Service Evaluation of Scotland’s NATIONAL Take-Home Naloxone Programme Practitioners’ Report
The aim of this service evaluation was to examine how the Take-Home Naloxone (THN) programme is being implemented across Scotland in order to ensure that it is as effective as possible in preventing fatal opioid overdoses. The research was undertaken between August 2013 and March 2014.
The national THN programme was rolled out across Scotland in 2011 following successful pilots. It extends the distribution of naloxone beyond patient-specific prescriptions to those at risk of opioid overdose including prisoners on liberation. All those who receive a supply of naloxone must first have received specialist training in its use.
This short report for practitioners sets out the key findings and policy implications and highlights examples of interesting practice.
Programme processes and structures
There are national structures in place including a National Naloxone Advisory Group (NNAG) and two posts, both based at the Scottish Drugs Forum (SDF), a national Naloxone Co-ordinator and a Training and Support Officer. In addition the
Scottish Government has funded the development of information and training materials, a website, and reimburses Health Boards for the kits they distribute. The Scottish Government's role in this programme also supports an in-depth monitoring and evaluation programme, including measuring progress against a baseline measure, which is delivered by the Information Services Division (ISD) of NHS National Services Scotland. ISD has produced two annual monitoring reports to date (2011-12 and 2012-13) and it provides quarterly reports to the National Naloxone Advisory Group so that its members can assess progress.
At local Health Board level there is some similarity but also variety in the way the programme is managed and delivered. Most, but not all, Health Boards manage the programme through a partnership, while nearly all Alcohol and Drug Partnerships (ADPs) are involved in this partnership the nature of this involvement varies. Nine of the 13 Health Boards taking part in the THN programme have a Steering Group to manage the programme locally. Six of the 13 Health Board areas use community pharmacies as supply of naloxone outlets. Peer trainers/educators are used in nine Health Boards and in two prisons and in some places are heavily relied on: for example in one prison all training on naloxone is undertaken by peer trainers. Since November 2011 Health Boards have had responsibility for delivery of the THN programme in prisons.
There are regular training the trainers (TTT) courses across all Health Boards provided mostly by SDF and sometimes by local trainers. Across all sectors a total of 989 staff have been trained to date.
Training about naloxone and how to administer it for people with problem drug use is provided by staff from both statutory and voluntary sectors. It is voluntary in both community and prison settings. The supply of naloxone is regulated by a Patient Group Direction and is mainly administered by nurses or pharmacists where they are participating in the programme. In prisons the kit is supplied by placing it in the person’s property prior to liberation. Training and supply can take place in a range of settings including drug treatment agencies, prison, pharmacies and outreach, such as hostels and mobile buses.
The effectiveness of the processes and structures
The report provides evidence from the various research sources on the effectiveness of the processes and structures. Key points from this include the following.
Training the Trainers
Training for those who provide training on naloxone to service users and their relatives is regarded as effective and covers the required aspects of the naloxone programme. There may be some need for refresher training for those who have not used the skills acquired after training.
Within the community, the most valuable method of recruitment to THN training is by word of mouth, either by peers or professionals. Within prisons, there were reports of difficulty in attracting prisoners due to the voluntary nature of the training and competing interests/activities. Those who decline training about naloxone tend to do so because they do not wish to be seen as still belonging to the life of people who use drugs.
Training people with problem drug use
Training on a 1:1 basis is increasingly seen as the best method of training in the community setting but in prison group training is still the main method. Peer trainers are regarded as an effective way to reach people with problem drug use but the demands on those who are peer trainers/educators are quite high and this can contribute, along with normal progression to other activities, to a high drop off rate.
Supplying naloxone is most effective when it is done within close proximity to the location and time of training. Being unable to access supplies through the community pharmacy network in some areas has been identified as a problem. A few service users are providing a service to peers by publicising (in one example through social media) the fact that they hold a supply of naloxone should anyone require it. The kit itself is generally seen as effective in terms of ease of use by service users.
Family members who had received training found it useful but due to the fact that naloxone is a Prescription Only Medicine (POM) they are unable to access a supply of naloxone unless patient consent is in place. Consent forms have been developed to attempt to partially address the problem of supplies to family members.
Partnership working, for example within the NNAG at national level and between public and third sectors at local levels is generally regarded as being effective.
The impact of the programme is being monitored by the NNAG through progress against the baseline measures: number and % of opiate related deaths and number and % that occur in 4 and 12 weeks of release from prison.
The NNAG reviews quantitative data gathered by ISD on a regular basis. At present this current research estimates that the programme is reaching around 8% of the population with problem drug use based on the number of kits supplied (5,830).
The programme has made service users more aware of life-saving techniques and the causes of overdose. It has increased their sense of empowerment and improved self-esteem. It is hard to quantify “potential lives saved” as no-one can tell if an overdose would have been fatal but for service users this is seen as a clear impact of the programme: that it “saves lives”.
For families and carers the main impact is peace of mind in relation to knowing they could reverse the effects of an overdose.
For service providers there is a sense of empowerment and the benefit of being able to offer something positive.
Conclusions, lessons learned and implications for policy and practice
The report provides a final chapter outlining conclusions, lessons learned and highlighting implications for future implementation and/or policy. It commends the progress made to date but recognises the need for further reach of naloxone kits to those at risk of opioid overdose. The key implications highlighted include:
- At strategic local level it appears that having a steering group to guide the programme is helpful;
- Greater consistency of ADP involvement across Scotland;
- Greater involvement of GPs in the programme;
- Extending the staff training programme to a greater number of practitioners who are likely to come into contact with people at risk of opioid overdose, in order to enable them to provide naloxone training;
- Increasing the 1:1 brief interventions approach to help reach more of the target group;
- Explore further how outreach can be undertaken effectively, particularly in rural areas, to reach those who do not use addictions services;
- Explore further the issues relating to peer training raised in the research and provide guidance as to best practice;
- Greater and more consistent involvement of community pharmacies across Scotland: consideration given to naloxone training and supply in future negotiations with community pharmacies;
- Consideration of how to increase the training and take-up of supply for those leaving prison;
- Explore further the training police receive with regard to naloxone;
- Consideration of the potential to gather systematic and widespread data about the incidence and outcomes of the use of naloxone kits.
The programme and its national coordination have been viewed very positively by those interviewed in this research and it is hoped that the issues identified above will help to increase the reach of naloxone to those most at risk of opioid overdose.
The full report can be found here:
Email: Fran Warren