Vol 16 Edition 4

A Scottish world-first and the lessons that could save lives here

Record levels of drug-related deaths have led Scotland to introduce a world-first naloxone prisoner training program in Scottish prisons, and to also equip prison night staff with naloxone. It’s an initiative that has attracted attention in Australia.

The Scottish Drugs Forum (SDF) were commissioned by the Scottish government to deliver the prisoner training program across the country’s 15 prisons in 2011, when it was the first of its kind in the world.

More recently, a lack of overnight nursing staff led SDF to equip prison night staff with naloxone to help prevent overdoses in jail, said SDF drug-death prevention strategy co-ordinator, Kirsten Horsburgh.

Kirsten Horsburgh

“In 2017 it was identified as a risk from prison service headquarters that there were no nursing staff available overnight in prisons,” Kirsten said.

“If someone were to overdose overnight, there would be no one there to administer naloxone until the ambulance arrived.

“We ran a program with night staff prison officers, and they are now equipped with naloxone kits overnight in case there is an emergency,” she said.

“It is not something night staff are faced with regularly but overdose in prison does happen, and we wanted to ensure there was coverage in case it does.”

Prisoners willing to be equipped with naloxone are also trained and supplied with Prenoxad® multi-dose pre-filled naloxone syringe and two intramuscular needles shortly before their release.

While the rates of drug-related deaths in Scotland are still the highest in Europe, the number of deaths would likely be much higher had take-home naloxone not been available. Take-home naloxone has been used thousands of times in the community to reverse potentially fatal overdoses.

The rate of drug-related deaths was exponentially higher among those recently released from prison, with research by the Society for the Study of Addiction showing that someone in their first two weeks of prison release was seven times more likely to fatally overdose than their community-based counterpart.

Since then rates of fatal overdose for recently released prisoners, across all genders and age groups, has fallen by 36 per cent.

The success of the program has been its ability to adapt to meet a range of challenges, said Kirsten. At the same time, what started as a program run by prison staff has now evolved into the inclusion of a peer-educator based model.

“The challenges in the prison services are always operational,” she said.

“Availability of staff, competing priorities in the prison regime like work, gym sessions, and visits, getting people to the correct place at the right time, and the willingness to get prisoners to attend the sessions were all challenges we faced.

“What we’re doing with the peer education model is making sure the interventions are similar to what is delivered in the community, and that it happens as a natural conversation between people, rather than any formal program type scenario. In doing this we’ve seen marked improvements in engagement.”

Staff support in helping prisoners to deliver the Scottish National Naloxone Program training is also vital to its success.

“We ask as much as possible for prison and health staff to be included in the program. We really rely on support from prison staff to make sure that peer educators can deliver what they have been trained in, and that they are given the time, the space, the support, that sort of thing,” Kirsten said.

“A lot of the people involved in delivering the interventions might have had previous experience of overdose or might have known people who have died from overdoses. And when you’re speaking to people about that all the time its important they have support in dealing with the feelings that come up. I guess in the same way you expect staff to have support in their workplace, we expect that same level of support for peer educators too.”

A similar prisoner naloxone program has also been trialled in Australia in the ACT. Since 2016, soon-to-be-released prisoners at risk of opioid overdose have been given naloxone training and access to naloxone ampoules following their release.

Dr Michael Levy

This program has also evolved from group training delivered by prison staff, to individual prisoner training delivered by an alcohol and other drugs nurse, said former program facilitator and Clinical Director of ACT Justice Health Services, Dr Michael Levy.

Michael said that while prisoners have engaged with the new model, its success has been hampered by the unwillingness of the ACT prison service to supply released prisoners with intramuscular syringes in their naloxone kits.

“It’s a totally unnecessary obstacle that has been placed in what could be a really simple process,” Michael said.

“These are people who are well versed in proper use of injecting equipment, it is given to them for a good reason, a health promoting reason.”

The introduction of naloxone intra-nasal spray earlier this year could provide a potential solution to operational and supply issues, said Michael, and is a life-saving intervention that could easily be adopted by prisons in other states.

“It’s very simple,” he said.

“There is no reason why it shouldn’t be offered. It’s community equivalent. The expectation is that all opiate dependent people should have some knowledge of Narcan use so that it can be used properly, and lives will be saved.”

– Tom de Souza