More naloxone programmes to prevent the increasing opiate-overdose deaths in England are urgently needed

Globally thousands of lives could be saved by simply increasing opiate users’ access to naloxone. England experienced an alarming 32% increase in opiate-overdose deaths in 2013, totalling 765 in 2013. Blenheim and IDHDP were so appalled by these figures they called a Naloxone Action Summit to see what could be changed to reduce this number of unnecessary deaths. The Summit took place on Monday 27th October and the room was packed with people who wanted to see change happen quickly.

Participants were asked a series of questions before the event and what was clear was there was marked variation of naloxone availability, ranging from nothing to wide available to all. The main barriers to availability appeared to be lethargy, lack of understanding and knowledge, competing priorities, finance and confusion, particularly what you can and can’t do currently. Nationally, the lack of clear guidance or instructions from the centre, confusion about the MHRA consultation, the October 2015 date and funding issues. The main drivers were usually champions in the area with a real desire to reduce these deaths.

The summit got off to a positive start with Professor John Strang of the National Addiction Centre setting the scene and giving a history of naloxone. The evidence has long been available but it took until 1998 for Jersey to provide naloxone to opiate users, but then we had to wait until 2010 to see Scotland launch the first national programme. He then went on to encourage us to do the things we could, like prescribe to all entering  opiate substitute treatment (OST). Professor Strang also stressed the necessity of considering families as a key work-force and highlighted the great importance of normalising use of naloxone. “Why should Naloxone use be any different from the use of insulin, glucagon, the EpiPen or defibrillators?”.

John Jolly reminded us of the ACMD recommendations made in May 2012, which after a review of naloxone said that it should be more widely available in the UK, there should be less restrictions to access and more training is needed. It would appear that saying more training is needed has been used to delay the immediate implementation until after the next election – particularly as training has been going on for sometime now and continues to do so.

Good practice saves lives

Rhian Hills from Wales and Kirsten Horsburgh from Scotland explained how both countries are moving forward with naloxone use. In Wales, as in all places, large numbers of opiate users have witnessed overdoses so clearly a programme was needed. Hills highlighted how since naloxone access programmes were launched in 2010, the overdose deaths decreased 53%.

Kirsten Horsburgh agreed; “the most likely person to witness an overdose is another drug user. So, if the person who uses drugs is carrying naloxone, deaths can be prevented”. Scotland funds the cost of naloxone kits and prioritizes the supply to people who use drugs. They also try to ensure people starting OST have a supply and normalise naloxone provision in services. The training on how to use it is brief (10 minutes is enough!) and they involve peer trainers.

One of the few places in England that has a well established scheme is Birmingham and Dr Judith Yates gave “top tips” on how to get it going e.g. getting on and doing it, prescribing it to all people starting OST, holding naloxone meetings every month, providing training in the management of overdose and in the use of naloxone to all potential first responders (such as hostel workers, families and friends) and making every contact count. “The naloxone experience in Birmingham was not driven and pushed by commissioners, but by doctors, nurses and pharmacists!”, Dr Yates stated enthusiastically.

Kevin Jaffray explained the role of user activism and how they are vital to the process; Elsa Browne discussed the role of training and Kirstie Douse, Head of Legal Services of Release, explained how to use the legal challenges, such as a judicial review, to improve naloxone access.

Both, during the presentations and after, there were lively discussions, focusing on what can be done now and not getting distracted by what you can’t do. We can prioritise people starting, or on OST, leaving rehab or detox and many other situations where the person could become a patient and have it prescribed to them. Also provision through A+E and prescribing it to all opiate users that access health care for other things. Discussion included how it fitted perfectly into the recovery agenda, how to use PGDs (patient group directives) and PSDs (patient specific directives), how to make training sharp and to the point and involve peer trainers. Very important is to normalise its use in services - “It makes no sense prescribing methadone as a harm reduction measure and not  also prescribing naloxone!” PHE stated that they are planning  to provide guidance to be issued before the end of the year, on what can and should be done  immediately, without waiting for  October 2015.I It was agreed to work with them on that, while also producing a separate clear statements with guidance and advice from the expert members of this group.  This will  be helped by the WHO  guidance on overdose prevention published on 4th November  that completely endorses naloxone.

There is work to be done so a smaller group was formed to take the work forward called Naloxone Action Group - England (NAG - England!). John Jolly CEO of Blenheim was elected as chair. Summing up before leaving one delegate from Penrose put it so well: “It’s a no brainer, training is easy, we need to push the agenda and sort it out!”.

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More resources:

• Early day motion 445: Naloxone availability (UK Parliament)
• MPs debated UK drugs policy (30th October 2014)
• WHO: Community management of opioid overdose
• The BMJ editorial: Take-home emergency naloxone to prevent deaths from heroin overdose

See below the presentations: