would not get the dispensing fee. And it’s a pretty hefty dispensing fee.  According to the pilot program documents.  It seems community pharmacies get paid around $50 for every nasal spray supplied and around $35 for the injection.   The Take Home Naloxone Program is certainly lucrative for community pharmacies.

So who’s really benefiting here?  Who was the Take Home Naloxone Program really designed for?

Not chronic pain patients, that’s for sure.

We get dragged through the mud by doctors who run safe injecting sites.  By addiction medicine specialists. And by pharmacists who know very well that it is not chronic pain patients who are overdosing. 

They just don’t want the world to know that the government wasted 19 million on the Take Home Naloxone Program that could have been far better spent elsewhere.  It was always only ever going to benefit pharmacists, and illicit drug users.  Not pain patients.

Take note of this quote:

“The number of unintentional deaths involving opioids has almost doubled over the past 20 years, rising to more than two a day in 2021, with fatal overdoses just as likely to be from prescription medication as heroin.”

There were two overdoses per day in 2021. 

Naloxone was marketed hard, and the marketing campaign and the people promoting the pilot were crowing from the rooftops that the estimates showed that naloxone would save “THREE LIVES PER DAY”.

How is this possible when only two people die of overdoses currently?  That’s a pretty amazing medicine, on reflection.  Naloxone saves one more person per day than is currently dying of opioid overdose. Very impressive!

Clearly someone did some very creative math when they were estimated the benefits, just as they did when they were reporting the number over opioid overdoses.  People regularly quote the numbers of ALL drug overdoses and attribute them as opioid overdoses. Nothing new about that in the world of the Australian ‘opioid crisis’.  The ‘opioid crisis’ that does not exist.

I am not arguing against the naloxone program, I am arguing against the constant implication that this program is for people on prescription opioids.  That people on prescription opioids are overdosing in their thousands.  It is simply not true.  And I am tired of seeing the media promoting this very wrong idea.  This misinformation is what is increasing stigma for people living with severe chronic pain, who rely on safe, effective long term opioid therapy.

The naloxone program has saved lives, but they have not been chronic pain patients’ lives.

“Nationally, 136,776 doses have been distributed, reversing an estimated 3000 opioid overdoses, or eight adverse reactions, a day.”

Just call a spade a spade. The take home naloxone program is primarily to aid people living with opioid use disorder, who take illicit opioids and who are at high risk of overdose.  That’s the target patient population. That is a worthy cause and saving the lives of people who are addicted to illicit opioids is just as important as saving any life.

People who live with opioid use disorder matter too, their lives matter, and saving these lives is important.

Why isn’t that good enough? Why do they have to invent a different problem that needs fixing?  Why do they have to pretend that chronic pain patients are benefitting, that they are saving the lives of chronic pain patients?

The implication here is pretty appalling.

Just tell the truth. Illicit opioids are dangerous.  And naloxone can save many lives in this population.

Long term opioid therapy is safe and effective for people living with severe, daily pain.  Addiction and overdose are vanishingly rare. 

Now when will doctors tell the truth and the media report the facts?


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