The primary outcome for the effectiveness of the Scottish naloxone programme was to show a reduction in the number of opioid-related deaths within 4 weeks of liberation from prison.
These deaths decreased by 36% from 9.8 to 6.3% during the evaluation period.
Scottish Drugs Forum introduced an innovative Naloxone Peer Education Programme in 2012, which continues to be implemented across Scotland to date (Scottish Drugs Forum, 2012).
Peer educators are recruited from a variety of services in the community, most have a history of using drugs but in some cases, they are family members who have lost a son or daughter to an overdose.
Peer educators are trained by SDF over four days focusing on different components of the skills and knowledge required in carrying out brief interventions in the community and are supported by face-to-face meetings on a monthly basis.
Local support is provided by a named service lead in the area, with meetings planned on a regular basis with peers to discuss any training or personal issues that arise.
Support as a group or 1-1 is then offered to people depending on the issues raised. Peer educators have, to date, provided thousands of hours of their own time to help increase the awareness and supplies of naloxone throughout Scotland with several thousand people now having been trained by a naloxone peer educator.
In 2015, new regulations regarding the supply of naloxone mean that people employed or engaged in the provision of drug treatment services can provide it to anyone who may witness an overdose without the need for a prescription. This important change means that in addition to nurses and pharmacists, other people undertaking roles within drug treatment services can also make supplies of naloxone, such as volunteers.
In August 2017, the UK’s first naloxone peer supply model was launched in Glasgow (Scottish Drugs Forum, 2017).
It is hoped that the volunteers will contribute to increasing the availability of naloxone within the community so that it is more likely to be present when an overdose occurs, and the project will also provide additional skills and opportunities for the volunteers themselves.
The newly established group will first target Recovery Communities in Glasgow, then move to supported accommodations, residential and community programmes, as well as aiming to reach people at risk in the streets of Glasgow who may be homeless or roofless and not currently engaged with services. Through adding the supply element to the current peer naloxone training, the model aims to be more effective in reaching these at-risk populations.
The Peer Supply Model will be evaluated and if deemed a success, the model will be implemented in other Health Boards across Scotland.
Within the first 3 months of operating, peers had supplied over 300 take-home naloxone kits to people likely to witness an overdose.
These deaths decreased by 36% from 9.8 to 6.3% during the evaluation period. It was estimated that had issued nearly 12,000 naloxone kits during 2011–13, Scot- land’s national naloxone programme may have prevented 42 prison release opioid-related deaths.
The secondary outcome was to show a reduction in the number of opioid-related deaths following hospital discharge and in contrast, the national naloxone programme had little apparent effect in this area (Bird et al. 2016).
It should be noted that hospitals were not targeted as an essential naloxone supply route in the same way that prisons were. There are only small numbers of hospitals across Scotland currently providing take-home naloxone via the hospital setting. Unfortunately, over the course of the programme, drug-related deaths as a whole have continued to increase.
Naloxone has been used thousands of times to reverse potentially fatal opiate-related overdoses so it is realistic to suggest that the number of deaths may have been much higher had naloxone not been available.
Depending on our definition of effectiveness, there are other ways to look at the impact of the Scottish programme.
From a treatment provider perspective – the introduction of the national programme made it more likely for practitioners to have conversations with people attending their service about the risks of overdose and how to respond. In a culture of what is often seen as ‘punitive’ type services, the programme offered a way to break down barriers and improve relationships with the client group.
Providing naloxone is a very powerful message, indicating that it matters whether the individual lives or dies.
The programme has succeeded in normalising the provision of naloxone to people who use drugs, their family members and now anyone else likely to witness an overdose, and is addressing stigma by doing so.
Despite all the above, naloxone is not present where all overdoses are occurring and we need to ensure much better coverage to improve this.
Police Scotland is not currently involved or accepting of the use of naloxone by their staff. Incidentally, police are very often first on the scene when an overdose occurs and therefore in a prime position to respond effectively with naloxone. One of the reasons used to justify this lack of acceptance is due to the product being injectable. In light of this, it is hoped that in 2018 we will have access to an intranasal formulation which will assist in these discussions, which are still currently ongoing regardless.
General Practitioners are well placed to be prescribing naloxone to people who may not be in contact with traditional drug services as many GPs prescribe opiate replacement therapy. It has been difficult to engage GPs in the programme, despite what previously appears to have been a potential will for them to do so (Pflanz-Sinclair et al. 2013).
The Scottish Ambulance Service is another organization that could have a key role in the distribution of naloxone when they attend non-fatal overdoses. Many people do not go with the paramedics to a hospital and can be at risk of further overdose. This is a perfect opportunity to offer some brief training and provision of naloxone kits.
Due to the regulation change in 2015, 3rd sector organizations can now provide naloxone, however many areas are not taking advantage of this change.
Prison supply of naloxone has been variable across the estate and therefore could be better embedded to be more effective.
Finally, the role of peers in the programme could be broadened to have more supply networks across the country which would greatly enhance the distribution to people most at risk.