Why in the name of public health is naloxone distribution still a postcode lottery, asks Neil Hunt.
I live in Kent, one of 16 sites from the 2010 NTA naloxone pilots for families and carers of heroin/opioid users. Locally, ‘Take Home Naloxone’ (THN) for service users, their families or carers has since become integral to our treatment system due to the numerous, ongoing, successful, documented overdose reversals. Yet this week, I received an email from a colleague 240 miles away in NW England asking if I knew how to help a man living 140 miles away in Peterborough, a city 120 miles from me.
He wanted THN for two close friends who were just leaving prison and – as he quite rightly understood – were at much heightened risk of overdose. He is highly educated and computer literate, yet had been unable to obtain this potentially life-saving medicine. To see if he was overlooking anything obvious, I did the natural thing and Googled ‘Peterborough’ AND ‘naloxone’; however, I couldn’t find any information about its availability, let alone how a heroin user, their lover, parent, son or daughter might obtain it.
The latest published UK drug-related death data show that, annually, Peterborough has 6.21 drug-related deaths per 100,000 population – largely opiate-related ie ones for which THN is relevant. This is pretty much the midpoint rate between those UK localities with the highest and lowest drug-related death rates. In plain English, in Peterborough and places like it, year-on-year a modest number of opiate users die from overdoses, some of which are almost certainly preventable.
It’s important to emphasise that the fact that this happened in Peterborough is almost entirely incidental. It’s just where one persistent guy lives. I barely know the city/its services and have no reason whatsoever to think they are any better or worse than those elsewhere. On the contrary, Peterborough’s services could be truly excellent in all respects other than its THN service. I honestly have no idea.
The crucial point is that this well-informed, justifiably concerned friend could have lived in numerous, similar English cities where THN is unavailable. Or, conversely, assorted other areas where THN is actively promoted. His ability to take measures to reverse a friend’s potentially fatal opioid overdose is determined in an arbitrary way, according to where he lives. A situation that would be regarded as intolerable if it were applied to, say, provision of patient-held adrenaline for people with a history of anaphylaxis from bee-stings.
Clearly, we should be cautious about deducing too much from one isolated case, however many hundred miles of unnecessary communication it involved. Nevertheless, I’d argue that this example warrants serious consideration for several reasons:
a) A Peterborough citizen and taxpayer who cares for his friends and understands the risks and issues around heroin overdose sought help via two perceived ‘experts’ on different sides of the country across about 500 miles, only to be told, ‘Sadly, it’s up to your local commissioners. If they don’t fund THN then you can’t get it.’ This seems a very potent illustration of well-informed demand in an area where drug-related deaths need to be reduced.
b) Anecdotally, harm reduction, needle exchange, active drug user and recovery networks often hear that the ‘THN availability problem’ is widespread, yet no reliable mapping of English THN outlets/availability exists. An interactive naloxone finder database is being developed for Scotland in a way that could be extended across the UK (www.naloxone.org.uk), but England currently lacks both coordination and strategic vision in its approach to THN, rendering it both less effective than it might be and probably with higher unit costs too.
c) Public Health England (PHE) is currently navigating its way through complex political and organisational changes and clarifying its role at a time of economic austerity. THN is an affordable intervention that naturally fits within public health and could potentially benefit from comprehensive PHE advocacy and support. At present, many commissioners and providers of drug services and, vitally, many of the people who are most likely to witness an overdose – opiate users and their friends, families and lovers – seem barely aware of its existence.
Take Home Naloxone is a potentially important test of the role that Public Health England will fulfil in the new system in which we are now operating. PHE is not responsible for the THN policy shambles it has inherited. Nevertheless, in 12 months time, if people who need THN to protect the lives of those they care for are still jumping through such tortuous, long-distance hoops, only to discover that they are arbitrarily denied services that are readily available in an adjoining locality, I think many people may be left questioning whether ‘public health’ has been well served, and how PHE can in any way claim to be an agency that serves all of ‘England’.
Neil Hunt is honorary research fellow, The Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine and honorary senior research associate, School of Social Policy, Sociology and Social Research, University of Kent