Opioids are potent respiratory depressants, and overdose is a leading cause of death among people who use them. Worldwide, an estimated 69 000 people die from opioid overdose each year. Among people who inject drugs, opioid overdose is the second most common cause of mortality after HIV/AIDS. A recent rise in opioid-overdose deaths in a number of countries is associated with an increase in the prescribing of opioids for chronic pain. In 2010, an estimated 16 651 people died from an overdose of prescription opioids in the United States of America alone.

New World Health Organization (WHO) guidelines, released this month aim to reduce the number of deaths from opioid overdose globally by providing evidence-based recommendations on the availability of naloxone for people likely to witness an opioid overdose along with advice on the resuscitation and post-resuscitation care of opioid overdose in the community. The guidelines recommend countries expand naloxone access to people likely to witness an overdose in their community, such as friends, family members, partners of people who use drugs, and social workers. In most countries, naloxone is currently accessible only through hospitals and ambulance crews who may not manage to get help to the people who need it fast enough

According to the Guideline, people dependent on opioids are the group most likely to experience an overdose. The incidence of fatal opioid overdose among opioid-dependent individuals is estimated at 0.65 per 100 person years. Non-fatal opioid overdoses are several times more common than fatal ones.Although people taking prescribed opioids are at lower risk of overdose than people using unprescribed opioids. The high number of people receiving prescribed opioids in many countries mean that they constitute a significant proportion of opioid overdose deaths, if not the majority. Risk factors for overdose in people taking prescribed opioids include higher prescribed dosage, male gender, older age, multiple prescriptions (including benzodiazepines), mental health disorders and lower socioeconomic status. The risk of overdose is significantly higher where the prescribed dose is 100 mg morphine equivalents daily or greater.

Opioids depress the respiratory drive and overdose is characterized by apnoea, myosis and stupor. A severely reduced respiration rate results in hypoxaemia, leading to cerebral hypoxia and impaired consciousness. Cardiac arrest is a late complication of opioid overdose and secondary to respiratory arrest and hypoventilation. Prolonged cerebral hypoxia is the mechanism for brain injury and death in opioid overdose, resulting from apnoea or cardiac dysrhythmias and cardiac arrest.

The Guideline concluded that death in opioid-overdose can be averted by emergency basic life support resuscitation and/or the timely administration of an opioid antagonist such as naloxone. Most opioid overdoses occur in private homes, and most of these are witnessed. Close friends, a partner or family members are most likely to witness an opioid overdose. The other key group of individuals likely to witness overdoses are people working with people who use drugs. They include trained health professionals and first responders, such as ambulance, police, fire and drug-treatment workers as well as outreach workers. Naloxone has been used in the management of opioid overdose for more than 40 years. It is a safe drug with a low risk of serious side effects. Any adult capable of learning basic life support can also learn to recognize an opioid overdose, and administer naloxone in time to save lives.

Naloxone is a prescription medicine in almost all countries. In recent years, several countries in different regions have started distributing naloxone to people likely to witness an opioid overdose, initially in pilot programs, but now also in some cases state or national policy, demonstrating the feasibility of this approach and prompting calls for widespread adoption of this approach.

The California legislature passed Assembly Bill No. 1535 this year and it was signed by the Governor on September 15, 2014. The new law adds Section 4052.01 to the Business and Professions Code, relating to pharmacists. Existing law, generally, authorizes a California pharmacist to dispense or furnish drugs only pursuant to a valid prescription except for nicotine replacement products and emergency contraceptives and hormonal contraceptives. The new law would now also authorize a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both the Pharmacy Board and the Medical Board of California, in consultation with specified entities. The new law would authorize the California State Board of Pharmacy to adopt emergency regulations to establish the standardized procedures or protocols that would remain in effect until the earlier of 180 days following their effective date or the effective date of regulations adopted as described above. California therefore will provide non prescription access to naloxone and will be on the forefront of these new WHO Guidelines. Claim examiners may wish to take advantage of this new law in cases where risk factors are high for overdose.