they might have naloxone on them, search them, find the naloxone and
administer it. We thought a much more sensible way of doing it would be to
hold a stock of naloxone in every service that comes into routine contact with
people who are at risk of overdose.’
CRI’s naloxone provision began ‘piecemeal, project by project,’ he says. ‘But
we then set off on a wave of excitement about having an organisation-wide
approach to how we would provide naloxone, across not just substance misuse
services but also into hostels and outreach teams and so on. It had to be put on
hold when I saw the most recent lot of guidance that explicitly says that it’s still
a controlled drug and you still can’t use it in hostels. We knew we could provide it
routinely in any CQC-registered locations, any regulated activities, and hold it as
stock – which is how it works with paramedics – but what we were looking to do
was extend that and order it for sites that weren’t necessarily CQC-registered.’
How much of a frustration has he found this? ‘It is frustrating because it just
doesn’t seem to make sense,’ he says. ‘It’s about the law needing to catch up with
practice – we know it’s safe, we know it’s virtually side effect-free, and we know
it’s an effective way of preventing drug-related deaths. So it seems crazy not to.’
In fact, the Scottish Lord Advocate’s ruling allowing treatment and homeless
hostel staff to hold naloxone ready for emergency use without prescription, and
protecting medical professionals supplying naloxone in cases of liability, was
described as ‘commendable’ by ACMD.
*****
Naloxone does have its critics, however. What about the argument that it could
encourage riskier behaviour? ‘I’m not sure that people do say that,’ says
Pattinson. ‘I think that we fear that’s what people would say, but I’ve never
actually heard anyone say it. There isn’t any evidence that that’s the case –
people take drugs because they want to get stoned, they don’t take them
because they want to see how far they can push themselves towards an
overdose. Almost every overdose will be accidental, unless it’s a suicide attempt.’
Indeed ACMD’s letter to Anne Milton states that while ‘critics have suggested
that naloxone provision in the community could encourage people to use drugs
more dangerously if they know naloxone is available’, the council was ‘not aware
of any significant body of evidence that naloxone provision encourages increased
heroin use’, and Pattinson wants to see every service that routinely comes into
contact with people at risk of overdose having its own stocks as soon as possible.
‘We’re ready to go,’ he says. ‘We have the training protocols written out, we
the have patient group directives written out. We know it’s relatively cheap, it’s
effective, and there’s no evidence that I know of that people will take more risks
because they think they can be resuscitated. If we can extend it beyond the
clinical or substance misuse settings to outreach workers, they’re the ones who’ll
come across people in squats or on the streets who’ve overdosed – it’s often
people in the homeless hostels, which is why we’ve done the work in Brighton.’
This would also go a long way to addressing the situations that can result from
‘panic among the client group’, he argues. ‘They know they should call an
ambulance but they panic about whether that means the police are going to get
involved, and all the myths that are still around, so often people are just abandoned.
‘We strongly recommend a review of this because it’s such a cheap and effective
way of saving lives – you could expand the coverage at almost no cost,’ he says. ‘If
we can have workers on hand we know it can be done, because we’ve worked out
how it can be done. It’s only the law that’s preventing us from doing it.’
Consideration of naloxone
available at www.homeoffice.gov.uk
Nigel Brunsdon can be found at http://injectingadvice.com
August 2012 |
drinkanddrugsnews
| 9
www.drinkanddrugsnews.com
Cover story |
Naloxone
and increase its availability (
DDN
, June, page 5).
Successful pilot programmes have led to naloxone being made more widely
available in Scotland and Wales, and Scottish lawmakers have also ruled that the
drug can be provided to some services for use without prescription in an emergency.
However, while naloxone has been provided locally to service users and carers in
England for years – and the NTA has run a naloxone and overdose programme which
saw families and carers of drug users across England trained in how to administer it
(
DDN
, 13 July 2009, page 4) – no comparable roll-out has followed.
The ACMD’s letter to public health minister Anne Milton accompanying its
Consideration of naloxone
report stated that, while provision of naloxone reduced
rates of drug-related death, the maximum impact would only be achieved if the
World Health Organization-approved medicine was ‘given to people with the
greatest opportunity to use it, and to those who can best engage with heroin
users’. At the moment, however, it remains prescription-only, which means that, in
the words of the ACMD, ‘non-medical services which may experience frequent
opiate-related overdoses are not able to legally hold stocks of naloxone to use in
an emergency’.
The council’s report, however, acknowledges that wider provision alone would not
be enough to significantly bring down drug-related death rates, and the ACMD aligns
itself with ‘UK and worldwide research that indicates that training service users,
peers and carers in all aspects of how to respond to an overdose’ is essential.
*****
At CRI’s Sefton service, all service users issued with take-home prescriptions of
methadone or other substitute medication are trained to administer naloxone,
usually via a mini-jet, while the organisation’s service in Brighton and Hove, as well
training all of its service users has so far trained around 80 family members and
carers. ‘Anecdotally, they feel much more confident and empowered,’ says CRI’s
director of operations Mike Pattinson. ‘There’s always that kind of fear of, “Do I have
to call an ambulance, have I got time to call an ambulance?” They feel much more
confident that they can do something proactive.’
The service has gone further, however, and extended its focus to the city’s
highest risk populations. Residents in Brighton’s homeless hostels have been trained
in the use of naloxone and staff trained to recognise the signs of an overdose and
administer naloxone injections, while in East Sussex, training and naloxone is also
provided to 120 prisoners a year as they leave HMP Lewes. ‘Every single one of our
hostel residents in Brighton and Hove has been trained and issued with naloxone
mini-jets, and drug-related deaths in the city are down significantly,’ says Pattinson.
‘They peaked in 2009 at about 52, in 2010 they were down to 30, and figures for
last year will be in the high teens, maybe 20.’
While all of CRI’s CQC-registered sites now carry a stock of naloxone – ordered by
a CRI GP – what the organisation is calling for is the ability of all services that
routinely come into contact with drug users to be able to hold it as stock.
‘At the moment, anyone can administer it but it has to be prescribed to the
individual,’ explains Pattinson. ‘So you’re reliant on the individual having naloxone
and then a third party being able to recognise an overdose, recognise the fact that
The ACMD regards naloxone as an evidence-based
intervention that saves lives – yet it remains prescription only.
David Gilliver hears from a service that’s calling for provision
to be rolled out. Graphics (including cover) by Nigel Brunsdon
cription?