Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 16 February 2012

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

Late opening for pubs and bars aggravates alcohol-related harm ...

Weekend alcohol sales equals more weekend alcohol-related harm ...

Naloxone empowers carers to save lives of overdosing heroin users ...

Naloxone-based overdose prevention training spread slowly in England ...


Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms.

Hahn R.A., Kuzara J.L., Elder R. et al.
American Journal of Preventive Medicine: 2010, 39(6), p. 590–604.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hahn at rhahn@cdc.gov. You could also try this alternative source.

UK research is inconclusive, but international research from developed nations supports the belief that increasing on-licence opening hours leads to more drinking and more alcohol-related harm.

Summary International bodies have recommended controlling hours and/or days when alcohol sales are permitted as way of reducing excessive alcohol consumption and related harms. Such measures are thought to work by altering the availability of alcohol, leading consumers to change their purchasing habits including how much they buy and when and where. Such changes may then affect drinking patterns or overall levels, resulting in changes in alcohol-related problems. Changes in drinking may not be the only way hours of sale affect alcohol-related health. For example, some changes may lead to greater concentrations of drinkers in pubs and bars, increasing the risk of alcohol-related aggression, or divert drinkers to less restricted areas with consequent displacement of drinking and related harm, and perhaps extra harm due to more driving and more drink-driving.

A companion review of the effects of changing days of sale concluded that increases lead to increased consumption and related harms. The question addressed by the featured review was how – within allowable days of sale – the number of hours during which regulations allow alcohol to be bought and served affects excessive alcohol consumption and related harms. It also asks whether such impacts are only noticeable above a certain threshold change in hours. The threshold it seemed reasonable to investigate was two hours a day. Most prior reviews have combined findings on days and hours, and none have investigated threshold effects.

It also seems possible that any resultant harm will be reduced when premises have to apply for extra hours and meet certain safety criteria rather than when the extra hours are applied across the board, though in the event the studies found by this review were unable to answer this question.

Results of reviewed studies had to be published in English and reflect non-transient changes in hours (eg, not for a special one-off event) in high-income Intended to improve generalisability to the USA. Similarly the results can be expected to be more applicable to the UK than studies of poorer countries. economies when these were the sole intervention affecting drinking and related harm rather than part of a combined programme. Studies of impacts outside the jurisdiction where changes were made were not considered. Within the jurisdiction, trends in drinking and related harm had to be benchmarked against a comparison area not subject to changes in hours or against the same area before the changes.

Main findings

Ten studies were found of six changes in hours (four in Australia) of at least two hours a day, all increased opening hours at on-premises outlets such as pubs and bars and mostly comparing before and after outcomes. Of the ten studies, six found an increase in alcohol-related harms including crash and alcohol-related injuries, violence, emergency room admissions, and driving under the influence. Two found decreased alcohol-related harms, one no effect, and another an increase in alcohol consumption which did not meet criteria for statistical significance.

Among these studies were three of the UK Licensing Act of 2003 which (subject to local licensing requirements) permitted sales 24 hours a day in England and Wales. Two studies found a relative decrease in harms (violent crime and alcohol-related facial injuries) while a third study found a relative increase in alcohol-related assault and injury.

Six studies were found of five changes in hours of under two hours a day, all increased opening hours at on-premises outlets such as pubs and bars and mostly comparing before and after outcomes. Results were mixed and inconsistent. Only one (Australian) study reported clearly negative effects in the form of substantial increases in wholesale alcohol purchases, assaults, and motor vehicle crashes. Other studies reported small and inconsistent changes in sales, consumption, alcohol-related mortality, and motor vehicle crashes.

Among these were studies of the extension in Scotland in 1976 of closing time from 10 to 11 at night. These found only small changes in sometimes opposing directions, including increased consumption among women but decreased among men and a small per capita increase in beer consumption. In 1988, England and Wales extended closing hours from 10:30 to 11 at night and opening time from 11 to 10 in the morning. Associated changes in alcohol-related mortality and morbidity, dependence, and absenteeism varied in size and direction, and included the seemingly contradictory findings that compared with the benchmark jurisdiction (Scotland), convictions for underage sales increased by 64% while sales to minors fell substantially. Another finding was a near 16% increase in recorded violent crime.

The authors' conclusions

This review found that increasing the hours when alcohol may be served in on-licensed premises by at least two hours a day increased alcohol-related harms. According to criteria adopted by the US government's Community Guide to identify effective health-related programmes, on grounds of alcohol-related harm, these findings are sufficient to support resistance to attempts to add two hours or more a day to permitted alcohol sales hours. By extension, it seems reasonable to assume that reducing hours by the same amount would reduce harms, but no study tested this proposition directly. Evidence was insufficient to determine whether smaller changes in hours have any meaningful impact, none was available relating to off-licence sales, and none assessed economic impacts, in particular any losses in sales and tax revenues from restricting hours.


Findings logo commentary This is one of a number of reviews intended to inform decisions made by US communities on health-related programmes. The reviews are considered by a task force with particular expertise in public health, which takes their finding in to account in making its recommendations. The task force considered this review and another on changes in the days on which alcohol can be sold. On the basis of "strong evidence of effectiveness", it recommended maintaining existing US limits on the days on which alcoholic beverages are sold as one strategy for the prevention of excessive drinking and related harms. On the basis of the featured review, the task force judged the evidence "sufficient" to also recommend similar actions for similar reasons in relation to the hours during which alcohol can be sold at on-premises outlets.

The task force was concerned with impacts on "excessive" alcohol consumption, but the featured review reported on impacts on total or per capita consumption. Presumably the presumption is being made that overall increases also mean increases in the proportion of the population drinking excessively and/or in the intensity of drinking by excessive drinkers. That presumption is reasonable but by no means certain.

Though it found UK evidence equivocal ( below), Britain's National Institute for Health and Clinical Excellence also concluded that as well as reducing the number of outlets, making it harder to buy alcohol by limiting days and hours when it can be sold effectively reduces alcohol-related harm.

Despite some possible local impacts (notably in alcohol-related overnight emergency department admissions at an inner London hospital), nationally and in aggregate the UK Licensing Act of 2003 which permitted sales 24 hours a day in England and Wales lacked a clear and consistent impact on overall levels of drinking or related crime and disorder (1 2 3). But the act permitted rather than required 24-hour service and changes in hours were subject to local licensing decisions. In practice, on-licence premises extended hours only slightly and apart from hotels, which have always been able to serve guests 24 hours a day, all-day licenses were largely confined to off-licensed premises including supermarkets and petrol stations.

Last revised 08 February 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2010 Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms

REVIEW 2009 Effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms

STUDY 2011 Achieving positive change in the drinking culture of Wales

REVIEW 2010 Polarized drinking patterns and alcohol deregulation. Trends in alcohol consumption, harms and policy: United Kingdom 1990–2010

REVIEW 2010 The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms

REVIEW 2012 Are alcohol prices and taxes an evidence-based approach to reducing alcohol-related harm and promoting public health and safety? A literature review

STUDY 2008 Independent review of the effects of alcohol pricing and promotion

REVIEW 2010 Effects of alcohol tax and price policies on morbidity and mortality: a systematic review

STUDY 2015 The impact of extended closing times of alcohol outlets on alcohol- related injuries in the nightlife areas of Amsterdam: a controlled before-and-after evaluation

STUDY 2010 Social host liability for minors and underage drunk-driving accidents





Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms.

Middleton J.C., Hahn R.A., Kuzara J.L. et al.
American Journal of Preventive Medicine: 2010, 39(6), p. 575–589.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hahn at rhahn@cdc.gov. You could also try this alternative source.

International research from developed nations offers some support for the belief that allowing or disallowing Saturday or Sunday alcohol sales and service affects drinking and alcohol-related harm.

Summary International bodies have recommended controlling hours and/or days when alcohol sales are permitted as way of reducing excessive alcohol consumption and related harms. Such measures are thought to work by altering the availability of alcohol, leading consumers to change their purchasing habits including how much they buy and when and where. In turn these changes may affect drinking patterns or overall levels, resulting in changes in alcohol-related problems. Changes in drinking may not be the only way days of sale affect alcohol-related health. For example, more days of drinking offer more days when concentrations of drinkers in pubs and bars raise the risk of alcohol-related aggression. Changes in days and/or hours may also divert drinkers to less restricted areas with consequent displacement of drinking and related harm, and perhaps extra harm due to more driving and more drink-driving.

A companion review has assessed the effects of changing hours of sale, concluding that at two hours or above, increases in on-licence opening hours lead to increased consumption and related harms. The question addressed by the featured review was how changes in the days of the week during which regulations allow alcohol to be bought and served affect excessive alcohol consumption and related harms.

Results of reviewed studies had to be published in English and reflect non-transient changes in days (eg, not for a special one-off event) in high-income Intended to improve generalisability to the USA. Similarly the results can be expected to be more applicable to the UK than studies of poorer countries. economies when these were the sole intervention affecting drinking and related harm rather than part of a combined programme. Trends in drinking and related harm had to be benchmarked against a comparison area not subject to changes in days or against the same area before the changes.

Main findings

Fourteen studies were found. Seven concerned increased days of service at on-premises outlets such as pubs and bars, all but one concerned solely with effects related to motor vehicles and driving. The exception investigated the 1977 law allowing Sunday alcohol sales in the four major cities and within the central belt of Scotland. It found significant increases in consumption among men including 2.4 UK units (19g alcohol) more per week among men aged 18 to 45, but none among women, and the proportion of the population drinking on Sunday itself increased only slightly and non-significantly. Five studies (four in Australia and one in the USA) examined the impact of allowing Sunday on-premises sales on indicators of alcohol-impaired driving on that day of the week, recording generally significant increases in deaths, crashes and arrests for drink-driving.

Four studies conducted in Sweden and the USA concerned increased days of sales (permitting Sunday or Saturday sales) at off-licensed premises where alcohol is sold for consumption elsewhere. Generally they found significantly increased per capita consumption but less clear links with harm: assault rates were not significantly affected, and there were equivocal impacts on drink-driving. When New Mexico allowed Sunday sales, alcohol-related crashes and resultant deaths clearly increased on Sundays [Editor's note: and were not compensated for by reductions on other days]. The increase in drink-driving arrests when Sweden allowed Saturday sales was significant only in the pilot phase and not when the law was extended nationally. It was suspected that the initial increase was an artefact due to more intense policing.

Three studies investigated the reverse process – banning Saturday or Sunday off-licence sales in Sweden, Norway and New Mexico. In Sweden assaults, domestic disturbances and incidents of drunken people being dealt with by the police all fell on Saturdays with no countervailing increases on other days. In selected communities Norway later experimented with banning Saturday sales from its state spirits and wine monopoly stores, though beer remained available. Compared to matched communities, drinkers consumed less alcohol from wine and spirits but more from beer, summing to a small net increase. Domestic altercations and arrests for drunkenness fell but reports of violence increased. Finally, after Sunday sales were allowed, some New Mexico communities took the option of reinstating the ban locally. If they did so rapidly, their counties experienced lower increases in alcohol-related crashes after Sunday sales were allowed than other counties in the state.

The authors' conclusions

This review found that increasing days of sale by allowing previously banned alcohol sales on either Saturdays or Sundays increased excessive alcohol consumption and related harms, including motor vehicle crashes, drink-driving, police interventions against drunk people, and, in some cases, assaults and domestic disturbances. The implication is that maintaining existing limits on Saturday or Sunday sales – the situation against which increases were benchmarked in these studies – can avert the extra alcohol-related harms which would happen if days of sale were extended.

In respect of the reverse process – reducing days of sale – a study of a Saturday ban in Norway showed mixed effects, whereas a study of the imposition of a Saturday ban in Sweden and one of the reversal of a lifted ban in New Mexico found a decrease in alcohol-related harms.

According to the Community Guide's rules of evidence, this body of work constitutes strong evidence that maintaining limits on days of sale prevents alcohol-related harms. These studies also offer some evidence that imposing limits on days of sale can reduce alcohol-related harms.


Findings logo commentary This is one of a number of reviews intended to inform decisions made by US communities on health-related programmes. The reviews are considered by a task force with particular expertise in public health, which takes their finding in to account in making its recommendations. The task force considered this review and another on changes in the hours on which alcohol can be sold. On the basis of "strong evidence of effectiveness" from the featured review, it recommended maintaining existing US limits on the days on which alcoholic beverages are sold as one strategy for the prevention of excessive drinking and related harms. The task force judged the evidence "sufficient" to also recommend similar actions for similar reasons in relation to the hours during which alcohol can be served at on-premises outlets.

Though it found UK evidence equivocal, Britain's National Institute for Health and Clinical Excellence also concluded that as well as reducing the number of outlets, making it harder to buy alcohol by limiting days and hours when it can be sold effectively reduces alcohol-related harm.

The US task force was concerned with impacts on "excessive" alcohol consumption, but the featured review reported on impacts on total or per capita consumption. Presumably the presumption is being made that overall increases also mean increases in the proportion of the population drinking excessively and/or in the intensity of drinking by excessive drinkers. That presumption is reasonable but by no means certain. Though in relation to off-licence sales the evidence for increased consumption is quite consistent, and such increases may to lead to increased alcohol-related problems, direct evidence of increased harm seems relatively weak. In relation to increased days, it rests largely on findings from New Mexico, which in the light of a later US-wide study have been revealed as atypical. In relation to decreased days, it also rests partly on evidence from New Mexico which may be similarly atypical. More convincing are findings from Sweden, but findings from that country with its state alcohol monopoly stores and strict regulations may also not typify those to be expected elsewhere. Details below.

Weak evidence for an impact of days of off-licence sales

The suspicion that the increase in drink-driving arrests after Sweden piloted Saturday off-licence sales was an artefact due to more intense policing was supported by a later analysis from the same authors, though it has been argued that changes in alcohol import limits during the time when the two Swedish studies were conducted would have obscured the consequent increase in drinking and with it resultant alcohol-related harm.

Whatever the truth of that contention, of those included in the review, it leaves only the New Mexico study finding clear increases in drink-driving consequences as result of extra days of off-licence sales, in this case confirmed by blood tests on those killed in traffic accidents. However, a later study suggested that in this respect New Mexico was atypical. Of the 14 US states which relaxed or repealed their bans on the Sunday off-licence sales, only the repeal in New Mexico led to more deaths. It seems this was because there the repeal led to larger increases in drinking than elsewhere, coupled with the facts that New Mexicans drive relatively more and their traffic fatalities are more likely to involve alcohol. The evidence in relation to New Mexico communities which rapidly reinstated the ban is suggestive of a protective effect, but this was not subject to statistical tests of significance, and it seems possible that the few communities which rapidly took up this option differed in other ways from the communities which did not.

Last revised 08 February 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2010 Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms

REVIEW 2009 Effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms

STUDY 2011 Achieving positive change in the drinking culture of Wales

REVIEW 2010 The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms

REVIEW 2010 Polarized drinking patterns and alcohol deregulation. Trends in alcohol consumption, harms and policy: United Kingdom 1990–2010

REVIEW 2012 Are alcohol prices and taxes an evidence-based approach to reducing alcohol-related harm and promoting public health and safety? A literature review

STUDY 2008 Independent review of the effects of alcohol pricing and promotion

REVIEW 2010 Effects of alcohol tax and price policies on morbidity and mortality: a systematic review

STUDY 2015 The impact of extended closing times of alcohol outlets on alcohol- related injuries in the nightlife areas of Amsterdam: a controlled before-and-after evaluation

STUDY 2010 Social host liability for minors and underage drunk-driving accidents





The NTA overdose and naloxone training programme for families and carers.

National Treatment Agency for Substance Misuse.
National Treatment Agency for Substance Misuse, 2011.

Up to 18 lives were known (and more perhaps unrecorded) to have been saved after the National Treatment Agency in England piloted training for the carers of opiate users on how to administer the overdose-reversing drug naloxone. But how does catering for relapse in this way square with the optimism of the recovery movement?

Summary This account also draws on the appendices to the study.

Naloxone is a medication administered usually by injection which rapidly reverses the effects of opiate-type drugs such as heroin, including the respiratory depression which can cause what are normally referred to as 'overdose' deaths. In the UK naloxone-based overdose prevention programmes were hampered by the prescription-only status of the medication, but in 2005 the law was amended to permit emergency administration by any member of the public. A prescription is written for the opiate user at risk but the drug can then be kept for them by other people who can legally use it in an emergency, and not just for the named patient. The first people to find overdosing drug users are often family members, partners and other carers (who may themselves be drug users), many of whom are willing to carry naloxone.

Given this context, in 2009 the UK National Treatment Agency for Substance Misuse (NTA) – a special authority within the National Health Service dedicated to monitoring and improving addiction treatment – launched an overdose and naloxone training programme for families and carers of opiate users. The pilots ran at 16 sites in England from July 2009 to February 2010 and were evaluated by the NTA through questionnaires to be completed by carers before and immediately after training and three months later (to check among other things on the use made of the naloxone the carers had been provide with), and by focus groups with carers and interviews with trainers and project leaders at the pilot schemes. Of 495 trained carers, 425 completed at least one questionnaire, but few completed the three-month follow-up version, meaning that focus groups and interviews were the main sources of information.

Main findings

The 16 pilot projects trained 495 carers to respond to an overdose using basic life support Including phoning an ambulance, the recovery position, and cardiopulmonary resuscitation. techniques, and all but one also trained them to administer naloxone.

After the training and up to August 2010, trained carers had deployed naloxone to reverse 18 overdoses and in two cases administered basic life support. All the drug users survived. Most incidents were 'opportunistic' interventions, during which the carer used naloxone on someone other than the person named on the prescription.

Pilot leads and carers both felt it made sense to train people most likely to be present when users were taking drugs and running the risk of an overdose – often family members, but also other users. Several sites trained pairs of mutual carers (partners, close friends, or housemates), who both received a naloxone supply. Some were former service users no longer at risk of overdose themselves, but who cared for somebody at risk.

It was more difficult to recruit carers for training than expected, but sites remained committed to running the training. Every site was able to train at least some carers. Most carers responded positively to the initial approach for training, but not all felt ready for training. Some, including a few with long histories of contact with carer support groups, found the subject too distressing to confront. Others whose adult children had overdosed (fatally and non-fatally) could clearly see naloxone's potential for saving lives.

One site targeted people exiting inpatient detoxification. Despite their high risk of overdose, this site found it difficult to engage them, possibly because the stigma around drug use in their community (ethnically diverse, with a large Asian population) meant the offer of training would have exposed their drug use to families who up to then had been unaware. Also detoxification was seen as the doorway to a new non-drugtaking life, so it was difficult to persuade users and their carers that the training was necessary. Despite this, the site worked with nine carers, showing them how the training could fit into a recovery plan for the user.

At three sites it was also challenging to provide training to carers of users about to leave prison. At one, family members were reluctant be trained while visiting as this took time away from the visit. At another, health and safety concerns prohibited the supply of injecting equipment to prisoners before release (prisons have different rules on possession and transfer of property, including needles and syringes). Some prisoners and family members worried that the training would imply the prisoner was using drugs in prison or would after leaving, possibly affecting the length of their sentence or eligibility for parole. However, pilot sites successfully promoted training as a step towards recovery on release and a means of encouraging the drug user to keep away from drugs, with overdose being an unexpected but potential occurrence.

Commenting on the training, many carers felt it had clarified the causes of overdose and dispelled myths about how to respond. Several said that even if they forgot all else, they would remember how to use the naloxone. Parents said the training had increased their knowledge about overdose, as well as feelings of empowerment and confidence. Now they felt able to intervene in an overdose when previously they had felt powerless. Training also meant they were more willing to intervene in overdoses, partly because they were less concerned about using needles and about triggering withdrawal symptoms in revived users.

Other benefits included promoting contact between service users and treatment services, and more open dialogue between users and carers about opiate misuse. Some also said their attendance on the course had, in part, caused the user they cared for to reduce their drug use or even stop.

Pilot sites found the training worked well when provided alongside their other day-to-day treatment services. All pilot leads who were interviewed said that – subject to local funding and governance arrangements – they wanted to continue training carers. While recognising the value of training carers, they said that next time they would also include service users.

The authors' conclusions

Despite difficulties with recruitment, and limited evidence that carers are the best people to receive the training, the project seems to have helped save lives. Carers who were trained said they found it valuable. A wider impact on overall fatal and non-fatal overdose rates may be possible if the training is offered to all service users at risk of opioid overdose. Further detailed guidance is available in the appendices to the study.


Findings logo commentary Given the few follow-up surveys returned by trainees, the 18 times lives may have been saved by administering naloxone must be considered a likely under-estimate. Even if it were not though, such figures from 16 pilot sites suggest that widespread implementation taking in not just carers but drug users themselves in and out of treatment could prevent an appreciable minority of the 1000 or so opiate overdose deaths now occurring annually in Britain.

Like many initiatives however, and especially those reliant on voluntary effort, real-world impact is limited less by the potential of the intervention than by the impediments to its being widely implemented. For treatment services and especially those with a recovery orientation, catering for the likelihood that their patients will not recover but relapse to life-threatening opiate use may be a hard pill to swallow, and swallowing it in the form of training clients and families may seem to counter-therapeutically undermine the optimism at the heart of the recovery movement.

Similarly for patients looking forward to a new life where they have escaped drugs and as part of this, drugtaking social circles, learning how to use a substance whose use is predicated on continued contact with (largely) injecting drug use may seem undermining and irrelevant. Another issue exposed by the NTA study is that when opiate users are highly vulnerable to overdose – when they have stopped using in a protected environment which they are leaving – is also the time when they and their families may be least receptive to anti-overdose training. Families and carers of active users who are aware they are using, and active users themselves, especially those out of treatment, will be less subject to these concerns, but harder to reach and possibly harder to train than those more stable and/or in treatment.

Such problems are, it seems from the featured study and others, not insurmountable, and services found ways of accommodating to similar apparent contradictions when many years ago it became important to counsel drug users leaving treatment about the risks of HIV transmission due to sharing of injecting equipment – a warning predicated on the recognition that even treatment 'successes' often relapse. However, surmounting such difficulties might require a reprioritisation of the anti-overdose part of the harm reduction agenda. More detailed commentary below.

In recent years satisfaction in the UK at meeting addiction treatment targets has been tempered by concern about rising drug-related deaths. In England and Wales drug poisoning deaths totalled 2747 in 2010, of which 1784 were linked to drug misuse and 791 to heroin/morphine, As heroin breaks down in the body into morphine, the latter may be detected at post mortem and recorded on the death certificate. Therefore the cited report gives a combined figure for deaths involving heroin or morphine. in all three cases slight reductions from the peaks of 2008. Scotland in 2010 recorded 485 drug-related deaths, of which 312 were considered to have been caused by drug abuse and 254 involved heroin/morphine. As heroin breaks down in the body into morphine, the latter may be detected at post mortem and recorded on the death certificate. Therefore the cited report gives a combined figure for deaths involving heroin or morphine. These were all appreciable downturns from the peak figures of respectively 574 (in 2008), 380 (in 2009) and 324 (in 2008). However, analyses of trends Trend analysis is complicated by the fact that instructions to pathologists were changed for 2008. They were asked to report any drug found in the body as well as those they thought might have been involved in the death, and the wording for the second category was revised. However, heroin/morphine totals seem only to have been slightly affected. revealed by averaging annual fluctuations suggested that it was too soon to be confident that long-term upward trends had reversed. A more detailed analysis highlighted the fact that 60% of cases had been in contact with drug treatment services, nearly 40% in the past six months, suggesting there had been chances to intervene which for these patients had been insufficient to avoid death.

Since the relaxation of prescribing restrictions in 2005, naloxone, has been the main new hope for curbing the death rate. The first large-scale UK follow-up study of naloxone-based overdose prevention training found that this can successfully be delivered by treatment services to their patients, resulting in substantially improved knowledge and competence. Among the 239 trainees, 10 of the 172 who responded to this question had in the next three months used naloxone to reverse an overdose suffered by another person, mostly encountering little difficulty during the administration and no unexpected adverse effects.

A later report from the study followed up a subsample of 70 trainees (nearly all from Birmingham) for six months after the training. The 46 recontacted at this time and three months earlier had retained much of what they had been taught. They had witnessed 16 overdoses since the training and generally responded appropriately, but none were known to have administered naloxone. For many this was because they were reluctant to carry the pre-loaded syringe around with them, partly due to fear of being identified as a drug user, and partly because some had completed treatment intended to divorce them from drug use and by extension, drug using associates, including those who might overdose.

This finding highlights an inherent contradiction between treatment which the patient hopes and expects to divorce them from drug use and drug using circles, and being provided with training and medication of direct use only if they stay sufficiently involved in such circles to witness an overdose. The featured study found analogous concerns among families, who wanted detoxification and a spell in prison to signal to the drug user and to others that their relative was starting a new drug-free life. Similar concerns were found among homeless drug users in England interviewed about using naloxone.

Another target group for training are workers in drug services, who are then equipped to deal with overdoses at the service and to train other staff, patients, carers and families, as well as (if they are qualified to do so) prescribing the required naloxone. When this was tried by the National Addiction Centre in London, the centre's three trainers trained 100 clinicians in four sessions, who over the following year trained a further 119 clinicians. The 219 trained clinicians trained 239 drug users. The magnitude of this training 'cascade' was considered modest. Staff resource issues in terms of time and caseloads were found by all services to be a major barrier to the training, a reflection of the priority given to overdose prevention in the form trialled by the study.

For these and other reasons, while naloxone certainly can contribute to reducing deaths, it is not the whole solution. Other limitations include the fact that fatal overdoses in particular tend to happen when the person is alone and/or out on the street. One concern is that naloxone might displace rather than supplement routine resuscitation techniques which remain important in the period before naloxone takes effect. Studies suggest too that despite training, having naloxone available might offer a further excuse for drug users who witness an overdose to avoid contact with the authorities by calling for an ambulance. There is also the prospect that people revived by naloxone might be unhappy about having an expensive heroin high reversed and/or withdrawal precipitated, deterring its use. Though such concerns cannot be dismissed, most can be addressed in volunteer recruitment and training programmes, and they do not threaten the potential for such programmes to on balance save very many lives. See these background notes to an earlier Findings analysis for details and relevant studies.

For the public in particular the need to inject the drug is a barrier to its use. There is however a nose spray which seems equally effective and could help extend the use of the medication (1 2).

Though the literature on naloxone provision by the public is new and still scarce, it is unanimous in its support, while also highlighting issues which need to be addressed in training programmes. In 2005 a review found only "anecdotal, although promising" evidence. Published in 2008, a review of literature on overdose prevention conducted for the Scottish government found in respect of naloxone "a consensus among the reviewed papers that there is a potential to prevent many opiate overdose deaths" and recommended its inclusion among the interventions offered to people who might witness an overdose.

Further guidance is available in the appendices to the featured study. In 2008 staff from one of the English NHS trusts which piloted naloxone training for families and carers produced a UK-focused practical guide to naloxone prescribing, training and use. A UK web site offers advice to professionals on take-home naloxone. Guidance on overdose prevention in general with an emphasis on the role of naloxone has been produced by the Eurasian Harm Reduction Network. In the USA the Chicago Recovery Alliance has produced a freely available training video. For more Findings analyses on naloxone in overdose prevention run this search, and for more on overdose prevention in general see this 'hot topic' entry.

Last revised 14 February 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2011 Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging

STUDY 2012 The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN Project in Wales

HOT TOPIC 2015 Overdose prevention

STUDY 2008 Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses

REVIEW 2016 Preventing opioid overdose deaths with take-home naloxone

REVIEW 2012 Consideration of naloxone

DOCUMENT 2014 Community management of opioid overdose

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

STUDY 2013 Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

STUDY 2016 Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before (2006–10) versus after (2011–13) comparison





Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging.

Mayet S., Manning V., Williams A. et al
International Journal of Drug Policy: 2011, 22, p. 9–15.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Mayet at Soraya.mayet@tewv.nhs.uk.

Training for addiction treatment staff in managing overdose using naloxone, seeded in London by the National Addiction Centre, 'cascaded' to other staff and to patients at a disappointingly slow pace; on average each clinician trainee trained one drug user every 11 months.

Summary Naloxone is a medication administered usually by injection which rapidly reverses the effects of opiate-type drugs such as heroin, including the respiratory depression which can cause what are normally referred to as 'overdose' deaths. In the UK naloxone-based overdose prevention programmes were hampered by the prescription-only status of the medication, but in 2005 the law was amended to permit emergency administration by any member of the public. A prescription is written for the opiate user at risk but the drug can then be kept for them by other people who can legally use it in an emergency, and not just for the named patient.

The featured report derives from a study of the impact of training opiate-using patients in overdose prevention and providing them with a take-home supply of naloxone. The parent study concluded that training in overdose management can successfully be given to drug users in treatment, resulting in substantially improved knowledge and competence. Among the 239 patients trained, 10 of the 172 who responded to this question had in the next three months used naloxone to reverse an overdose suffered by another person, mostly encountering little difficulty during the administration and no unexpected adverse effects.

Rather than the final result in the form of the trained patients and the use they made of naloxone, the featured report concerns the professional training phase of this study. The issues addressed are how well the study's strategy worked at recruiting professionals to be trained who would then train patients, what the barriers and facilitators were to engaging in training, and how far the professionals benefited from their training.

Main findings

Training was initiated by the National Addiction Centre in London, where three trainers trained 100 drug treatment service clinicians in four sessions. Clinicians were also advised on how themselves to conduct a group or individual training session and given training materials. Armed with these resources, the clinicians were then expected to train other clinicians (and drug using patients) in a 'cascade', encouraged by project leaders appointed in each service. In the event the 100 clinicians cascaded the training to a further 119 clinicians, totalling 219 trained clinicians at 20 drug treatment services in six locations London, Manchester, Birmingham, Darlington, Morecombe, and Bristol. in England. Over the following year, the 219 clinicians then trained 239 drug using patients. On average, only 1.2 additional clinicians were trained for each of the original 100 trainees, who then on average each trained 1.1 drug users.

A sub-sample of all 41 trained clinicians at three services were surveyed by post about the main barriers to implementing naloxone training and how these might could be overcome. Over 9 in 10 responded. Most frequently and in all the three services, they indicated that staff resource issues in terms of time and caseloads were a major barrier to training. Other barriers were that clients did not feel they needed the training as they were stable and/or being prescribed opiate substitutes, they could not get to the training sessions or simply did not turn up, clinicians lacked confidence in training, felt they needed more training or refresher training, the naloxone preparation was too difficult to assemble or administer, and lack of funding for a continued naloxone service.

Pre- and post-training questionnaires were used to assess the impact of the training on the clinicians. Of the 219, 185 completed both sets. Some of the questions were about overdoses in general: factors which heighten the risk of an opioid overdose, how to recognise signs of an overdose, and what actions should be taken during an overdose. On these issues, before training clinicians scored an average of 18 out of 26 correct answers. After training this had risen significantly to 21. Other questions were specific to naloxone. Here too knowledge had improved, particularly in respect of the length of time (usually around 20 minutes but up to four hours) during which naloxone exerted its protective effect. Before training 4 in 10 did not know the answer to this question; after training, virtually all did. Among the other findings, the proportion who felt confident about administering naloxone rose from just under half to nearly 9 in 10, and the proportion willing to do so in an overdose situation rose significantly from 70% to 99%.

The authors' conclusions

Whilst training significantly improved individual knowledge and confidence of clinicians when dealing with an opioid overdose, the 'cascade method' was only modestly successful in disseminating this training to a large clinician workforce. When large numbers of clinicians were trained, this was in services with a local lead who took responsibility for and personally delivered most of the training, suggesting that the cascade approach might be most suitable where local leads are willing to implement training. Given the barriers identified, training trainers alone may not be sufficient to cascade training successfully.

There were clear signs that before training other people, clinicians in drug treatment services themselves require training. Their pre-training knowledge of risk factors, signs and actions to be taken in respect of opioid overdose was reasonable, but many gave wrong answers to important questions, such as failing to recognise 'pinned pupils' as a sign of an opioid overdose. Many believed some 'overdose myths' – such as that stimulants reverse an opioid overdose – which could dangerously waste time during an incident. In these respects, before training they were no or only a little more knowledgeable than the drug users they went on to train. Training largely remedied these deficiencies for both clinicians and drug users, though some clinicians continued to be unsure of appropriate responses, indicating a continued training need.

Before training fewer than half of the clinicians – all of whom worked in environments where opioid overdoses can and do occur – were not confident of their ability to administer a naloxone injection. Training effectively enhanced clinicians' confidence in undertaking this emergency procedure.


Findings logo commentary Just how slowly the 219 clinicians extended the training to their drug user patients can be appreciated by calculating that on average each trained one every 11 months. Among the reasons given, the second most common (excluding research requirements) was that stable clients or those being prescribed opiate substitutes felt they did not need the training. A report from the same study followed up a subsample of 70 drug user trainees (nearly all from Birmingham) for six months after the training. The 46 recontacted at this time had witnessed 16 overdoses since the training and generally responded appropriately, but none were known to have administered naloxone. For many this was because they were reluctant to carry the pre-loaded syringe around with them, partly due to fear of being identified as a drug user, and partly because some had completed treatment intended to divorce them from drug use and by extension, drug using associates, including those who might overdose.

Such findings highlight an inherent contradiction between treatment which the patient hopes and expects to divorce them from drug use and drug using circles, and being provided with training and medication of direct use only if they stay sufficiently involved in such circles to witness an overdose. A study of the training of the carers of opiate users conducted by the English National Treatment Agency for Substance Misuse found analogous concerns among families as well as drug users, who wanted detoxification and a spell in prison to signal to the drug user and to others that their relative was starting a new drug-free life. Training might also expose the trainee as a drug user to their families and prison authorities. In the end the 16 pilot sites recruited 495 carers for the training over eight months, on average 31 carers per site and just under four per month. Concern that getting involved in overdose prevention would mark them out as a drug user was also found among homeless drug users in England interviewed about using naloxone.

Another issue exposed by the NTA study is that when opiate users are highly vulnerable to overdose – when they have stopped using in a protected environment which they are leaving – is also the time when they and their families may be least receptive to anti-overdose training. Families and carers of active users who are aware they are using, and active users themselves, especially those out of treatment, will be less subject to these concerns, but harder to reach and possibly harder to train than those more stable and/or in treatment.

Recruitment problems are, it seems, not insurmountable, and services found ways of accommodating to similar apparent contradictions when many years ago it became important to counsel drug users leaving treatment about the risks of HIV transmission due to sharing of injecting equipment – a warning predicated on the recognition that even treatment 'successes' often relapse. However, surmounting such difficulties might require a reprioritisation of the anti-overdose part of the harm reduction agenda. Even among the clinicians who agreed to be trained for the featured study and the services which agreed to release them for the training, the lack of priority given to overdose prevention is revealed by the primary barrier of insufficient time to train drug users. In essence this means overdose prevention in the form trialled by the study was considered well down the list of priorities with a call on the clinicians' time.

For these and other reasons, while naloxone certainly can contribute substantially to reducing deaths, it is not the whole solution. Other limitations include the fact that fatal overdoses in particular tend to happen when the person is alone and/or out on the street. One concern is that naloxone might displace rather than supplement routine resuscitation techniques which remain important in the period before naloxone takes effect. Studies suggest too that despite training, having naloxone available might offer a further excuse for drug users who witness an overdose to avoid contact with the authorities by calling for an ambulance. There is also the prospect that people revived by naloxone might be unhappy about having an expensive heroin high reversed and/or withdrawal precipitated, deterring its use. Though such concerns cannot be dismissed, most can be addressed in volunteer recruitment and training programmes, and they do not threaten the potential for such programmes to on balance save very many lives. For more detailed commentary see the Findings analysis of the main report of the featured study.

Further guidance is available in the appendices to a study of the training of the carers of opiate users conducted by the English National Treatment Agency for Substance Misuse. In 2008 staff from one of the English NHS trusts which piloted naloxone training for families and carers produced a UK-focused practical guide to naloxone prescribing, training and use. The Scottish Drugs Forum runs a web site offering resources, advice, guidance, information and news on naloxone programmes and administration. This international web site offers advice and practical assistance on starting a take-home naloxone programme. Guidance on overdose prevention in general with an emphasis on the role of naloxone has been produced by the Eurasian Harm Reduction Network. In the USA the Chicago Recovery Alliance has produced a freely available training video. The manufacturers of the naloxone preparation Prenoxad licensed for emergency use in the home or other non-medical setting by appropriate individuals for reversing opioid overdose offer advice on its use. For more Findings analyses on naloxone in overdose prevention run this search, and for more on overdose prevention in general and developments in the UK see this 'hot topic' entry.

Last revised 17 January 2014. First uploaded 14 February 2012

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