The Scottish National Naloxone Programme: what is it and how

did we get there?Andrew McAuley

Public Health Adviser (Substance Misuse)NHS Health Scotland

‘Naloxone Saves Lives’ Conference Swansea, 19.05.11

Acknowledgements

Lisa Ross, NHS Highland

Stephen Heller-Murphy, Scottish Prison Service

Jennifer Stoddart, Scottish Government

Dr Roy Robertson, National DRD Forum Chair

National Naloxone Programme

“The aim of this national programme is to increase the availability and awareness of naloxone across Scotland, in order to increase the chance of it being administered during an opiate overdose… I hope that the impact of increased naloxone availability will contribute to a reduction in fatal opiate overdoses in Scotland and I am very grateful for your support in taking forward this important initiative.”

Fergus Ewing, Minister for Community Safety, 01/11/10

Background

DRDs in Scotland per calendar year, 1996-2009

Source: GROS (2010)

0

50

100

150

200

250

300

350

400

450

500

550

600

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

registered in year 3-year average5-year average likely lowerlikely upper

DRDs per 100,000 population (all ages), 2009

Source: UK Focal Point (2010)

2.81.96

10.24

3.4

0

2

4

6

8

10

12

Eng & Wal N Ireland Scotland UK Ave.

Scottish DRD circumstances

Majority are opioid related

Majority are male

Average age is increasing

~ 50% have previously been in prison

Majority are ‘accidental overdoses’

Majority witnessed / have others present

Most interventions often ineffective or too late

Sources: Zador et al, 2005; GROS et al, 2010, Graham et al, 2011

The Journey to a National Naloxone Programme…

Journey to a National Programme

1996 Strang et al propose naloxone for peer administration2004 Local proposals for naloxone pilots (Lanarkshire)2005 Scottish Advisory Committee on Drug Misuse (SACDM)2005 Medicines for Human Use (Prescribing) (Miscellaneous

Amendments) Order2007 National Forum on Drug Related Deaths Annual Report2007 Glasgow / Lanarkshire Pilots Launched2008 Glasgow Pilot Evaluation Published2009 Lanarkshire Pilot Published2009 Inverness Pilot Launched2010 Inverness Pilot Evaluation Published2010 National Forum on Drug Related Deaths Annual Report

2010 National Naloxone Programme launched!

Scottish Advisory Committee on Drug Misuse (SACDM)

2005 Working group on drug-related deaths…

“those in a position to administer naloxone should receive appropriate training to do so”

Legislation

In June 2005 the ‘Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order 2005’ amendment of article 7 contained provision to the administration of naloxone (by anyone) for the prevention of overdose.

National Form on DRDs 2007 Annual Report Recommendation 3…

“With take-home naloxone being more widely used across the world to save lives, e.g. in Berlin, San Francisco and Chicago, consideration should be given in Scotland to extending take-home naloxone provision beyond Glasgow into other areas. This recommendation is made with the understanding that any pilot is rigorously evaluated to prove effectiveness.”

Scottish Govt. Response…

“Local planners should consider the findings from the evaluations when they are published, and decide if naloxone provision is an intervention they would wish to adopt in their area. Before any roll-out of the programme, thorough training would have to be in place that covered the use of naloxone and overdose awareness, such as the training programme devised for the Glasgow pilot. Naloxone should not be distributed without such a training programme being in place first.”

Lanarkshire / Glasgow Pilot Results

Lanarkshire / Glasgow PilotsKey Findings

195 clients trained & supplied, 12 saves – all by clients

Scottish drug users can be effectively trained to identify and respond to an opiate overdose utilizing basic life support and naloxone administration skills similar to their peers from around the world.

The majority of which can responsibly manage their own personal THN supply when trained appropriately.

o No increase in risky behaviouro No inappropriate use

Improved knowledge and confidence in OD awareness, BLS & naloxone post-training

A ‘buddy’ system where clients are encouraged to attend training with a friend/family member is an effective way of engaging wider user networks who may be able to intervene in an OD situation.

Lanarkshire / Glasgow Pilots

Key challenges

Recruitment Follow-up

Media reporting

POSITIVE:

‘Addicts to be given personal supply of anti-overdose drug’, 28/05/06

‘Overdose drugs given to families of addicts’, 29/05/06

‘Saving Lives is the priority’, 30/05/06

‘Project to aid addicts may be extended’, 17/10/07

NEGATIVE:

‘Fears over anti-OD drug for addicts’, 29/05/06

‘Pressure on addicts plan’, 12/06/06

‘Addicts jag row’. 13/06/06

‘Drugs expert condemns overdose kits’, 18/11/07

Lanarkshire / Glasgow Pilots

Inverness Pilot

Inverness PilotKey Findings

First attempt to pilot naloxone in a rural area

Linked local Harm Reduction Nurse and Addictions Nurse in Porterfield Prison

Significant client engagemento 170 clients trained (68 prisoners)

Early impacto 37 saves, (35 by clients, 1 by family, 1 by staff)

Peer liaison worker / peer education approach

Improved confidence and self-esteem among participants

Roll-out to wider NHS Highland area confirmed from July 2010 onwards

Drug-related deaths in Inverness 2009/10

20

13

21

0

5

10

15

20

25

2008 2009 2010 2011

n

Pilot duration, July ’09 -Jun ‘10

• 64 successful OD reversals using naloxone to date

• 1 unsuccessful

Jan ’08 to Jun ’09 = 28 deaths

Jul ’09 to Dec’10 = 7 deaths

2011

= 1 death

(on 1st Jan)

National Forum on DRDs 2009/10 Annual Report,

Recommendation 2…

“‘Take home’ naloxone should be available to all high risk individuals on release from custody later this year. This programme should be underpinned by a detailed evaluation which builds on data already held by SPS for the three years preceding the implementation date. This should be supported by increased availability of ‘take home’ naloxone though specialist and primary care services and the Forum encourages the development of local ‘take home’ naloxone programmes where this is not already in place.”

The National Naloxone Programme

The National Naloxone Programme

Nationally funded roll from 1 Nov 2010 out across the country including the prison estate (~ 6000 kits in yr 1)

National Protocol & Guidelines (SLWG) PGD Training Product Monitoring / Evaluation Child Protection

Media reporting

‘Free lags given OD Antidote’

18/08/10

‘Addicts will get pill to reverse heroin overdose’

18/08/10

The National Naloxone Programme

Training

National Naloxone Trainers (3 posts, 2.0 WTE)

‘Heartstart UK’ accredited

Cascade Model (i.e. Train the trainer) 1 or 2 day course OD Awareness /

prevention, BLS, Naloxone

Product

Naloxone Hydrochloride1mg/1 ml (2ml) pre-filled syringe…o Multi-doseo Contained within a hard plastic caseo One step assembly processo Cost-effective

Prison

For all prisoners at risk of opiate OD

Promoted throughout sentence

Trained pre-release

Co-facilitated by Nursing and Phoenix Futures staff

Monitoring Mandatory minimum dataset

o Consento Demographicso Prison Historyo Prescription

Optional supplementary dataseto Contextual info on naloxone use e.g.

- Drugs Involved- Location- Other BLS used- Ambulance involvement- Outcome of use

Monitoring National minimum dataset aims & objectives:

o How many individual are receiving kits?o How many kits have been issued?o What is the rough demographic picture of those receiving kits

(gender, age, geographical location)?o How many of the kits issued are re-supplies? o Why are people receiving re-supplies – lost/stolen/expired/used? o What kind of services are issuing kits?o Where are these services located?o What is the spread of naloxone supply across Scotland?

Evaluation

Measures the impact of increasing the availability of naloxone on the number of fatal opiate overdoses in Scotland against the following baseline…

Of the total number of drug-related deaths:

i) What proportion of these were opiate related;

ii) What proportion of these were opiate related and occurred within the first four weeks following release from prison custody;

…in calendar years 2007,2008,2009 broken down by gender and age groups

Ongoing support

National Naloxone Advisory Group

Practitioner Network (ScoNN)

Information Materials (leaflets / posters / wallet cards)

Letter from the CMO

Lord Advocate Guidelines (‘letter of comfort’)

Progress to date…

Naloxone commitment in 29 / 30 ADP areas

> 20 services now routinely training & prescribing via range models:o Groupo 1 to 1o Coupleso Home-visitso Professional and peer-led sessions

Prisoner take-up lower than expected

Summary

Long road to a National Programme

Research, advocacy and legislation all essential

National Policy vital to improving adoption and reach

More research and evaluation needed

Thank you

Andrew McAuleyT: 0141 354 2935 (ext: 2935)F: 0141 354 2901E: andrew.mcauley@nhs.net

www.healthscotland.com www.take-homenaloxone.com