Make it stick

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Making sure naloxone is in the hands of everyone who needs it, whenever they need it, requires far more than simply handing it out from drug treatment services. DDN reports.

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Despite all the good work that’s been done over the last couple of decades to fight the battle for naloxone and tackle the associated stigma, one key fact remains. As Judith Yates told DDN last month, ‘You need to have it with you’ (DDN, June, page 15).

A commuter reads a copy of a newspaper while waiting on the subway, a pharmacy carries posters in its window, Spanish language adverts on buses. In 2017 New York’s Department of Health conducted an advertising campaign urging people to carry Naloxone. Photos: Richard B Levine / Alamy

Release’s landmark Finding a needle in a haystack report made headlines when it revealed that while all but three of the local authorities who responded to the charity’s FoI request were supplying naloxone, they were doing it in such small quantities that the impact was negligible (DDN, March 2019, page 4).

‘This life-saving medication is not reaching those who most need it’, Release stated, with the document stressing the need for naloxone to be made easily available to people not in contact with mainstream treatment services, for example via pharmacies or peer networks. In many areas, take-home naloxone was only available ‘through the main drug treatment provider’, the report found, with a quarter of councils failing to provide kits to people in contact with outreach services for homeless populations, for example. If there was ever any doubt over the need for this, a St Mungos report from last year stated that in 2018 around 12,000 rough sleepers had gone without drug or alcohol treatment – the same year that recorded a 55 per cent increase in drug deaths among people sleeping rough. It also found that the number of rough sleepers with a drug problem had increased from 50 per cent to 60 per cent in just four years.

It’s about Harm Reduction

‘Getting out as much naloxone as possible to people who don’t necessarily engage with standard services is really important,’ says Megan Nash, team leader for WDP’s Redbridge outreach service, where all workers have carried it since the service’s inception. ‘That’s both because it’s getting a life-saving drug to the people most at risk of drug-related deaths, but it’s also starting a conversation about harm reduction. It allows you to have a short conversation about how to use it and about risk of overdose – what to look out for and how to prevent it.’

Crucially, it’s also about ‘giving someone something’, she points out. ‘I think that can be a really nice engagement tool. It just feels friendlier to give someone a little present, and people can then spread the word.’ This kind of harm reduction approach can be transformative when dealing with people with very complex needs, such as the Redbridge team’s clients. ‘It’s a way of showing you care about people, and a way of getting them in contact with services, which they may have struggled to engage with in the past as they’re expected to turn up at a specific time, and not intoxicated. I absolutely appreciate that it can be difficult for a lot of mainstream services to manage these kinds of clients, but just having that positive engagement and being told “we care about you”, that someone genuinely is worried about your safety and whether you live or die, is crucial for us.’

None of her team have ever had to administer naloxone themselves, she says, an illustration of how important it is to ‘get it distributed – because a lot of people will be using in hidden places. Often our service users tend to use in groups – in temporary accommodation and squats and things like that. It’s not as easy to see as an outreach worker, and you can’t be there all the time, so it’s really important that it gets out through people who will be in that situation.’

This kind of peer-to-peer distribution model is vital agrees her colleague Dave Targett, WDP’s operations manager. ‘We had a massive squat in the city centre in Chester a year or so ago and we kept giving it to people to take in there to give to others – targeting those high-population areas is really important.’

Inadequate supply

Another alarming finding from the Release document was that only half of prisons and one in five young offender institutions were actually providing naloxone to those leaving custody – this despite the up-to-eightfold increase in risk of a drug-related death the first two weeks after release, as a result of reduced tolerance levels. The amount of take-home naloxone being given out to people on release in 2017-18 was ‘wholly inadequate’, it said, with kits and training provided to just 12 per cent of opiate clients as they left custody. The report also called for take-home naloxone programmes to be extended to immigration removal centres and policy custody suites. A pioneer when it comes to the latter has been Durham Constabulary, where more than 200 police officers and civilian staff have so far received naloxone training (DDN, May, page 13).

Temporary chief inspector Jason Meecham
Temporary Chief Inspector Jason Meecham

The force began having naloxone onsite at its custody suites after a spate of opiate-related overdoses in 2018-19, and it’s now offered on release to anyone over the age of 18 who has a problematic drug issue, has had one in the past, or lives with someone who has one. ‘It’s no strings attached,’ temporary chief inspector Jason Meecham tells DDN. ‘They’re offered an opportunity to watch a video on how to assemble a kit but they don’t have to, and we run through a quick checklist of basic first aid stuff. We also provide them with details of local treatment services, but there’s no catch.’

So does everyone who’s offered it accept? ‘No, they don’t,’ he says, and while the force is looking at ways to drive up acceptance levels they’re also not expecting to be ‘giving away dozens’ every week. ‘Some people don’t want one. They’ve either already got a kit – and we’re more than happy for them to have another – or it’s not what they want, so we’re working with the county council to try to drive that up. The majority of people we’re in contact with are also in contact with local treatment services, which are very good, so they’ve probably already got access to it. There’s only a limited number of individuals we see in custody who don’t deal with GPs or drug treatment services.’

These, however, are precisely the people who need naloxone the most, and overall provision has ‘gone fantastically well, as you’d expect from a drug that’s simple, proven and effective,’ he says. ‘We now have a stock of it in all of our custody suites throughout the county’.

If we’re going to create a widespread culture of supplying naloxone in custody suites a key element is effective communication between forces to get it out there, he says. ‘I’ve got a phone call later this week with another force who are looking to introduce it, and what we also need is more widespread understanding over the legality of it, the guidance, the litigation issues, safety.’

While the force’s frontline staff could see the need for naloxone on the streets and had been asking for it, with some custody staff there had been ‘a bit of a lack of understanding, which is to be expected. We just had to provide that clarity over the safety, the integrity of it, the efficacy of it, just going over those worries people had about something unknown. But overwhelmingly it was, “We want this and can we as an organisation make it happen?” For the staff, it’s been overwhelmingly positive.’

One important factor for any other force looking to introduce it is Durham Constabulary’s close working with the public health team at the county council, he says. ‘Other forces could look at how that relationship is managed. We took a partnership approach and really worked hand-in-hand, and we really learned a lot because they were very familiar with naloxone. At the moment it’s about trying to ensure a continuous supply from the county council, and trying to ensure that when cops see someone in the street possessing it it’s not grounds for a stop-and-search. We have to make sure they know what it is even if they don’t carry it themselves – raising that level of awareness and confidence.’

But if we’re going to be successful in making sure naloxone is in the hands of everyone who needs it – whenever they need it – then people working in the sector need to be the standard bearers, Dave Targett believes. ‘Ultimately, it starts with us. I was at a drug-related deaths conference a couple of years ago and when someone asked how many people were carrying naloxone only half a dozen or so put their hands up. Those are professionals in the sector who weren’t carrying it. We are the carriers of the message in the first instance, and I think we have to act how we want others to act. You can’t use it if you haven’t got it, and I think the best way to get people to carry it is for us to lead the charge.’

This article has been produced with support from Ethypharm, which has not influenced the content in any way.