The Scottish National Naloxone Programme: what is it and how did we get there?

1. 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

2. Acknowledgements • Lisa Ross, NHS Highland • Stephen Heller-Murphy, Scottish Prison Service • Jennifer Stoddart, Scottish Government • Dr Roy Robertson, National DRD Forum Chair

3. 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

4. Background

5. DRDs in Scotland per calendar year, 1996-2009 Source: GROS (2010)

6. DRDs per 100,000 population (all ages), 2009 Source: UK Focal Point (2010)

7. 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 Scottish DRD circumstances Sources: Zador et al, 2005; GROS et al, 2010, Graham et al, 2011

8. The Journey to a National Naloxone Programme…

9. Journey to a National Programme 1996 Strang et al propose naloxone for peer administration 2004 Local proposals for naloxone pilots (Lanarkshire) 2005 Scottish Advisory Committee on Drug Misuse (SACDM) 2005 Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order 2007 National Forum on Drug Related Deaths Annual Report 2007 Glasgow / Lanarkshire Pilots Launched 2008 Glasgow Pilot Evaluation Published 2009 Lanarkshire Pilot Published 2009 Inverness Pilot Launched 2010 Inverness Pilot Evaluation Published 2010 National Forum on Drug Related Deaths Annual Report 2010 National Naloxone Programme launched!

10. 2005 Working group on drug-related deaths… “those in a position to administer naloxone should receive appropriate training to do so” Scottish Advisory Committee on Drug Misuse (SACDM)

11. 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.

12. 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.” National Form on DRDs • 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.”

13. Lanarkshire / Glasgow Pilot Results

14. Lanarkshire / Glasgow Pilots Key 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. • No increase in risky behaviour • 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.

15. Key challenges Recruitment Follow-up Lanarkshire / Glasgow Pilots

16. Lanarkshire / Glasgow Pilots 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

17. Inverness Pilot

18. Inverness Pilot Key Findings • First attempt to pilot naloxone in a rural area • Linked local Harm Reduction Nurse and Addictions Nurse in Porterfield Prison • Significant client engagement • 170 clients trained (68 prisoners) • Early impact • 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

19. Drug-related deaths in Inverness 2009/10 Pilot duration, July ’09 -Jun ‘10 Jan ’08 to Jun ’09 = 28 deaths Jul ’09 to Dec’10 = 7 deaths 2011 = 1 death (on 1st Jan) • 64 successful OD reversals using naloxoneto date • 1 unsuccessful

20. 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.” National Forum on DRDs

21. The National Naloxone Programme

22. 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

23. The National Naloxone Programme Media reporting ‘Free lags given OD Antidote’ 18/08/10 ‘Addicts will get pill to reverse heroin overdose’ 18/08/10

24. 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 Training

25. Product • Naloxone Hydrochloride1mg/1 ml (2ml) pre-filled syringe… • Multi-dose • Contained within a hard plastic case • One step assembly process • Cost-effective

26. For all prisoners at risk of opiate OD Promoted throughout sentence Trained pre-release Co-facilitated by Nursing and Phoenix Futures staff Prison

27. Monitoring • Mandatory minimum dataset • Consent • Demographics • Prison History • Prescription • Optional supplementary dataset • Contextual info on naloxone use e.g. - Drugs Involved - Location - Other BLS used - Ambulance involvement - Outcome of use

28. Monitoring • National minimum dataset aims & objectives: • How many individual are receiving kits? • How many kits have been issued? • What is the rough demographic picture of those receiving kits (gender, age, geographical location)? • How many of the kits issued are re-supplies? • Why are people receiving re-supplies – lost/stolen/expired/used? • What kind of services are issuing kits? • Where are these services located? • What is the spread of naloxone supply across Scotland?

29. 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: • What proportion of these were opiate related; • 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

30. 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’)

31. Progress to date… • Naloxone commitment in 29 / 30 ADP areas • > 20 services now routinely training & prescribing via range models: • Group • 1 to 1 • Couples • Home-visits • Professional and peer-led sessions • Prisoner take-up lower than expected

32. 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

33. Thank you Andrew McAuley T: 0141 354 2935 (ext: 2935) F: 0141 354 2901 E: andrew.mcauley@nhs.net www.healthscotland.com www.take-homenaloxone.com