Through the gate

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Sue ReynoldsSue Reynolds, the clinical lead of sub­stance misuse at HMP Littlehey, tells DDN about joining the growing number of prisons to introduce a life-saving take-home naloxone pro­gramme for prisoners upon release

HMP/Young Offender Institute (YOI) Littlehey is a purpose-built category C prison which holds convicted and sentenced adults and young adults. The average number of patients engaged in substance misuse treatment is typically around ten to 15.

The treatment regime for substance misuse was based on a recovery-focused approach and risks at release for these patients were high due to social and economic pressures, including their home situation, family support and employment. The highest risk was that they would have developed a low or zero tolerance to opiates/substances as a result of having been stabilised during custody, and so would be at an increased risk of overdose when released.

The local service provider had initiated a take-home naloxone programme, and so there was already support for these patients as they returned to the community. For these reasons, we wanted to initiate a programme within the prison.

The task was to gain agreement from the governor of HMP/YOI Littlehey and other senior staff for a take-home naloxone programme to be introduced, allowing for patient training to be undertaken and naloxone to be available ‘at the gate’ upon release back into the community.

Initially the idea of implementing the programme was made a reality by free training provided by Nina Bilbie, a Prenoxad representative. The appointment was set up by myself, with the full support of Dr Ruth Bastable, GPwSI prescriber for substance misuse treatment. Follow up meetings between myself, Nina and Ruth were key to identifying and overcoming the barriers to implementation. It turned aspiration into reality.

A needs assessment, which allowed objectives to be clearly defined, and a working plan to ensure that all boxes were ticked, needed to be in place. The Prenoxad protocol was adapted to reflect what HMP/YOI Littlehey would be delivering, and due to the small numbers, it was agreed that a patient group directive (PGD) would not be required and each prescription would be generated to the named patient on an FP10 prescription.

A business plan proposal was put together, using the support and information provided by Prenoxad, and presented at the drugs and therapeutics/medicines management meeting to the governor and other senior staff, including the lead chief pharmacist managing the prison. They were very supportive and due to the small numbers involved, the costs were minimal, which contributed to the positive outcome of the idea.

Training was delivered both to the clinical healthcare staff and non-clinical, psychosocial drug and alcohol recovery team (DART) workers in the prison, and a prison training package for patients was also developed. A DVD and sample syringes, needles, algorithm and instruction packs were supplied by Prenoxad. Training was provided by the substance misuse lead on a one-to-one basis with the prisoner, as well as a training evaluation checklist.

It was important to ensure there was a pathway in place for purchasing and accessing the naloxone. The source supply is as and when required for a prisoner’s release on an FP10 prescription, and the local pharmacist supplies it. The naloxone is given at reception upon release, and signed for by the prisoner and the nurse dispensing it. A letter is also presented at the gate, asking the prisoner to send it in if the naloxone is used and providing information on the circumstances.

The plan has been successful due to the large amount of people offering positive support and having the motivation to take it forward. The key factor was that shared expertise was available and easily accessible. The same commissioners (the DAAT) who provide the Inclusion programme both within the prison and the local community also commission and provide the clinical substance misuse treatment services in the prison. The GPwSI working within the prison also provides for the local community, and all key players involved were in agreement for the plan to be implemented. This was running concurrently with the community service providers who were initiating the same implementation plan.

There were no huge obstacles or barriers to overcome, as the support was there from the head of healthcare, the governor and the chief pharmacist. The materials provided by Prenoxad were excellent and enabled things to happen very quickly, while the protocol was easily adapted to reflect local practice.

The patients thought it was an excellent idea – they were very keen and appreciative that this was available to them and it made them feel empowered and supported. It has been included in the programme delivered on the drug recovery wing as part of the first aid and overdose session, and the prisoners who have had training have felt it has boosted their confidence in being able to manage an opioid overdose situation.

To be able to have naloxone injections available for prisoners being released is a huge breakthrough for drug treatment intervention in the prison setting. It takes away some of the worry of releasing vulnerable people into the community with a high risk of overdose. It has been a fantastic achievement and I was provided with tremendous support from colleagues. I hope this initiative continues to spread nationwide with little resistance – if it is available in the community, it can be made available within secure settings too.