Service Evaluation of Scotland's Take-Home Naloxone Programme

6 conclusions, lessons learned and policy implications

6.1 This chapter draws together the findings from the research and highlights lessons that can be learned and where appropriate implications for policy and/or future implementation. These implications are shown in bold throughout the text.

Structures

6.2 The NNAG and the national staff posts based at SDF play an important role in national leadership of the programme. This has been supported by the more practical delivery focused work of ScoNN.

6.3 As might be expected each area has developed the programme at local level to suit local circumstances. This has resulted in a varied approach both to governance and to operational delivery. At strategic level it appears that having a steering group to guide the programme is helpful. In addition having a named naloxone lead at local level provides the leadership and energy to keep the implementation of the programme moving forward: in one area where there had been a turnover of staff in this role and there was currently no designated lead, the absence of this role was thought to be affecting the implementation of the programme: it had lost momentum.

6.4 The composition of the steering group varies as well, with some involving a wider group of partners than others. The ADPs, where they are involved, can play a useful leadership role across partners, but this is not as yet consistently applied across Scotland. It would be helpful to see a more consistent approach of ADP involvement across Scotland to increase effectiveness of partner involvement and implementation.

6.5 This research found little evidence of GP involvement in the programme either at strategic or operational level. Some areas commented on the need to do more to involve GPs in the programme and this merits further attention.

Systems and operational delivery

6.6 The THN programme in Scotland has been operational since 2010 and in its first three years has made good progress in terms of establishing systems for training staff to provide training and supply naloxone to people who use drugs. While this service evaluation confirms that systems and processes have been established and are generally perceived to be working well, evidence on the current reach of the programme suggests there is clearly more to do to ensure that as many people as possible who are at risk of opioid overdose have access to a naloxone kit and that those close to them are able to respond to an overdose situation.

Staff training

6.7 This research has shown that nearly 990 staff in statutory and voluntary sector organisations have been trained but it is not possible to estimate whether this is an effective "reach" or not as there are no available figures for the total number of staff who work in addictions services in Scotland. Clearly the higher the number of people trained the better in order to spread knowledge and skills in training on naloxone as widely as possible. However a clear message from the evaluation is that the reach of the staff training programme needs to be extended to equip a greater number of practitioners who are likely to come into contact with people who use drugs with the skills to provide naloxone training, and issue supplies where appropriate. This could include increasing the number of addictions services staff who are trained (who have been the main focus of training delivered so far) but might also include more training for those who work with people at risk of opioid overdose in a variety of settings such as homeless hostels, housing bodies, social work departments and criminal justice settings.

Reaching people who use opioids

6.8 In terms of reaching people who use opioids it is estimated that around 8% of people who use drugs have been reached in terms of the numbers of naloxone kits distributed. This figure combined with some of the qualitative research suggests that there is much more to be done. One of the approaches that appears to be developing is that of "normalisation" where addiction services as a matter of course introduce and train service users about naloxone, as part of their initial assessment or first interview. Increasingly this "training" is being undertaken almost by way of a brief intervention rather than over the course of a couple of hours which appears to have been the more common approach at the start of the programme. This approach has evolved to meet the needs of the target group and to ensure that as many people who are at risk as possible are trained. It results in more 1:1 training and less group training (except in prisons where group training is still the norm). This appears to be a development from evidence found in the literature review where group training was cited as the norm although the Welsh demonstrator programme research^[28] suggested that shortening the training might be one way to increase recruitment. Increasing this 1:1 brief intervention approach may assist in helping to reach more of the target group.

6.9 One of the issues that is striking, however, is that in the main it is those who already use services who are being reached and that the programme is not yet accessible for harder to reach groups. Only in one area (case study A) does outreach appear to be working reasonably well: in the other three areas examined it was clear that although some attempts had been made at outreach it was still either in its infancy or had been put to one side as it was not really working. There is scope to explore further how outreach can be undertaken effectively to reach those who do not use addictions services; this may include expanding access to Training the Trainers beyond specific addictions services. Some of those interviewed in this research have suggested the idea of automatic or mandatory naloxone training and supply as part of service delivery in both community and prison settings but this would require further discussion as it would reduce the current voluntary nature of the programme. There is some evidence from the literature review of compulsory training for those on agency prescribing programmes in the Welsh demonstrator programme research.^[29]

Peer trainers

6.10 The use of peer trainers in nine of the Health Boards raises issues about how best to deploy peer trainers and whether it would be useful for all Health Boards and prisons to have them. In some areas peer trainers undertake their work alongside a professional service provider; in others it appears they undertake training either in pairs or even in some instances on their own. Work by peer trainers is undertaken on a voluntary basis and there are signs that inevitably there is drop off from those willing to undertake the work either because they leave to go on to other activities such as further education or a job, or because the pressure of the demands made on them becomes too high. It would be useful to have further debate about whether there should be peer trainers in each Health Board and prison; whether there should be any recompense for their work; whether they should be asked to do it for a time limited period; and whether it is appropriate for services to leave training to peer trainers on their own or not, and if so, what kind of mechanisms should be in place to support and review peer educators in their role. There is an argument that services may avoid their own responsibilities in relation to training about naloxone if they can leave it to peer trainers on their own to undertake it. On the other hand this research demonstrates the benefits that peer trainers bring particularly in being able to connect with the target audience. There is a need to explore further the issues relating to peer trainers raised in this research and provide guidance as to best practice.

The supply of naloxone

6.11 It is clear from this research that ideally the supply of naloxone should be as close as possible (in time and location) to the provision of training to minimise the risk of those who are trained failing to obtain a naloxone kit. This raises issues about where supply is able to be offered and by whom. At present the supply of naloxone is restricted, as a POM, to trained medical and pharmaceutical staff and to people who use drugs who have been trained in its use. Other services such as hostels for the homeless may keep a supply of naloxone for use in emergency but are not able to carry it with them. The desire to see the PGD expanded so that more people can supply naloxone has been expressed many times in this research. In addition the relatives of those at risk would like to be able to access a supply of naloxone without necessarily having to gain the consent of their relative to get it (which is currently the case). Some of those who work with those at risk would like the option of carrying naloxone with them for use if needed. This is a complex issue which may be difficult to resolve as the legal framework for prescribed medicines is not a devolved issue.

6.12 However, separate from potential changes to the PGD one of the key findings from this research is that there should be greater and more consistent involvement of community pharmacies across Scotland so that there is equal access to the supply of naloxone kits through pharmacies. At present six Health Board areas have community pharmacies involved in the supply of naloxone and those in more rural areas in particular would like to see access to naloxone through pharmacies increased. It would be helpful to see consideration of naloxone training and supply in future contract negotiations with community pharmacies.

6.13 There is a different set of issues in prisons where the supply of naloxone appears to be low. Although training is offered to prisoners considered to be at risk, the programme is voluntary and this research has found that there appear to be some issues with take-up of training with other activities taking place at the same time as naloxone training sometimes being viewed as preferable. In contrast the research undertaken for the Welsh demonstrator project cited in the literature review^[30] identified few problems with recruitment in the prison service as all prisoners were told about the programme as part of induction. The supply of the kit is through the prisoner's "valuable property" which is collected on liberation and it appears that some prisoners refuse to have the kit partly because they do not want to be perceived as still having issues with drugs. This latter finding reflects a similar finding from the research undertaken by the National Treatment Agency^[31] discussed in the literature review. There is a need for further thinking about how to increase the take-up of naloxone training and supply for those leaving prison given the high level of risk of overdose that research has highlighted for former prisoners.

The use of the kit

6.14 Once the kit is supplied it is clearly important that people have it easily to hand when it is needed. The kit also has to be checked to ensure it is up to date (and some services have this as part of a regular checklist question with those they work with at general appointments). Some service users talked about keeping it available even although they themselves had given up drugs in order to ensure it was readily available. Others were not able to see that having a supply might not be a reflection on their own drug-using habits but might allow them to help someone else: this is an important point for those who are encouraging people who use drugs to take a naloxone kit which has been referred to in the research. Service users generally thought the kit itself was very usable and this reflects findings in the literature review.^[32]

6.15 There were a number of concerns raised in the research about the role of the police. Some service users have reported not wanting to carry the kit for fear of being searched by the police who they perceive do not always understand what it is. In addition to this, the other fear was that if there was an overdose and an ambulance was called, if the person making the call stated that it was an overdose the police would be alerted and they would then face questioning. This has led in some instances to people not wanting to call the ambulance or to them leaving once the call has been made and even to professional staff advising people who might be making the call to say the person is unconscious and not to use the word "overdose" in order to avoid the police being called. This points to the need to explore further what training the police receive and how the fears of those who might be using naloxone to reverse an overdose can be allayed.

6.16 One of the questions raised by the literature review undertaken at the start of this research was whether the naloxone kits are being mis-used. There was very little evidence in this research to suggest that this was the case. There were a few examples of people saying that some former prisoners did not keep their kit on liberation but threw them away but very few other examples.

6.17 Overall the data kept about the actual use of the kit appears to be limited. Some services collect information about use, but this tends to be on an ad hoc basis, and it is unclear if and how this information is reviewed or used. Some services may not be in a position to undertake follow up data gathering with those whom they have trained or to whom they have issued a supply. However, it would be useful to explore the potential of establishing more systematic and widespread gathering of data about the incidence and outcome of the use of kits to expand the evidence base on programme effectiveness.

Impact of the programme

6.18 As outlined in the literature review it is difficult to be precise about the numbers of lives saved partly because there are no completed sizeable cohort studies that examine comparative survival rates for use/non-use of naloxone and it is impossible to know what proportion of events where naloxone was administered would have proved fatal.^[33] However interviews with service users in this research have shown that those who take the kit see its potential to save lives as being of very high importance. From this stems a clear sense of self-worth for some of those interviewed during this research: that they have been able to contribute something to others. One or two people had clearly taken this to heart and established themselves as the "person to go to for naloxone" in their area. This is almost a sense of "peer kit supplier" as well as peer trainer which has evolved organically through the enthusiasm of some service users. It might be useful, in terms of reaching those who are less easy to reach, to examine whether to make more use of this kind of "peer kit supplier" as at least in a very local area those who take drugs will know who the person is who has the supply of naloxone.

6.19 There has been an impact for staff involved with the programme as well not just in terms of additional workload but also a sense of empowerment through having something practically positive to offer those they work with.

6.20 The impact for families and friends is the peace of mind that comes from having a supply of naloxone should they require it.

6.21 The staff and service users involved in this research have spoken highly of the naloxone programme and service users in particular value its potential to save lives. Many we spoke to simply wanted to see more kits, more widely available, being carried by more people. The paragraphs above have set out implications from the research which might further facilitate an increase in the supply and use of naloxone.