The Scottish Highland Overdose Prevention Programme Goes to Prison

Lisa Ross

NHS Highland Clinical Harm Reduction Nurse Specialist / Naloxone Lead

In July 2009, I started the Highland programme in Inverness, in the north of Scotland, to deliver overdose prevention services to those at risk of opiate overdose, their friends and family members, and staff working with those at risk. The program is part of the Scottish National Health Service, our universal public health care system. 

Trainees were given a supply of naloxone for intramuscular administration to take home and use in the event of witnessing an opiate overdose. The programme also included Inverness prison; those who were identified as at risk were trained whilst in prison and given a naloxone pack on their liberation date.

The Programme was rolled out after the first year throughout the Highland area. To date over 900 kits have been supplied and there have been over 200 recorded uses of naloxone with successful reversal of the overdose state. In 2012, the programme was developed to include supply of naloxone for intranasal administration.

Last year I also started to develop a network of peer trainers; one of the aims of this was to increase uptake to those at risk, particularly those who had not previously engaged with the programme. Peer trainers are ideally placed to deliver this training; after all they hold the most experience and are far more likely to engage with the identified target group.

This again included Inverness Prison; I trained a peer trainer as a trainer and he now delivers the training in prison to those at risk. The results of this have been hugely positive so far. In a short space of time he has managed to engage with more individuals and deliver the training to them than the health and addictions staff have managed throughout the year. This is even more impressive when we consider the prison is in its fourth year of delivering this intervention and supplies of naloxone were starting to decrease given that the majority of people had already been trained. Or so we thought!

There will be the opportunity for the peer trainer to continue delivering the programme upon his own liberation, working in the community with the Harm Reduction Service and the community peer trainers.

My ongoing intention for the programme is to increase the number of peer trainers throughout Highland; there is no doubt that when it comes to overdose prevention and Naloxone training; peer trainers can have the maximum impact.

Naloxone laws to prevent overdose

There have been a slew of recent bills introduced or passed to improve naloxone access around the United States. Most of these are similar to previous U.S. models, although some are quite innovative. 

First, here's a summary from the Network for Public Health Law of naloxone (and Good Samaritan) laws as of October 2012, when 8 U.S. states had naloxone access laws (CA, CT, MA, NM, NY, IL, WA, RI).

Now, below are some links to recently approved or newly considered bill/law text. Please let us know if there are others and offer comments on any of these. It's getting hard to keep track, so I've added a simple map - black areas have naloxone laws and orange areas have pending laws (black states with an orange mark have existing laws with pending modifications).

New laws:

Virginia

Washington DC

Bills:

California (builds on existing law that is to sunset)
Colorado

Kentucky

Maryland

Massachusetts (not sure in what ways this expands on existing law Act 192)

New Jersey

New Mexico (appropriations to support naloxone distribution)

North Carolina

Oregon (SB 384, passage appears likely, bill with amendments here)

Vermont (bill appears to require only consideration of a law change to encourage naloxone prescription)

West Virginia (requires naloxone be offered to all patients receiving chronic opioid therapy)

News: FDA denies Reckitt's request to block generic buprenorphine/naloxone tablets

The U.S. Food and Drug Administration has roundly denied all requests from Reckitt-Benckiser to block approval of generic buprenorphine/naloxone tablets. This request was made at the time when the monopoly on the product was ending and was based on risks of pediatric exposures that the company claimed were higher with the tablet than their new film product. The FDA provided an excellent review of the issues and rejected all components of the request.

This is an enormous relief for public health agencies providing buprenorphine services, many of which would have dropped buprenorphine services altogether or would have ceased to provide the buprenorphine/naloxone formulation due to cost.

PubMed Update December 2012 - January 2013

This is a really exciting time for research into overdose in general and naloxone in particular. 15 papers this time.

1. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.

Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A.

BMJ. 2013 Jan 30;346:f174. doi: 10.1136/bmj.f174.

Comments: A long-awaited paper for which the authors deserve high praise, as they have produced the first real evidence of naloxone effectiveness and arguably the most important contribution to naloxone literature to-date. Although not randomized, the interrupted time series analysis is respectable and the results are impressive.

2. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal.

Coffin PO, Sullivan SD.

Ann Intern Med. 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.

Comments: I’ve wanted to write this paper for about a decade, when I thought about cost-effectiveness as three to four calculations on the back of a napkin, rather than years of work and RAM-straining matrices. There’s a long way to go with overdose research that will certainly contribute to future iterations of the model. In the meantime, this is probably a fair, if quite conservative, initial estimate. There is one sensitivity analysis – in which naloxone results in behavior change such that overdose risk is lower – which I suspect may be closer to the actual truth.

3. Naloxone for heroin overdose reversal.

Ann Intern Med. 2013 Jan 1;158(1):I-30. doi: 10.7326/0003-4819-158-1-201301010-00001. No abstract available.

Comments: An excellent editorial from our colleagues at NIDA and the FDA.

4. Prescription opioid use among addictions treatment patients: Nonmedical use for pain relief vs. other forms of nonmedical use.

Bohnert AS, Eisenberg A, Whiteside L, Price A, McCabe SE, Ilgen MA.

Addict Behav. 2012 Nov 23;38(3):1776-1781. doi: 10.1016/j.addbeh.2012.11.005. [Epub ahead of print]

Comments: Survey of prescription opioid use among treatment program patients. Use for reasons other than pain relief was associated with overdose as well as use of several other agents that increase the risk of overdose.

Naloxone reduces community-level opioid overdose mortality

Alex Walley and colleagues have published their analysis of the Massachusetts naloxone program, which shows what I'm going to call a per capita dose-dependent reduction in opioid overdose death (rate ratio of 0.73 [95%CI 0.57-0.91] if naloxone was given to 1-100 people per 100,000 population and 0.54 [0.39-0.76] for naloxone to >100/100,000). This provides the first real community-level effectiveness data to-date.

The finding that naloxone was more effective the more people per population were given kits suggests that aggressive distribution may be the optimal approach for naloxone programs. This study doesn't answer the question as to why there was a dose-dependent response - was it simply because more is better? were there social network effects where naloxone became substantially more effective if it reached into certain social networks, which was more likely if it was more widely distributed? Social network issues have yet to be explored in overdose prevention research.