Service Evaluation of Scotland's Take-Home Naloxone Programme

5 Impact of the programme

5.1 In this chapter, we provide an early indication of the programme's impact including consideration of the outcomes for those who have engaged with the programme and whether the programme is reaching those who do not typically engage with drug treatment services.

5.2 The evidence for this chapter is drawn from all elements of the research in particular the interviews with programme beneficiaries undertaken in the four case study areas.

Impact of the programme at national level

5.3 The impact of the programme in terms of quantitative measurements is being monitored on a quarterly basis through the work of ISD which reports to the National Naloxone Advisory Group and there is a baseline measurement in place so that the overall impact can be measured.

5.4 The single most important quantitative indicator of the impact of the THN programme is the fact that there have been 365 successful uses recorded^[25] of a naloxone kit to reverse an overdose since the programme started in 2011. This does not take account of the many unreported instances of use, but a greater number can be implied from the research carried out as part of this evaluation. For example, a very rough estimate of successful reversals of overdose reported in the online survey shows in excess of 500 and this is probably an underestimate^[26].

Impact on service users

5.5 The majority of the 186 service provider respondents to the online survey reported that the THN programme had a positive impact on service users as demonstrated in table 5.1 below. The statement most agreed with is that the THN programme has made people who use drugs more aware of life saving techniques (92% agreement). There is also high (90%) agreement with the statement that the programme has made them more aware of the causes of overdose. In addition, 86% considered that the programme has potentially saved lives. There is a lower percentage, 73% agreeing/strongly agreeing, about whether the programme has empowered people who use drugs to take greater control of their health although this is still represents a high level of agreement. These findings reflect the findings from the studies in the literature review where naloxone training was seen to result in increases in knowledge about preventing, recognising and responding to overdose.

Table 5.1: Impact on service users

	Strongly agree	Agree	Disagree	Strongly disagree	Don't know
The THN programme has empowered people who use drugs to take greater control of their health (n=169)	17%	56%	8%	2%	17%
The THN programme has made people who use drugs more aware of the causes of drug overdose (n=169)	37%	53%	3%	2%	5%
The THN programme has made people who use drugs more aware of life saving techniques such as resuscitation (n=169)	42%	50%	2%	1%	5%
The THN programme has saved lives (n=169)[27]	48%	38%	1%	1%	12%

5.6 86% said they were personally aware of potential lives saved as a result of naloxone administration. There was a clear perception among the majority of service providers interviewed in the four case study areas that lives had potentially been saved through the THN programme, but equally striking was the lack of hard evidence or systematic data for this. The view was generally based on anecdotal evidence. Only a small number of staff interviewed in community settings had specific evidence of the successful use of naloxone.

5.7 NHS staff working in prisons reported that prisoners often felt proud at having undertaken the training, but they were unable to provide many examples of positive uses of naloxone (two women who had been in prison reported that they had reversed the effects of overdose of a friend and a partner). Where they were able to, it was often as a result of prisoners sharing their experiences when readmitted to custody.

"We don't see the impact, it's all hearsay… I guess the numbers [of opioid-related deaths] will tell." (Nurse)

Service users' views

5.8 There was generally a positive view expressed about the programme and what it was trying to achieve. Usually, interviewees couched this simply in terms of their perception that 'it saves lives'. Several said how it could have saved a loved one or friend, had it been available previously.

"I thought it was a really good idea. Before it came in I actually lost a friend to an overdose. If I had naloxone at the time, he might be alive today." (Male, 40-50)

5.9 The interviewees described the programme as giving hope and peace of mind.

"It's good, it's gonnae save someone's life. I think it is necessary, it gives people a wee bit of hope." (Female, 40-50)

5.10 Interviewees reported that their confidence to know what to do in an overdose situation had improved.

"Aye, it does [increase your confidence] aye. They showed with the dummy and how to do the compressions, and the facemask over their face." (Male, 30-40)

5.11 Without exception, all service users who had been trained would recommend being trained and having a naloxone kit.

Impact on families / carers

5.12 The impact of naloxone on family members was the reassurance it could provide:

"Gives them a safety net and peace of mind that they'll be able to help if they find their loved one after an overdose. Some parents have experience of finding their son or daughter after an overdose but being powerless to do anything other than phoning 999." (Senior practitioner -drugs worker)

5.13 Service users and family members who were interviewed felt that parents should not need the permission of the person with problem drug use to ensure a naloxone kit is supplied for them (as is currently the case as it is a POM).

5.14 Some service users thought it important to raise awareness further about the programme, including the training, among parents of people who use drugs, especially those who did not attend family support groups. This could be through media campaigns.

5.15 There was the suggestion that all family members would benefit from training.

"I think everyone that knows a user should be trained to use it." (Female, 40-50)

Impact on service providers

5.16 The overwhelming majority of staff involved in the THN programme were enthusiastic about it, reporting both positive outcomes for service users and a sense of empowerment for themselves. This underscored the positive nature of the programme. Staff reported that they welcomed the opportunity to be able to offer concrete practical help to a highly vulnerable target group of clients. Although a few expressed concern that their work on the THN programme was 'extra' to their normal work, the overwhelming majority were content to be involved.

5.17 A nurse working in residential rehab commented:

"It's empowering for us. It means we can save lives. We don't need to wait for the ambulance." (Nurse)

5.18 Similar views were expressed by a group worker.

"The whole [name of place] is as bad as anywhere in the world. Drug workers at the sharp end all know people who have died. To be part of a programme to tackle the problem is great." (Group worker)

5.19 A few service providers commented on the positive impact this had in terms of their relationship with service users and the fact that they could show the service users that their lives were valued.

5.20 The need for greater support and leadership was mentioned by a few service providers in community settings. In one area there was a sense of lack of leadership due to staff changeover and in another the sense of being isolated was expressed by one person who felt she was the only one working on the programme with no team support.

5.21 NHS staff working in prisons were positive about the THN programme, and reported that the naloxone training constituted an additional harm reduction 'tool' that could help prisoners survive in the outside world.

"It's driven home what we're all about, what we're trying to do: reduce drug deaths and get people safe and into treatment" (Nurse)

Impact on those less likely to engage with drug treatment services/reaching those most at risk

5.22 It is harder to determine the impact of the THN programme on those who are outwith the orbit of current drug treatment services, or on the periphery of them. The DRD database report suggests that around two-thirds of those who died had been in contact with a service and one-third had not. It is the one-third that now presents the greatest challenge.

5.23 The research undertaken as part of this evaluation shows some promising methods for reaching this target group. These include the use of peer trainers (including in prisons), the extension of the programme through community pharmacies, the further development of prison based programmes, and the use of outreach methods such as work with hostels and homeless accommodation.

5.24 However, many of those interviewed acknowledged that their attempts at outreach had not always been successful and that there was more to do to extend the reach to those furthest away from services.

5.25 Those living in homeless hostels were frequently described as highly vulnerable and in need of naloxone training. Two residential workers identified that because of the shortage of homeless accommodation in the city, more B&Bs were currently being used - without access to the support of trained staff.

5.26 There was a commonly held view by several interviewees from across the four case study areas that 'normalising' naloxone as part of routine drug treatment programmes would be an effective way of reaching more vulnerable people with problem drug use.

"There's a massive dispensing service across the city. I don't understand why it's not obligatory to give naloxone when dispensing Methadone." (Voluntary sector worker)

"It needs to be normalised, with everyone on a Methadone script having naloxone supply. Because people take drugs in groups, you only need one person in the group to be naloxone trained." (Pharmacist)

5.27 Peer trainers who were interviewed suggested that other groups who could potentially use naloxone positively, and would therefore be worth considering for training, included: hostel staff, first aiders at music festivals, night club doormen, bus drivers, taxi drivers, bin men, Big Issue vendors, and those working with rough sleepers.

5.28 Peer trainers' street knowledge combined with their contact with senior staff through having done presentations at ADPs led them to suggest that some awareness raising with the police was necessary. This could help with removing a major obstacle to people with problem drug use accessing naloxone - perceived police harassment.

"The top coppers know about it. It's getting it down to the guy that's gonna lift you." (Male, 30-40)

5.29 Other suggestions made by service providers for reaching the most at risk in the community included increasing the use of peer trainers/educators.

"This a great initiative. They speak their language and people listen. It also helps their own recovery" (Senior addiction worker)

5.30 Staff interviewed working in prisons acknowledged that not everyone at risk from overdose was engaging with the THN programme, not least because it was a voluntary programme. There were two main suggestions for reaching the most at risk. Making naloxone training a compulsory part of pre-release programme for those on substitute medication (although this would have resource implications); using peer trainers to deliver the programme to prisoners, thus providing a measure of credibility (as happens in some prisons).

5.31 We asked service users we interviewed to convey how they thought those who use drugs but are not engaged with services felt about naloxone and its use. They reported that other people who use drugs seemed to have a more limited understanding of the programme. It was not always widely known about, and one couple estimated that only three in ten people with problem drug use had a naloxone kit.

"A lot of people don't know anything about it. The first thing they say is 'do you not go into a rattle when you take it?'" (Male, 30-40)

5.32 There was a view expressed by some that people would see it, not as life saver, but as a hindrance to 'successful' use of opioid drugs. There were a small number of accounts of people being brought round from an overdose by use of naloxone, and the person who had administered it being abused by the person who had overdosed as they had been 'cheated out of a hit'.

Priorities for future development of programme

5.33 For those service providers interviewed in community settings, further training and supplying of service users was seen as a priority by most.

"Flood the market with naloxone. Everyone who has a script or who uses services should have it." (Pharmacist)

5.34 A significant number wanted all frontline staff in drug services to be trained and ideally able to supply naloxone at the same time as the training takes place.

5.35 Training and supplying families and carers was a priority for over a third of interviewees.

"Every home with a drug user should have a naloxone kit" (Nurse)

5.36 There was a suggestion by some people that there should be an increase of supplies through pharmacies, and that this should be normalised.

"Pharmacies are in an ideal position. Everyone uses a community pharmacy at some point." (Pharmacist)

5.37 There was recognition of the importance of trying to reach those who do not use addictions services and to continue, or in some areas renew, efforts to undertake outreach for example through soup kitchens and homeless hostels. Naloxone training and supply needs to be taken out to where people who use drugs but who do not use addictions services are likely to be found.

5.38 For NHS staff working in prisons the main priority was ensuring there is maximum uptake of the programme in prison. There was a difference of view about whether it should be mandatory for all those on opiate replacement therapy, with some in favour, while others disagreed.

Summary of main points

5.39 While it is hard to quantify "potential lives saved" this is very clearly seen by service users as the main benefit of the programme. There is very little hard evidence about the successful use of naloxone although ISD keeps statistics on the number of kits issued, whether it is a first or repeat supply and details of the age and gender of those who receive the kits. There are a number of identified "softer" outcomes for service users including an increased sense of empowerment and greater self-esteem from the knowledge that they can be of service to others.

In terms of the impact on those who are less likely to use services it is recognised that they may still not be being reached. Suggestions to increase this included "normalising" naloxone as part of drug treatment services, making more use of peer trainers and ensuring that police on the ground have greater awareness of naloxone. Other ways to reach people included training a far wider section of community-based service providers.