Wales and Scotland and have national naloxone programmes, England does not. In light of the jump in drugs deaths related to opioids, concerns have been raised again about the situation. John Jolly, CEO of Blenheim, writes powerfully on his blog about the shame of this and points the finger at disinvestment in harm reduction and drug services.
He praises the situation in Scotland:
Scotland has allowed naloxone to be provided to services without prescription, for use in an emergency. This enables Scottish drug treatment and homeless hostel staff to have naloxone ready for use. We urgently need the law in the UK changed to allow this.
Something else caught my attention here though:
Many people I suspect are now being encouraged to leave treatment before they are ready.
This echoes comments made on my blog recently by Detox Nurse, a regular commenter on Recovery Review. Considering the rise in deaths, Detox Nurse writes:
I wonder if this is a reflection of a change in service provision and how services are implementing the transition from harm reduction to recovery, particularly in relation to ORT prescribing.
An example of concerning practice is given:
I shadowed a doctor in another service last year. I recall one particular client he saw, a lady who had recently been started on 20mg methadone. She’d been providing 6AM positive urine samples and was in tears, requesting the doctor increase her prescription to 30mg. He said he wouldn’t increase her methadone until she gave some negative urine samples. I felt uncomfortable as I thought this were the wrong way round. She wanted an increase in methadone to help to stop using heroin – if she’d been able to stop using on 20mg, then she wouldn’t have been asking for an increase. I often wonder what happened to her.
But drug deaths are down in Scotland which also has a recovery-oriented drugs policy. (I’m aware we need to be careful when comparing individual years and countries.) Detox Nurse responds:
Yes, that’s a good point, though I wonder if there’s a possibility that Scotland still favors a harm reduction approach over a recovery treatment system? I guess what I’m saying is, is it easier to get on a script in Scotland than in England/Wales?
I don’t know the answer to that, but I do know I’ve never come across the sort of practice where a patient is punished for using on top of the script during a titration onto methadone – not being able to stop using is the very reason they are asking for help. If everything is as it seemed, what on earth is going on? Detox Nurse gives a view:
With regards to the doctor I shadowed, I think this was his consultant’s interpretation of how methadone should be prescribed within a recovery service. From speaking to other workers within that organisation, this wasn’t an isolated incident (time limited prescriptions was another issue).
I do find this to be of concern. Is it possible that a recovery orientation is being interpreted as externally imposed abstinence? Clearly that would be dangerous and ethically quite wrong.
It is possible to have harm reduction embedded in the heart of recovery-oriented services. In fact, an ideal situation would be that we stop thinking that the two are separate. They should be joined at the hip, though there are tensions to be explored and resolved.
Naloxone is a part of the armory that we can use to tackle drug-related deaths. So is equitable and timely access to opioid replacement therapy. Although we still have an evidence gap I suspect that equitable and timely access to recovery communities will also be shown to be protective, as will access to high quality abstinence oriented treatment of adequate duration and with good aftercare provision. The other side of the coin, and this is for another blog perhaps, is that there are also reports (often from people in recovery) of having attempts to move on thwarted by treatment professionals.
For the moment, if poor practice is happening under the flag of recovery, it needs to be called out and halted. We have national clinical guidelines for a reason and as they are revised over the next year or so, perhaps some of the tensions inherent can be teased out.
In the meantime, I support calls for a national naloxone programme for England – why not have recovering people help deliver training? This already happens in some services. We need a full range of options from coal-face injecting equipment provision through to residential rehab. These services need to be joined up, with good clinical governance across the range, to ensure that scenarios like the one described above do not happen.
[Update: Northern Ireland also has a Naloxone programme. A regional protocol and Patient Group Direction were produced in order to deliver an effective programme. Thanks to Trudi Coyne for the information]