Naloxone in a prison setting
A new research report looks into the difficulties in distributing “take-home” naloxone to released prisoners to try to prevent deaths from heroin and other opioid overdoses.
The research, written by Arun Sondhi, George Ryan and Ed Day, is formally titled: Stakeholder perceptions and operational barriers in the training and distribution of take-home naloxone within prisons in England and can be downloaded for free from the current issue of the Harm Reduction Journal.
Take home naloxone
Naloxone is an opioid antagonist that is used to counteract an overdose of an opioid drug such as heroin. The drug is used as part of an emergency overdose response, and there is evidence that mortality rates can be reduced. The use of take-home naloxone (THN) is seen as part of a package of interventions aimed at identifying and responding to an overdose, including use of rescue breathing and calling medical emergency services. The perceived advantage of THN is that it can be administered by non-medical individuals who have received at least some training.
Naloxone can also be seen as a useful medication for illicit drug users as it has no clear potential for abuse. The drug can be administered via intramuscular, intravenous, subcutaneous, or intranasal routes.
[For more information on naloxone, check out this excellent new publication from the European Monitoring Centre for Drugs and Drug Abuse.]
Naloxone for prisoners
The importance of THN for prisoners is that there are high rates of heroin overdose amongst released prisoners, particuarly in the first few days and weeks back in the community when drug users revert to high levels of usage following months or years in prison when heroin is generally less available and often of a much reduced purity.
The research is mainly based on a series of ongoing interviews and meetings with key healthcare and substance misuse staff and serving prisoners in ten prisons across England and Wales.
Barriers to implementation
The researchers found that organising the effective distribution and implementation of THN in a prison setting was extremely problematic; they identified four main barriers which are discussed in turn below:
Negative and confused perceptions of THN amongst prison staff and prisoners
Many prisoners were uncertain about the concept of THN and what it aimed to achieve. Some confused naloxone with naltrexone, an opioid antagonist that is used to help people who have stopped drinking alcohol or using opioid drugs to maintain abstinence. More importantly, there was confusion amongst prisoners about the overarching message underpinning the use of THN within a prison context — most prisoners in treatment inside were focused on abstinence so discussing overdose prevention appeared to be a contradiction.
Some prisoners were also concerned about what police officers would say if they stopped and searched them and found them in possession of naloxone.
Prison staff also expressed concerns that THN could undermine work towards recovery and give permission for released prisoners to go back to using heroin with a state-provided safety net.
Inherent difficulties with the identification and engagement of eligible prisoners
Staff highlighted pragmatic concerns regarding the identification of prisoners with a history of opiate use and engaging appropriate individuals in the THN training programme. Typically, there was competition between different initiatives to engage prisoners at the same time and attempts to enlist prisoners during their induction generally failed. This was unsurprising as new prisoners are often over-whelmed with information during their first few days in prison when they are trying to adjust to prison life, make contact with families etc.
Practical problems in the effective distribution of THN
There were a host of practical problems (unimaginable to anyone who hasn’t worked in a prison setting) which made it difficult to get the take-home naloxone kits in the right place at the right time to ensure that they were given to prisoners on the day of their release.
Healthcare staff were often (bizarrely) apprehensive about prison officers being the people to actually hand over the kits — particularly odd since the value of giving out naloxone is so that a non medical person can save a life.
The need for senior prison staff engagement.
The research identified that it was most effective for large numbers of staff within the prison to be engaged in the programme and receiving the appropriate training (a whole prison approach) and that it was vital to enlist the support of senior staff who could resolve difficulties.
The authors conclude that the key finding from this study is that it is insufficient for prisons to merely offer training and distribute naloxone kits to opiate-using prisoners without conducting a more enhanced planning and preparation process.
My own experience is that positive initiatives such as take-home naloxone tend to succeed despite, rather than because of, prison processes and that the challenge has become even more difficult in the context of substantial reductions in prison staff over the last five years.
The engagement of senior staff is certainly critical, but so is making sure that the project is championed by an able and determined leader who knows how to make things happen in a prison context.