Last year there were 765 deaths related to heroin and morphine in England – a sharp rise of 32 per cent from the 579 deaths in 2012. The reasons for this failure are the subject of much debate, with many in the field suggesting that enforced detox and being encouraged to leave treatment too early are strong contributory factors.
But what is certain for the growing number of service users, treatment workers and medical professionals who have formed themselves into an action group – now called the Naloxone Action Group (NAG) – is that many of these deaths could have been prevented if naloxone had been available to use as an intervention to reverse overdose.
At the Action Summit on Naloxone (from which NAG was formed) held at Bleinheim’s headquarters in London last month, the agenda was split between sharing information and updates on naloxone, looking at examples of good practice from areas of effective distribution, and forming an action plan to challenge every area of the country that was slow or reluctant to roll out distribution and training.
Before arriving at the summit, participants had been asked to complete a questionnaire about the availability of naloxone in their area, the drivers for availability and the barriers to distribution both locally and nationally.
‘From participants’ responses there’s a marked variation,’ said Dr Chris Ford, clinical director of IDHDP, who chaired the meeting. ‘One area had total provision, most areas had nothing…. There is a definite postcode lottery. We’re going back to the bad old days and it stinks.’
The group identified those most at risk, with Professor John Strang referring to evidence that more frequent deaths happened during early stages of methadone treatment and early days of release from prison. One important factor to concentrate on was that many people died in the presence of friends, so the group agreed it was incredibly important – and an obvious move – to involve these potential ‘first responders’ with naloxone distribution and training. Families were also ‘absolutely crucial’ – ‘we want to get away from it being revolutionary to it being normalised,’ he said.
GPs would need to prescribe naloxone to patients and authorise family members to collect it and do the training. Oliver Standing from Adfam said that his experience of running a bereavement project had shown that families were ‘desperate to be involved’, while Jamie Bridge of the International Drug Policy Consortium (IDPC) and the National Needle Exchange Forum (NNEF) said ‘having family voices in this will be invaluable – it will make commissioners care.’ The idea of involving recovery assets such as family also ‘fits beautifully into the recovery framework’, said Fraser Shaw of Compass.
Elsa Browne of SMMGP added that her organisation had launched an e-learning module, written by Dr Kevin Radcliffe, to help with training. Around 100 people a month were doing it, ‘and the evaluation is brilliant’, she said.
John Jolly, Blenheim’s chief executive, brought the discussion back to the critical lack of action in England.
‘What’s happened in politics?’ he asked. ‘In May 2012 the ACMD recommended that naloxone should be more widely available, that the government should ease restrictions on supply, and that people should be better trained to administer it.’ The ACMD also commented on Scotland’s strategy running, Wales’ strategy being about to run, and England having no policy. ‘There are some great areas of good practice in England, but it’s very patchy,’ he added.
A letter from the Department of Health was shown to the group. It was a response to Dr Judith Yates’ letters to public health minister Jane Ellison, in which she pressed for answers on the lack of action. The letter assured Dr Yates that, following the ACMD’s advice, PHE and the Medicines and Healthcare Products Regulatory Agency were ‘working on amending medicines regulations to allow the wider distribution and administration of naloxone’. But new regulations would not come into effect until October 2015, ‘the earliest practicable date’ to avoid the distractions of the general election campaign.
The overwhelming reaction of the group was that this was ‘choosing to do nothing’ as October would not be within this government. ‘We’re not happy with the date that’s been set,’ said service user activist Kevin Jaffray. ‘A date a year from now leaves space for another 32 per cent rise in deaths. There’s been a constant rise since 2009.’
Steve Taylor, programme manager for alcohol and drugs at PHE, was invited to give a response to the situation. ‘We’re not kicking things into the long grass – things will have started to take place by October,’ he said, agreeing that ‘anybody walking out of the door with a methadone script and not naloxone is ludicrous.’
Any changes made in October would not make a huge amount of difference, he added, saying ‘there are things you can be doing’ that didn’t require any change in legislation. It was our responsibility ‘as doctors and clinicians’ to prescribe naloxone to people on methadone treatment, he said, and it could be given to families for the named patient. ‘What is it that’s going to change, that we don’t already do?, he asked.
PHE was looking to produce a briefing by the end of this year, using expertise to advise on what arrangements for wider provision might be. ‘But,’ he advised the group, ‘there is not going to be a national programme in England because of localism.’
Rhian Hills from the Welsh Government and Kirsten Horsburgh from the Scottish Drugs Forum shared their experience of naloxone strategy in each country, both of which had shown a decline in drug-related deaths since the strategies’ implementation. Wales had made a commitment back in 2008 to reduce drug-related harm and deaths, and had set up a national group that included police and paramedics. Demonstration sites had followed, evaluated by the University of South Wales, and the main recommendation to roll out the programme was completed in November 2011.
A decline in deaths of 53 per cent spoke for itself. ‘I don’t think it’s rocket science,’ said Hills. ‘It’s simple, it saves lives. It’s down to commissioners – get your priorities right.’ Involvement of service users – ‘the experts’ – had been really important in making risk logs, and from there, distribution had been increased to carers and their engagement encouraged. ‘Naloxone should be second nature,’ she said.
Kirsten Horsburgh acknowledged there had been ‘challenges and barriers’ in Scotland, starting from having one of the highest rates of drug-related deaths in Europe. But a national naloxone programme, launched at the end of 2010, had responded to common circumstances – that the average age of victims was 40, that they were not in treatment and likely to have had a recent period of abstinence, and that they were likely to die in their own or a friend’s home with witnesses (other drug users) present.
A Patient Group Direction (PGD) had been sent out to nurses and pharmacists in community addiction teams, needle and syringe programmes, harm reduction teams and the Scottish Prison Service, and Lord Advocate’s Guidelines allowed naloxone to be supplied by staff working for services in contact with people at risk of opiate overdose, such as in hostels. Anyone supplied with naloxone had to do training to make sure they were confident.
‘The key messages are prioritise the supply of naloxone to people who use drugs, make it normal in services and ensure people on ORT [opioid replacement therapy] have a supply,’ she said. ‘Make the training brief – just a ten minute chat – and involve peer trainers. All this potentially saves hundreds of lives.’
On 4 November the World Health Organization (WHO) recommended expanding access to naloxone, from just medical professionals to people likely to witness an overdose in their community, including friends, family members, partners of people who use drugs, and social workers. The report emphasised the safety of the drug, the ease of administering it, and its potential to reduce 69,000 deaths a year globally from opioid overdose.
The group around the table in London agreed that action was needed now, and there was no need to wait for PHE’s October 2015 directive to make each area of the country accountable for including naloxone in its localism agenda.
Dr Judith Yates gave the example of Birmingham’s progress – a process driven by doctors, nurses, pharmacists and service users, rather than commissioners.
‘Naloxone kits have become normal – we hear about reversals every month,’ she said. Dr Yates had trained drug workers from local service Swanswell, who were in turn carrying out training. ‘We don’t do risk assessments – we give naloxone to all first responders, we give it to everyone who uses drugs,’ she explained. ‘We have stories of residents in hostels saving each others’ lives.’
‘We’re obsessed with controlled drugs, but this is like giving an asthma inhaler, not methadone,’ added Emily Finch of SLAM. ‘I’ve signed hundreds of naloxone prescriptions.’
At NAG’s second meeting on 21 November, the group prioritised the need to overcome the obstacle presented by localism, which prevented England from having a national naloxone strategy.
‘PHE’s October deadline is disappointing, but it’s less than a year away. Of more concern is that we can’t have a national strategy because of localism,’ NAG chair John Jolly told DDN. ‘We agreed the need to bring this to the attention of politicians as well as clinicians. Naloxone distribution is not a minority sport, it’s day-to-day business. If you’re giving opiate treatment, you should be giving naloxone.’
With thousands of doses administered by ambulances, clear messages on distribution from the ACMD, and the Medicines Act ‘clearly empowering every citizen to use it’, there should be no obstacle to making naloxone available in every part of the country, he said. The recovery agenda was directly relevant: NAG identified that those most at risk were those starting on a journey of recovery, and emphasised the need for training alongside naloxone distribution.
‘We need to be identifying areas that are delivering good practice and naming and shaming areas that aren’t,’ said Jolly.