Provision of Naloxone and related legislation in Norway, Denmark, Germany and Spain.
The community intranasal naloxone programme, commenced in Oslo and Bergen in 2014, has previously been unable to implement on a large scale within the prison setting. As the programme expands, emphasis on establishing within prisons is a priority. In Norway, the programme provides a pre-filled naloxone syringe (2mg/2ml) with a nasal atomizer rather than needles for injection.
A study conducted inside prisons was completed to assess the impact of brief overdose prevention training. It assessed the knowledge of prisoners in Oslo pre and post naloxone training (Petterson and Madah-Amiri, 2017).
Participants were found to have a high baseline knowledge of risk factors, symptoms and care regarding opioid overdoses. However, the brief training significantly improved knowledge, particularly in relation to naloxone.
They concluded that the need for overdose prevention programmes is critical and that naloxone training provided in the prison setting may improve the ability of inmates to recognize and manage opioid overdoses after their release.
In Estonia, as well as having a community-based programme (launched in 2013), from 2015 naloxone began being issued by medical departments within prisons. These prisons organize training for inmates with previous experience of IV opioid use before they are released from prison and upon release, give them a pre-filled naloxone syringe kit to take home.
From June 2015 to the end of 2016, a total of 107 inmates received relevant training in Viru Prison, Harku and Murru Prison, and Tartu Prison; 85 pre-filled naloxone syringes were issued to inmates upon release.
Intranasal naloxone distribution started in 2013 in Copenhagen, Aarhus, Odense and Glostrup. As of 2014, 121 people who use drugs had received overdose prevention training and THN kits (EMCDDA, 2016a).
THN is provided to people who use drugs, family members, friends and staff working in services. Training is provided on overdose prevention and management before people are provided with a THN kit.
The kit is a 2mg/2ml pre-filled syringe with a separate nasal atomizer. There are 5 doses of 0.4mg with instructions to administer the first 3 doses intranasally and the remaining two by intramuscular injection.
“Fixpunkt” Berlin began distributing THN in 1999 but the project did not secure funding after the pilot phase in 2002. THN did, however, continue to be provided in lower numbers following the pilot (Dichtl et al. 2018; Dichtl and Stöver 2015).
Currently, there are approximately 10 initiatives of NGOs providing THN, and also some self-help organizations. However, no THN programme is focusing on the period of release from prison.
THN is now being discussed widely in Germany as well as the development of a network in order to improve the provision of THN (coordinated by Akzept e.V.; see www.naloxoninfo.de).
Barcelona began formally distributing THN in 2008, although there were reports of this happening informally since 2001.
The formal programme commenced in 2008 and THN is now provided to people who use drugs from a broad range of services including drug treatment services, drug consumption rooms and detox centres.
Initially, there was a financial incentive for people who use drugs to attend training. By December 2013, 5830 THN kits had been supplied with 40% reporting having used it on someone.
Challenges noted by the programme coordinators include attitudinal barriers from abstinence-focused services, limited carriage of naloxone kits and a lack of provision via the prison service (EMCDDA 2016a).