Learning from 25 years of preventative interventions in Scotland

12. Scotland's National Naloxone Programme (NNP)

Scotland's National Naloxone Programme for reducing opioid ‐related deaths

In 2011 the Scottish Government implemented the world’s first National Naloxone Programme (NNP), providing take-home naloxone kits to people who use drugs likely to witness an overdose. The programme lasted five years and cost over £1 million. The NNP was evaluated and was associated with a 36% reduction in the proportion of opioid-related deaths (ORDs) occurring four weeks following release from prison between 2011-13 and by 50% between 2011-16.

Introduction

The NNP was a tertiary preventative intervention, the aim of which was to prevent fatal opioid overdoses in Scotland. Accidental overdose is a common cause of death among people who use drugs such as heroin, morphine and similar drugs, commonly referred to as opioids. ^[263] Naloxone is a life-saving ‘opioid antagonist’ medicine, which temporarily reverses the effects of a potentially fatal opioid overdose, providing more time for emergency services to arrive and treatment to be given. The NNP ran between 2011 and 2016, and Naloxone remains a key part of Scotland’s current drugs policy. ^{[264], [265]}

Context

Between 2006 and 2010 in Scotland there were an average of 500 drug-related deaths (DRDs) each year, nearly 80% of which were opioid‐related. ^[266] During that time, Scotland had higher rates of DRDs than other parts of the UK, one of the European Union's highest DRDs rates, and was closely behind the United States.⁴

Drug-related deaths can have devastating effects on individuals, families and the wider community. The estimated economic and social costs of problem drug use (including drug deaths) in 2008 in Scotland were estimated to be around £2.6bn every year, and people living in deprived areas were much more likely to die from drug misuse. ^[267]

In 2008, there was a clear association between deprivation, drugs and health inequalities, and problem drug use was identified in the Drugs Strategy at that time - ‘The Road to Recovery’ - as a key driver of ‘economic underperformance, crime, risk to children and health inequalities’.⁵ The life chances of children and young people growing up in households where parents use drugs can be negatively affected, and health inequalities exacerbated. Together this increased pressure on a range of public services such as healthcare, emergency services, children’s services, housing, and the justice system.

The Road to Recovery pointed to drugs as a cause as a well as a consequence of health inequalities in Scottish society. This was reflected, for example, in the vastly elevated rate of drug hospital admissions amongst the most deprived quintile compared to the least. The Strategy stated:

“Problem drug use is one of the most significant contributors to health inequalities. Its negative impact on health and well-being produces inequalities between individuals and communities, reducing the chances and choices for many. Drug users can also face many barriers to obtaining treatment and other services.” ⁵

The evidence showed the ‘typical’ drug death in Scotland as a male, in his thirties, who died in a home environment and where there was ‘a window of opportunity for someone to intervene’ demonstrating that these DRDs were preventable.⁵ Taking preventative action to reduce drug deaths presented an opportunity to reduce inequality, improve outcomes and improve Scotland’s ailing international reputation.

Response

In response to the increasing number of DRDs, the Scottish Government implemented the world’s first NNP, providing ‘Take-Home’ Naloxone (THN) kits to those at risk of an ORD.² Pilots were introduced in three Health Board areas - NHS Greater Glasgow and Clyde and NHS Lanarkshire in 2007 and the Inverness area of NHS Highland in 2009. ^[268] The pilots successfully demonstrated that it was feasible to train and supply those at risk of opioid overdose with naloxone, that they were able to use it in emergency situations, and that they were able to manage it responsibly.⁶

Intervention

The NNP was a five year nationwide programme launched by the Scottish Government in November 2010 and implemented in April 2011. It was centrally funded and coordinated by the Scottish Government and cost £1 million over the five years from 2011 to 2016. The intervention allowed for the distribution of naloxone (a Prescription Only Medicine) using a Patient Group Direction (PGD)^[269] through supplying THN kits to those at risk of opioid overdose, which allowed naloxone to be administered intramuscularly by anyone in an emergency to save the person's life for whom naloxone was prescribed.^[270] Kits were supplied in community health settings and in prisons to prisoners on release. Over 46,000 potentially lifesaving THN kits were supplied between 2011-2012 and 2017-2018.²

The risk of dying from drug overdose is particularly high for those with problematic substance use soon after prison release and hospital discharge, after periods of relative abstinence (which is in large part, but not exclusively, due to a loss of tolerance of opioids).⁴ Participation was supported and coordinated by all but one of Scotland’s Alcohol and Drug Partnerships (ADPs) and Health Boards and all 16 Scottish prisons.⁶ Before anyone received a supply of naloxone, they had to have first received specialist training in its use.⁶ The Scottish Government commissioned the Scottish Drugs Forum (SDF) to coordinate the programme and deliver training for trainers to staff across Scotland. Training for people who use drugs was delivered as a brief intervention. THN was then supplied by nurses or pharmacists working in community drug treatment/harm reduction services and across the prison estate, where the THN kit was placed in the person’s property prior to release (if they agreed to this after training).⁶

Some areas in Scotland also used community pharmacies as a supply route, particularly those with injecting equipment provision. Another feature of the NNP was the network of peer educators across Scotland which was launched in 2012, both in the community and in prisons, who played a key role in engaging those people that services find hard to reach, and supported the development of local networks of peer volunteers to help widen the reach of the naloxone training.^[271],6

The NNP was overseen by the National Naloxone Advisory Group (NNAG), a group of expert members including stakeholders from Scottish Government, NHS Boards, Scottish Prison Service, the voluntary sector and academia. The NNAG concluded its work in March 2016. The responsibility for national oversight transferred to the Partnership for Action on Drugs in Scotland (PADS) Harms Group.

Monitoring and Evaluation

Since the NNP’s inception, there have been a number of strands of monitoring and evaluation to improve understanding of how naloxone supply and distribution can reduce DRDs.

The Scottish Government supported an evaluation programme through the NNAG which examined the progress of the programme at both a national and local level.⁶ This included an impact evaluation published in 2016 by members of the NNAG. It was the first attempt to evaluate a NNP at a population level with a before (2006-2010) and after (2011-2013) comparison analyses by design at three and five years.⁴ The evaluation of Scotland's NNP had prison release ORDs as its primary outcome, because of the elevated DRD risk in the weeks following release from prison.

The range of evaluation evidence on naloxone in Scotland should be taken into account when assessing the success of programme. Besides the service evaluation of NNP (2014)⁶ there is also evaluation evidence on the impact of NNP on ambulance attendance at overdose incidents,^[272] a pilot evaluation of naloxone in Police Scotland,^[273] and the implementation of the programme in prisons.^[274] Public Health Scotland (PHS) are independently evaluating the National Mission,^[275] and continue to publish annual monitoring reports and quarterly bulletins on the number of THN kits provided.

Key Findings

The evaluation of Scotland's NNP examined the effectiveness of the programme in reducing ORDs in the four weeks following release from prison or hospital discharge. Key results are outlined below.

a) Reduction in Opioid Related Deaths

The NNP was found to be highly effective in reducing ORDs in the four weeks following release from prison. It was associated with a 36% reduction in the proportion of ORDs that occurred in the 4 weeks following release from prison between 2011-13 and by 50% between 2011-16.

The 2016 evaluation found that in 2006-10, 9.8% of ORDs were in people released from prison within the previous four weeks, whereas only 6.3% of ORDs in 2011–13 followed prison release, a difference of 3.5%. This reduction in the proportion of prison release ORDs translated into the prevention of 42 ORDs following release from prison during 2011–13, when almost 12,000 naloxone kits were issued.⁴

Table 1 shows an updated analysis by the authors for longer term outcomes (up to 2016), showing that ORDs in former prisoners within 4 weeks of release from prison reduced by 50% between 2011-16, preventing between 39 and 60 ORDs. ^[276]

Source: Adapted from Scotland's National Naloxone Programme (2019)

Scotland’s NNP had little apparent impact on the hospital discharge component of the secondary outcome measure. Possible explanations might be that: elevated DRDs following hospital discharge were less well understood at the time; naloxone kits not being accessed by older users of methadone (people aged over 35 years); or the evaluation methodology used.^4,14

b) Cost savings

Cost‐effectiveness was assessed by comparing the costs of prescribing naloxone kits against the life‐years gained from ORDs averted. Almost 12,000 kits were issued during 2011–13 and Scotland's NNP may have prevented 42 prison release ORDs at a prescription cost (at the time of writing in 2015) of less than £225,000. The evaluation found that prescription cost per quality‐adjusted life‐year (QALY) gained are £4900–16,900 and £560–1940 depending on whether it is being measured over one year or 10 years respectively (based on a 95% confidence interval).⁴

c) Wider Outcomes

There are likely further benefits and outcomes of the NNP beyond reducing DRDs which are not evaluated here, related to the avoidance of traumatic loss on people and communities, and reducing demand on essential public services. The service evaluation highlighted a number of “softer” outcomes for service users, including an increased sense of empowerment and greater self-esteem from the knowledge that they can potentially save lives.⁶

Learning and Next Steps

After the five year NNP ended, the Scottish Government continued to support the embedding of naloxone provision in Health Board areas. DRDs in Scotland have continued to increase over the last few decades with over four times as many deaths in 2023 compared to 2000. ORDs make up the largest proportions of DRDs with opiates/opioids involved in 80% of drug misuse deaths in 2023. ^[277] The rapid increase in Scotland’s ORDs over the last decade has particularly affected those aged 35 years or older. In 2023, people living in the most deprived areas were more than 15 times as likely to die from drug misuse than those in the least deprived areas.¹⁵

This increase in DRDs was anticipated by the evaluation authors, who suggested that the effectiveness of Scotland’s NNP should not be based on a before-and-after comparison, because further increases in ORDs despite the NNP have occured.¹⁴

The use of naloxone for peer administration has been identified as an essential part of reducing DRDs in many countries worldwide, including Canada, Norway, and the USA.^{14, [278]} It is not a silver bullet to the complex problem of ORDs but it is an important component.¹⁶

The service evaluation highlighted the lessons learned and implications for future implementation and/or policy, in particular the need for further ‘reach’ of naloxone kits to those at risk of opioid overdose.⁶ Evidence shows that a key element in the success of a THN programme is the actual number of kits distributed, with research indicating this should be about 20 times the number of a country’s ORDs.¹⁶

The National Mission on Drugs Deaths: Plan 2022-2026 sets out how the national mission will be delivered over the course of this parliament.³ The strategy commits to ‘increasing the distribution and availability of naloxone’ and the distribution of naloxone remains a key priority in preventing DRDs in Scotland. The National Mission monitoring report, which accompanies the plan provides more information on how the use of naloxone is contributing to reducing risks for those who use drugs. It shows that the ‘reach’ of the NNP^[279] has continually increased since data collection began. In 2022/23, the reach of the NNP was 70.4%, an increase of nearly six percentage points since 2021/22 (64.8%) and over 20 percentage points compared to 2019/20 (50.2%). ^[280]

The plan and monitoring report demonstrate the ways in which the NNP has evolved and how Scottish Government continue to identify new ways through which to distribute naloxone. While those who are highest risk of overdose remain the priority, increasing the wider reach of naloxone to peers, family members and members of the emergency services has been shown to be effective in helping to reduce DRDs. Through cross-organisational work, new avenues for naloxone distribution have been identified and implemented. This includes working with Police Scotland to have them as the first police force in the world where all front-line officers are trained in naloxone use and also carrying kits. In December 2024 Police Scotland officers had administered over 580 doses of naloxone, undoubtedly saving lives in the process.^[281]

Following changes to how individuals could access drug treatment services (in response to COVID-19), Scottish Government sought to increase the availability of naloxone. This was supported by a statement of prosecution policy by the Lord Advocate, which allowed for a wide range of non-drug services to distribute naloxone to members of the public including family and friends of those who are at risk. There are now over 100 non-drug services and organisation that currently distribute naloxone including community hubs, sexual health, homeless and women’s services.^[282]

Due to this statement from the Lord Advocate, an award winning and confidential ‘click and deliver’ naloxone service was established by Scottish Families Affected by Alcohol and Drugs and which is now the second most common source of community supply, providing over 5000 kits in 2022/23 (latest annual figures).^[283] Following the UK Government amendment to the naloxone legislation,^[284] the Scottish Government will be setting up a new registration system, alongside the other UK administrations.

Naloxone is also likely to become more essential in the future should the detections of new synthetic opioids continue to increase. These new substances, in particular the ‘nitazene’ family, are significantly stronger than traditional opiates such as heroin and have already been detected in a number of DRDs in Scotland and across the UK. Naloxone is still an effective antagonist in a nitazene related overdose, however, due to the increased strength of these substances, there have been a number of reports where multiple naloxone kits have been required to reverse the effects, again very different to traditional opiates which, in the majority of cases, would only require 1 dose.