Peer naloxone – Peer naloxone – present present or future?or future?

Issues for service deliveryIssues for service delivery

Nigel ModernNigel Modern

Current status of Take Current status of Take Home NaloxoneHome Naloxone

We have good evidence of We have good evidence of effectiveness in individuals but not effectiveness in individuals but not evidence which shows effectiveness evidence which shows effectiveness in populationsin populations

This leaves naloxone open to the This leaves naloxone open to the ‘seat belt’ argument‘seat belt’ argument

Research is in progress to resolve Research is in progress to resolve thisthis

Does this prevent its Does this prevent its introduction into practice?introduction into practice?

No!No! However we need to accept we are However we need to accept we are

dealing with an intervention in dealing with an intervention in development with as far as I am development with as far as I am aware no national guidanceaware no national guidance

There are clear at risk groups at There are clear at risk groups at which to target the intervention…which to target the intervention…and and consensus on good practice?consensus on good practice?

Good practice in Naloxone Good practice in Naloxone prescribing(a local guideline)prescribing(a local guideline)

The prescriber should have a The prescriber should have a continuing duty of care towards the continuing duty of care towards the individual for whom they prescribe individual for whom they prescribe and will normally be a prescriber and will normally be a prescriber within a service where the person is within a service where the person is in treatment or their registered GPin treatment or their registered GP

Good practiceGood practice

The prescriber has an unclear duty of The prescriber has an unclear duty of care towards a person that their care towards a person that their patient revives using naloxone patient revives using naloxone prescribed for their own use. However prescribed for their own use. However naloxone has growing international naloxone has growing international recognition and its use is very similar recognition and its use is very similar to eg glucagon in diabetes and the to eg glucagon in diabetes and the Epipen in anaphylaxis. Epipen in anaphylaxis.

Good practiceGood practice

Naloxone (in the UK) is included in Naloxone (in the UK) is included in the list of parenteral drugs which can the list of parenteral drugs which can be given ‘…by anyone for the be given ‘…by anyone for the purpose of saving life in an purpose of saving life in an emergency…’ in Medicines for emergency…’ in Medicines for Human use (Prescribing) - Human use (Prescribing) - Miscellaneous Amendments Order Miscellaneous Amendments Order 2005 No. 15072005 No. 1507

Target groupsTarget groups Naloxone can and (perhaps?) should Naloxone can and (perhaps?) should

be offered to all opiate users but the be offered to all opiate users but the following groups are particularly at risk following groups are particularly at risk of overdoseof overdose

i. Injecting drug users ii. Service i. Injecting drug users ii. Service users in the early stages of users in the early stages of treatment iii. Service users with treatment iii. Service users with possible lowered tolerance possible lowered tolerance eg post eg post detoxification or on prison releasedetoxification or on prison release

Not a ‘new drug’Not a ‘new drug’

Naloxone is a safe, long established Naloxone is a safe, long established and effective medication with no and effective medication with no addictive potential and is addictive potential and is notnot a a controlled substancecontrolled substance

Good practice?Good practice?

Current significant initiatives involve Current significant initiatives involve quite complex delivery processes quite complex delivery processes involving a group training session with involving a group training session with evaluation of effectiveness of trainingevaluation of effectiveness of training

In other places services are starting to In other places services are starting to deliver the intervention to individuals deliver the intervention to individuals with or without evaluated group with or without evaluated group trainingtraining

Who is right?Who is right?

Who is right?Who is right?

Don’t know but audit of results is Don’t know but audit of results is essentialessential

Audit of reported naloxone use:Audit of reported naloxone use: An important part An important part of the role of service user advocates and staff of the role of service user advocates and staff involved in service provision is to encourage the involved in service provision is to encourage the reporting of all uses of naloxone so that information reporting of all uses of naloxone so that information can be gathered to aid in future service design. There can be gathered to aid in future service design. There is a defined dataset for audit purposes and the is a defined dataset for audit purposes and the contact number to give to service users for this contact number to give to service users for this purpose is included with the information purpose is included with the information accompanying the standard script wording.accompanying the standard script wording.

Future planningFuture planning

Currently locally services run Currently locally services run evaluated group training plus audit evaluated group training plus audit of naloxone useof naloxone use

In future we may in Primary Care run In future we may in Primary Care run an individual brief training session an individual brief training session delivered by drug workers who then delivered by drug workers who then trigger a Shared Care GP to prescribetrigger a Shared Care GP to prescribe

This may utilise intranasal naloxoneThis may utilise intranasal naloxone

My own current practiceMy own current practice

I explain the use of naloxoneI explain the use of naloxone I provide the materials developed for I provide the materials developed for

the Primary Care intitiative which is in the Primary Care intitiative which is in preparationpreparation

I provide a prescription (with tear-off I provide a prescription (with tear-off quick reference strip) to service users I quick reference strip) to service users I come across from the at risk groups…come across from the at risk groups…but I am not entirely consistent owing to but I am not entirely consistent owing to time constraints…in fact I’m pretty badtime constraints…in fact I’m pretty bad

Unresolved issuesUnresolved issues

The usual dose IM is 400mcg but more The usual dose IM is 400mcg but more could be needed in some individualscould be needed in some individuals

The Minijet is fiddly and multiple doses The Minijet is fiddly and multiple doses means multiple injectionsmeans multiple injections

Intranasal naloxone could give Intranasal naloxone could give flexibility of dose, greater acceptability flexibility of dose, greater acceptability and availability in the community but and availability in the community but many feel more evidence for its many feel more evidence for its effectiveness is neededeffectiveness is needed