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McAuley A., Munro A., Taylor A.
International Journal of Drug Policy: 2018, 58, p. 46–54.
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Important implications for overdose prevention policy and practice in Scotland and the UK from this qualitative study which provides the first detailed insights into how people who inject drugs experience administering naloxone rescue kits.
Summary For over 20 years supply of the overdose antidote naloxone for administration by other people who use drugs has been promoted as a means of preventing opioid-related deaths. Scotland has had a national naloxone programme since 2011, which has increased the supply of naloxone, and generated a considerable body of evidence that it can save lives (1 2 3). However, less is known about the lived experiences of people who inject drugs with administering naloxone, despite the potential for this to inform policymakers’ decisions about the adoption of ‘take-home naloxone’ programmes in nations where none yet exist, as well as in nations where national programmes do exist but may require modification in order to achieve the best results.
The featured study involved face-to-face interviews with eight peopleAn additional interview was conducted but the data was excluded from the final analysis because the person had shown signs of intoxication, and the researchers were concerned of the ethical implications of including their story. known to have used take-home naloxone in an overdose situation. Participants were recruited from a harm reduction service in a large urban area in Scotland. Half had been using opioids for over 10 years, and half were still injecting drugs at the time of the interview, though all were injecting at the time of the overdose event when they used naloxone. Five had previously overdosed.
One of the overarching findings was that responding to an overdose administering take-home naloxone was challenging for those involved – but despite this, participants appeared to remain committed to using naloxone in their communities, with some even feeling obligated to intervene in future overdoses.
Looking back to the first time they administered naloxone, participants described the scene as chaotic – emphasising their alarm, anxiety, and panic. These emotions were linked to feeling unprepared, wanting to respond quickly, being concerned about the person in danger, and afraid of being blamed ‘whatever the outcome’. Some participants also put their apprehension down to their inexperience with witnessing an overdose, administering naloxone, or of injecting others. These stresses – alone or in combination – often contributed to overdose responses based on instinct rather than on following protocol.
While all the participants saw themselves as legitimate overdose responders, sometimes their peers agreed with this and sometimes they did not. There was also variation in how participants perceived their ability to help in the case of an overdose, with some supremely confident in their skills, and others less assured at the outset but gaining confidence after administering it for the first time. One participant described this in the following way: “Once I’d done it … it was like writing your name, you know. It was something you know you’re capable of and you’re no gonna be worried about it.”
On some occasions, peers that participants attempted to help were reportedly verbally and physically abusive. The reasons for these negative responses were wide ranging and included a lack of awareness that the overdose could be fatal, the naloxone causing acute withdrawal, people feeling ‘robbed of their hit’, and intervening in a suicide attempt.
After seeing naloxone work, participants started to view their own role as a lifesaver.
Among some participants, access to naloxone increased their sense of responsibility toward their peers – causing them to realise that they were able to save others where they previously might not have been able to. After seeing the naloxone work, they viewed their own roles as that of a lifesaver.
The findings of this study have important implications for overdose prevention policy and practice in Scotland and the UK by providing the first detailed insights into how people who inject drugs experience this key public health policy. Stories of successful ‘saves’ described in this research could also be used to inform policymakers and practitioners when developing materials to communicate take-home naloxone to a wider audience – something vital in normalising naloxone in communities and reducing stigma, while at the same time positioning people who inject drugs as responsible and important community public health resources.
commentary Under UK regulations, anyone can use naloxone in an emergency situation. Though its supply is not limited to specific individuals, it tends to focus on drug users at risk, carers/friends/relatives of drug users, as well as outreach workers, hostel managers, or any other people working in an environment where there is a likelihood of them witnessing an overdose. Yet despite people who inject drugs being prime candidates for witnessing and intervening in a drug overdose, this qualitative study demonstrated that there can be a reluctance to use naloxone even in a life-saving situation.
Another study set in Scotland observed a reluctance to carry naloxone (necessary for being able to use it away from home) among needle exchange attendees who had been prescribed a kit in the previous year. There was a drop in the rate of people carrying a kit between 2011–2012 and 2013–2014 from 16% to just 5%. The researchers concluded that it was possible this hesitance to carry the kits played a role in undermining the programme’s potential to save lives. However, as an Effectiveness Bank hot topic notes (skip to the relevant section), the training associated with the supply of naloxone may give participants the skills and information they need to save lives even without naloxone, a frequent occurrence which alleviates one of the main limitations of the schemes – kits not being available at the time and place of an overdose.
One setting currently not available to UK drug users in which occupants are prepared and equipped for overdoses at all times is the drug consumption room – a hygienic and supervised space for the consumption of illicit drugs. In Denmark, a study of five drug consumption rooms – including 250 hours of participant observation, followed by in-depth interviews with 42 clients and 25 staff members – found that staff were consistently observing people who used the facilities in order to detect whether anyone was at risk of an overdose. Staff were attentive to which drugs were in circulation at any given time, as well as to how potent they were – cautioning clients and suggesting they reduce their doses by half in order to prevent overdoses. In cases where clients experienced respiratory problems or became unconscious, naloxone was administered. However, this was unpopular among some of the clients because they believed it would ‘dull their high’ and produce withdrawal symptoms. Staff were conscious of the limitations of naloxone in another way, specifically that the half-lifeThe half-life of a drug is the time it takes for the drug to stop acting. The term describes the period of time required for the concentration or amount of drug in the body to be reduced by one-half. of naloxone was shorter than that of opioids, meaning that the effect of the opioid may return after the client had left the drug consumption room, and the client could potentially be at risk of an overdose once out of reach of the facility.
Connected to the finding in the featured study that overdose responses tended to be based on instinct rather than on following protocol, some participants referred to administering all the naloxone at once rather than in smaller doses as recommended within UK national prescribing guidelines. Lower doses of naloxone are advised because they are less likely to trigger acute withdrawal which can be physically unpleasant for the patient and potentially distressing for those administering the drug. The discussion section of the paper recommended that naloxone trainers be mindful of this evidence and focus on how peers can administer naloxone as efficiently as possible while avoiding potentially negative effects among the people receiving the naloxone, and said that “This message should be continually reinforced post-training within treatment services or needle/syringe exchange services in the same way that other harm reduction advice is provided routinely”.
The Effectiveness Bank features a hot topic on how naloxone became the main new hope for curbing the rise in drug overdose deaths.
Last revised 23 November 2018. First uploaded 12 November 2018
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HOT TOPIC 2017 Overdose deaths in the UK: crisis and response
HOT TOPIC 2017 Overdose antidote naloxone takes harm-reduction centre stage