Original Title: Avis - Réanimation en contexte de surdose d’opioïdes dans la communauté - Mise à jour et complément de l’Avis de l’INESSS publié en 2018 : Réanimation cardiorespiratoire (RCR) dans le contexte de l’administration de naloxone pour surdose d’opioïdes dans la communauté

Authors' objectives: In 2018, INESSS published a report on best practices regarding CPR in the context of opioid overdose. However, heterogeneity in opioid overdose resuscitation protocols and training persists among organizations throughout Quebec. It was against this backdrop that the group of Québec community organizations represented by the Association québécoise des centres d'intervention en dépendance (AQCID) and the Table des organismes montréalais de lutte contre le VIH/Sida (TOMS) asked INESSS to review its resuscitation protocol in order to determine: 1) the best clinical and organizational strategies for the resuscitation and administration of naloxone in cases of opioid overdose in community settings, along with ways in which these strategies can be adapted to the specific realities of Quebec, and 2) to propose strategies to improve the applicability and acceptance of these recommended practices. The purpose of this update is to consider the protocol’s application context, training and applicability issues, so that anyone who witnesses an opioid overdose can optimally apply the protocol.

Authors' results and conclusions: RESULTS (#1 WITH REGARD TO CARDIOPULMONARY RESUSCITATION): No studies comparing CPR maneuvers (ventilation and/or chest compressions) in the context of opioid overdose were found. • Guidelines and protocols intended for CPR-trained witnesses who volunteer to perform it recommend full CPR, which involves both ventilation and chest compressions. • The guidelines and committee members consulted recommend chest compressions alone for untrained witnesses. • Several Canadian provinces recommend using ventilation alone in cases of opioid overdose but they do not specify the necessary level of training of overdose witnesses. • Certain protocols and input from the committee members suggest that the ventilation alone would be sufficient in the case of an overdose in presence of a witness. However, detecting the difference between respiratory arrest and cardiac arrest may prove challenging for those without proper training. • The Québec and Nova Scotia protocols recommend the use of chest compressions alone for non-CPR-trained witnesses. • A single, simple protocol involving chest compressions alone would be more likely to be applied by non-CPR-trained witnesses. (#2 WITH REGARD TO NALOXONE ADMINISTRATION – CONDITIONS OF ADMINISTRATION, DOSE AND CONTENTS OF THE NALOXONE KIT): The evidence shows that intranasal (IN) naloxone appears to be as effective as intramuscular (IM) naloxone. • However, IN naloxone is associated with a slower response time in comparison to IM naloxone and a higher probability that an extra dose will be necessary. • In Québec, naloxone is available in two forms, IN and IM. However, the IN form is more commonly dispensed than the IM form, following the preference of the opioid users. The use of the IN form is widely accepted due to its ease of use, quick administration, and enhanced safety as it requires minimal handling. • Naloxone administration should be repeated every three minutes as necessary, if for instance the initial dose does not generate improvement or if respiratory depression reoccurs after an initial response. • Specific informations should be provided to users of IN naloxone during training or when a kit is provided. First, there is a risk of the product freezing in the winter. Secondly, the IN spray contains a single dose of naloxone and should not be tested, as this could result in being unusable in the event of an overdose. Lastly, it is crucial to consider the possible emotional impact of intervening in an overdose situation. • The evidence indicates that a higher dose results in a greater response to naloxone, reduces the need for a second dose, and improves survival rate. However, it is also associated with more adverse effects. • The naloxone kit available for the public should contain at least four doses of naloxone (usable in two different overdose situations) as well as a barrier mask with a one-way valve. (#3 WITH REGARD TO INFECTIOUS DISEASE PREVENTION): The stakeholders consulted believe that the protocol should not be altered based on COVID-19 status or any other suspected infectious disease and that universal protective material should be provided. • A good-quality and safe barrier mask with a one-way valve should be used by CPR-trained individuals when responding to an overdose, since any victim could potentially infect the witness. (#4 REGARDING THE RESPONSE SEQUENCE IN AN OPIOID OVERDOSE): The initial step noted in the identified resuscitation protocols is to reassure the victim. • An overdose witness should have the ability to recognize the signs of overdose. • It is imperative to continue promoting the utilization of emergency services by calling 911. • Fear of police involvement and potential legal consequences can impede the act of calling 911. Key stakeholders consulted recommend that the Ministère de la Santé et des Services sociaux, the Ministère de la Sécurité publique and the Ministère de la Justice reinitiate intersectoral efforts to promote collaboration and cooperation. • The current evidence does not suggest that one sequence (naloxone before or after CPR) is more effective than the other. (#5 WITH REGARD TO OXYGEN ADMINISTRATION): Due to the paucity of scientific literature on the subject, the information regarding oxygen administration are primarily derived from experiential and contextual data obtained during consultations, meetings with committee members, and ad hoc meetings with key informants. • Although very sparse, the scientific literature suggests that naloxone is administered in the majority of cases where oxygen was initially provided. • In Québec, workers at supervised consumption sites are often requested to reverse overdose effects when medical personnel are not present on the premises. Certain sites have the capacity to offer oxygen to overdose victims. • According to some opioid users who utilize supervised consumption sites, oxygen is preferred to naloxone due to the latter's significant withdrawal effects. • Administering oxygen prior to the use of naloxone to prevent severe overdose is consistent with the harm reduction approach underlying the creation of supervised consumption sites. • In cases of overdose where the effectiveness of naloxone would have little or no effect (e.g., opioids mixed with benzodiazepines), it might be more advantageous to administer oxygen instead of naloxone. (#6 WITH REGARD TO ACCESS TO NALOXONE ): In Québec, the dispensing of naloxone to individuals is limited to certain community organizations and pharmacies. • All individuals consulted for this project expressed support for enhancing access to naloxone, primarily by expanding its availability at various locations and reducing the stigmatization individuals may face when seeking it. • Challenges with supply and unequal distribution of naloxone kits are faced by community pharmacies and organizations in remote areas. (#7 WITH REGARD TO OPIOID OVERDOSE RESUSCITATION TRAINING): The available guidelines recommend that anyone who may witness an opioid overdose, including psychoactive substance users and relatives, receive resuscitation training to act in the event of an opioid overdose.

Authors' recommendations: CARDIOPULMONARY RESUSCITATION RECOMMENDATION 1 Witnesses not properly trained in CPR – opioid users, relatives and members of the general public): Witnesses not properly trained in CPR, e.g., opioid users, relatives, members of the general public, should respond to suspected opioid overdose by performing only chest compressions. RECOMMENDATION 2 CPR-TRAINED COMMUNITY ORGANIZATION WORKERS): CPR-trained workers at selected community organizations should perform chest compressions and provide ventilation (full cardiopulmonary resuscitation) in the event of a suspected opioid overdose. NALOXONE ADMINISTRATION RECOMMENDATION 3 Conditions of naloxone administration): Community organizations and pharmacies designated as dispensers of naloxone directly to individuals should provide either intranasal (IN) or intramuscular (IM) naloxone, depending on the individual's preference.

Authors' methods: For this request, a rapid review of the scientific and grey literature was conducted in addition to consulting with various stakeholders, including experts, workers, users, and close relatives. The collected scientific, contextual, and experiential data were analyzed to draw key findings and recommendations. These findings underwent a thorough deliberative process to develop meaningful and effective recommendations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/reanimation-en-contexte-de-surdose-dopioides-dans-la-communaute.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/reanimation-en-contexte-de-surdose-dopioides-dans-la-communaute.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)