Implementing local Take Home Naloxone Programs (UK)

On 19th February, Public Health England released guidelines aimed at local authorities for Take Home Naloxone programs. This is aimed at following the recommendations in the letter from Department of Health (Jane Ellison) to Advisory Council for the Misuse of Drugs chair Les Iverson where there was a date for the National implementation for Naloxone programs, and recommendations into the preparation for the programs to be initiated on 1st October, 2015. Although the general consensus around this date is that it is too far in the future and leaves to much scope for a further increase in drug related deaths, this date is the one that NAG (Naloxone Action Group) England are now holding providers to as a set deadline. Here are a few ways in which you can inform / support your local authorities to ensure that this is being implemented locally in time to meet the 2015 deadline.

Follow hyperlink for copy of guidelines: http://www.nta.nhs.uk/uploads/take-home-naloxone-for-opioid-overdose-feb-2015.pdf

THE GUIDELINES INCLUDE CLARITY ROUND UK LAW SURROUNDING NALOXONE

UK Law.

Like all medicines in the UK, naloxone sale and supply is regulated under the Medicines Act of 1968. This act brought together most of the previous legislation on the regulation of medicines but also introduced some new legal provisions for the control of medicines. When thinking about the regulation of medicines, it’s important to recognise that medicines (broadly) fall into one of four categories;

• GSL. General Sales List Medicines sold or supplied direct to the public in an unopened manufacturer’s pack from any lockable premises
• P. Pharmacy Medicines sold or supplied from registered premises by, or under the supervision of a pharmacist
• POM. Prescription Only Medicines sold or supplied to named patients by prescription. Applies to all injectable preparations, including Naloxone
• POM (CD). Controlled Drugs

As stated above, injectable naloxone is a POM and can therefore only be SUPPLIED to a person identified as ‘at risk’ of potential future opiate related overdose. It can be supplied to the friends/loved ones of those identified as at risk, but only with the written consent from the person for whom it’s to be supplied.

Who can administer naloxone?

Anyone can administer naloxone for the purpose of saving a life. In November 2005 naloxone was added to the list of injectable drugs in Article 7 of the Medicines Act, this is the part of the act that covers drugs like insulin for diabetics (and adrenaline, atropine, snake anti-venom etc).

Who can supply naloxone?

Naloxone can be prescribed by any medical doctor, but can also be prescribed by some other registered medical staff using a Patient Group Direction (PGD). This means that naloxone can be given out via drug projects that don’t necessarily have a doctor on their staff.

(Taken from Scottish drugs forum Naloxone: http://www.naloxone.org.uk/)

This would mean that in order to get Naloxone out into the community there needs to be a prescription given to an individual who has been ‘catagorised’ as high risk. This could mean treatment naive community members, those still in treatment, those leaving treatment, including residential rehab, prison leavers, in light, anyone receiving any kind of opioid medication, on prescription.

At this particular moment in time, following a freedom of information request carried out by National Needle Exchange Forum, Release and NAG Engand members, the evidence would suggest that 1 out of every 3 Health and Wellbeing boards are supplying naloxone. Considering the high level of drug related deaths Nationally in 2013. This seems to be a small amount for such a major public health issue.

In light of this information, there are a number of things you can do locally to help push this program forward and to make sure that it is firmly on the agenda in your area in line with the guidelines.

• Identify local champions: Local authorities will be looking to identify local champions. This could be you, or it could be someone who is sympathetic to the need for Take Home Naloxone programs. If your local MP signed the Early day motion 445 – NALOXONE AVAILABILITY – UK then you may well have you local champion there, sympathetic GP’s, Pharmacists, local recovery / harm reduction groups, etc. Identify who your champion is and encourage them to engage with Naloxone Action Group (NAG) This can be done via the NAG England website or via the facebook forum page. This will enure that they have all the support they may need when engaging with any local authority agents on any level.

website: https://nagengland.wordpress.com/

facebook: https://www.facebook.com/groups/1455313511394512/?fref=ts

• Organise an initial ‘informing the managers’ or ‘train the trainer’ session: While this is being done by local authorities, you could be raising awareness of your plan of action to disseminate information into your community. If you are planning local train the trainer sessions or have been asked by your local authorities who might be delivering the training, but are unsure how to go about it, please contact me at drugactivist@gmail.com and I will direct you to your area representative. You can then pass relevant information over to local authorities and support them in initiating the training.

• Consider who will receive Naloxone supplies, and how, users and carers, hostels and pharmacies, etc: The aim here is to have Naloxone freely available in all providers that come in contact with high risk individuals, and eventually, being ambitious, over the counter. However, the first step would be identifying key areas where there are high risk individuals, treatment services, hostels and prisons, might be a good start. The local authorities should be more that aware of where there is an immediate need. You may have to prioritise here as a first step and decide where there is the most benefit to be had. Needle exchange programs, would be an ideal starting point.

• Consider who will pay for Naloxone supplies in different areas: Commissioning for such programs sits firmly with Department of Health as the overseers of Public Health but on a local level responsibility sits with the CCG (clinical commissioning groups) following a transfer of responsibilities through localism. To find out your local CCG contact details: NHS England » CCG Directory Also as a matter of interest here Frontier Medical Group are now the official distributor of Prenoxad / Naloxone kits for Martindale Pharma so they will be the single point of contact for provision of supplies.

• Agree how you will re-supply people when Naloxone is used or it expires, and who will pay. Will you have a system that flags up appraoching expiry dates to keyworkers, pharmacies, etc: As with any form of medication there needs to be a medication management database for monitoring purposes. This would need to monitor all needs and results pertaining to Naloxone provision. How many kits were given, when given, adverse effects of medication, etc. Once the basics for this are done then it would need to be reviewed to see how to monitor a case by case study of each individual involved in the program. All input would need to be evidence based and precise in it’s records. Medication regimens for every naloxone reciever need to be monitored and also all different naloxone products of there is to be intranasal available as well as injectable, etc. Most of this should be in place for already existing medications in the community and it would simply be a matter of adding Naloxone to the list of medications already monitored. Another thing that may need to be discussed here is the need to expand the monitoring to co-morbid conditions and socioeconomic status, substance use, homelessness, chronic health conditions, employment status, etc. As already stated there should already be a monitoring system in pace which could provide the basis on which to ad the information needed regarding Naloxone provision. This action lay with local authorities primarily so does not hold any weight on what you might be forming as a part of your action plan to offer support locally.

• Hold regular meetings for Naloxone champions – including people who use drugs – to encourage progress, discuss barriers of concerns, and learn from each other: This is already happening in a number of areas so it is simply a matter of inviting the local authorities to come along and join the already existing platform that you have provided. If there is no platform locally, you can create one in the form of a local Harm Reduction Cafe where local provision and action plans can be discussed and implimented. All you need to set one up is available on the website. This should be publicised and openly supported / attended by all providers who deal in the care of those considered at risk in the community. Also as stated attended by local service user reps, groups, and people who are currently using substances.

• Explore the products and prices available, speaking to the local pharmaceutical representative,  and decide together with local providers which to purchase: At this moment in time in the UK there is only one licensed product available and that is Prenoxad Injection This sight gives you all the relevant information around this particular product. The main suppliers of this product as stated before are Frontier Medical Group A kit costs £18 and there is an agreement in the contract with the pharmaceutical company that this price will stand unchanged for at least the first three years of the contract. It has been advised that two kits are complimentary to the needs of those who would be accessing services for it. One to carry on their person and one to leave in home environment. So if you can find out the local statistics pertaining to injecting drug users then you will effectively be able to get a rough estimate of how much is needed to ensure enough kits are bought in to meet the needs of your user community. There may be an online needs assessment for local IV users on your local authority webpage that can help you with this.

• Complete the paperwork and processes of a PGD, working with the local CCG and director of public health as appropriate:A PGD is a written agreement that in the case of naloxone allows nurses or pharmacists to distribute the drug to people at risk of overdose. It’s important to note that a PGD is only related to the supply of the drug and has nothing to do with administration (as we’ve stated above anyone can legally administer naloxone to save a life). A PGD should contain the following information:
  • The name of the business to which the direction applies
  • The date the PGD comes into force and the date it expires
  • A description of the medicine(s) to which the direction applies
  • The class of health professionals able to supply or administer the medicine (as named individuals)
  • Signature of a doctor or dentist, as appropriate, and a pharmacist
  • Signature by a representative of an appropriate health organisation
  • The clinical condition to which the direction applies
  • A description of those patients excluded from treatment under the direction (if applicable)
  • A description of the circumstances in which further advice should be sought from a doctor and the arrangements for referral
  • Details of the appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered. Legal status of the drug should also be indicated
  • Relevant warnings, including potential adverse reactions
  • Details of any necessary follow-up action and the circumstances
  • A statement of records to be kept for audit purposes

Sample PGD: http://www.naloxone.org.uk/images/pdf/pgd%20naloxone%20approved%20apr%202011.pdf

• Inform and liaise with police, local coroners, ambulance service lead, hostel managers and pharmacies: This one is also something that is best coming from local authorities as experience tells us that correspondence is less than positive when coming from action groups. However if you have been identified as local champion then it might be possible to be cc-d in on any local correspondence or contact to keep you up to date with progress and to put you in a position to inform the local action group of that progress. By all accounts local police should be trained and equipped and it is surprising how many police do not know what Naloxone is, following a number of ‘stop and question’ scenarios I was asked a number of questions surrounding the medication but when I suggested training options they never came to anything. Lcal coroners could be a valuable asset with regards to them being able to give first hand statistical data on causes of death, although this is jaded as cause of death isn’t always recorded correctly. This is for the benefit of the family afterwards. And also there are times when the actual cause of death cannot be attributed to one single underlying cause. This can at times work in favour of some research but in this particular case it does not. Local ambulance crews should be aware of the fact that naloxone is locally available and also on a national scale this needs to be addressed as when you call in a situation, at present, the best way to get a response is to not mention drugs at all and if you do mention that you are equipped and trained you are told under no circumstances to administer. Hostel managers should be a priority with regards to involvement in the program as they are involved in the care and support of some of the more vulnerable in the community. There are number of areas where hostels were approached first for training in preparation. This can also be something that can be carried out by local action groups in support.

• Purchase the naloxone kits and make the necessary arrangements for stocking and distributing them, and for re-supply when naloxone has been used or expired:  The arrangements for re-supply should be straight forward, all services in possession of naloxone should encourage those who lose, use or have a kit that expires to come in to get a kit  replaced. The ideal place for distribution would be Needle exchanges, pharmacies and prison healthcare. Any other places that you may consider should be suggested at any meetings with local authorities.

• Provide training for all drug keyworkers, all opioid substitution therapy (OST) prescriber’s locally, dispensing pharmacists, local service user groups, all of whom can contribute to the onward dissemination of information:   This target has already been partially reached in a number of places and training has or is being done already. This is where local service user groups come into their own and provide an invaluable part of the localised agenda. If you have been on point with the call to arms then you will already have been trained locally and can then put yourself or your group forward to disseminate the training and relevant information around naloxone, basic life support and administration, individual certificated training can be done online at SMMGP – Substance Misuse Management in General Practice website. There are also local reps strategically placed nationally to deliver training, if you contact me at drugactivist@gmail.com then I can direct you towards your local train the trainer.

• Arrange for training to be provided to people who use drugs, patients and clients, and their families and friends, Consider who is best placed to deliver this training. Offer this training to as many people as possible:  It stands to reason that those who are in the best position to cascade the training out to their communities are those out there on the frontline, this again would fall into the responsibilities of the local service users groups. If your group is not trained then then I wold suggest that you look into arranging training and put this in place. It may hold up the process or put the partnership options that are presenting into the hands of someone else. Once trained you are then in a position to offer yourselves as local trainers and pass this onto everyone you meet who has an interest. And id you are anything like me, even even those that don’t.

• Consider whether and how you will record the numbers of kits dispensed, and report the number of times naloxone was used: Part of the initial training and something that is also advocated for in an overdose situation is that an ambulance is always called. This is to reduce risk of the individual slipping back into an overdose as the naloxone wears off after 20-40 minutes. The research around this does state that the effects of street heroin is not much more but the risk is still relevant as due to prohibitive laws surrounding illicit heroin there is no quality control, etc.   There are however times when they may not be called,  a formula may need to be discussed as to how to monitor this, The number of kits dispensed should be easily monitored and most uses, hopefully, recorded by ambulance call outs, etc. This message is something that you can carry out into your communities. We have fought long and hard to get this far, in order for it to stay as part of service provision then we need to ensure that we are responsible, sensible and accountable for our part in the program which includes carrying the message that supports those who support us in maintaining the program at a local level.

ALL IN ALL WE HAVE PUSHED TO GET THIS TO THE LEVEL IT HAS NOW REACHED, THE JOB LAID OUT FOR LOCAL AUTHORITIES IN THESE GUIDELINES IS NOT SIMPLE ONE AND IT IS A TURNING POINT OF THE CAMPAIGN, YOUR NEXT STEPS SHOULD BE TO OFFER SUPPORT TO YOUR LOCAL AUTHORITIES TO ENSURE THAT THIS IS SUSTAINABLE. YOU DEMANDED NALOXONE, NOW YOUR ROLE SHOULD BE TO SUPPORT THE LOCAL AUTHORITIES TO GIVE YOU IT.

TEMPLATE LETTER FOR TAKE HOME NALOXONE PROGRAM CAMPAIGN (NAG ENGLAND)

(To whom it may concern),

I am contacting you in relation to a current national campaign to reduce drug related deaths in England. In light of the recent 32% rise in drug related deaths bringing the statistical data of those dying from overdose involving opioid substances in 2013 to a staggering 765 deaths, each one preventable.

Please find attached below a brief timeline of Naloxone from it’s inception up until present .

https://futuremoves.wordpress.com/2015/01/07/a-brief-timeline-of-naloxone-for-reference/

As you will see there are a number of periods where there has been open endorsement from a number of sources here in the UK. These endorsements have been made by:

Professor John Strang in the British Medical Journal (1996).
ACMD (Advisory Council for the Misuse of Drugs) (2000) (2012)
UK Clinical Guidelines (2007)
NTA (National Treatment Agency) (2007) (2009)
MRC (Medical Research Council) (2008)

The department of health chairperson Jane Ellison sent a letter, in July of last year, to the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015….

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf

This letter lays out a clear and direct plan of action which advocates for training and any other preparations to be supported ‘prior’ to the date given for roll out and was a direct result of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

I feel that a delay until October 2015 is irrational given the evidence of support given and believe that this delay warrants a judicial review based on the evidence collated globally and also from the National programs in both Scotland and Wales where take home programs have had a positive effect on th statistics surrounding drug related deaths. I also feel that this delay is a serious breach of human rights in that every human being has the right to access life saving medication and the right to live. This delay has the potential to interfere with the right to life and also the right to a family life.

Given the case that I hereby put forward for direct and immediate action towards implementation of Take Home Naloxone programs nationally. I would be grateful if you could reply to my concerns by:

A: Informing of what is currently happening locally to put this program in place
and
B: Informing me of the reasons for delay in implementing a local program.

I look forward to further correspondence with you regarding this issue.

Yours sincerely,

A BRIEF TIMELINE OF NALOXONE FOR REFERENCE

 1961:  Naloxone was first cited by Jack Fishman and researched by Harold Blumberg in 1961. The synthesis stated that although naloxone was not the first and only opioid antagonist it was however the first that did not produce analgesic qualities. The synthesis also explained other qualities of naloxone stating that it was indeed a medical breakthrough with regards to the reversal of respiratory depression in all synthetic and natural opioid related substances. It was also useful in coma situations where the cause was of unknown origin to eliminate whether there was opioid presence that had induced the coma like state. It was used on new born babies following the administration of opioid related medication to mothers during pregnancy. Nalorphine preceded Naloxone but after further research was found to cause analgesia and in higher doses hallucinations. Naloxone was found to be the ideal balance between agonist and antagonist and prove to be the only pure agonist which made it the more effective and preferred of all previous researched chemicals.

1962: The previous mentioned document was an abstract in Federation proceedings and the first full report was later released by a group working for Sankyo company in Japan in the Science citation index. Sankyo applied for the British patent for Naloxone in March 1962 and it was awarded in October 1963. The early delays in patent were attributed to the fact that Naloxone was of more interest in the academic field than it was in the commercial one in the earlier years of it’s beginnings. Also at this time the main interest of researchers and scientists was to research and produce analgesics.

1966: Blumberg released a full paper on the qualities and uses of Naloxone which was later to become the centre of the field of endogenous opioids where Naloxone became one of the key components and was heavily relied on for its qualities. Throughout the early 1970’s both Fishman and Blumberg’s research and related work on and around Naloxone focused primarily on the clinical applications of the medicine as did most of those involved in the researching and practice of medical compounds.

1971: The FDA (Food and Drug Administration) in the USA licenced Naloxone stating that access to naloxone would require a prescription from an authorized health care provider. Some physicians were reluctant to prescribe the medication to suspected opioid-misusing patients. At least one legal analysis, by Burris et al, concluded that health care providers ”do not act outside state and federal regulations in prescribing naloxone to their at-risk patients and the risks of liability are low and commensurate with those generally associated with providing health care” The Good Samaritan laws in a number of states in America provides legal protection to physicians for prescribing the medication and also to those in the community carrying and administering the medication.

1973: A patent was issued in 1973 for an analgesic combination which comprised of an orally inactive dose of naloxone and an orally active strong analgesic. Naloxone was also found to reduce obesity in further studies on animals, this research is still ongoing to date. Towards the end of the 1970’s the importance of Naloxone as one of the most relevant medicinal breakthroughs in the research of endogenous opioids and further qualities within the medical world was beginning to gain recognition.

1982: Jack Fishman and Harold Blumberg were awarded the John Scott award for their synthesis and investigations on Naloxone.  The John Scott award is awarded to those most deserving for inventions that contribute to the ”comfort, welfare and happiness of mankind” John Scott was a pharmacist in Edinburgh, Scotland whose interest were in awarding ”ingenious men or women who make useful inventions” Other individuals who were awarded the John Scott Award included Marie Curie, Thomas Edison and the Wright Brothers.

1996: Professor John Strang made a proposal for Take Home Naloxone via report in the British Medical Journal (BMJ). This report stated the case for community Naloxone and went on to say.…

Home based supplies of naloxone would save lives.

Non-fatal overdose is an occupational risk of heroin misuse1 and fatal overdose is a common cause of premature death in heroin users.2 3 4 One of the major contributors to a fatal outcome is the inadequacy of heroin users’ responses to the overdoses of their peers. They may delay calling an ambulance for fear of the police arriving, and their efforts to revive comatose users are often ineffective. The distribution of naloxone to opiate users was first mooted in 19925 as an intervention that would be life saving in such situations.6 With a rising toll of deaths from heroin overdose it is time to take the suggestion seriously.

  This study also concluded that at least 80% of those in an overdose situations were witnessed by peers. This posed the question as to why so many fatalities were found alone and on further investigation it revealed that there was even more reason to further investigate and promote the need for community provision of naloxone distribution by peers and significant others .

1996 also saw pilot programs started in 15 American states and the district of Columbia. All results from these pilots were positive. Chicago Recovery Alliance became one of the first providers of Naloxone to peers and the first Take Home Naloxone program went live in the USA. In the following link Dan Bigg talks about this groundbreaking achievment…. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/naloxone-program-case-studies/chicago-recovery-alliance/

1998: Other areas that followed suit with initiating THN programs were Bologna, Padua and Turin in Italy and Jersey in the UK pioneering peer led take home Naloxone programs.

1999: Australian studies found that Naloxone provision was ”not only feasible but acceptable in the community with regards to the target population” The report eventually materialised in December of 2011 in the form of the ACT program…. http://www.atoda.org.au/policy/naloxone/

2000: The ACMD (Advisory Council of Misuse of Drugs) released a report entitled ”Reducing drug related deaths” This document recommended further exploration of the efficacy of Take Home Naloxone programs. This report stated that ”Attempts are needed actively to involve drug users themselves in responsibility for reducing drug-related deaths” The full report can be read here… http://www.drugsandalcohol.ie/5017/1/Home_Office_Reducing_drug_related_deaths_2000.pdf

This year also saw the release of a report from Australia stating that based on the earlier studies in 1999 the ‘feasibility’ of the THN program had met with substantial legal challenges.

2001: San Fransisco and New Mexico began ‘distributing naloxone hydrochloride to heroin users as a simple, inexpensive measure with the potential to reduce mortality from heroin overdose’ There were again legal aspects that caused restrictive supply due to the ‘uncertainty about its legality or the risk of malpractice suits’ Naloxone was seen as a politically charged topic. This fear and uncertainty slowed the process of further provision in other states and around the world. Despite the evidence already being insurmountable as to it’s effectiveness as a life saving medication…. http://www.fixpunkt-berlin.de/fileadmin/user_upload/PDF/Notfall/Artikel_burris_naloxone.pdf.

This year also saw the the beginning of a Take Home Naloxone program in the UK in South London. The original Chicago program became the trusted format for Take Home Naloxone programs globally.

2002: This year saw the first ever reports of lives saved through the community provision of Naloxone and was reported in the BMJ (British Medical Journal) by Chicago Recovery Alliance. This report stated that there had been 52 successful reversals to date since the inception of their take home Naloxone program…. http://www.bmj.com/rapid-response/2011/10/28/chicago-experience-take-away-naloxone

2003: A report was released which has been cited in numerous other publications stating that the high risk period following release from prison, more prominently among females needed to be addressed and looked at with regards to naloxone being provided to those leaving the prison population. The first two weeks following release from this environment are particularly high risk with regards to overdose being prevalent for obvious reasons, tolerance, etc. Further studies took the research into the 12 week period where the findings can be found here…. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955973/#b22

Also in 2003 there was a further report aimed at the community use of naloxone. This report was aimed at highlighting the reports of risk of overdose following administration of naloxone. The results of this study, which included 998 case studies, showed that after a period of 12 hours following naloxone being given in the field, and further support being refused there were no listed fatalities. This challenged the commonly used reasoning against community provision of the risk of overdose after naloxone wears off, 20 minutes later. 12 hours allowed for this short acting period, and also for the fact that after being administered naloxone the withdrawals would require redosing of opioid for relief. This report was reviewed by dates, times, age, sex, location, and ethnicity when available.

2005: The first report on THN programs was released in USA showing that there was unsurmountable evidence to support the program. The pilot study was carried out in 2001 and released here in 2005. http://www.ncbi.nlm.nih.gov/pubmed/15872192

This year also saw the UK law changed to permit the the use of naloxone by any member of the general public for the purpose of saving a life. http://www.naloxone.org.uk/index.php/lawpolicy/law/uklaw1

2007: The 2007 UK Clinical Guidelines supported the use of naloxone as a means of preventing fatal overdoses and reducing drug related fatalities.

This year also saw the NTA (National Treatment Agency) initiate training for families, carers and users following a survey that identified the need for take home programs to reduce the fatalities.

2008: Both the USA and the UK released an impact paper showing the effectiveness of training in overdose awareness and Naoxone administration to families, carers and users. This showed the potential positive impact that Naloxone in the community could and indeed was having.  http://www.biomedcentral.com/content/pdf/1477-7517-4-3.pdf?origin=publication_detail The release of this report highlighted a number of potential barriers including. Political climate and prescription laws.

The MRC (Medical Research Council) approved the N-Alive program. This was a randomised controlled trial aimed at research within the prison community. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx fronted up by Professor John Strang, (This is still ongoing, The randomised trial period ended in December 2014 and the follow up of those involved in the trial will commence in March, 2015) Results from a similar study can be found back in 2003, follow the link to NCBI (National Centre for Biotechnology Information)

2009: In 2009 the NTA (National Treatment Agency) funded 16 pilot trials all over England. These pilots set out to train the carers and significant others in all matters relating to Naloxone. Information on the product, basic life support and overdose awareness, including administration. Overall the project was found to promote the reduction of fatalities induced by opioid related overdose. There was difficulty and resistance reported in finding individuals to train but 495 carers were trained and evidence relating to the training showed that, in reality, the training would be better served in a peer to peer environment.

This was also the year that Wales launched it’s first pilot program as well…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en The full data and evaluation report around the 34 areas where this spanned out to can be found here in a report stored on the Welsh Harm Reduction database…. http://www.wales.nhs.uk/sites3/documents/457/Naloxone%20report%202013%20FINAL.pdf 2130 kits were issued between 2009 and 2013 the full statistical data has been reproduced in the report.  

2010: Scotland launched the National Naloxone program. This progress started in 1996 when the BMJ (British Medical Journal) proposal by Prof John Strang was released, see earlier comments from 1996. This move followed a number of pilot schemes and the end result was that pre-filled syringes of naloxone are now provided to everyone considered at risk of overdose, this is after comprehensive training is given. The lord advocate endorsed the program and the National program is fully funded by the Scottish government. The Lord Advocate guidelines can be found here…. http://sdf.org.uk/sdf/files/LordAdvocatesGuidelines.pdf There are numerous reports from Scotland around the provision of Naloxone and the success of the National program. NHS Highlands also now provide nasal naloxone as well as the prefilled syringe.

2011: The Assembly Government in Wales announced their plans to make take-home naloxone available alongside training. This decision followed the evaluation report that was submitted which is here…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en

2012: The CDC (Centre for Disease Control and Prevention) and the FDA (Food and Drug Administration) hosted a workshop that hosted a large number of presentations including topics such as populations at risk, public health interventions, criminal overview, ethical and regulatory considerations, expanded considerations, and lots more. The full details and presentations an be found here…. http://www.fda.gov/Drugs/NewsEvents/ucm277119.htm

The UNDOC resolution 55/7 clearly recognised that the high number of opioid related deaths demanded immediate assessment and action, this statement was based on the world drug report 2011, https://www.unodc.org/unodc/en/data-and-analysis/WDR-2011.html This report clearly stated that opioid overdose treatment, ”including the provision of opioid receptor antagonists such as naloxone, is part of a comprehensive approach to services for drug users and can reverse the effects of opioids and prevent mortality” This report also recognised that there were a number of public health inequalities that also contributed to addictions and overdose including, polyuse, mental health, etc. The full resolution can be read here…. https://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-7.pdf

The N-ALive (NAloxone InVEstigation) trial went live. A full understanding of the content of this investigation and the different stages which include the pilot trial and then the full trial, the reasons the trial was randomised and how the final results will be used can be found here…. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx As stated earlier the randomised period of this investigation finished in December 2014 and the follow up to this will commence in March 2015.

The ACMD also released a report recommending that the department of health make naloxone more widely available and also that the prescription only status be reviewed. The full report from the ACMD ”Consideration of Naloxone” went as follows…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/119120/consideration-of-naloxone.pdf

Over in the USA in 2012 the AMA (American Medical Association) adopted a policy to endorse THN, The endorsement read….

Promoting Prevention of Fatal Opioid Overdose

Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. Naloxone is a drug that can be used to reverse the effects of opioid overdose. The AMA today adopted policy to support further implementation of community-based programs that offer naloxone and other opioid overdose prevention services. The policy also encourages education of health care workers and opioid users about the use of naloxone in preventing opioid overdose fatalities. “Fatalities caused by opioid overdose can devastate families and communities, and we must do more to prevent these deaths,” said Dr. Harris. “Educating both physicians and patients about the availability of naloxone and supporting the accessibility of this lifesaving drug will help to prevent unnecessary deaths”

Full list of other indorsements can be found here for general interest…. http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-new-policies.page

2013: The AMA (Australian Medical Association) closely followed the lead of it’s American counterparts and also endorsed THN programs. http://www.anex.org.au/ama-and-its-naloxone-policy-position/

Coffin et al released a paper showing the cost effectiveness of naloxone programs…. http://www.ncbi.nlm.nih.gov/pubmed/23277895 this report was cited in a further report on naloxoneinfo.org…. http://naloxoneinfo.org/sites/default/files/Cost%20Effectiveness%20Summary_EN.pdf

A further report in 2013 looking at yet another myth that states that naloxone promotes increased opioid use as released…. http://www.biomedcentral.com/1471-2458/14/297

Also in this year Victoria department of health fully funded naloxone programs to coincide with already existing overdose prevention programs…. http://hrvic.org.au/naloxone-position-statement/

Martindale Pharmaceutical company releases the only licenced product for community use in the UK…. http://www.prnewswire.co.uk/news-releases/martindale-pharma-launches-prenoxad-injection-for-the-emergency-treatment-of-opioid-overdose-205920351.html

2014: The department of health chairperson Jane Ellison sent a letter the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf This letter laid out a clear and direct plan of action which advocated for training and any other preparations to be supported prior to the date given for roll out and was adirect relut of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

N.A.G. (National Action Group) England was founded to address resistance and cut through the red tape with regards to the THN program nationally. The group is made up of representatives from IDHDP, IDPC, NNEF, DRUGSCOPE, PHE, MORPH, SUSSED, SCUFF, HIT, and also a few other independant representatives. To compliment this Action group a forum was also set up on social media which has members from all areas covered by Health and wellbeing boards nationally and information sharing promotes action in all respective areas.

The World Heath Organisation released new guidelines endorsing THN… http://www.who.int/features/2014/naloxone/en/

HOPEFULLY THIS WILL HELP ANYONE OUT THERE CAMPAIGNING FOR TAKE HOME NALOXONE PROGRAMS AND AID IN RESEARCH FOR INFORMATION REGARDING KEY ELEMENTS OF THE INCEPTION OF NALOXONE SINCE ITS BIRTH. AND TO END THIS IN RESPECT OF THE MAN WHO GAVE US THE PRODUCT JACK FISHMAN WHO SADLY DIED IN 2013, WE THANK YOU FROM THE BOTTOM OF OUR HEARTS FOR THE LIVES YOU HAVE SAVED BY GIVING US THIS AMAZING PRODUCT. WHAT A LEGACY YOU LEFT US.

http://www.nytimes.com/2013/12/15/business/jack-fishman-who-helped-develop-a-drug-to-treat-overdoses-dies-at-83.html?_r=0

NALOXONE AND NON FATAL OVERDOSE.

There was a recent research paper released in DDN Magazine that focused on non fatal overdoses which was carried out by a group of academics in the University of South Wales. Which can be found here….

New research on non-fatal overdoses

 Following on from this I decided to do a little non-academic research for myself to look primarily at the possible effects of a non fatal overdose on the individual, Firstly from a physical / medical perspective. In the UNODC discussion paper released in 2013, “Opioid overdose: preventing and reducing opioid overdose mortality” (http://www.unodc.org/docs/treatment/overdose.pdf) it states that….

“Non-fatal overdose can significantly contribute to morbidity, including cerebral hypoxia, pulmonary oedema, pneumonia and cardiac arrhythmia, that may result in prolonged hospitalizations and brain damage”

 Asphyxia and hypoxia lead to a redistribution of cerebral blood flow. This can result in a 25% reduction in oxygen saturation (in lambs, no human research found). Research has found that naloxone can quite significantly reverse this redistribution, this has a massive effect on the oxygen in the brain and therefore, as an opioid-mediated homeostatic mechanism, in hypoxia promotes preferential perfusion of the vital structures of the brain. During severe prolonged asphyxia there was an increase of cerebral blood flow which was more prominent in new born lambs with hypoxia. As opioids play a role in the regulation of cerebral circulation the potential in a non fatal overdose for cerebral redistribution stemmed by naloxone was proven to be significant in redistributing and therefore reducing the the hypertension, increasing the oxygen levels in the brain, reducing arterial blood pressure and reducing the risk of any longer lasting effects. Full recovery and reversal possible if naloxone is administered as soon as is possible after signs appear. For a clear understanding of the signs, symptoms of hypoxia please follow the hyper link below….

http://www.webmd.com/asthma/guide/hypoxia-hypoxemia

 Pulmonary Oedema is fluid accumulation in the air spaces and the lungs which leads to respiratory failure. There are a number of reports published around possible adverse effects of naloxone and most of these include pulmonary oedema, however, most were also highlighted in the presence of an underlying cardiorespiratory disease which has made it impossible to differentiate between what the underlying cause of the pulmonary oedema. “Many episodes of pulmonary oedema secondary to opioid toxicity have been published since it was first noted by William Osler in the 1880s and it has been suggested that naloxone simply reveals the opioid induced pulmonary oedema that had been masked by the already existing respiratory depression”

  Seizures and arrhythmias have also been recorded in pulmonary oedema but ths is more likely to be caused by hypoxia. Which in previous paragraph is reversed by naloxone. Further research around this has shown that hyperventilating patients prior to administration of naloxone could reduce the risk of sympathetic mediated adverse effects. All studies based on this and the findings from those studies were conducted in early trial periods where the main reason for research was to find out what dose of naloxone would be most effective in treatment of non fatal overdose situations to prevent them from becoming fatal. Out of 185 papers on the subject matter, studies were  only deemed to be relevant if they compared doses and routes of administration of naloxone or if they produced evidence about rates and timing of complications. This comment is a summarised account of those that were accepted. For signs and symptoms of pulmonary oedema please follow the hyper link below….

http://en.wikipedia.org/wiki/Pulmonary_edema

  Pneumonia Opioid analgesia impairs gastrointestinal motility. Enteral administration of naloxone allows selective blocking of intestinal opioid receptors caused by extensive presystemic metabolism. Therefore, the effect of enteral naloxone on the amount of gastric tube reflux, the frequency of pneumonia, Results on studies around this particular subject provided evidence that the administration of enteral opioid antagonists in ventilated patients with opioid analgesia might be a simple—and possibly preventive—treatment of increased gastric tube reflux and reduces frequency of pneumonia. This study was carried out on 84 fentanyl treated human patients and was a prospective, randomised, double blind study with 43% given a placebo. For more information on pneumonia please follow hyper link below…..

http://www.patient.co.uk/health/pneumonia-leaflet

 Cardiac arrhythmia: Administration of naloxone before a coronary artery occlusion (http://www.netdoctor.co.uk/ate/heartandblood/203287.html) reduced the incidence and severity of cardiac arrhythmias during coronary occlusion for a period of 20 minutes and reperfusion for a period of 2 hours. It also reduced the mortality. Naloxone totally wiped out the appearance of the life threatening ventricular fibrillation (http://www.patient.co.uk/doctor/ventricular-fibrillation) and ventricular tachycardia (http://www.patient.co.uk/doctor/ventricular-tachycardias) This study again was carried out on dogs, and there is no searchable research on humans. The results suggest a possible involvement of endogenous opioid peptides in arrhythmogenesis (http://medical-dictionary.thefreedictionary.com/arrhythmogenic) during coronary occlusion and reperfusion in the dog.

 Therefore the conclusion of my research is that…again…naloxone is effective in reducing the risks associated with non fatal overdose as well as reducing the risks of the overdose situation becoming fatal. Not bad for a non academic, done in the space of three hours and didn’t cost a penny.

SOMEONES DAUGHTER, SOMEONES SON.

(The title of this blog is from a poem written by a very good friend of mine who’s words resonate with me a thousands of others globally who are joining together in advocacy for the provision of naloxone in their respective communities which can be read the end of this article)

As the fatalities rise, on a global scale , and opioid related deaths tear families and whole communities apart, there is momentum growing in the debate to get naloxone out there into the hands of everyone who would be prepared to carry this lifesaving kit, PUD’s, friends of PUD’s, family members, concerned others, street pastors, dealers, community groups who may find themselves faced with an overdose situation, in fact, absolutely anyone who had a desire to carry a kit.

With Scotland (Scotland should be releasing figures following an audit internally in the prison system over the next few months to add to the evidence that this program has successfully reduced the DRD stats in those leaving incarcertion. This will directly show that although N=ALive pilot, which is still ongoing, had the right idea, it could have been done for lot cheaper and a lot quicker. And guess what it will also show that ‪#‎prenoxad‬ works, surprised?)and Wales (An Evaluation of the Take Home Naloxone Demonstration Project can be found here) leading the way, in the UK, with national programs and Ireland not far behind, (Ana Liffey Drug Project are coming through as a glowing example of best practice when it comes to saving lives in Dublin’s fair city. Statistics in Ireland have shown that almost 4,000 PUD’s exchanged 24,000 needles at drop-in centres across Ireland last year. Merchants Quay Ireland have recently shown the extent of the country’s drug problem as demand for its services soared. These statistics are shown to be closely related to poverty and hardship when looking at demographics of need in relation to specific areas. Statistical data also showed that 75% of those accessing structured service were poly drug users, with a combination of heroin, benzodiazepines and alcohol most commonly used substances, and also the most common in related overdose situations. Design has also shown that there is a current trend which is reaching out to regional areas outside of the city and the need for services outside the city is becoming increasingly evident. There are estimated 20,000 Heroin addicts in Ireland, with 10,000 men and women on Methadone programs. With this evidence coming out that clearly shows a desperate need for the expansion of services to support the growing need and funding cuts hitting where support is most needed this is a potential time bomb waiting to explode in the face of the communities where poverty and addiction are rising) it would seem that for some unknown reason England is dragging her heels with a devastating pace that is leaving its marked evidenced in the 32% rise in drug related fatalities last year. Recently, July, there was a glimmer of hope in the form of a letter from the Department of Health to Les Iverson, chair of the ,Advisory Council on the Misuse of Drugs (who first endorsed take home naloxone in 2009), stating that following a survey by the MHRA there had been a resounding call for a national take home naloxone program. Following this there was a date set for a National Take Home Naloxone (THN) Program which, and wait for it, is, October 2015? Now although this is a shimmering silver lining to those among us who have been advocating for this for quite some time now, it is still not acceptable.

As stated, in 2013 there was a huge rise in opioid related deaths, and this is just the ones that were recorded as that.

Although we do not have 2014 statistics through, my fear is that they could well show another rise, and again in 2015. I digress and hopefully misplace my fear but the truth and evidence cannot be denied here, any death that is preventable is unacceptable. So I ask you what could possibly be the hold up with getting this out there. So far there has been no solid evidence to support a delay. Well none that could possibly warrant such Negligence towards the cost of a human life….is there?

Best practice and substantial evidence to support can be found in Scotland where the Lord advocate, the chief legal officer of the Scottish Government saw fit to sign off a national program which is showing us, over time, that there is a need for such a program wherever there is a prevalence of opioid related deaths. This also showed us that, time, is something that we do not have when it comes to getting naloxone out in the community.

“In many countries, overdose is the leading preventable cause of death among people experiencing problems with drugs. Overdose prevention measures delivered in community settings are incredibly effective; the introduction and scaling up of such measures would save lives of thousands of people” (Eurasian Harm Reduction Network (EHRN))

http://www.harm-reduction.org/library/guide-developing-and-implementing-overdose-prevention-programs-eastern-europe-and-central

Naloxone has been around since the early 60’s and has, to date, given us no reason to doubt it’s efficacy. There have been no fatalities attributed to it’s use in whatever arena it has been used, there is no diversionary value, it has no long lasting side effects that overshadow it’s benefits and yet there is still a debate as to whether it should be available in the community for the purpose of saving lives. Some might say that there is an underlying issue here as to the lives that are being saved and would argue that there is more risk associated with Epinephrine autoinjector (EpiPen), and yet there are no concerns with that and there was not the same debate or delay when it was being passed through as an injectable medication.

Naloxone has the potential to help services reach out to those who may be hard to reach in the community. People who use Drugs are extremely conscious of Criminalization, Stigma and Discrimination whenever they access any kind of service, so knowing that naloxone is safe and legal could put people at ease. Naloxone programs can provide a safe starting point to engage in more open conversations about their health and choices, like seeking out and using clean needles, regardless of whether that is legal or encouraged” Not to mention staying alive in order to promote chances of making a ‘full’ recovery. There are a number of those out there who have been on the receiving end of naloxone who have stated that that second chance was indeed a turning point in their journey.

As it stands now there is an overwhelming outcry not only from Drug User Organisations, such as International Network of People Who Use Drugs (INPUD), National Users Network, and recovering community groups and structured services such as UK Recovery Walk charity, RISE Manchester, COPE Lincoln,morph – Southampton, NHS Highland, Scottish Drugs Forum, Release, Support. Don’t Punish, International Drug Policy Consortium, IDHDP, SUSSED , Bedford, Harm Reduction Coalition, SCUFF, Nottingham, World Health Organization, Criminal Justice Drugs Team, Leicester, Martindale Pharma, Department of Health (The list is endless and I am sorry if I have missed anyone out) but from Significant others (although following this hyper link it shows that in the scientific use of significant other there is still some work to be done), mothers, fathers, sons and daughters, and a number of professionals with regards to this becoming more widely available to those who may be witness to an overdose situation. For a number of reasons when faced with an overdose situation and calling the emergency services there is again fear around the already mentioned criminalization and stigma and therefore sometimes the emergency service are not called. Also the response time if there is any mention of substance use seems to take longer sometimes when thy are called. I’m not taking away the importance of calling the emergency services it makes perfect sense to me for those at the scene as and when it happens to be able to administer naloxone and potentially save a life alongside the services being called.

There are 150 Health and wellbeing boards (follow hyper link to find contact details for your local board) in England. At present, one third of them are actively rolling out programs, one third are in debate and discussion and the final third are still resistant yet unresponsive when questioned around this. So what barriers have they given us so far….

1: There is a risk due to it being an injectable medicines? (follow hyper link for guidance on safe use of injectable medicines) So is the epipen and insulin yet there was no problem when this was being put out there in order to save lives. (In fact the only recorded risk that I am aware of was an American police officer using it to ‘kill’ someones buzz?) No other recorded risk since the early 60’s when it was first marketed. There is no diversionary value….nothing. It does have the potential to cause problems with liver if liver is already compromised, as do most medications, but this is treatable whereas death is final.

2: It’s not licensed? Neither are a number of medications but they are still put out there around an off license route. And….there is a licensed product specifically for community use in the form of Prenoxad Injection

3: It’s not cost effective? (I know, ridiculous but a barrier none the less!!!) Well lets look at that, 20,000 for a basic overdose fatality when you look at the services cost, the coroner inquiry, the hospital bed, the machinery used, etc, not to mention the cost on the surrounding family members, emotionally, mentally and financially,  and community this cant be into monetary value! 400 estimated cost here naloxone was used successfully. In Bedfordshire alone during the last year there were 40 kits handed out and in the last three months 9 reversals, that’s, in monetary value, 720 cost of kits for all 40. lets say services were called on all situations, thats an average count, based on the estimated successful situation cost from Wales, of, 3600 which makes a grand total of under 5000. Savings on community budget in 9 highlighted cases? 175000!!!!! So in my humble opinion then damn straight it’s cost effective and there are still 9 individuals walking around breathing. This information cannot be used officially sadly due again to the current state of play, but there are a number of areas that are coming up with the same math and adding to the evidence to support community provision of naloxone, yet I am still waiting to here the evidence against!!!! (Cannot cover all evidence in all areas at present and have used my home town to demonstrate how a small group of user activist have managed to conduct a small pilot with the potential to save quite a significant amount of funding on the emergency services and in general on the community)

And to show the overview of cost effectiveness in rolling out naloxone programs….

http://www.medscape.com/viewarticle/777455?src=stfb

4: Political agenda? Lets take it back to the political agenda in the shape of the 2010 strategic agenda. It actually fits into that quite nicely into the full recovery setting by keeping people alive and giving them that second chance at recovering. And reducing drug related fatalities. But doesn’t fit in with the general election next year? Possibly why there is an October 2015 date?

So given this very basic but clear little picture what is missing? Other than another 32% of the opioid user community and some common sense? Yep, the evidence and reasoning to support the argument against..why? Because there is none?

So lets backtrack a little bit and look at the stages and times when naloxone has been highlighted and not adhered to in a number of areas.

One of the key directional questions in the 2011 JSNA Support pack for commissioners in section three on the first page of guidance in setting up a recovery oriented integrated service it clearly advocates for naloxone when asking the clear and direct question…..

•Is effective overdose awareness training and information
available? Where appropriate, is naloxone provided for service
users and their family/carers?

All drug users SHOULD have prompt access to:

•Interventions to prevent drug-related deaths and blood-borne
viruses.

•A range of early interventions, treatment and recovery support
appropriate to their needs, at all stages of their recovery journey.

(Sadly this need is not being fully met with regards to naloxone being the ideal intervention along with other recognised and structured interventions)

Effective integrated commissioning of services that achieve
positive outcomes for individuals, families and communities by:

•Effective partnership working between local authorities, health
(including mental health) and social care, and criminal justice.

(And effective service user input surely?)

•Operating transparently according to assessed need.

(Unless it involves explaining why naloxone is not recognised as a high priority need and why members of our communities are dying)

•Bringing providers together into cost-efficient delivery systems.

(Naloxone is a blatant evidenced based cost effective medicine with regards to savings on emergency services and communities on the whole with regards to emotional and mental wellbeing cost)

•Fully involving local communities.

(Providing they are in agreement with the way the agenda has been adopted and don’t put the value of human life first)

A seering indictment to the lack of support and attention to this issue from those that have the power to make the relevant changes can be found here in a blog by John Jolly Blenheim CDP who clearly calls out the English shame and highlights that People are dying because of a lack of harm reduction and again in another excellent article here…

http://recoveryreview.net/2014/09/enforced-recovery-unethical/

 As User Activists and supporters have pushed as far as they can in their respective areas, some more successful than others, Nottingham and Birmingham proving that this works and is effective, to mention two early adopters of programs. Where is Englands equivalent of the Lord Advocate? With great emphasis on the medications in recovery report, surely this should include naloxone? And although I am possibly a little dubious with regards to the review of the Orange Guidelines that is currently in progress, I find comfort in the fact that naloxone has been highlighted for discussion in that review, but fear that in other aspects there will be a price to pay.

(The following poem has been reproduced with kind permission from Lee Collingham. Nottingham rep….)

“SOMEONES DAUGHTER SOMEONES SON”

Why do we do the things we do,
Well it’s not for money that bits true,
For personal gain usually not,
It’ for what, most have forgot.

Our dream is everyone will have naloxone,
Somewhere safe in their home.
We don’t look upon ourselves as saviours,
We just think of it more we’re doing life a favour,
For someone’s daughter for someone’s son,
For their fathers and for their mum.

Is it not human nature to help someone?
Especially when all their Hope has gone,
And for those who moan about round here,
Try spending 6 months in Crimea.

See most only strive for what they can’t get,
They’re close minded and often forget,
But for the grace of God go they,
Who knows maybe it will be one day.

Our dream is everyone will have naloxone,
Somewhere safe in their home.
We don’t look upon ourselves as saviours,
We think of it more we’re doing life a favour,
For someone’s daughter for someone’s son,
for their fathers and for their mum
(c)lrcpublications

‘WE CALL ON THE ‪GOVERNMENT‬ TO HONOUR THEIR COMMITMENT TO ‪SOCIAL JUSTICE‬ AND RESPECT THE BASIC HUMAN RIGHT TO LIVE, AND MAINTAIN SERVICES THAT PROTECT THE MOST ‪VULNERABLE‬ MEN AND WOMEN IN OUR COMMUNITIES, OUR VIEW IS THAT IF YOU ARE NOT PART OF OUR SOLUTION THEN YOU ARE INDEED PART OF OUR PROBLEM”

CHALLENGING IDEAS IN MENTAL HEALTH.

Defining and understanding mental health and illness.

Conditions of state of mind if not correctly placed can be stigmatising and create a confusing scenario when discussing with an individual. Always be clear and precise when discussing elements of care with an individual and make sure that what you re discussing or conveying is explained in full with no room for misunderstanding. When dealing with a person who is living with  condition or who is going through a period of mental distress there must be clarity and understanding to reduce the risk of current, historic and future distress and confusion. For instance there is a distinct difference between mental illness and mental health that is at times lost in translation when discussing the topic. At all times your definition must be clear and fully evidenced.

Respecting personal experience of mental distress.

Always refrain from categorising, judgements, etc. Always meet the individual where they are and allow for among other considerations, cultural, religious and social background, a full understanding of the nature and background of an individual should be taken into consideration when working and caring for a specific individual. When approaching a person who is living with a condition it should be approached in the same way you would approach an individual under any other circumstances, with unconditional positive regard, non-judgemental, open-minded and empathetic, always respecting equality and diversity. Anything less could add to the already perceived or at times very real stigma experienced by an individual.

Community care, fear and the high risk user.

There has been a distinct change in the care of individuals in our communities who are living with a condition. This has changed from asylum’s for the ‘mentally unstable’ to care in the community. This does not always promote a change for the better. Way’s of collating and reporting care in the community have been ‘socially structured’ and therefore have a negative impact on those living with a condition in the community therefore adding to the stigma. There is an element of fear and misunderstanding that has been added to by negative media coverage. The social structure has been designed to report the negative aspects of individuals suffering from mental distress. Links between violence and negative aspects and mental distress are weak and most are lacking in evidence to support. In fact when looking at other concerns in the area such as alcoholism and substance use the evidence clearly finds these concerns higher risk when it comes to health, emotional and physical complications. The statistics are clear that violent crimes are more frequent where alcohol is concerned yet due to the reports and the design of the reporting the evidence collated and the way it is collated would have us believe that those suffering mental distress are higher risk.

Mental health as a business.

A lot of this could be attributed to the influence of pharmaceutical companies on the world of psychology. Big pharmaceutical industries have become big business in the field of mental illness resulting in a toxic and lucrative relationship between services designed to support and treat and those that produce medications to treat. This has created a need for individuals and has had a massive impact on the promotion of medication, which in turn has hugely influenced the changing face of mental diagnoses. This has, in effect, created a conflict of interests between ‘real’ care and big business with psychiatry almost selling out to the interests of the big pharmaceutical companies that manufacture the medications designed to treat. The number of diagnosed conditions has effectively grown resulting in a vast and intricate business rather than focusing on real and effective psychiatric treatment and this also began to have an influence on the decision’s made by a small handful of psychiatrists which could result in misdiagnoses and add to the stigmatising of individuals and the negative impact that a diagnoses may have on a specific individual. Also the dependence of research could easily be influenced by this as an effective way of funding research programs. Two prime examples of this are ADHD which when discovered resulted in a huge surge in ritalin and at the same time a huge rise in Autism which demanded a new form of treatment. Antidepressants were the ideal example of big pharmaceutical companies influencing the field of psychiatry and marketing strategies have been created to sell the product to the consumers, in this case the professionals dealing with individuals in frontline situations. This has resulted in misrepresentation of some drugs where side effects were not recorded but were reported. Research not being truly reported difficulties and true evidence being extremely hard to find. This also in turn creates a major cost to the communities and the general public.

Public health and mental health promotion.

When discussing public health there are two angles to consider. The first is reducing the risks to the general public and the second measuring disease and devising strategies to prevent illness. Mental health can be seen as a considerable ‘burden’on public health with it’s cost reaching in excess of £77 billion a year. £12 on the NHS, £23 billion due to the fact that those diagnosed with a condition may not be able to work and the remaining £42 billion attributed to the reduced quality of life and indeed the loss of life among those living with and living with another who has a condition. The relationship between mental health and public health is inextricably linked with most conditions affecting not only the ones who have the condition but also their significant others. Concerns and worries arising from the conditions of a loved one, such as fear of self harm and suicide, schizophrenic episodes, to mention a few, can affect the social functioning of all involved. Quality of life is intertwined with psychological well-being. Alongside this the individual living with the condition, it has been evidenced, have worse physical health than others. This can sometimes be attributed to the side effects of some medications given to treat the condition. Public health incorporates the care of all those living in and around the confines of mental health, this can include: homeless, prisoners, abused individuals, dual diagnoses, and people with disabilities, and also covers all ages. It also covers all platforms from home to hospital and school to work. In order to promote mental health we must address stigma and discrimination at all levels, supporting inclusion at every level and learning about the health, emotional and physical trauma’s faced by those living with the condition and those surrounding and supporting them. This is imperative in supporting an individual to take control of their lives.

Harm Reduction and Hepatitis C: it works to stop stigma.

Harm Reduction and Hepatitis C: it works to stop stigma..

NALOXONE: WHATS THE HOLD UP?

Naloxone is a type of medicine called an opioid antagonist. It blocks the actions of opioid medicines such as morphine, diamorphine, codeine, pethidine, dextropropoxyphene and methadone.

 High doses of opioids, excessive opioid intake, or abuse or overdose with these drugs can cause reduced lung function and slow, shallow breathing (respiratory depression), which can be life threatening.

 Naloxone is used to treat respiratory depression caused by opioids. Opioids produce their effects by acting on opioid receptors in the brain and nervous system. Naloxone works by blocking these opioid receptors, which in turn stops opioids from acting on them. This reverses the effects of the opioid.

Naloxone may be given by injection into a vein, muscle or under the skin, or via a drip into a vein (intravenous infusion) or nasally.

What is Naloxone used for?

• Reversing breathing problems (respiratory depression) caused by opioids, for example following surgery, or in people taking high doses to control cancer pain.
• Reversing breathing problems (respiratory depression) in newborn babies whose mothers were given opioids during labour.
• Diagnosing and treating opioid overdose.

Use with caution in….

• Disease involving the heart and blood vessels (cardiovascular disease)
• People taking medicines that can have side effects on the heart
• People who have received very large doses of opioids or are physically dependent on opioids, as this medicine could result in severe withdrawal symptoms.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect.

• Nausea and vomiting
• Sweating
• Increased heart rate (tachycardia)
• Hyperventilation
• Increased blood pressure
• Reversal of pain relief if larger than necessary doses are given
• Irregular heart beat (ventricular arrhythmias)
• Low blood pressure (hypotension)
• Accumulation of fluid in the lungs (pulmonary oedema)

The side effects listed above are listed but are not necessarily going to effect the individual whose life is threatened by overdose. The fact is that the individual would be alive. 

 Right with the explanation as to what naloxone is I move onto the positive and in my opinion undeniable argument that it is a positive step forward in reducing the drug related fatalities associated with all opioid substances from illicit to prescription. 

 The latest statistics from the Office of National Statistics (2012) show that there were 1,706 male drug poisoning deaths and 891 female and in total 2,597 drug related deaths registered.

 Although the male statistic has decreased by 4% the female statistic has steadily increased since 2009. The highest mortality rate from substance misuse fell into the age bracket of 30-39 year olds. 

 The most commonly used substances with the highest mortality rate was opiates which accounted for 52% of the figure, (in males, slightly higher (nearly two thirds) 63%….

• HEROIN / MORPHINE: 579.
• TRAMADOL: 175. (more than double the number in 2008, which was 83)

 The previous years where there was a drop in numbers in male fatalities could be attributed to the fact that in 2010-11 there was a heroin shortage in the UK, This was also the case in 2012-13. In 2009 there was also an average street quality of 46% whereas in 2013 the average quality of street heroin was 15-20%. Public Health England also report that the number of those accessing treatment for heroin and / or crack addiction, including those who are returning to treatment has fallen to 64,288 (2005-06) to 47,210 (2011-12) however evidence from national crime survey states that there has been little to no variation in heroin use since their measurement began. 

 These statistics, I’m sure you’ll agree are scary and reflect the fact that opioid use is taking too many necessary lives.  

 There is no standard definition of an opioid-related overdose death.  These fatalities can be broken down to include deaths of any intent, including unintentional, suicide, homicide, or undetermined. Suicide and homicide are very different from unintentional overdose deaths, and the ‘undetermined’ category undoubtedly includes some combination of the other three in unknown proportions. There is no standard definition of an opioid related overdose death. Most fatal overdoses involving opioid analgesics entail the simultaneous use of other central nervous system depressants, such as barbiturates, benzodiazepines, and/or alcohol and there could be a greater tendency to use opioid analgesics in conjunction with these other drugs. A high proportion of substance users are polydrug users and although Naolxone does not work on other substances it does reverse the effects of the opioid in the system thus giving a greater chance of surviving an overdose situation. 

 There are a number of situations that are deemed high risk situations where overdose can be more prevalent. For instance, after a period of abstinence, incarceration, etc. Mortality rates in prisoners leaving incarceration are 10.33% times more likely to overdose compared to the general population mainstream mortality figures in those leaving prison. Female overdose rates in those leaving prison are considerably higher than in males. Generalisation of this study may differ from region to region but the statistics are similar. 

 Asurvey in an american prison which looked at a total of 76,208 individuals released from prison found that out of that number there were 2,462 deaths in the population (3.2%) th emost common cause being unintentional death, 828. Overdoses among those unintentional deaths accounted for 558, car accidents accounted for 183. Drug breakdown put heroin overdose statistics at 123, methadone at 176 and pharmaceutical substances, prescription drugs at 259. 

 Statistics of those who accessed treatment and achieved a period of abstinence is much harder to determine and as far as I’m aware the statistics have not been collated, however if there are any stats out there pertaining to this I would be grateful if someone could direct me to them via the comments. 

In may, 2012 the Advisory Counsel for the Misuse of Drugs undertook a review of  naloxone availability in the UK, presented in the attached report. 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/119120/consideration-of-naloxone.pdf

 The purpose of the report was, as is stated in the above report hyper link, to inform the government on whether or not naloxone should be made widely available in the UK. 

 “The evidence presented in the report showed that naloxone provision reduces
rates of drug-related death. Evidence also shows that training in all aspects of
overdose response is important alongside naloxone provision, and benefits
both service users and carers. Naloxone is already available on prescription
to people at risk of opioid overdose, such as heroin users. However,
maximum impact on drug-related death rates will only be achieved if naloxone
is given to people with the greatest opportunity to use it, and to those who can
best engage with heroin users” 

 This report clearly stated that Naloxone provision is aligned with the drug strategy 2010 aim of reducing DRD’s, Which was highlighted as one of the 8 key outcomes for delivery in all recovery oriented services. Naloxone training and overdose awareness alongside psychosocial interventions were highlighted as being important factors in improving an individuals health and also in maximising their chances of a full recovery. 

 Naloxone is now licenced for community use. This means that it can be supplied to the friends, family or other representative of someone identified to be at risk, but only with the written consent from the person for whom it is to be supplied. Prenoxad Injection can only be made available once the prescriber has assessed the suitability and competence of a client or representative to administer it in the appropriate circumstances. This highlights the need for extensive drive towards training and raising awareness around the medication within our communities.  Prenoxad Injection is legal and will not result in any confiscation if the pack has not been opened.

The law allows Prenoxad Injection to be used by members of the public to save a life in an emergency. This could be a friend or family member of someone who is at risk of opioid overdose. It may be used in the home or elsewhere outside of a hospital. Prenoxad Injection is designed as an emergency rescue or first aid treatment so it does not replace the need to get medical attention as soon as possible. It is crucial that an ambulance is still called by dialling 999 and that the casualty is seen by the ambulance crew. This is because Prenoxad Injection will wear off after a short time and there is a danger of the casualty going back into an overdose.

http://www.prenoxadinjection.com/index.html

 The above link includes all relevant information pertaining to prenoxad injection (naloxone hydrochloride 1mg/1ml solution for injection) contains 2 ml naloxone hydrochloride 1 mg/ml. It covers all angles from healthcare professional to someone who is either currently using opioids or may come in contact with someone who may be in a high risk situation. 

 Another helpful and extensive resource that covers all things Naloxone related is..

http://naloxone.org.uk/

 

 

IT’S ALL IN HOW WE BEHAVE….APPARENTLY?

Research over the last decade has shown that some of the major causes of death have come to be connected or attributed to specific ‘risk factors’ These have been, in general attributed to the individuals overall behaviour. So…in this context….lung cancer, cardiovascular disease and stokes have been attributed, largely, to smoking, Lack of excercise and alcohol consumption. It stands to reason that governments and local commissioners may find an element of appeal in this, especially when it comes to public spending, however….anyone with a practical outlook on such an approach would argue this point and advocate to educate rather than deflect. This way of looking at things also shows that those at the lower end of the social scale, suffer a disproportionate amount of disease, and therefore sends out a message that they are the subsection of society that are most likely to indulge in ‘unhealthy’ habits. An argument for the other side of this view would be that if, for instance someone at the upper end of this ‘social scale’ were to be a successful business man who fell foul to a debilitating disease which rendered him incapable of carrying out his daily routines, work, family functions, etc, then he would slowly but surely slide down the social scale and then become a statistic to support the flawed outcome stats that eventually are used to support this debate. How many times have you read articles where a death has been attributed to substances, and excessive substance use, added to the stigma surrounding the drug using community, then a little further down the line found out that there were underlying issues that contributed to the death. The daughter of a police officer in 1995 made headline news death was given to her use of MDMA, but then research brought to light that she also had an underlying heart condition and the main contributor to her death was water intoxication!! 7 litres, if I’m not mistaken, and if I am then the principle can still be taken from the statement. Although there is a need to look at the behaviours of some individuals, articles like this lead us down a path of misleading hysteria and diluted messages, it is not the way forward in public health intervention. 

  Health professionals, politicians, policy makers and similar guiding lights have, in all admission, promoted successfully that an individuals behaviour is not only the prime cause of ill-health but also the main factor in the maintenance of good health. Reinforced by the general media, and thus taken into the public domain, via usual routes and more increasingly social media platforms, this is being upheld with little to no critical debate around it’s scientific origin. Surely ‘Public health’ should be concerned with the the more immediate factors primarily in both the social and cultural structure which can severely affect the health status of an individual rather than the isolated activities of that individual. Dominance of health officials and commissioning bodies who are in a position to define health needs and issues according to their own criteria may well create a serious imbalance in the research being carried out, the quality of the information shared and also the policies that are subsequently adopted to address specific issues. 

A flawed outlook: If we allow ourselves to focus on an individuals behaviour then we may be deflecting attention from the more real and relevant issues that cause that behaviour. Factors in social structure, class divides, etc. If we are to look at the bigger picture, it stands to reason that most individual behaviours are a result of a number of different aspects and attributes. To look at the end result and base our outcomes on solely that is an unsatisfactory way of achieving positive outcomes. If I self harm, it’s okay giving me a band aid and doing an on the spot assessment to assess where I am at at that particular moment in time but does it take away the reasons as to why I self harmed in the first place??? If I use substances as a means of self medicating, taking away the substance then leaves me with the problem and no ‘solution’ therefore I need to look at why I chose to medicate in the first place. Looking at my behaviours is not going to take away the root cause. Another dilemma with the statistical side of this is the fact that most statistics around social class and the issues surrounding are collated by middle classes. The reach of social deprivation and the adverse health experiences of those living in deprived circumstances is obviously going to be in contrast with those living in less deprived status. Mortality rates are more significant in those who are living in disadvantaged conditions. There are a number of different attributes that add to the outcome of behaviours… housing, employment, finance, economic, social interaction, All of these can contribute to a number of significant health problems Statistics have proven that perinatal mortality rates are higher in those who have low capital in the above mentioned areas in their lives. Those who own their own homes have less mortality rates than those who are living in social housing accomodation, Those in stable employment have a significantly higher mortality rate than those who are living in poverty. As I’ve already said as well, if someone is living in high quality of living standards and falls ill then their capital could significantly reduce, not being able to keep employment, not being able to provide for family, not being able to maintain bills and cost of general living, therefore they would inevitably fall from their social standing into a lower category which in turn would turn the stats….flawed.

RECLAIMING YOUR PLACE IN THE COMMUNITY.

 

 

 

 

RECLAIMING YOUR PLACE IN THE COMMUNITY.

 

Becoming an empowered member of the community means having choices within that community and also having a voice where you’re opinion is valued. Giving back and sharing your experiences with other people can promote this and gives weight and depth to your role within the community. Becoming accountable for your actions, and, facing up to your responsibilities as a recovering individual. Making a difference can promote empowerment and self esteem, building confidence and self awareness at the same time. Having said this you need to be aware of when and how to express your opinion and in what arena your voice would be most effective. The beginning of your journey may be making sure you have a solid foundation on which to build your first step into the community. Exploring your new found direction. Working out your first year plan. Taking risks and trying new things. Learning to accept the consequences of your actions and finding the best ways of dealing with those consequences.

1: What could you do to give back to your community?

2: How would you start this off?

3: Who would be your target group?

4: How can we help you to achieve this?

 

Reclaiming your place in the community can be daunting and at first seem like an uphill battle. But once you start the journey it becomes easier as you involve yourself in more and more. Getting involved in things that you enjoy, volunteering, furthering your education, sports, socialising, attending interest groups. All of these can promote a positive social network and this in turn takes away a lot of the irrational fear that can kick in when making these first steps. Having a nice place to hang out, local café, park, etc. Some areas are lucky enough to have recovery cafes and centres designed for just this. Having a routine that is not all work but involves a fun aspect as well. Making new friends and rekindling old friendships can also promote wellbeing in a new environment. Filling your week with new challenges.

 

1: What fears do you have around re-engagement?

2: What evidence is there to support these fears?

3: How can we address those fears?

4: Where would you like to see yourself in 3 months time?

5: Set yourself a challenge right now to achieve for next week?

 

Redefining self is something  that can take time but where to start is to look at yourself and ask yourself…what are my strengths and resources. Knowing your addiction is only a small part of who you are and knowing what you are capable of and that you are worth so much more than what you give yourself credit for is the key to your foundation. Not allowing yourself to be labelled any more and standing up for your rights as an individual, exploring life outside of your comfort zone and beyond treatment. Be aware of what you can offer and being accountable. Proving to those who repeatedly told you that you would never amount to anything with your life that you are capable of anything life throws at you. You are a survivor, not a victim.

 

1: Who are you?

2: Who do you want to be?

3: What are your strengths?

4: What are your weaknesses?

5: How can you use your strengths to combat your weaknesses?

6: What would the child you were say to the adult you’ve become?