Peer naloxone – present or future?

1. Peer naloxone – present or future? Issues for service delivery Nigel Modern

2. Current status of Take Home Naloxone • We have good evidence of effectiveness in individuals but not evidence which shows effectiveness in populations • This leaves naloxone open to the ‘seat belt’ argument • Research is in progress to resolve this

3. Does this prevent its introduction into practice? • No! • However we need to accept we are dealing with an intervention in development with as far as I am aware no national guidance • There are clear at risk groups at which to target the intervention…and consensus on good practice?

4. Good practice in Naloxone prescribing(a local guideline) The prescriber should have a continuing duty of care towards the individual for whom they prescribe and will normally be a prescriber within a service where the person is in treatment or their registered GP

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

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

7. Target groups • Naloxone can and (perhaps?) should be offered to all opiate users but the following groups are particularly at risk of overdose • i. Injecting drug users ii. Service users in the early stages of treatment iii. Service users with possible lowered tolerance eg post detoxification or on prison release

8. Not a ‘new drug’ • Naloxone is a safe, long established and effective medication with no addictive potential and is not a controlled substance

9. Good practice? • Current significant initiatives involve quite complex delivery processes involving a group training session with evaluation of effectiveness of training • In other places services are starting to deliver the intervention to individuals with or without evaluated group training • Who is right?

10. Who is right? • Don’t know but audit of results is essential • Audit of reported naloxone use: An important part of the role of service user advocates and staff involved in service provision is to encourage the reporting of all uses of naloxone so that information can be gathered to aid in future service design. There is a defined dataset for audit purposes and the contact number to give to service users for this purpose is included with the information accompanying the standard script wording.

11. Future planning • Currently locally services run evaluated group training plus audit of naloxone use • In future we may in Primary Care run an individual brief training session delivered by drug workers who then trigger a Shared Care GP to prescribe • This may utilise intranasal naloxone

12. My own current practice • I explain the use of naloxone • I provide the materials developed for the Primary Care intitiative which is in preparation • I provide a prescription (with tear-off quick reference strip) to service users I come across from the at risk groups…but I am not entirely consistent owing to time constraints…in fact I’m pretty bad

16. Unresolved issues • The usual dose IM is 400mcg but more could be needed in some individuals • The Minijet is fiddly and multiple doses means multiple injections • Intranasal naloxone could give flexibility of dose, greater acceptability and availability in the community but many feel more evidence for its effectiveness is needed