10 May, 2021
One of my primary motivations for beginning a PhD in substance use and addiction were the encounters I had as a junior doctor with patients who were experiencing these. As a clinician, I felt increasingly frustrated that I was not able to take a broader view of how we could help people, curtailed by the need to focus on the health issue they were presenting with, time and job constraints, rather than having the freedom to more fully explore or help to address underlying issues that were exacerbating or causing harm. At that time, there were really no widely promoted structures or policies in place for providing meaningful, practical harm reduction interventions in hospital settings. There was very little general awareness of the need for harm reduction or overdose education in these settings, and no availability of take-home naloxone. The need for improvement here is being recognised, with the most recent RCPE policy report, which highlights the increasing role that the medical community must play in addressing “problems related to drug and alcohol dependency”. Thus, there is the recognition that change here is needed, particularly in light of the current number of drug-related deaths being experienced in Scotland.
Drug related deaths (DRD) continue to escalate in Scotland, with the deaths of 1264 people recorded in the latest figures. 86% of these deaths linked are linked to opioids which is the highest proportion than in any preceding year. Whilst the use of take-home naloxone, an opioid antagonist (read anti-overdose) drug, is no panacea, the evidence shows it can reduce the risk of overdose for people who use opioids. High risk time points for overdose include after detox treatment, release from prison and discharge from inpatient hospital episodes, all times where a person has experienced a period of abstinence and so has a lower opioid tolerance than they might usually expect. The most recent Scottish Naloxone report and further research appears to indicate that levels of overdose after prison-release have reduced since implementation of overdose education and naloxone distribution (OEND) was commenced in this setting. However, the same report indicates that as yet no impact has been made on overdose deaths subsequent to hospital discharge. Research confirms the increased risk of overdose to people who use drugs which is posed both during hospital admission and within the 28 days after discharge. Similarly, the most recent National Drug-related Deaths Database (Scotland) report which makes reference to overdose deaths in relation to hospital admission indicates that 11% (78/709 deaths) of opioid-related deaths were within four weeks of hospital discharge in 2017. This increased to 21% (151/709 deaths) within 12 weeks of hospital discharge. Given the significant increase in total DRDs since that time, it is not inconceivable to imagine that this has also increased proportionally or in real terms. The question then is what can be done to ensure that this particular timepoint of increased risk is addressed?
Given what we know of the evidence base for THN in reducing overdose, there is a strong theoretical basis for provision of THN for PWUD during hospital inpatient episodes. There is very little research evidence regarding the outworking or practice of this at present, a number of pilots have been conducted which show promise however most of these have been from the Emergency department. Some of this promise hinges on addressing factors such as increasing awareness of both staff and patients of the heightened overdose risk after an inpatient admission, increasing staff and patient familiarity with THN training and provision, and the need for clear holistic assessment and training protocols.
The ethical tenet which clinicians subscribe to of “first do no harm” here has weight – the moment a patient who is known to regularly use opioids is admitted to hospital the risk of their having an overdose is significantly increased. This is one of the reasons why we are focusing on exploring the potential for providing take-home naloxone from acute and general medical inpatient settings, to find out what might facilitate it, what the possible barriers might be and how well staff and service users might feel able or supported to engage with it. Additionally, given the current impact of COVID on our health service, some may feel it is unfair to expect more from colleagues who are already stretched thin. What we must recognise however, is that COVID is also having a similar impact on those who use drugs, with increasing pressures and harms being exerted on this very vulnerable population too. It is so important to begin addressing the gaps that we can see, where people who use drugs remain vulnerable. This means, among a plethora of other provisions, there is a need to start providing harm reduction interventions such as THN from every available service, so that as many people as possible are engaged with providing it and as many service users as need it can access it.