NETWORK A national newsletter on substance misuse management in primary care
Samantha Perry and Carole Hunter describe how the families, friends and carers of drug users can play a crucial role in preventing drug related deaths by being involved in a programme that includes administering naloxone. Ed.
Can we reduce drug related deaths in Scotland? A Glasgow initiative which involves families and friends
Drug related deaths have generally been on an upward trend across Scotland in the past 20 years as heroin use has become more widespread. In recent years Greater Glasgow and Clyde has consistently accounted for around 30% of these deaths, 326 deaths over a three year period from 2005 to 20071
. The majority of deaths
involved a combination of drugs with heroin, benzodiazepines, methadone and alcohol being most commonly detected at post- mortem 2
(see chart 1).
Chart 1 Main drugs involved in drug related deaths Greater Glasgow 2003-2005 (General Records Office Scotland [GROS] 2006)
Actions taken during an overdose 3 ■ 44% CPR ■ 6% Recovery position ■ 21% Inflict pain, cold shower, cold water ■ 38% No intervention attempted ■ 82% Ambulance called ■ 81% Dead on ambulance arrival
Naloxone is a competitive antagonist for the mu opiate receptor and can temporarily reverse respiratory depression during an opiate overdose. It is effective when given by the intramuscular, intra- nasal, intravenous and subcutaneous routes. It has been used by health care professionals in both pre-hospital and hospital settings to reverse the effects of both accidental and iatrogenic opiate overdoses for years 4
In 2005 a change in section 7 of the Medicines Act 1968 reclassified naloxone to a medicine which could be administered by any person in the event of an emergency to save life. The Advisory Council on the Misuse of Drugs report on drug related deaths was of the view that as a matter of principle naloxone should be made more widely available to drug users but careful consideration should also be given to prevention, first-aid and resuscitation5
. Research in Europe and
North America also supports the rationale for the supply of naloxone as a means to reduce drug related deaths 6 7
A multidisciplinary working group was set up in Glasgow in 2006 to explore how naloxone could be made available to the drug using community and their friends and families. The group’s work involved the development of a robust training programme, which could be delivered in less then 2 hours, together with supporting literature, and the development of a Patient Group Direction to allow nursing and pharmacy professionals to supply naloxone.
In summary the aims of the Glasgow naloxone programme are not to merely supply naloxone but also to give comprehensive advice on minimising the likelihood of an overdose occurring and to recognise an overdose state when it occurs. Participants are also taught how to manage and assess an unconscious person, perform basic life support, inject naloxone safely and place the unconscious person in the recovery position. Emphasis is given throughout the programme to the vital importance of calling the emergency services as soon as possible.
The principal cause of death following an opiate overdose is respiratory depression culminating in respiratory arrest and death. This is exacerbated if other respiratory depressants such as alcohol and benzodiazepines have also been taken.
A high proportion of overdose events take place in a home setting and are often witnessed by other drug users, their friends and family members3
The budget for the initial pilot of 300 naloxone supplies was approximately £12,000, and did not include evaluation of the programme. Maximum use was made of existing resources. The programme became affiliated to Heartstart, who supplied initial resuscitation equipment and permitted the issue of a recognised qualification to participants. Evaluation of the pilot phase was conducted by the Scottish Drugs Forum and was very positive8
. . In the majority of cases people who witness an
overdose are willing to intervene (chart 2) as opposed to the popular myth that overdose victims are left to their fate. However many of the interventions are inappropriate and contact with the emergency services is often delayed for a variety of reasons, including fear of police involvement 3
1 General Records Office Scotland (2008) Drug related deaths in Scotland 2007. 2 General Records Office Scotland (2006) Drug related deaths in Scotland 2005
3 Scottish Executive (2005) National Investigation into Drug Related Deaths in Scotland 2003
Since the programme’s beginning in 2008 over 100 instructors have been trained and 800 drug users have successfully completed the
4 Dollery C (Ed) (1991) Therapeutic Drugs. Edinburgh: Churchill Livingstone
5 Advisory Council on the Misuse of Drugs. (2000) Reducing Drug Related Deaths. London:HMSO,2000;80-1.
6 Dettmer K, Saunders S, Strang J. (2001) Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes. BMJ 2001;332:895-896.
7 Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich (2006) Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis 2006;25:89-96
8 Shaw A, Egan J, Houston M. (2008) Evaluation Report. Glasgow Naloxone Programme. email@example.com
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