Prisons have a unique opportunity to introduce a life-saving naloxone strategy, so is the message getting through? DDN reports.
Naloxone saves lives, and for people leaving prison it can be a vital component in their survival kit. We know that the first few weeks following release carry a much higher risk of dying from a drug-related overdose, as tolerance is low while the availability of drugs in social situations returns.
Despite the strong link with unacceptably high drug-related death figures, there has been an absence of clear strategy and accountability. Both Public Health England and the government have recommended that local areas need to have naloxone provision in place, but when John Jolly reviewed the situation in July (DDN, July/August, page 14), he found that it was rare for any of Blenheim’s service users to have been provided with naloxone on release from prison.
Jolly investigated further and found that of the 36 prisons in England and Wales claiming to give out naloxone on release, many were failing to give out kits, citing ‘operational difficulties’
Since Jolly’s research, the government has responded to parliamentary questions from Grahame Morris MP, stating that new data on prisons issuing naloxone is being collected and is ‘expected to be published in January 2019’. Apart from that, any progress depends entirely on regional interest, with a continued lack of engagement on the issue from NHS England, according to Jolly.
‘There is no national oversight and accountability for providing take-home naloxone to people released from custody,’ says Zoe Carre from Release, adding ‘It is therefore crucial that every prison strategy includes take-home naloxone programmes.’ Many unnecessary deaths could be prevented if all prisons adopted the strategy, but ‘while some prisons are leading the way, sadly others are still not making this life-saving medication available,’ she adds.
In Scotland, where a naloxone programme was made an important part of public health policy in 2011, there has been effort to adapt to the challenges of making it a part of prison culture. Naloxone kits are given to people at risk of overdose, or likely to witness overdose, on release from all 15 prisons in the country.
‘This is a crucial component of the programme due to the increased risk or overdose for individuals within the first four weeks of release,’ says Kirsten Horsburgh, strategy coordinator for drug death prevention at the Scottish Drugs Forum (SDF). The results speak for themselves: ‘The percentage of opioid-related deaths within four weeks of prison release is substantially lower now that it was pre-implementation of the programme,’ she says.
The programme depends on a clear strategy in place to be effective, she stresses, and that includes key stakeholders being fully engaged in the process. ‘The majority of the obstacles faced in a prison setting are operational and should be addressed with clear communication, training and guidance.’
In a paper published in the Australian journal, Drugs and Alcohol Review, Horsburgh and co-author Andrew McAuley gave a detailed account of the challenges involved in implementation. These included availability of staff (for escorting prisoners as well as co-facilitating sessions), and problems around a group format for training sessions – the subject under discussion had the potential to be emotive for those involved, as ‘the majority of people who use drugs will have had personal experience of overdose or experienced the loss of friends and loved ones’.
Bringing in peer education had helped, giving the choice of a one-to-one training session delivered by peers themselves as well as the option of a group session. This had also achieved collaborative working between prisoners and staff.
The other area highlighted for attention had been staff training throughout the prison. Once a prisoner had been trained, nursing staff needed to label a naloxone kit and deliver it to the reception area for prison officers to add it to prisoners’ valuable property, ready for them to collect on release. It was vital that prison officers knew what this medication was, so there was no disruption to a streamlined process of release.
The authors concluded that the naloxone programme had been an ‘important milestone’ in drug policy in Scotland and that prisoners on release were ‘reaping the benefits in terms of reduced opioid-related mortality’.
Karen Blatherwick, nurse manager at Turning Point’s substance misuse services at HMP Leicester, underlines the risks during the first two weeks after release, particularly for those who inject.
‘We encourage service users to carry the naloxone kits at all times, so if they are found with signs of overdose a friend or family member can use the naloxone on them,’ she says. ‘We also train service users to use the naloxone and encourage them to use it on other people if necessary.’
The need for a clear strategy seems to be working its way into the infrastructure of some of the larger providers of prison healthcare, including Care UK Health in Justice.
‘A number of the prison healthcare services we manage give training in naloxone use to prisoners close to their release dates,’ says their national medical director, Dr Sarah Bromley.
She calls the training sessions ‘critically important to saving lives’ as they also teach participants to recognise symptoms and respond to people who are experiencing an overdose, supporting them until the emergency services arrive.
‘These group sessions are set to increase nationwide as more NHSE commissioners ask us to incorporate the training and dispensing into broader community strategies,’ she says, adding that the commissioners’ understanding and buy-in has been crucial: ‘We believe that commissioners recognise that prison healthcare is in a unique position to teach and reinforce messages on preventing overdose deaths at a time when prisoners are more stable than at other points in their journey.’
Elsewhere there are also signs that naloxone has a firm footing in prison healthcare. Inclusion, part of South Staffordshire and Shropshire NHS Foundation Trust, were early adopters and pioneers of naloxone strategy, including in their prison-based services. ‘We have been issuing naloxone with Birmingham and Solihull Mental Health Trust at HMP Birmingham since 2005,’ says head of Inclusion, Danny Hames.
When Change, Grow, Live embraced naloxone strategy, they made it ‘an objective to ensure that those integrating back into society from the prisons with which we work are provided with take-home naloxone kits, as well as guaranteeing that they receive advice, information and support around access to local community services,’ says CGL executive director, Mike Pattinson. ‘We have been taking this approach in our prison-based services for some time and shall continue to do so as part of our overall harm reduction plan.’
For Forward Trust, whose substance misuse work spans 18 prisons, ‘a more organised and structured approach to promoting naloxone’, began at HMP Lewes. By having a designated ‘naloxone lead’ in the team, they make sure each new service user is added to the naloxone waiting list, regardless of whether their release date has been set. They also make sure clients who are ready for release are booked in for an appointment in the two weeks before they leave.
They believe the scheme is working well because of the staff and client training, good organisational skills, and efforts to improve communication – between Forward team members and with other departments in the prison. Keeping a database of staff members who have completed their training helps them to analyse progress.
‘Sometimes clients refuse the naloxone or training when we first offer it, but change their minds later on,’ says Forward’s Amy Williams. They are offered more chances to engage including, crucially, when they are close to their release date, which ‘lets them know that even if they don’t think they will need it, it could be used to save the life of someone else. This ensures that we are not only helping them on their recovery journeys in prison, but out into the community too.’
WDP’s substance misuse team have also come across the issue of prisoners refusing naloxone, during their work at HMP Woodhill. As part of each prisoner’s release plan they are offered training, harm reduction advice, and a kit on release.
‘Some inmates who are on a stable dose of methadone, or who have recently detoxed, may decline the offer of a kit, saying that they feel that they have achieved stability or detox in the prison and have no intention of using drugs or associating with their drug-using former associates,’ says WDP’s Kate Bonner. ‘But they are reminded that prison is a false environment and that while they may be perfectly capable of managing their own lives, they have no control over who they might meet on the street or who might come to their home.’
From those who have come to realise the value of naloxone as they prepare to leave prison, there is gratitude. Whether all prisons will extend this safety net to their inmates in the new year remains to be seen.