Now that naloxone is officially ‘out there’, CGL are among those searching for the people most in need of it. DDN reports on their naloxone outreach services.
Guy Phillips is preparing for his nightshift as an outreach worker in Newham, east London. In his rucksack he will carry needles, a first aid kit, condoms, information leaflets – and four naloxone kits, plus a training kit. His mission is to give naloxone to ‘anybody that needs it’ and to offer friendly advice and a route to further help.
Phillips is employed by CGL but coordinates his shifts to do joint outreach with East London NHS Foundation Trust and homeless charity Thames Reach, to find the people in most need. ‘I’ll have my lists of people I want to see and they’ll have their list of people they want to see, so we’ll form a plan before we go out,’ he says. Shifts vary to try to cover all hours within a fortnightly period, and can be as early as 4am to 8am.
Many of those they will be trying to reach will be rough sleepers ‘who might be walking around, about to bed down somewhere’; others will be tuned into the night-time economy – sex workers, who don’t keep hours that fit in with regular drug services.
Some of the people they meet are glad of a friendly face and interested in hearing about naloxone – particularly if word has already reached them of this life-saving drug. Others are more difficult to engage – the sex workers for example, who may be earning £400 a night, can buy as much heroin as they want, don’t need methadone, and can’t see the need to talk to a drugs worker.
Looking at those most at risk, ‘It’s difficult to say who’s most likely to overdose, but imagine the effects of rough sleeping on people, in terms of being out in the cold and not having the facilities we normally have, plus the likelihood of having a lowered immune system,’ says Phillips. So the night’s naloxone outreach schedule focuses on rough sleepers. ‘I’ll ask them if they want to have naloxone, and if they say no, I’m going to have to persuade them it’s a good idea,’ he says. He might get the reply ‘I’m only smoking’, and will have to dig deeper to find out if they are taking anything else. ‘Most people who die of overdose die because they’ve used more than one substance – and each drug can multiply the effect of the other substance,’ he says.
A brief chat will often reveal they are taking ‘all sorts of drugs at all sorts of times – methadone, buprenorphine, alcohol, anything that suppresses the central nervous system’. Then there’s ‘quite a bit of persuasion to do, because people think they don’t necessarily need naloxone, and I have to explain that they do’. When he’s got their attention, Phillips runs through what an overdose can look like and what can happen throughout the course of it. ‘Then there’s obviously telling them how to use it, which is a mechanical thing. They can say whether they’ve understood or not, and have a go with my test kit to learn how to use it.’ He tells them that each shot will last for 20 minutes and that people can go back into overdose afterwards – which is why there are five shots in each syringe. He also cautions them that ‘people can be quite angry with you for administering it’ while coming round.
The other important part of the message is that ‘if in doubt use it – because you can do no harm. And also call 999’ to get the ambulance on its way. The whole intervention – the information, training session, Q&A – has to take place quite quickly. ‘You’ve got to get the information out and it’s got to be quite snappy.
You might be on the street, or in an exposed situation; there might be people walking by. You might be in the darkness, doing it by torchlight, and you also need to consider your own safety because you’re crouched down.’ There are also ‘a lot of places to go and people to see’ on each shift. While the immediate benefits of the naloxone are obvious, the other important reason for using it in outreach is to connect with people and offer them the lifeline into services.
Unfortunately this rarely happens immediately, says Phillips. ‘You wish they’d say “I’m going to change my ways today” but this rarely happens. So it really is about mounting a campaign, visiting people more than once and persuading them, giving them leaflets, increasing their awareness, showing that your door’s open and that you’re a nice kind organisation.’ At CGL’s head office, Stacey Smith is director of nursing and clinical practice and explains that the organisation created a naloxone strategy and turned it into a project management process.
The purpose was to spread naloxone training and distribution far and wide – from all frontline workers and community partners to anyone who might need it, whether in services or not. ‘We thought, we need to really get passionate about this, because the formula is so simple when you think about it. It’s given, it saves lives, and people have a second chance,’ she says. So when the law changed, allowing wider distribution, CGL were ready. ‘Naloxone champions’ had been trained within every project and the initiative was being taken out to pharmacies, community groups, rehabilitation centres, shelters, lifeguards, toilet attendants, to ‘saturate the high-risk areas with naloxone’.
The overall aims, just as for outreach, are ‘obviously to cut down on death – and the other is to get people to feel that they can come into services, no matter what state they’re in or what they’re using’. Smith is encouraged by the 261 people who have reported back to them that they have administered naloxone, but says ‘the potential for life-saving is a lot higher’.
It’s the second year of the naloxone outreach strategy now, ‘so we’re looking at areas where people are not actually getting into services – people that are just on the brink and feel that services maybe aren’t for them,’ she says. This includes districts with ‘extensive homeless populations’, as well as talking to hospitals to make sure people who have been admitted with an overdose are discharged with naloxone, and working with prisons around giving naloxone on release.
‘There’s no closed door on how we can get naloxone outreach to people,’ says Smith. ‘We talk to the police about them carrying it, and we talk to all sorts of people who have contact with our service users to try to get as much out there as possible.’ It’s not just about the naloxone, but about ‘the whole harm reduction message’, she says. ‘We’re trying to make it a whole health and wellbeing approach, rather than just “here’s naloxone”.’ Among the community partners, she says pharmacies have been an important link to people who may need naloxone, ‘as they often see people way before we do’.
The superintendent of a community pharmacy in Birmingham agrees with the benefits of the naloxone outreach programme. She explains how her colleague had received training and knew exactly what to do when a client in the tattoo parlour next door overdosed and staff ran into the pharmacy for help. The pharmacy colleague took a naloxone kit and saved his life. ‘The guy was in the right place at the right time, which was really very lucky because he only came round after the second injection,’ says the superintendent. ‘Had I been in the branch, I’d not been trained to do this. All of us pharmacists should be aware of what we can do with these injections. We’re trained to give the EpiPen – adrenaline for anaphylaxis. But to my knowledge this programme for the drug users is not a general programme, and I think it should be. ‘Let’s hope the programme can be extended – without it that guy wouldn’t be here now.’
Karl Price is someone who would wholeheartedly agree with that. As one of the ‘success stories’ he says he ‘wouldn’t be sitting here today’ if it wasn’t for naloxone. He had three life-saving injections to reverse overdose, when he was in ‘the power of addiction’. ‘I’ve had a friend that’s died and a partner that died – accidental overdoses because the person at the time is not thinking that they’re using too much, or that they’re at risk of overdose,’ he says. ‘But if I’d had a naloxone kit with me, my partner would probably still be here today.’ DDN Tell us about your naloxone initiatives – email firstname.lastname@example.org