Service Evaluation of Scotland's Take-Home Naloxone Programme

2 Context

2.1 This chapter sets out the context for the THN programme including the prevalence and nature of DRDs in Scotland, the programme's evolution and the key structures to support it. It highlights key questions from the literature review that informed the design of the research and which will be addressed in later chapters.

Prevalence and nature of drug-related deaths in Scotland

2.2 Rates of DRDs in Scotland are higher than other UK regions^[4], with the majority involving opioids, either on their own or in combination with other drugs. In 2012, 581 DRDs were registered in Scotland. This was the second highest number ever recorded and 199 (52 per cent) more than in 2002. The number of DRDs has been on an upward trend over the past decade.

2.3 Scotland's current national drugs strategy^[5] (2008) focuses on recovery from problem drug use but also stresses the specific need for action to prevent DRDs. The strategy highlights that there are opportunities for preventative action to reduce DRD incidence through activities such as increased general health care and a range of education and awareness raising measures. Giving people the confidence to know when to intervene, what to look for and do in the case of an overdose is highlighted as a possible way of preventing DRDs, as is the training and the provision of relevant information to staff and service users, family and friends.

2.4 A national DRDs database was established in 2009 to increase knowledge and understanding of the circumstances around DRDs in Scotland. Findings from it have confirmed earlier research^[6] that those most vulnerable to DRDs are male, live in deprived areas, and are aged 25-44. Furthermore, it has established that the majority of DRDs are 'accidental', involve opioids, are witnessed (highlighting potential for intervention) and two thirds involve someone in contact with a drug treatment service prior to their death. According to the recently published report 'National Drug Related Death Database (Scotland) Report: Analysis of Deaths occurring in 2012'^[7], around half of the cohort (47%) had been in prison at some point in their lives prior to death. Over one in ten (12%) had spent time in prison in the six months prior to death, a decrease compared to 2011 (18%).

Background to the Take-Home Naloxone programme

2.5 The use of naloxone as a peer administered intervention in opioid overdose was first advocated during the early 1990s. A recommendation to the Scottish Advisory Committee on Drug Misuse in 2005 that those in a position to administer naloxone should be trained to do so, was followed by an amendment to the Medicines Act 2005 making it legal for any-one to administer naloxone to save a life.

2.6 Pilot naloxone programmes were subsequently launched in Lanarkshire and Greater Glasgow and Clyde Health Boards in 2007, and in Inverness in 2009. The pilots were able to show that it was feasible for those at risk of opioid overdose to be trained and supplied with naloxone, that they were able to use it in emergency situations, and that they were able to manage it responsibly.

2.7 The Scottish Government launched the Scottish National THN programme in November 2010, in response to a recommendation of the National Forum on Drug-Related Deaths^[8], and it was rolled out from 2011 onwards.^[9] The programme allows for distribution of naloxone 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.

2.8 In 2011, the Chief Medical Officer issued a letter alerting doctors to the programme and highlighting the increased risk of overdose in the first few weeks post-hospital discharge. The Lord Advocate's local guidelines issued in 2011 enabled the supply of naloxone to all staff working for services which have regular contact with people at risk of opioid overdose, such as hostel workers for emergency use only (as naloxone is a prescription-only medicine).

Themes from the literature review

2.9 We have drawn out the following key questions from the literature review (contained in Appendix 2) to inform this service evaluation and these were used to help design the research tools and will be addressed in the following chapters.

• What are the experiences of THN implementation in Scotland at a local level including how training is delivered, participants recruited and the differences in implementation between community and prison settings (see Chapter 3).
• What is the extent of partnership working in Scotland and how does it assist the programme? Which agencies are involved, and how are they involved in different areas? In particular, how, if at all, are General Practitioners, ambulance and police services involved? (see Chapter 3)
• Are concerns about inappropriate use of naloxone prevalent? (see Chapter 4)
• How do Scottish participants feel about the programme including the kit itself, carrying the kit, the training received, and the impact it has had on them (see Chapters 4 and 5).

Summary of main points

2.10 This chapter has highlighted the high incidence of DRDs in Scotland which led to the decision to implement the THN programme following successful pilots. The programme distributes naloxone using a PGD to allow nurses and pharmacists to supply THN to named patients 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.