Where Are the Best Public Places to Put Naloxone Kits?

By placing public-access naloxone kits at transit stations, harm reduction programs can improve accessibility for bystanders to help during potential opioid poisonings, according to new research.

In Vancouver, locations participating in a take-home naloxone program covered an area where about 35% of opioid poisonings historically occurred. With geospatial analysis, researchers found that placing naloxone kits at transit stops could cover as much as 53% of opioid poisonings.

“The opioid epidemic claims over 80,000 lives each year across Canada and the United States. Administering naloxone can reverse opioid poisoning effects, but it must be administered in a timely manner for it to be effective,” lead author Benjamin Leung, PhD, a recent doctoral graduate at the University of Toronto, Toronto, and current research fellow at Duke University in Durham, North Carolina, told Medscape Medical News.

“Similar research for automated external defibrillator (AED) placement for cardiac arrest — which members of our team have worked on previously — shows that proximity of AEDs to cardiac arrests is a key predictor for AED usage and cardiac arrest survival,” he said. “We sought to translate what we know from the cardiac arrest literature to the opioid poisoning context.”

The study was published online on March 17 in CMAJ.

Optimizing Kit Placement

Leung and colleagues evaluated opioid-poisoning incidents reported by BC Emergency Health Services in the metro Vancouver area between December 2014 and August 2020, using geospatial analytics to model how public-access naloxone kits could cover the city.

The research team defined opioid-poisoning “coverage” as naloxone access within a 3-minute walk of a given location or the time it could take for a bystander to retrieve and use a naloxone kit before BC emergency personnel arrived in its median 6-minute response window.

Next, the researchers determined the coverage percentages of the following three strategies: Existing locations participating in a take-home naloxone program; blanket naloxone kit placement at chain businesses, pharmacies, and registered public-defibrillator locations; and optimization-based strategic kit placement at transit stops based on historical poisonings.

The analysis included 14,089 opioid poisonings. In the first strategy, 647 existing locations participating in take-home naloxone programs covered the area of 4988 poisonings, or 35.4% of the total.

Under the second strategy, a blanket kit placement combining chain businesses (12-810 locations), 790 pharmacies, and 980 public defibrillator locations covered between 97 and 3152 poisonings, or 0.7%-22.4%. By location, coverage at pharmacies was 22.4%, followed by fast food restaurants (16.5%) and AED locations (12.1%).

Under the third strategy, the optimization-based strategic placement of naloxone kits at transit stops generally led to higher coverage levels, ranging from 2907 poisonings (20.6%) with 10 kit locations to 7506 poisonings (53.3%) with 1000 kit locations.

“We were intrigued by how much more efficient the strategy of optimizing naloxone kit placement at transit stops was in comparison with the other strategies,” Leung said. “For example, to achieve the same number of opioid poisonings within a 3-minute walk by placing public naloxone kits at all 647 take-home naloxone program locations, we would only need 60 transit locations selected using our optimization strategy. This finding is an example of the power of using data-driven optimization to maximize the value that we get with our limited healthcare resources.”

Based on the findings, Leung said it’s important to advocate for municipal, provincial, and territorial governments, as well as health agencies, to allocate funding and enable public-access naloxone kit placement in high-risk areas.

“At the same time, it’s important to remember that public-access naloxone is limited by whether bystanders retrieve and administer the naloxone,” he said. “It’s vital that a public-access naloxone program be paired with community outreach and education about the benefit and availability of naloxone kits, such that their usage can be maximized.”

Changing Kit Placement

Similar advocacy and education have been undertaken for AED placement, Ross Tsuyuki, PharmD, professor of medicine at the University of Alberta in Edmonton, told Medscape Medical News. Tsuyuki, who wasn’t involved with this study, co-authored 2020 Canadian national consensus guidelines for naloxone prescribing by pharmacists.

“This is analogous to placement of AEDs — you need to know where one is when you need it,” he said. “Finding a kit quickly is important to save lives.”

Creating a naloxone kit registry could also be helpful, Tsuyuki said. For instance, Alberta Health Services maintains an AED registry and map for people to find nearby locations.

“Just as public areas need AEDs, they also need naloxone kits — perhaps by placing them together,” Tsuyuki said. “Healthcare professionals have an important role in education and supporting policies to make these life-saving kits available.”

The study findings also raise important questions about implementing naloxone programs in various public areas, said Michael Beazely, PhD, chair of Rural Substance Use at the Gateway Centre of Excellence in Rural Health and associate professor of pharmacy at the University of Waterloo in Waterloo, Ontario.

“Can we apply the lessons learned to other large urban jurisdictions, as well as to smaller cities, towns, and regions that may differ with respect to opioid poisonings and naloxone availability?” he asked.

Beazely, who wasn’t involved with this study, has evaluated community pharmacy-based take-home naloxone programs in Canada. Broadening naloxone kit access across community pharmacies and public places such as restaurants can help reduce opioid deaths, he said.

“I would also be interested to learn whether, beyond geographical placement, different businesses and employees would have differing levels of interest, training, or stigma about opioid use,” Beazely said. “That could impact the willingness to not only house public-access kits, but also to advertise or communicate to the public that they have naloxone kits available.”

The study was supported by the Canadian Institutes of Health Research and Michael Smith Health Research BC. Leung, Tsuyuki, and Beazely reported having no relevant financial relationships.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.