Home > Launch of the Evaluation of the HSE Naloxone Demonstration Project.

Lynn, Therese (2017) Launch of the Evaluation of the HSE Naloxone Demonstration Project. Drugnet Ireland , Issue 60, Winter 2017 , pp. 18-19.

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On 30 August 2016, Minister of State for Communities and National Drugs Strategy Catherine Byrne TD attended the launch of the Evaluation of the HSE Naloxone Demonstration Project in Temple Bar, Dublin.1 The external evaluation was commissioned by the HSE National Social Inclusion Office and its launch coincided with International Overdose Day. The key theme was ‘Time to Remember, Time to Act’, which acknowledged the trauma and suffering of families and friends affected by drug misuse. The aim of the day was to reduce the stigma of drug-related deaths and to spread the message that overdose death and injury is preventable.

 

Background

In Europe, between 6000 and 8000 deaths by overdose are reported annually with the majority as a result of heroin or opiate overdose.2 In Ireland, based on figures reported in the National Drug-Related Deaths Index (NDRDI) for 2013, opioids were implicated in 203 deaths, representing 58.2% of the total number of poisonings that year.3 A principle finding in this data was that 42% of these individuals were not alone at the time of death. This indicated that an appropriate intervention, such as the administration of an opioid reversal agent like naloxone, could have potentially saved these lives.

 

Naloxone is a semi-synthetic drug used to temporarily alleviate the physiological symptoms of opiate overdose. It is listed by the World Health Organization as a specific antidote and was included on the Model list of essential medicines in 2013.4 Administered intravenously, intramuscularly or by nasal spray, naloxone temporarily reverses the respiratory depression experienced during an overdose, providing a life-saving period before emergency services arrive for further medical intervention.

 

Naloxone Demonstration Project

Under Action 40 of the current National Drugs Strategy and addressing the four tiers of the Rehabilitation Pathway of the National Drugs Rehabilitation Implementation Committee (NDRIC),5,6 the purpose of the HSE Naloxone Demonstration Project was to test the feasibility of making naloxone available to prevent death from overdose. The first part of the project involved formal briefing and training of drug users and those close to them (including service providers, front-line workers, family members, and friends) on how to use naloxone and how to recognise and manage overdose events. The second part involved prescribing naloxone kits to 600 opioid users in Dublin, Limerick, Cork and Waterford following training. The naloxone kits were single, individual use prepacked syringes containing five doses of Prenoxad® (1 mg/ml injection). Intramuscular administration of naloxone was used as no intranasal device has been approved for the European market.

 

Over a two-year preparatory period, a quality advisory group (QAG) was established to oversee the implementation of the project and extensive input was sought from a number of different stakeholders7. A cascade-style training model for the project was agreed and comprehensive training materials and resources were developed. The project formally commenced in February 2015 and the external evaluation began in June 2015, involving action research which continued until October 2015. A process evaluation was carried out to analyse the content and quality of the training programme, and to gather feedback from training participants. In addition, an outcome evaluation of the training was conducted, and the effect of the practical application of naloxone and harm-minimising techniques to reduce the number of fatal overdoses was investigated.

 

An open invitation was sent to all relevant services to take part in the naloxone and overdose training alongside the implementation of a programme to increase awareness of the project in potentially interested stakeholders, e.g. homeless services, National Family Support Network (NFSN). Thirty-one people took part in a train-the-trainer programme, one-third of whom cascaded the training programme across the four demonstration sites. By October 2015, close to 600 people had received the naloxone and overdose training, comprising a diverse group of general practitioners (GPs), pharmacists, front-line workers, HSE and Irish Prison Service personnel, opioid users, family members and outreach workers.

 

Results of evaluation

Each participant completed a survey before and after the training. The results revealed significantly increased understanding and awareness of how to recognise and manage an opioid overdose event and the steps taken to administer naloxone appropriately. In total, 95 naloxone prescriptions were issued during the project by six GPs; the majority (67%) of prescriptions were in Dublin and the remainder (33%) in Limerick. As the project ended, another GP began prescribing naloxone in Waterford, as did the Drug Treatment Programme in the Irish Prison Service at Mountjoy Prison, Dublin. There were five separate overdoses during the project and in each case naloxone was administered in accordance with the predefined procedure. Four of these administrations were carried out by a front-line worker and the fifth was peer-to-peer. Notably, each naloxone kit was administered to a person other than for whom it had been prescribed. The evaluation found that the project successfully minimised the number of potentially fatal overdoses in Ireland between February and October 20158 and concluded that widespread accessibility and availability of naloxone was crucial to its life-saving function in the community.

 

Post-overdose event interviews were conducted, which showed that those who administered the naloxone felt pride and relief in their contribution to saving a life. Being armed with a tool to use in the event of an overdose situation provided these individuals with increased confidence and a sense of empowerment.

 

Although four demonstration sites were initially included in the project, no prescriptions were issued in Cork. The factors which improved uptake in the other demonstration sites were listed as increased prior knowledge of and interaction with the project; availability of local champions; belief in the efficacy of naloxone; clear communication of the process and referral pathways; acceptance, willingness and availability of GPs locally to engage and prescribe naloxone from the outset; and support from the NFSN and its membership on the ground.

 

Recommendations

The evaluation recommended the national implementation of the demonstration project in a managed, phased and strategic manner. This process will demand intense logistical coordination and specific areas of the project will require revision and reworking. The evaluation provided six key recommendations centred on ‘communication, consultation, training design, robust research and planning for future roll out and distribution of naloxone in Ireland’ (p. 57)1.

  1. Improved communication is required on a national level. Feedback should be given adequate consideration in advance of an all-Ireland rollout of the scheme.
  2. The governance of the QAG should be strengthened and membership extended to include clinical expertise and regional representation.
  3. Naloxone should be rolled out in Ireland in a measured, phased and strategic manner with a focus primarily on the Waterford/South East and Cork region. Dedicated staff and resources should be assigned to coordinate this process efficiently.
  4. The training programme should be accredited by an appropriate body and should incorporate the learning from the evaluation. In addition, the programme should be flexible and constantly evolving to incorporate future feedback from participants, changes in legislation and product availability.
  5. The briefing of opioid users, family members, friends and front-line workers should be continually monitored carefully and supported. In particular, the opioid users receiving the naloxone prescriptions should be given special attention where health, well-being and drug-related behaviour are tracked over time.
  6. Multidisciplinary research with a focus on clinical governance should take place relating to naloxone in Ireland. This research should be overseen by the QAG. 

In terms of health economics, the project represented a good return on investment (€62,500) for the HSE. The Demonstration Project was responsible for the widespread training of opioid users, service providers and a wide range of other organisations about the threat of overdose and the potential of naloxone to save lives. It has removed some of the stigma associated with drug misuse and provided people with a powerful life-saving, harm-minimising tool for use in overdose situations.

 

The evaluation highlighted the positive effects of naloxone as a ‘catalyst for positive change in behaviour in drug use and harm minimisation’ (p. 52). The authors felt that the demonstration project was well received in Ireland among the family members and front-line workers, and was deemed a success. In addition, given the approval of an intranasal formulation of naloxone by the US Food and Drug Administration in 2015, it is possible that the use of this device may be incorporated into new legislation in Ireland once a European equivalent becomes available.

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  1. Clarke A and Eustace A (2016) External evaluation of the HSE Naloxone Demonstration Project. Dublin: Health Service Executive (HSE). https://www.drugsandalcohol.ie/26037/
  2. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2015) European Drug Report 2015: trends and developments. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/24029/
  3. Health Research Board (2015) Drug-related deaths and deaths among drug users in Ireland: 2013 figures from the National Drug-Related Deaths Index. Dublin: Health Research Board. https://www.drugsandalcohol.ie/24676/
  4. World Health Organization (WHO) (2013) WHO model list of essential medicines. 18th edn. http://www.who.int/medicines/publications/essentialmedicines/en/
  5. Department of Community, Rural and Gaeltacht Affairs (2009) National Drugs Strategy (interim) 20092016. Dublin: Department of Community, Rural and Gaeltacht Affairs. https://www.drugsandalcohol.ie/12388/
  6. Department of Community, Rural and Gaeltacht Affairs (2007) National Drugs Strategy 2001‒2008: rehabilitation. Dublin: Department of Community, Rural and Gaeltacht Affairs. https://www.drugsandalcohol.ie/6267/
  7. Consultation took place with ‘key stakeholders within the Department of Health, Health Products Regulatory Authority (HPRA), National Family Support Network (NFSN), voluntary support network, Irish Prison Service (IPS), Ana Liffey Drug Project (ALDP), Merchants Quay Ireland (MQI), National Drugs Rehabilitation Implementation Committee (NDRIC), SafetyNet, Primary Care, Pre-Hospital Emergency Care Council (PHECC) and the HSE Addiction Services’. (p27)
  8. A further three overdose events and naloxone administrations occurred between November 2015 and January 2016.
Item Type:Article
Issue Title:Issue 60, Winter 2017
Date:January 2017
Page Range:pp. 18-19
Publisher:Health Research Board
Volume:Issue 60, Winter 2017
EndNote:View
Subjects:B Substances > Opioids (opiates)
B Substances > Opioids (opiates) > Opioid product > Naloxone
G Health and disease > Substance use disorder > Drug use > Drug intoxication > Poisoning (overdose)
J Health care, prevention and rehabilitation > Health care delivery
P Demography, epidemiology, and history > Population dynamics > Substance related mortality / death
VA Geographic area > Europe > Ireland

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