Service Evaluation of Scotland's Take-Home Naloxone Programme

Executive Summary

Introduction

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 methods used included:

• a rapid literature review;
• initial scoping interviews with key stakeholders;
• online survey and interviews with the local naloxone coordinators in order to map how the programme is being implemented in each area;
• online survey with service providers which resulted in 186 responses;
• in-depth work in four case-study areas to interview service providers, service users and their families/carers resulting in 115 interviews in total; and
• analysis and synthesis of all elements of the research.

Context

The report sets out the context for the development of a national THN programme. It highlights the fact that Scotland has higher rates of drug-related deaths than other parts of the UK and that between 2002-2012 there was an upward trend in the number of drug-related deaths (DRDs) registered in Scotland.

The national THN programme was rolled out across Scotland following successful local pilots in three Health Board areas (NHS Greater Glasgow and Clyde; NHS Lanarkshire and the Inverness area of NHS Highland). It allows for the distribution of naloxone (which is a Prescription Only Medicine) 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.

Findings

Programme Processes and Structures

As the national naloxone programme in Scotland is centrally coordinated and directed there are clear coordination and support structures in place at national level. The National Naloxone Advisory Group (NNAG), which comprises a range of expert members, monitors the progress and delivery of the programme, at both a national and local level, on a regular basis.

The Scottish Government's role in this programme supports:

• a national Naloxone Coordinator and a National Training and Support Officer based at the Scottish Drugs Forum (SDF);
• the development of national information and training materials including a website (www.naloxone.org.uk);
• reimbursement to NHS Boards for the THN kits issued in their area;
• an in-depth monitoring and evaluation programme, including measuring progress against a baseline measure, 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^[1];
• specific support for the roll out of the programme in prisons.

At local Health Board level there is some similarity but also variety in the way the programme is managed and delivered, as would be expected given the need to adapt the programme to local circumstances. Most, but not all, of the 13 Health Boards which participate in the programme manage their participation through a partnership; and while nearly all Alcohol and Drug Partnerships (ADPs) are involved, the nature of their involvement varies. Nine Health Boards have a Steering Group to manage the programme locally (four do not). Six Health Board areas use community pharmacies to supply naloxone (seven do not). Peer trainers/educators are used in nine Health Boards and in some places are leading delivery: for example, in one prison all training on naloxone is undertaken by peer trainers. Since November 2011 and the transfer of prisoner healthcare to the NHS, local Health Boards have had responsibility for the delivery of the programme in Scottish 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 at risk of opioid overdose is provided by staff from both statutory and voluntary sectors. Taking part in the training is voluntary in both community and prison settings. The supply of naloxone is regulated by a Patient Group Direction (PGD) and is mainly supplied by nurses or pharmacists where they are participating in the programme. Training and supply in the community can take place in a range of settings including drug treatment agencies, community pharmacies and outreach, such as hostels and mobile buses. In prisons the kit is supplied following training by placing it in the person's property prior to liberation.

Effectiveness of processes and structures

This report provides evidence on the effectiveness of the processes and structures.

Key points from this include the following.

Training the Trainers

This is regarded as generally effective in giving people the knowledge, skills and confidence they require to train service users in how to administer naloxone. However it is clear from the numbers of those who then go on to provide training that some people, maybe through general lack of presentation or training skills, are still not confident to deliver training themselves after the TTT. In particular there may be some need for refresher training for those who have not used the skills acquired after training.

Recruitment

The most valuable method of recruitment is by word of mouth, either by peers or professionals. There were reports of difficulty in attracting prisoners due to the voluntary nature of the training and competing interests/activities. Those prisoners 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 who use drugs

1:1 is increasingly viewed as a more effective 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 who use drugs 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

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

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

Partnership working at national and local levels is generally seen as being effective.

Impact

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.