Evaluation Report:

Glasgow Naloxone Programme

Commissioned by:
Glasgow Addiction Services

May 2008

Prepared by: A. Shaw, J. Egan, M. Houston

CONTENTS

EXECUTIVE SUMMARY AND RECOMMENDATIONS 4

1. INTRODUCTION 5

2. DEVELOPMENT OF THE GLASGOW NALOXONE PRORGRAMME 9

3. EVALUATION METHOD 15

4. FINDINGS 17
4.1 Pre-Naloxone Training Sessions 17
4.1.1 Clients’ Profile 17
4.1.2 Recognising and Managing Overdose 17

4.2. Family and Friends Profile 20

4.2.1 Recognising and Managing Overdose 20

4.3. Comparing clients’ and carers’ overdose awareness 21

4.4 Follow-Up Interviews 23

4.4.1 Naloxone Training 24
4.4.2 Training Venue 26
4.4.3 Naloxone Supply Venues 27
4.4.4 Clients and carers disseminating GNP Training 29
4.4.5 Naloxone Storage 30
4.4.6 Comparing responses to recognising and managing overdose events: 31
Pre and post-training

4.5 Reported Uses of Naloxone 34

4.5.1 Overdose Casualties 37
4.5.2 Overdose Responses 37
‘
4.6 Training the Trainers’ 39

5. SUMMARY OF FINDINGS 44
5.1 GNP Training impact on clients and carers 44
5.2 Naloxone Use 44

1
 5.3 GNP training delivery 45
5.4 GNP Training the Trainers 45

6. DISCUSSION AND RECOMMENDATIONS 47

References 51

Appendix 1 Reported Naloxone Use 53

Appendix 2 Naloxone Hydrochloride - Pharmacological Information 64
Appendix 3 Questionnaires 65

2
Acknowledgements

Thank you to all the participants who agreed to willingly give up their time to take part in
this evaluation and to the staff at the Glasgow Drug Crisis Centre (GDCC), Turning Point
Scotland, for supporting this work. Thanks also to the members of the Glasgow
Naloxone Programme steering group and research subgroup.

This report was written by April Shaw (Research Officer) and James Egan (Head of
Policy and Practice) from Scottish Drugs Forum with statistical support from Dr. Muir
Houston.

For further details contact april@sdf.org.uk or james@sdf.org.uk

3
EXECUTIVE SUMMARY AND RECOMMENDATIONS

To be completed following feedback from steering group

4
1. INTRODUCTION

The Glasgow Naloxone Programme (GNP) is funded by Glasgow Addiction Services

(GAS) and began providing training to drug users and family members in March 2007.
This evaluation, which took place between March 2007 and March 2008, was
commissioned by GAS in order to assess the training programme’s achievements and
identify both areas of good practice and possible challenges within the training
programme and its delivery.

Background

Non-fatal overdose is an ‘occupational’ risk of opiate misuse - such as heroin - with fatal
overdose a common cause of premature death. A major contributor to a fatal outcome is
the ineffectiveness of heroin users' responses to the overdoses of their peers. This may
involve a delay in calling an ambulance for fear of the police arriving and ineffective
resuscitation efforts. Providing drug users with Take-Home-Naloxone (an antagonist
drug used by emergency health professionals to reverse opioid overdose) was first
mooted in 1992 as an intervention that would be life saving in such situations.1,2
Primarily administered by injection, a standard Naloxone Hydrochloride (hereafter
referred to as Naloxone) dosage of 0.4 mg would usually result in recovery without
producing drug withdrawal. It is a short acting drug which usually lasts for about 20
minutes. (See appendix 2 for further pharmacological information on Naloxone.)

Over the last ten years a range of Take-Home-Naloxone (THN) pilot work has been
carried out in Europe and North America to examine the impact of providing it to drug
users to administer during an opiate overdose. Salient components of these THN
initiatives have included providing different Naloxone dosages (from single to multi-dose
provision), training aimed at improving drug users’ emergency responses and relevant
information materials.

In Bologna, Italy, THN ‘key rings’ were developed and made available from 1995

1
Strang J, Farrell M. Harm minimisation for drug users: when second best may be best first. British
Medical Journal(BMJ) 1992;304:127-8.
2
Strang J. Drug use and harm reduction: responding to the challenge. In: Heather N, Wodak A, Nadelmann
E, O'Hare P, ds. Drug use and harm reduction: from faith to science. London: Whurr, 1993:3-20.

5
onwards to drug users through mainstream drug services, needle exchange sites and
over-the-counter pharmacies. Since 1997, Italian drug related deaths have halved from
1160 to 516 deaths in 2002. 3

THN initiatives have also been developed in the United States of America. In San
Francisco, health clinics started providing THN in 2003 with 116 reported ‘saves’.4
However, in Chicago THN has been widely distributed in an initiative strongly linked to a
training programme emphasising aftercare and follow up. The programme was set up in
2001 in response to rising drug deaths (198 in 1996 rising to 466 in 2000). There has
been widespread THN distribution with health care staff handing out 3,500 THN doses
with 319 reported uses. Since its introduction in 2001 Chicago’s drug-related deaths
decreased by 34% by 2003.5

Closer to home, a small scale study was carried out on the island of Jersey in 1998. In
this study, THN was distributed to 101 drug users with five reported successful
interventions, each leading to full recovery.6 A recent THN pilot has also been carried
out in England7 and a large randomised UK trial involving recently released prisoners will
begin soon.

Despite the above THN work and Naloxone being a tried and tested drug used for
overdose resuscitation by emergency frontline health staff8, some critics argue that there
is no scientific evidence demonstrating THN effectiveness through drug users
administering it to peers. 9,10,11 One commentator has suggested that Naloxone’s short
half life may give unskilled users a false sense of security thus introducing a "secondary

3
Simini, B. Naloxone supplied to Italian heroin addicts. Lancet 1998; Vol. 352 (19 Sept).
4
Harm reduction cuts OD deaths in San Francisco. Join Together 2005 (4 November).
5
Scott, G., Thomas, S., Pollack, H., Ray, B. Observed Patterns of Illicit Opiate Overdose Deaths in
Chicago, 1999–2003 Journal of Urban Health. 2007 March; 84(2): 292–306.
6
Graham C, McNaugton G, Alastair I, Cassells K. Take home Naloxone for opiate addicts. BMJ 2001;
323:934 (20 October).
7
Strang, J., Manning, V., Mayet, S., Kelleher, M., Semmler, C., Offor, L., Titherington, E., Santana, L.,
Mest, D. The Naloxone programme: Investigation of the wider use of Naloxone in the prevention of
overdose deaths in pre-hospital care. National Treatment Agency (June 2007)
8
Dollery C, ed. Therapeutic drugs. Edinburgh: Churchill Livingstone, 1991.
9
Sporer KA. Strategies for preventing heroin overdose. BMJ 2003; 326: 442-444 (22 February
10
Byrne, A. (2006) Letter Emergency Naloxone for heroin overdose Over the counter availability
needs careful consideration, BMJ ;333:754 (7 October), doi:10.1136/bmj.333.7571.754
11
Brewer, C. (2006) Letter: Emergency Naloxone for heroin overdose Naloxone is not the only opioid
antagonist BMJ;333:754-755 (7 October), doi:10.1136/bmj.333.7571.754-b

6
opiate overdose," particularly when used to treat overdose involving long-acting opiates
such as methadone.12 Other THN criticisms are that drug users will avoid calling
emergency services as they tend to associate emergency ambulance services with
police, unsuccessful use will go unreported and it could be used as a punishment tool by
‘dealers’.13

In Australia, workers have also expressed fears that drug users could potentially use
THN to increase their heroin tolerance by taking increased amounts of the drug to
experience enhanced euphoria.14 However other authors argue that the risk of abusing
Naloxone is unlikely due to the unpleasant withdrawal symptoms it provokes and the
lack of any reinforcing properties15&16

Despite these criticisms, some of this described THN work is occurring within the context
of ongoing legislative changes. For example, in North America state legislative changes
have taken place in New Mexico and New York. Public servants, such as police officers,
can administer Naloxone in New Mexico and doctors working in both states have
approval to administer THN.17

There have been UK legislative changes to the Prescription Only Medicines (Human
Use) Order (2005) which means that Naloxone can now be administered by any person
in an emergency to save life.18 Furthermore, in the same year, the Scottish Advisory
Committee on Drug Misuse (SACDM) commissioned a Working Group on Drug Related
Deaths which recommended that “those in a position to administer Naloxone should
receive appropriate training” to do so.19 This recommendation was recently endorsed in
the inaugural Scottish Government 2007 annual report on drug-related deaths.20

12
AJ, Ashworth. (2006) Letter Emergency Naloxone for heroin overdose Beware of Naloxone's other
characteristics BMJ;333:754 (7 October), doi:10.1136/bmj.333.7571.754-a
13
Ibid.
14
Scottish Advisory Committee on Drug Misuse: Working Group on Drug Related Deaths. Report
and Recommendations, Scottish Executive; 2005 (July).
15
McGregor, C, Darke, S, Ali, R and Christie, P (1998) ‘Experience of non-fatal overdose among heroin
users in Adelaide, Australia: circumstances and risk perceptions’, Addiction, Vol. 93, No. 5, pp 701-711
16
Bigg D. Chicago experience with take-home Naloxone. BMJ 2001 (19 October).
17
Sporer KA. Strategies for preventing heroin overdose. BMJ 2003; 326: 442-444 (22 February).
18
Statutory Instrument 2005 No. 1507: The Medicines for Human Use (Prescribing) (Miscellaneous
Amendments) Order 2005, http://www.legislation.gov.uk/si/si2005/20051507.htm#note3
19
Scottish Advisory Committee on Drugs Misuse (SACDM) Working Group On Drug Related Deaths:
Report And Recommendations, Scottish Executive (2005)
20
National Forum on Drug-related Deaths in Scotland Annual Report 2007

7
Against this backdrop of work in other countries, policy recommendations and legislative
changes, two similar THN pilots have recently been set up in Glasgow and Lanarkshire.

The Lanarkshire pilot has been completed and involved 42 recruits (20 staff and 22
‘clients’) and 18 'buddies'. There was a training component to this pilot which involved
sessions covering basic life skills and administering Naloxone. An evaluation report on
the Lanarkshire THN pilot will soon be completed soon.

The remainder of this evaluation report is divided into the following sections:

• Development of the Glasgow Naloxone Programme

• Evaluation Methods
• Findings
• Summary of Findings
• Recommendations

http://www.scotland.gov.uk/Publications/2007/12/17095935/14

8
2. DEVELOPMENT OF THE GLASGOW NALOXONE PROGRAMME

Drug related deaths - existing responses in Glasgow

Since 1996, the wider Greater Glasgow area has consistently had the highest numbers
of drug-related deaths (DRDs) in Scotland.21 A range of responses have been
developed to address these DRD challenges such as overdose prevention initiatives and
increasing uptake of drug treatment programmes.

The latest prescribing figures show that 9,165 people were receiving Methadone in the
newly configured Greater Glasgow area, mostly daily supervised.22 There have also been
prevention initiatives such as campaigns to reduce fatalities during at risk periods, such
as the Festive Holidays and the run up to the New Year. The campaigns have involved
widespread dissemination through drug services of key rings (with prevention advice),
the Scottish Government DVD ‘Going Over: four real stories of overdose’ and staff
offering drug users one-to-one information on overdose risks. Other ongoing initiatives
involve a Scottish Drugs Forum Critical Incidents Training Officer delivering overdose
prevention training to service users and carers.

Despite these responses, evidence suggests a culture of fear (real or perceived) among
drug users that if they telephone 999 for help the police will be in attendance23,24&25
Reducing delays in calling for an ambulance may significantly impact on preventing fatal
overdose, and although it was called to the overdose scene in 82% of cases in Scotland
in 2003, for most victims (81%) it was too late26. Yet, up to seven out of ten drug users
in Glasgow report having witnessed a drug overdose27 and with fatalities occurring
between one to three hours after drug injecting, there is a major opportunity to

21
General Register Office for Scotland, Drug Related Deaths in Scotland 2006, GROS (2007)
22
Scottish Government (2007) Review of Methadone in Drug Treatment: Prescribing Information and
Practice. 23 July. http://www.scotland.gov.uk/Publications/2007/06/22094632/0
23
Bennett, GA and Higgins, DS (1999) ‘Accidental overdose among injecting drug users in Dorset,
UK’, Addiction, Vol. 94, No. 8, pp 1179-1190
24
Pollini, RA, McCall, L, Mehta, SH, Celentano, DD, Vlahov, D and Strathdee, SA (2006) ‘Response to
overdose among injection drug users’, American Journal of Preventative Medicine, Vol. 31, No. 3, pp
261-264;
25
Tobin, KE, Davey, MA and Latkin, CA (2005) ‘Calling emergency medical services during drug
overdose: an examination of individual, social and setting correlates’, Addiction, Vol. 100, No. 3, pp
397-404
26
Scottish Executive. National investigation into drug related deaths in Scotland 2003; 2005 (August).
27
Glasgow City Addiction Planning & Implementation Group, Drug Deaths Monitoring and Prevention
Group: Final Report, 2004.

9
intervene.28

It has been suggested that offering THN to drug users in Glasgow could be useful29 and
although their motivation, ability and responsibility in emergency situations has been
questioned, studies show a high level of willingness to carry out resuscitation.30

Take Home Naloxone – developmental work in Glasgow

In 2006 a THN report was prepared for Glasgow City Addictions Planning
Implementation Subgroup (Monitoring and Prevention of Drug-Related Deaths).31 Key
elements of this report included reviewing THN work carried out in other countries and
examining the possible benefits and drawbacks of introducing a THN pilot in Glasgow.
The report concluded that THN should not be seen as a “cure for all drug related deaths”
but could significantly reduce them by strengthening existing responses such as
overdose prevention campaigns, critical incidents training and substitute drug prescribing
programmes. Following on from this report, a Glasgow THN working group was
established to develop a range of activities, outlined below:

• Undertaking a working group study visit to the Chicago Recovery Alliance

which involved observing their established THN work and producing a post-
study report.32
• Developing a THN training programme framework. Key areas of work
included producing and distributing a range of THN pilot materials such as an
information leaflet and contact details, signs of opiate overdose leaflet, and
what to do if someone is overdosing leaflet. Other materials developed
include a Naloxone ‘injection patient’ form and, most importantly, a
comprehensive instructor’s training manual to delivery the planned training
activities.

28
Sporer KA. Strategies for preventing heroin overdose. BMJ 2003; 326: 442-444 (22 February)
29
Graham C, McNaugton G, Alastair I, Cassells K. Take home Naloxone for opiate addicts. BMJ 2001;
323:934 (20 October).
30
Strang J, Best, Man, Noble and Gossop. Peer initiated overdose resuscitation: fellow drug users could
be mobilised to implement resuscitation; Int. Journal Drug Policy 2000; 11: 437-445.
31
Brand, B. (2006) Exploration of Take Home Naloxone HCl (THN) Administration in Glasgow – a
report prepared on behalf of Glasgow City Addictions Planning Implementation Subgroup on the
Monitoring and Prevention of Drug-Related Deaths.
32
Hill, D., Chicago Study Visit: Chicago Recovery Alliance Report (2006)

10
 • Developing a secure THN box which contained Naloxone Hydrochloride
2mg/2ml for intramuscular injection. (Appendix - photo of secured Naloxone
box)
• Setting up a Glasgow THN research subgroup to oversee and monitor the
ongoing evaluation activity.
• Developing and disseminating a range of promotional materials which
also involved setting up a public access web link outlining the THN
work.33 (See Appendix A for the Glasgow THN working group
membership details)

Take Home Naloxone - Instructor’s Manual

The Take Home Naloxone instructor manual is a comprehensive document that was
pivotal in developing the cascading training activity outlined in the next section.34 The
manual was developed by Dr Samantha Perry (NHS Consultant in Emergency Medicine)
and Graham Mackintosh (Critical Incidents Training Officer) to support all stages of the
training activity. Key training themes contained within the manual were:

Health and Safety and preparation for teaching.

Detailed sections on Naloxone for instructors and trainees (family members and
drug users).

Detailed sections on skills covering Basic Life Support, Recovery Position and
Injecting Naloxone (the emergency life support components were affiliated to the
Heart Start UK Initiative).

Other training areas included evaluation, dealing with difficult participants,
establishing ground rules, checklists and consent forms.

Glasgow Naloxone Training Programme

The Glasgow Naloxone Training Programme (GNP) was funded by Glasgow Addiction
33
http://www.glasgow.gov.uk/en/Residents/Care_Support/Drugs_Alcohol/PharmacyServices/NaloxonePilot
.htm
34
Perry, S. & Mackintosh, G. Glasgow Naloxone Programme – Instructor Manual. (2007)

11
Service (GAS) and began in April 2007.

There were two key, but interlinked, training aims:

• Stage One - to develop a bank of workforce trainers

• Stage Two - to cascade GNP training to the trainees (service users,
friends, carers and family).

Stage One - Training the Trainers (workforce)

The lead training coordinators were the two authors of the Naloxone instructor manual
(Emergency Medicine NHS Consultant and Critical Incidents Training Officer) and a
senior pharmacist from Glasgow Addiction Services. The developed “training-the
trainers” programme lasted for about four hours and covered the main contents of the
Naloxone Instructor’s Manual. In total, 38 workers completed the “training-the trainer”
sessions. They were recruited from a generic workforce involved in addictions such as
nurses, drug workers, pharmacist and prison officers.

A key aim was to strengthen the recruited workforce’s confidence to ensure their
participation in stage two – namely, delivering cascaded sessions to the trainees.

Stage Two - Training the Trainees (service users, friends, carers and family)

This stage was also initiated by the lead training coordinators. However, to promote
wider ownership, the new workforce trainers were encouraged to shadow the
coordinators and share delivery of this training. These training sessions were modified
to last approximately two hours.

A total of 47 sessions were delivered between March 2007 and March 2008 with a total
of 251 trainees completing the two hour sessions.

12
Box 1: Training Flow Chart

Stage 1
Training the Trainers

38 staff

Stage 2
User, Carers & Friends

221 trainees

Distribution of Take-Home-Naloxone (THN)

A recording system was set up when distributing all THN packs. Each participant
received a THN supply after completing their training session. All participants were
informed that a re-supply of the drug would be made available through the Glasgow
Drug Crisis Centre (GDCC) - the venue used for all THN training activity.

Overall, a total of 216 Take-Home-Naloxone packs were distributed to drug users and
family members who completed the training session. The number of service users
receiving THN packs (n 176) is equivalent to 1.6% of Glasgow city’s estimated problem
drug user population.35,36

35
Hay, G., Gannon, M., McKeganey, N., Hutchinson, S. and Goldberg, D. (2005) Estimating the National and Local
Prevalence of Problem Drug Misuse in Scotland. Edinburgh: Information and Statistics Division, Scotland.
36
Glasgow city’s estimated problem drug user population is 11,235. However, the above prevalence study is being
repeated and a report will be published soon.

13
Box 2: Naloxone Provision

Naloxone
216 packs

176 service users 31 family members 9 re-supplies

14
3. EVALUATION METHOD

An evaluation can serve two complementary functions. It can be prospective or

formative. That is, to improve and understand strengths in order to augment them or to
identify weaknesses and gaps in order to repair.37 It can also be retrospective or
summative to assess achievement, strengths/weaknesses and areas of good practice.

This final evaluation has identified areas of good practice and possible challenges of the
programme to ensure that the GNP can be further developed and replicated.

Aims and Objectives

The aim of this evaluation of the GNP pilot was to assess the achievement of the
programme and identify strengths and weaknesses in both the training sessions and the
administration of Naloxone itself.

The objectives, outlined below, were agreed by the GNP steering committee:

• To assess the training sessions in terms of trainees’ overdose knowledge,

retention and confidence.
• To identify individuals’ overdose experience and awareness.
• To identify potential training programme improvements or changes.
• To assess individuals’ use of Naloxone during overdose events.
• To inform any future decisions regarding further GNP service development.

Sample and data collection

Participants in the evaluation were recruited from the following samples:

• The workforce that completed stage one ‘training-the-trainers’ sessions (hereafter

referred to as trainers)

• The trainees that completed stage two training sessions (drug users, carers and
concerned others)

37
An interim evaluation report was submitted to the THN subgroup. This report could be regarded as a formative
evaluation through which the GNP steering group could consider the findings and if deemed necessary adjust the delivery
or objectives of the programme.

15
In order to assess the success of the programme, the evaluation sought to gather the
views of the trainers and trainees who took part in stage one and two training activity.
The data was gathered in two stages.

Data collection - phase one

All trainees were given information sheets and consent forms when they arrived at their
GNP sessions. They were given time to read through them and make an informed
choice as to whether they would take part in the evaluation process. This process of
seeking consent was supported by the trainers.

Baseline data was obtained by asking all trainees to complete a structured self-
completion questionnaire, prior to the start of training. Two separate questionnaires were
distributed among the trainees (drug users and carers). They were invited to leave their
contact details if they wished to participate in follow-up interviews to be undertaken in
stage two (see appendix three for details of the information sheets, consent forms and all
questionnaires).

Data collection - phase two

The second stage involved carrying out 55 follow-up telephone interviews with the clients
and carers at least three months after they had received the training. The aim was to
assess their retention of the overdose information provided during the GNP training
sessions. It also offered an opportunity to seek their views on the sessions thus
providing a feedback opportunity to help improve the programme’s design and delivery.

Follow-up telephone interviews and face-to-face interviews were undertaken among

those study participants that contacted the Glasgow Drug Crisis Centre for a re-supply of
Naloxone.

The 38 workforce trainers were sent a postal questionnaire which sought their views on
the training content, resources and its delivery (see appendix three).

16
4. FINDINGS

The following data analysis represents the findings of 188 GNP participants and 16
trainers. The first section looks at the findings from the pre-Naloxone training sessions;
the second section is an analysis of the follow-up questionnaires and the third section
explores the experiences of the professionals who attended the ‘training the trainer’
sessions.

4.1. Pre-Naloxone Training Sessions

The total number of clients and carers who completed a pre-training questionnaire is
188, 71% clients and 29% carers. Most of the clients (54%) were referred through the
GDCC with the remainder referred from a range of residential and community
rehabilitation projects. Over half the carers were referred through the Glasgow
Association of Family Support Groups (n30, 55%).

4.1.1 Clients Profile

The majority of the clients were male (60%) and the mean age was 34 years (SD=6.9),
range 22 - 57 years. Twenty clients (15%) reported living with opiate users or with non-
opiate users (22%) while the majority lived alone (62%). Twenty-one clients (16%)
reported current illicit opiate use. The majority (96%) said that although not using illicit
opiates at present, they had used in the past. That so few of the client trainees reported
using illicit opiates at the time of training is not surprising as the majority were accessing
residential or community rehabilitation.

Among the clients still using illicit opiates, 16 reported using heroin on a daily basis,
fourteen of whom were injecting. The mean reported time of illicit opiate use was 12
years (SD=6.7), range 1 - 26 years. The main drugs prescribed were methadone (n80,
60%) and Diazepam (n43, 32%).

4.1.2 Recognising and Managing Overdose

The majority of clients (n88, 66%) had witnessed at least one overdose with almost half
(n62, 48%) experiencing a personal overdose. Most of the clients (n78, 61%) reported

17
no previous overdose information or training prior to the Naloxone training session.

The majority (n80, 61%) felt confident they would recognise an opiate overdose. Of
those who felt confident they would recognise an overdose two thirds had witnessed at
least one overdose (n66, 82%) or had overdosed themselves (n45, 60%). Figure 1
summarises the signs and symptoms of an overdose that would cause clients most
concern. Cyanosis, unconsciousness and slow/shallow breathing were signs that would
cause concern to the majority of clients. Signs not symptomatic of an overdose that
would case concern were blood shot eyes, vomiting and fitting.

Figure1. Clients reporting signs and symptoms of overdose that would cause most
concern

Blood shot eyes* 6%

Vomiting* 19%
signs and symptoms

Snoring 27%
Pinned Pupils 27%
Fitting* 31%
Slow/Shallow breathing 68%
Unconscious/can’t be woken 90%
Blue Lips 92%

0% 20% 40% 60% 80% 100%

Percentage

* Signs not symptomatic of an overdose

While the majority of clients were confident they would recognise the signs of an
overdose less than one quarter (n28, 22%) reported they would know how to manage an
overdose. The clients were asked to tick a series of boxes which they considered
appropriate actions to undertake when someone has overdosed. Figure 2 summarises
the client responses.

18
Figure 2. Clients’ overdose interventions
Clients' Overdose interventions

No Action 0%

Give stimulants 2%

Shock person with cold water 10%

Inject saline solution 3%

Slap or shake the person 24%

Walk person round the room 39%

Admit person to hospital 44%

Iinterventions

Give basic life support 44%

Stay with person until they come round 77%

Check pulse 72%

Place person in recovery position 83%

Check breathing 89%

Check airways for obstruction 80%

Stay with person until ambulance arrives 92%

Call an ambulance 99%

0% 20% 40% 60% 80% 100% 120%

Percentage

As can be seen from the list above over half the clients’ listed appropriate responses.
However, the small minority who would shock a person with cold water or inject a saline
solution or stimulants raises concerns regarding some clients’ ability to manage an
overdose correctly without some form of advice or training.

There was a significant association between training status and recognition of certain
signs. Those who had previous overdose training or information were significantly more
likely to recognise the overdose signs of shallow breathing (Phi = -0.279, p<0.01), blue
lips (Phi = -0.204, p<0.01) and snoring (Phi = -0.214, p<0.01).

19
4.2 Family and Friends Profile
The majority of carers were female (n40, 73%). The average age was 52 years (SD=13),
range 16 – 72 years. Most of the carers lived alone (n15, 29%) or with non-opiate users
(24, 46%), while 13 (25%) lived with opiate users (three responses were missing).

4.2.1 Recognising and Managing Overdose

Twenty (36%) carers had witnessed at least one overdose and 40% (n22) reported
having had previous overdose training/information. Just over half of carers said they
were confident they would recognise an overdose (n28, 51%).

Figure 3 shows the overdose signs which would give carers most concern. Similar to the
clients the three main signs to cause concern were unconsciousness, cyanosis and
slow/shallow breathing.

Figure 3. Carers reporting signs and symptoms of overdose that would cause most
concern

Blood shot eyes* 7%

Snoring 29%
Pinned Pupils 29%
Vomiting* 34%
Fitting* 42%
Slow/Shallow breathing 60%
Blue Lips 85%
Unconscious/can’t be woken 91%

0% 20% 40% 60% 80% 100%

Percentage

* Signs not symptomatic of an overdose

The carers were asked if they would know how to manage an opiate overdose; six (11%)
people said they would, fifteen (27%) said ‘maybe’ but almost two thirds (n34, 62%) said
they would not. Figure 4 shows the interventions carers reported they would take. The
responses were not dissimilar to the clients in relation to applying appropriate
interventions though clients were more likely to report walking a casualty about, slap or
shake a person, or shock a casualty with cold water.

20
Figure 4. Carers’ overdose interventions
Carers Overdose Interventions

No Action 2%

Give stimulants 2%

Shock person with cold water 2%

Inject saline solution 4%

Slap or shake the person 11%

Walk person round the room 14%

Admit person to hospital 38%

Interventions

Give basic life support 44%

Stay with person until they come round 56%

Check pulse 60%

Place person in recovery position 82%

Check breathing 84%

Check airways for obstruction 87%

Stay with person until ambulance arrives 91%

Call an ambulance 98%

0% 20% 40% 60% 80% 100% 120%

Percentage

4.3 Comparing clients and carers’ Overdose Awareness

A comparative analysis of the carers and clients reveals some interesting results that
may prove useful for future planning and design of overdose training programmes for
different target groups.

There was a significant association between training status (clients and carers) and
several of the actions taken in an overdose situation. Those receiving
training/information were more likely to stay with the person (Phi = -0.140, p<0.05), to
place them in the recovery position (Phi = -0.235, p<0.01), to check their airways (Phi = -
0.259, p<0.01), to check their breathing (Phi = -0.218, p<0.01), give BLS (Phi = -0.162,
p<0.05) and check their pulse (Phi = -0.200, p<0.01).

21
When analysing client responses only, significant associations were found between
training status and specific items relating to managing an overdose. Those with no
training were more likely to walk the person round the room (Phi = 0.233, p<0.01), slap
or shake the person (Phi = 0.215, p<0.05) and shock with cold water (Phi = 0.204,
p<0.05). While those clients with training were more likely to place in the recovery
position (Phi = -0.207, p<0.05).

Figure 5. Comparing clients and carers overdose signs

7%
Blood shot eyes* 6%

Snoring 29%
27%

29%
Pinned Pupils 27%
signs & symptoms

Vomiting* 34%
19% Carers (n55)
42% Drug Users (n133)
Fitting* 31%

Slow/Shallow 60%
breathing 69%

85%
Blue Lips 92%

Unconscious/can’t be 91%
woken up 90%

0% 20% 40% 60% 80% 100%

Percentage

Clients were more likely than carers to stay with someone (Phi = -0.203, p<0.01) yet
were also more likely to engage in inappropriate interventions such as walking an
overdose casualty around the room (Phi = -0.240, p<0.01), shocking a casualty with cold
water (Phi = -0.146, p<0.05) and slapping or shaking them (Phi = -0.149, p<0.05). The
majority of trainees report that they would call an ambulance, stay with someone until
the ambulance arrived and place them in the recovery position and check their breathing
and airways for obstructions. However caution should be used when interpreting how
these findings would translate to real-life overdose events as almost one quarter (24%)
of those who have witnessed an overdose did not call an ambulance at the most recent
overdose event.

22
There were significant associations between training status and behaviour. A higher
proportion of trainees receiving overdose training/information reported they would check
breathing, place someone in the recovery position (Phi = 0.249, p<0.01), check airways
(Phi = -0.180, p<0.01) and give basic life (Phi = -0.214, p<0.01) support than those who
had not. Furthermore a higher proportion of those who had not received overdose
information and training would engage in unsuitable interventions such as walking
someone round the room (Phi = 0.226, p<0.01) or slapping or shaking a person (Phi =
0.238, p<0.01), or shocking a casualty with cold water (Phi = 0.155, p<0.05).

The people who had received overdose training/information prior to the last witnessed
overdose were more likely to have checked airways, checked breathing, checked pulse
and placed casualty in the recovery position and less likely to walk the casualty around
the room. Of those who had witnessed an overdose, there were no significant
relationships between status (client/carer) and interventions adopted. Those who had
witnessed an overdose were more likely to call an ambulance (Phi = -0.756, p<0.01),
stay with the casualty (Phi = -0.649, p<0.01), check airways (Phi = -0.543, p<0.01),
place the casualty in the recovery position (Phi = -0.549, p<0.01) and check breathing
(Phi = -0.662, p<0.01). However, and perhaps of interest, they were also more likely to
walk a casualty around room (Phi = -0.402, p<0.01)

Although this is a small sub-sample initial indicators suggests the provision of overdose
training and information helps drug users and carers respond more appropriately in
overdose situations.

4.4 Follow-Up Interviews

The trainees were asked to leave contact details for follow-up interviews in order to
gather their views on the training sessions and, if subsequently used, their experience of
administering Naloxone. Fifty-five follow-up questionnaires with 40 clients and 15 carers
were completed.

The majority (n43, 78%) of follow-up trainees live alone or with non-opiate users. Seven

23
clients and five carers were living with opiate users.

Four clients who reported using opiates at the time of the follow-up were asked ‘how has
the Naloxone programme affected your drug use?’ One current opiate user said he was
using ‘fewer drugs’; three said there was no change in their use although one said he
was ‘more aware of the dangers’. Eleven trainees stated they were in recovery at the
time of training and had remained drug-free since the GNP training. However one ex-
user said, ‘I felt that the Naloxone training was a possible trigger especially as I was
going from rehab to West Street [GDCC] and getting the needle put in [my] hand.’

Another client, who had received training and Naloxone, had an opiate overdose one
month after leaving residential rehabilitation. He used heroin, methadone and alcohol
while alone. He was found by members of his family who were not aware he had
Naloxone in the house. Trainees should be encouraged to tell friends or family that they
have Naloxone, where it is kept and what it is used for.

4.4.1 Naloxone Training

The overwhelming response to the training was positive with the majority of trainees
(92%) rating the Naloxone training ‘very useful’; five trainees rated it ‘quite useful’. No-
one rated it negatively.

Asked what they thought was the ‘most useful part of the training’; ten (17%) people said
all training was useful. Specifically though the trainees mentioned:

• Cardio Pulmonary Resuscitation (CPR)/first aid (n36, 60%)

• How to use Naloxone (n30, 50%)
• Explaining about myths/inappropriate responses e.g. walking people around
(n8, 13%)

Trainees also stated they found the practical exercises useful (e.g. CPR on the
dummies) and said the training was well presented and ‘easy to understand’. One
trainee said it was useful to ‘see the practical side of bringing somebody around and
seeing it visually. I’ve seen overdoses in the past and done the wrong things like

24
dumping them outside a hospital.’ One person who had a ‘needle phobia’ and reported
using Naloxone said: ‘the training helped me administer it. I thought about the orange
when I used it.’

The trainees were asked what they thought was ‘least useful part of the training’. The
response was largely positive but nine people expressed some criticisms. These related
to

• Practicing using the Naloxone (which involved injecting Naloxone into an

orange):
o “Getting the syringe put in hand can act as a trigger. It was totally
unexpected by the clients and staff”
o “Injecting the orange - just didn't see the point as I know how to
inject and thought there would have been a more advanced
method to practice on.”
o “Injecting the orange personally because I never used needles.”
o “Could have been spread out over a couple of sessions. And
putting in so much/measuring out Naloxone concerned me. I
thought why don't we just give them one shot. Would need my
glasses so it could be difficult to measure if you were in a panic.”

• The interactive first aid training

o “Didn't like the play acting but that's me”
o “Bit wary about mouth - mouth. Would do it for my son but would I
do it for a stranger. Would be wary.”

• Reiterating trainees knowledge

o “I could probably have done without CPR but only because I’ve done it a
couple of times”
o “Being told the signs coz I’m pretty knowledgeable about that anyway”
o “It was a wee bit uninteresting. There was a lot of people falling asleep so
it could be a bit more stimulating, more interactive at first part. That bit
dragged on a bit – boring.”
o “When we were told to call for an ambulance as it is just common sense

25
 although I understand why they went over it. But I wouldn't call an
ambulance unless the person did not come round after Naloxone injection
because of the police.”

There were no other criticisms and people took the opportunity to reiterate how well they
thought the sessions were presented.

4.4.2 Training Venue

The majority of trainees (n56, 95%) thought the GDCC was either a ‘very’ or ‘quite’
convenient venue for training. Two carers and one worker thought it ‘not at all’
convenient.

Twenty-three trainees felt it was convenient due to its proximity to public transport links
(buses and underground) and the motorway and because of its location which is close to
the city centre.

However when asked if there were any barriers to attending the GDCC for training
twelve user trainees had some reservations. These were:

• GDCC staff
• Going into GDCC could act as trigger to use
• Time it takes to get there from certain parts of the city
• Cost of travelling to GDCC from other parts of the city
• Some users not aware of GDCC
• Stigma of attending GDCC

Two user trainees stated that users may be wary of attending the GDCC for Naloxone
training if they were still using drugs as quoted below.

• “Could be if you're using and wanting Naloxone “

• “Maybe people still chaotic & using needle exchange might think it a
barrier with staff recognising them”

26
Any future training should be targeted at people still using opiates as well as those in
recovery and the trainers should assure clients receiving training that there will be no
penalty to them attending Naloxone training. This message would need to be
emphasised wherever training was held as this could be a potentially serious barrier to
attending such training. Further consideration should be given to potential travel costs
incurred by trainees which might be ameliorated by training being delivered locally.

Carers and workers had quite different reservations. These were:

• Feeling unsafe (particularly at night)

• Transport to GDCC difficult
• Training organisers need to consider issues of childcare for kinship carers
• Clients wary about meeting up with ex-acquaintances or rivals
• Some agencies may be wary of sending recovering drug users to a venue where
active drug users are present

Alternative Training Venues

Despite people rating the GDCC highly in terms of convenience, trainees did provide
suggestions for alternative training venues. In particular trainees thought training should
be more localised and targeting venues or areas where drug users and drug use is
prevalent. The trainees offered the following suggestions

• Services for drug users e.g. CATs, Methadone clinics, community and residential
rehabilitation units and needle exchanges (n21)
• Local venues e.g. community halls and medical centres (n16)
• City centre (n13)
• Areas where drug use is high (n9)
• Services for homeless drug users e.g. hostels, drop-in centres, Big Issue offices
(n7)

4.4.3 Naloxone Supply Venues

The majority of follow-up trainees (90%, n54) considered the Glasgow Drug Crisis
Centre (GDCC) ‘very’ or ‘quite’ convenient for re-supplies of Naloxone. Four people
thought it ‘not at all convenient’. The main barrier to accessing re-supplies was the

27
distance and transport to GDCC (n10).

Naloxone training in local areas may help improve participation rates and assist those
who may find it difficult to access the GDCC or centre of Glasgow due to transport
difficulties or the cost of travelling from the outskirts of the city.

Alternative Supply Venues

Alternative venues for re-supply of Naloxone that were suggested were

• Pharmacies/Needle Exchanges (n25)

• Local drug projects/health centres/GP surgeries (n24)
• GDCC (n13)
• Services for homeless drug users e.g. hostels, drop-in centres, Big Issue
offices (n5)
• Police stations (n3)

One carer said “Somewhere local and where there's support and someone to talk to
because it can be a harrowing experience and it would be good to have someone to talk
to.”

Twenty-one follow-up trainees thought it ‘very important’ that Naloxone is made available
to drug users and their families. One carer thought it ‘quite important’ and one response
was missing.

Two user trainees mentioned that diabetic pens would be better than the current
Naloxone pack as they are less likely to be used as tools for heroin use.

Further comments related to the usefulness of the training and that it should be made
more widely available to drug users and their families both within Glasgow and across
Scotland.

• Found it very enlightening and gives people a lot of confidence because it can be
a very frightening situation. We really need this training for addicts and their
families

28
 • Hope to see it rolled out across Scotland. Why should one mum from Glasgow
be any different from one in Aberdeen

• I believe that Naloxone training would be beneficial to people who are due to be
released from prison as a lot of drug overdoses and deaths occur on people's
release from prison due to their low tolerance

• I think it is the best thing since sliced bread. I can't see how it would fail to save
lives if it was completely rolled out. Also the training would make drug users more
aware at an earlier stage what they should be concerned about

Consideration should be giving to improving publicity for any future Naloxone training.
Five user trainees specifically mentioned the lack of publicity regarding Naloxone
training and the clarity of the posters that are available was another concern.

4.4.4 Clients and carers disseminating GNP training

There has been a small level of dissemination of the training from those who have
attended the GNP. Nine clients and two carers said they have trained other people to
use Naloxone – the carers had shown their adult children and the clients had shown
associates/friends/partners and carers. Two people who reported using Naloxone
provided an explanation to of what they were using to the other witnesses present:

• “Showed girlfriend of boy I used it on.”

• “Explained to people what I had used but don't know whether they thought
of it as a 'get out' for them or whether they were interested in Naloxone
themselves.”

The latter statement may pose a future question requiring attention: To what extent might
Naloxone play in encouraging riskier behaviour among sub groups of opiate users?

29
4.4.5 Naloxone Storage
The user trainees kept their Naloxone in various places

• Bedroom
• Fridge
• Locked cupboard
• High Cupboard
• Handbag/Rucksack
• Friends house
• Car
• Office at hostel

Ten trainees (25%) stated they carry their Naloxone with them when they go out and one
person said they had shown friends where it is kept. Three trainees specifically
mentioned keeping their Naloxone out of the reach of children.

A higher proportion (35%) of family/friends and workers carry their Naloxone with them.
Among these trainees, Naloxone was kept in

• Handbag
• Cupboard in house
• House
• Car

The majority of follow-up trainees (80%, n48) had no concerns regarding storing or
carrying their Naloxone: concerns that were expressed related to the yellow box being
large and conspicuous (n3) and the police (n2). Two people were not sure about the
efficacy of refrigerating their Naloxone and one person was not clear on the expiry date
and how long the supply of Naloxone would be effective for.

As noted previously one person had concerns about drug users abusing supplies of
Naloxone and he repeated his concerns at this question:

30
 • “Users might rely on it so they can go to the limit but I think this would be
in the minority rather than the majority.”

A second recovering drug user expressed concern regarding the provision of the syringe
and needles.

• “Set of tools could be a temptation to use, would prefer something like a

diabetic pen”

The issue of needles in the Naloxone pack was raised by another user. This trainee
reported knowing people who had used the needles provided in the box for injecting illicit
drugs. Suggestions put forward by a small number of trainees was the provision of
Naloxone in tools similar to the diabetic EpiPen® as these would be less likely to be
used as tools for heroin use.

4.4.6 Comparing responses to recognising and managing overdose events: pre

and post-training
The trainees reported increased confidence in recognising an opiate overdose following
GNP training as shown in Figure 6. Five people reported not feeling confident post GNP
training. However when asked which signs indicating an overdose would give them most
concern they mentioned shallow breathing, lips changing colour, eyes pinned and
needles lying about. This suggests that although not confident they still retain the basic
knowledge of signs and symptoms taught them during training.

Figure 6. Confidence: pre and post-training

Do you feel confident you would recognise an opiate
overdose?

100% 90%

80% 68%

60% Pre GNP Training

40% Post GNP Training
21%
20% 11%
4% 6%
0%
Yes No Maybe

31
The three signs that would give the trainees most concern were blue lips,
unconsciousness and slow/shallow breathing. Fewer trainees post training identified
fitting, and vomiting as signs of overdose and no-one reported blood shot eyes.

Trainees were more likely to report knowing how to manage an overdose following the
GNP training (p<0.001). No trainee reported being unable to manage an overdose as
seen in figure 7.

Figure 7. Overdose management: pre and post-training

Do you know how to manage an opiate overdose

100% 94%
90%
80%
70%
60%
47% Pre GNP Training
50%
36% Post GNP Training
40%
30%
17%
20%
6%
10% 0
0%
Yes No Maybe

Following GNP training no-one reported managing a casualty with inappropriate

interventions such as injecting a casualty with stimulants, shocking them with cold water,
walking the casualty round the room or taking no action at all. The top three interventions
trainees would use were call an ambulance, use Naloxone and place the person in the
recovery position.

The question on managing an overdose was open-ended thus allowing the trainees the
opportunity to talk through potential overdose management. Trainees retained a good
level of knowledge in relation to CPR, placing a casualty in the recovery position and
administering Naloxone:

• ‘Try chest compressions 30 compressions three times. Put them in the recovery
position and inject Naloxone. If it didn’t work I would repeat the compressions
and injection. Would ring an ambulance first thing before I did anything.’

32
 • ‘I would go through what I was taught. 30 compressions and mouth to mouth.
Use Naloxone if they don't come round and repeat. Put in recovery position, call
an ambulance. I always carry around instructions and Naloxone. Just in case I
panic I would do exactly what it tells me on the paper.’

In addition almost half the trainees (45%) reported they would try to get a response from
the casualty before attempting first aid and administering Naloxone.

• ‘CPR and hope I had Naloxone with me. Put them in an upright position while
waiting for an ambulance. But I would talk to them and see if they are able to
respond because if they can respond it’s not an overdose.’

Only three trainees did not say they would call an ambulance. One stated ‘if Naloxone
did work though I wouldn't ring an ambulance because they wouldn't be in an overdose.’

The findings from this sample indicate a significant improvement on the GNP
participants’ previous knowledge and confidence regarding overdoses and suggest that
the key messages of the THN training are being retained by the trainees and they have
the knowledge to put into practice what they have learnt at the training sessions.

A 26 year old male reported overdosing on opiates two months after attending residential
rehabilitation and receiving the Naloxone pack and training. He stated it was the first
time he had used heroin after attending the unit. He was on methadone and had been
drinking alcohol. He injected heroin whilst alone in his family home. According to the
trainee, his sister and her boyfriend managed to break into the bathroom where he had
injected and overdosed, dialled 999 and put him in the recovery position. The police
arrived first, followed by the emergency services who got him into the living room and
gave him Naloxone. The trainee had not informed anyone in his family that he had
Naloxone although he has since told his sister who may access training at GDCC. This
same trainee later informed staff at GDCC that he had also used Naloxone to revive
someone who had overdosed.

33
Trainees should be encouraged to tell friends or family that they have Naloxone, where it
is kept and what it is used for.

4.5 Reported Uses of Naloxone

There have been 12 reported uses of Naloxone up to March 2008 but only 11 cases
were recorded which represents 5% of the total trainee sample. Table 1 overleaf
provides a detailed overview of all recorded cases and includes data on age, gender,
overdose signs, perceived causes, actions, outcomes and verification.

The following analysis and accounts relate to ten of the reported Naloxone events. One
account (case 2 overleaf) has been removed from the final analysis as there was
considerable doubt as to the reliability of the account. One of the main challenges for
research or evaluation of Naloxone pilots will be the ability to verify witness accounts of
Naloxone use.

Case 7 (in table overleaf) was atypical as it involved two opiate overdoses occurring
simultaneously.

34
 Case Signs Perceived Actions Naloxone Ambulance called Outcom Verification
cause injection e
1 Male Unconscious could Poly-drug use: Basic Life Support Trainee (male No Survived Worker at
Age: not be roused. alcohol, and recovery user) gave 0.4 GDDC.
early diazepam and Position. mg - twice. Fear of putting
30s heroin. residency at risk Research
Recipient: not but made friend unable to
part of the study. stay overnight. establish
follow-up
2 Male “Just gone blue.” Using ‘pure’ Heart compressions Trainee (male No Survived Worker at
Age: heroin that had and mouth-to-mouth user) gave Claims house was GDDC.
32 not been cut. 0.4mg. raided by police.*
Telephone
Recipient: not research
part of the study. interview.
3 Male Lying on ground Poly-drug use: Cardio-pulmonary GDDC nurse Yes Survived Worker at
Age: outside agency - alcohol, resuscitation. Put in gave 0.4mg – Service user left GDDC
30s could not be diazepam and recovery position. five times. the premises and
roused. heroin. the ambulance was
Recipient: not cancelled.
part of the study.
4 Female Unconscious Known heroin GDDC staff gave Yes Survived Two GDCC
Age: and diazepam 0.4mg. Cancelled as staff members
23 user. person did not
Recipient: not want it to attend
part of the study.
5 Male Unconscious could Known heroin Checked `breathing Trainee (male No Survived Not verified
Age: not be roused. and diazepam and pulse. Placed user) gave Fear of
NK Breathing ‘bad’ and user. in recovery position. 0.4mg. jeopardising hostel
skin turning blue. place
Recipient: not
part of the study.
6 Male Could not be Consumed Cardio-pulmonary Trainee (male Yes. Survived Third Party
Age: roused – face was alcohol and resuscitation and user) gave
29 ‘cold and damp’. shared three mouth-to-mouth. 0.4mg. Verified
£10 bags of
heroin. Recipient: not
part of the study.

35
 Case Signs Perceived cause Actions Naloxone Ambulance called Outcome Verification
injection
Male Unconscious but Not known – two Checked breathing - Not given Yes. Survived
Age: breathing. overdose put in recovery naloxone: Verified by
20 casualties found position ambulance Grampian
together (nearby arrived. Police
pub lane). Recipient: not
part of the study.
Male Stopped breathing See above. Checked breathing - Trainee (female Yes Died:
7 Age: – blue extremities. chest compressions user) asked Deceased
22 and mouth-to- friend to give 0.4 before
mouth.* mg. naloxone
Recipient: not injection.
part of the study.
8 Male Unresponsive and Part of a group of Cardio-pulmonary Trainee (male No Survived Not verified
Age: “went a funny three people resuscitation user) gave Person came round
32 colour” injecting heroin. 0.4mg - twice. after few minutes and
Recipient: not did not want police
part of the study. involved.
9 Male Lips going blue Long term heroin Checked breathing, Trainee (male No Survived Not verified
Age: and unresponsive. user – ‘shooting heart rate. Put in user) gave Did not want police
38 - 40 gallery’ of five recovery position. 0.4mg - twice. involved - stayed with
people. Recipient: not casualty for 4 hours.
part of the study.
10 Male He “went over”. Injected two bags Tried to get a Trainee (male No Survived Not verified
Age: Eyes rolling and of £10 heroin. response user) gave Came round within
36 changing colour. Took Methadone 0.4mg. three to four minutes.
60mg. Recent Recipient: not Stayed with him all
prison release. part of the study. night – casualty was
trainee’s brother.
11 Male Telephone call Known occasional Put in recovery Trainee (male No Survived Not verified
Age: from casualty’s heroin injector position and ensured user) gave Casualty did not want
40 partner – trainee airways were clear. 0.4mg. one (children in the
advised to check Recipient: not house)
breathing. part of the study.

36
4.5.1 Overdose Casualties
Nine overdose casualties were male and one was female: ages ranged from early 20s to 40s.
Seven of the overdoses happened in a private space (houses and hostel) and three occurred in
a public space. The trainees ascribed the overdoses to low tolerance, chaotic drug use, poor
physical health, homeless and roofless and mixing alcohol and drugs.

It is worth noting that all overdose casualties who were administered naloxone had not taken part
in the GNP training and none of the trainees who administered the Naloxone reported that the
casualty wanted naloxone training.

4.5.2 Overdose Responses

In all ten cases the trainees tried to get a response from the casualty; in seven cases they
reported checking airways and breathing; seven overdose casualties were placed in the recovery
position and four people tried CPR before administering Naloxone. Eight of the trainees
administered the Naloxone themselves. In one event the trainee asked the GDCC nurse to
administer the Naloxone injection (this nurse has now administered Naloxone twice since
participating in the GNP training). At another event the trainee asked their friend to administer the
injection while they attended to a second overdose casualty.

The injections were administered appropriately into the leg/upper thigh. In seven cases only one
Naloxone injection was given; three trainees repeated the injection. No-one reported any
complications or adverse effects arising from the Naloxone injections.

The ambulance was initially called in four cases though two were cancelled when the overdose
casualties were revived. Six people did not call an ambulance for the following reasons:

• Did not want police attending

• Recovered and trainee stayed with overdose casualty
• Overdose casualty did not want ambulance attending (children in the house)
• Tenancy issues (occurred in supported accommodation and overdose casualty and
trainee did not want to risk potential eviction)

The two events at which the ambulances were cancelled occurred at the GDCC. The

37
ambulances were cancelled when the casualties recovered - one left the scene and the second
did not want an ambulance to attend but stayed under observation for two and half hours. This
person was admitted to a residential unit the next day.

There were no issues with the paramedics or police regarding the possession and use of
Naloxone at the incidents attended.

Eight trainees said they felt confident administering the Naloxone and that the Naloxone was
‘very easy’ to administer. One trainee who had previously talked about a needle phobia said of
the incident at which he administered naloxone:

• “I didn't think about it. Automatic reaction. But I did start panicking afterward because of
needle phobia.”

One said she felt ‘not at all confident’ and asked her friend (who had not been trained) to
administer the Naloxone while she attended to another casualty who was unconscious and
required attention.

The trainees stated that the GNP training they had received had been useful in helping them
manage the overdose situation and none required additional training on using Naloxone.

Two current drug users who administered Naloxone said

• ‘I feel very fortunate to have had the training and to have had Naloxone.’
• ‘Very grateful I took the course. Would never forget how to use it now I’ve used it. I owe
them my brother's life. One of the best courses I’ve took. Need to go to hostels as a main
priority.’

Only five out of the 10 trainees who used their Naloxone returned to the GDCC for a resupply.
When asked why they did not seek a resupply, the others reported the following:

• “Not had time yet”

• “Not usually in the company of injectors so don't feel the necessity. Just binned the box
once it was used. I probably will go back but don't need the other box.”

38
 • “Don't know. Didn't know how to get it replaced. Even though I’d used and had it used on
me didn't think about it but that's the frame of mind I was in when using. Thought you had
to have a serial number or identifier.”

• “Because I still have three units and a clean spike left. I'll go once I use this spike.”

Albeit a small sample, it is of some concern that trainees are not clear on the process of
replacing the Naloxone e.g. not clear whether they need to return the used box or whether they
should know their identity number. Furthermore the last comment raises some concern as
trainees are explicitly told they should replace their pack if they have used any of the Naloxone in
the syringe to avoid any risk of blood borne virus cross infection from used needle and syringes.

4.6 Training the Trainers

Thirty-eight professionals were recruited to the GNP with the aim of training them to deliver
Naloxone training to drug users and family members at the GDCC. Potential trainers were
recruited through the GNP steering group partners and via a general email to all primary and
secondary level addiction services e.g. pharmacists, nursing and social care staff. Staff who
volunteered for the ‘training the trainer’ sessions were not required to have had any training
delivery experience but they were expected to have an interest in addiction issues. They were
given a GNP Instructor Manual which outlined the instructor training programme, the participants’
programme and three key training areas - Basic Life Support, Recovery Position and Injecting
Naloxone.

There was a particular requirement to recruit pharmacists and nurses to the GNP as a person
who can supply Naloxone through the Patient Group Directive (PGD) is required for every GNP
training session. An additional training component specifically related to the PGD was given to
the pharmacists and nurses who took part in the GNP.

Those that attended the ‘training the trainer’ sessions were asked to complete and return a
postal questionnaire in February 2008. An email reminder with the questionnaire attached was
sent two weeks later. The response rate was 42%, with 16 questionnaires returned.

39
The professional breakdown of the 16 trainers returning questionnaires is:

 Nurse Practitioner n5
 Drugs Worker n4
 Prison worker n3
 Pharmacist n1
 Volunteer (GAFSG) n1
 Project Worker n1
 Medical student n1

The trainers’ experience of working in the drug field ranged from less than one year to over five
years; the majority (n9) had worked in the drugs field for more than five years. The majority
worked with less than 20 clients, although one drug worker currently works with between 41 - 60
clients.

While all agreed the training was both interesting and informative, two prison workers disagreed
with the statement that ‘the training is useful/relevant for [their] work in the drugs field’. One
trainer was ’unsure’ of its relevance to his work. The remaining 11 trainers agreed that the
training was relevant to their work.

The overall response to the presentation and delivery of the training was also positive and the
training manual which was provided to all those who attended was rated satisfactory to very
good.

Seven people commented positively on the training with one person noting a ‘good balance
between theory and practice.’ The ’mirroring exercise’ used to demonstrate how to inject
Naloxone was also deemed ‘useful and an easy way to remember how to administer Naloxone.’
A drugs worker noted that in their ‘opinion’ they would ‘make the training compulsory for all drug
and related workers.’

Five trainers offered further suggestions for additions or changes to future ‘training the trainer’
sessions:

 Ensure that there is the right mix of professions and staff for each locality

40
  From my personal point of view, different training times as very few of the sessions were
amenable to my timetable with work and university. More evening classes would have
been helpful. I'm confident that some families might benefit from more training sessions in
the evenings otherwise I wouldn't even mention it

 It would be good to change the training room as training room 1 at the crisis centre can
get rather hot at times because the sun shines in along a bank of windows

 There was not enough follow-up after initial training. I felt that nobody knew what we had
to do next; after training for trainers there was a void, and it still remains that way

 I haven’t been in a position where I can use it to actually train people. Some kind of
update would be useful

In terms of the trainers delivering Naloxone training sessions, the majority were satisfied with the
instructors’ manual and agreed they would be able to co-facilitate any future sessions. However,
the majority of trainers agree that a refresher training session would help them to deliver any
Naloxone training. Despite the apparent desire for a refresher course slightly more than a third
was unsure that it would be helpful to have contact with other professionals using the training
materials.

Seven trainers have co-facilitated Naloxone training at the GDCC, and five of these said they felt
confident delivering the training; a drug worker and nurse practitioner were unsure how confident
they felt. The eight remaining trainers were asked what had prevented them from delivering
Naloxone training at the GDCC: Two drug workers and a project worker said they had not been
asked to deliver training - one added ‘also management deem covering shifts more important.’
Four nurse practitioners cited caseloads and work commitments - with one adding that a
refresher course would be needed for them to deliver training and two said training times were
not conducive to their working hours: Naloxone training sessions have been primarily delivered
weekday afternoons.

Eleven professionals said they would be willing to deliver Naloxone training within their own
place of work; one nurse practitioner said it would provide ‘local access to more service users’

41
and a second would be able to provide training to both their residential and day service clients.
The three prison workers would not be willing to deliver training in their place of work, one stated
it was not ‘currently a priority in [their] area’ although a second prison worker said they would
deliver the training for other trainers to deliver. A fourth trainer stated his place of work was not
appropriate for delivering training to drug users or family members.

Six people said the training had a positive impact on their work. One said it had improved their
confidence in discussing overdose with clients while two said it had changed their outlook
regarding drug users:

 “I hadn't worked with drug users prior to this and I definitely have a more positive outlook
on their situation than I did before”
 “Working with service users on the Naloxone pilot has helped me retain a proper
perspective as it means I am getting a chance to work across the board with young
people, families and those struggling with addiction.”

Participation in the ‘training the trainers’ sessions had helped increase one nurse practitioner’s
awareness of overdose prevention and a second nurse was ‘making clients aware of the training
available to them.’ A drug worker who had facilitated a session stated:

• ’I have had the experience of being able to facilitate the practice in a live situation, and it
is a pretty fantastic feeling knowing that the persons who received the benefits of my
training are still alive.’

Final comments suggested the training was positively viewed and two people suggested
Naloxone training should be extended to other geographical areas. However one person pointed
out that if the programme is to continue there needs to be an improvement in the coordination of
the project. This trainer thought there was a ‘lack of leadership’ and that people were not clear
about their ’responsibilities.’

The trainers who participated in the ‘training the trainer’ sessions were on the whole relatively
positive about their experience and some have even stated that participating in the programme
has helped them in their own work situations. Nevertheless the responses do highlight a number
of gaps in the provision of the GNP to date.

42
The overall response to the ‘training the trainers’ sessions has been positive. The knock-on effect
of delivering training to drug users and carers has had a positive impact on the participants own
work practice. It would be useful to offer refresher training courses that may help involve trainers
who have disengaged from the GNP. A coordinated approach is required that takes advantage of
the number of trainers who may be willing to deliver training either in their own services or at the
GDCC.

Re-engaging with those who have already undertaken the ‘training the trainer’ sessions should
be encouraged to assess the numbers who would be willing to deliver training, sites at which
they could provide training and at times that would suit them.

43
5. SUMMARY OF FINDINGS
A number of important points were highlighted in this evaluation study. The key areas identified
were the impact of the training on clients and carers, recorded Naloxone use, training delivery
issues and feedback from trained staff (‘training the trainers’).

5.1 GNP Training impact on clients and carers

• The majority of drug users (n78, 61%) reported not receiving any overdose information or
training prior to this evaluation study. This suggests a significant gap which may require
further attention. On a positive note, the GNP training is reaching a key group of users
and family members who have not otherwise had previous access to overdose
information or training.

• Initial indicators suggest that overdose prevention training and information helps drug
users and family members respond more appropriately and avoid harmful interventions.
Following training, the sample of clients and carers reported feeling more confident in
recognising and managing overdose situations. Furthermore, they reported being
significantly less likely to engage in inappropriate responses and more likely to use taught
basic life support skills such as CPR, mouth to mouth and the recovery position.

• Prior to training, the majority of clients and carers stated that they would call an
ambulance in the event of an overdose. However, almost 1 in 4 of the baseline sample
had not called an ambulance at the last witnessed overdose. Furthermore, the majority
that used Naloxone did not call an ambulance.

• The overall response to the GNP training has been extremely positive in particular the
practical life support skills and being taught how to administer naloxone.

5.2 Naloxone Use

• There were 11 recorded uses of Naloxone since the beginning of the GNP with 10
successful reversals. There was one death which predeceased naloxone intervention.

• Trainees who reported using their Naloxone all carried out the life support skills taught to
them in the GNP sessions e.g. CPR, managed breathing and placed in recovery position.

44
 • The majority reported feeling confident using the Naloxone and found it easy to
administer.

• Emergency ambulance support was not called for in six instances of reported Naloxone
use, despite being a key training message. However, the trainees did stay with the
overdose casualties to ensure they did not use opiates again or fall into a secondary
overdose.

• It is worth noting that all recipients of Naloxone had not been a) prescribed the drug or b)
undergone the training. None of the casualties expressed an interest in attending the
GNP training. This may require future attention if GNP developments are being
considered.

• Accessing Naloxone supplies at the GDCC was considered convenient for most, although
a minority suggested resupply through local venues such as local drug projects or
pharmacists.

5.3 GNP training delivery

• While the clients and carers were largely satisfied with the GDCC as a convenient and
accessible venue for training, some suggested providing GNP training in local areas
would increase uptake.

• To strengthen future GNP recruitment, a small number of trainees suggested increasing

advertising and targeting at risk people particularly homeless drug users and areas with
high drug use prevalence.

5.4 GNP Training the Trainers

• The overall response from the staff who participated in the ‘training the trainers’ sessions
was positive and the resources provided were well received.

• A small strategic criticism worth noting was the reported absence of communication with
new trainers to take part in delivering sessions to clients and family members at the
GDCC.

45
• There was a willingness among the new trainers to deliver GNP training to clients within
their own services or as a training package to staff.

• Providing these training sessions has also had a positive impact on the work of the
trainers e.g. raising their own overdose awareness.

46
6. Discussion and Recommendations

A significant level of work has been carried out to support the Glasgow Naloxone Programme
(GNP) pilot: from the initial discussion paper, to the establishment of the working group and
subsequent development of the training programme. The authors of this GNP evaluation
endorse the conclusions from the discussion paper which noted that Take-Home-Naloxone
should not be seen as a “cure for all drug related deaths” but can play a significant role within
current responses such as prevention campaigns, training and opiate substitute prescribing
programmes.

Developing this GNP work may require a range of strategic responses, at a local and national
level. The next challenge will be to move beyond the pilot stage to ensure that it becomes part of
the mainstream policy responses aimed at reducing Greater Glasgow’s high levels of drug-
related deaths.

The drug users that took part in this evaluation represent 1.6 % of Glasgow city’s estimated
38,39
11,235 problem drug users. If the reported Naloxone use (5%) in this evaluation was
repeated among this wider population, then this would amount to 562 uses which may involve
dispensing at least 12,000 Take-Home-Naloxone (THN) dosages. This figure may require further
adjustment to take account of carers and THN re-supply.

Full GNP expansion would create 1,100 training events (ten drug users per two hour training
event) which would amount to 2,200 working hours. Within the 14 Community Addiction Team
(CAT) areas, full GNP coverage would involve delivering just under 80 events in each area.
These figures would require upward revision to include carers.

Recommendation 1: There is a need to develop a dedicated GNP team

There are significant staffing implications beyond the dedicated, part-time input to this pilot.
Programme expansion could be addressed by setting up a GNP team of seven staff (whole-time
equivalent of one staff member per two CAT areas) with part-time administrative support to
38
Hay, G., Gannon, M., McKeganey, N., Hutchinson, S. and Goldberg, D. (2005)
Estimating the National and Local Prevalence of Problem Drug Misuse in Scotland
Edinburgh: Information and Statistics Division, Scotland
39
NB: this prevalence study is being carried out again with a final report to be published soon. It is likely that Greater Glasgow’s
problem drug user figure may be upwardly revised.

47
deliver this phased work over a two year period.

A phased GNP expansion, over a two year period, could initially involve focussing on those most
at risk such as those completing detoxification, homeless drug users and those leaving
residential units or prisons. Furthermore, there is a need to target those in regular contact with
at-risk opiate users, such as partners, friends and relevant family members.

With senior CAT management agreement and support, the new GNP team aims and objectives
could be developed to include the following areas:

• Increasing overdose awareness and training for all primary and secondary
addiction service staff

• Engaging those who have already undertaken the ‘training the trainer’ sessions

• Design refresher training courses

• Create relevant partnership links

• Promote wider GNP ownership

• Wider dissemination of generic overdose prevention information and training

This work could initially be supported by the current GNP pilot coordinators. Furthermore, with
just under 50 pharmacies offering needle exchange services, there is a potential role for them to
play, such as offering THN re-supplies.

Recommendation 2: Increase client and carer participation in GNP training.

To increase the uptake of GNP training among clients and carers a range of responses covering
topics such as recruitment, venue and advertising should be considered. Staff working in CATs
with a captive audience and local Family Support Groups could play a more active role in
identifying and referring people on to the GNP.
The training should be provided in local areas in venues that are easily accessible and people
are comfortable attending.

48
Consideration should be given to those on very low incomes if they have to take public transport.

There is a need to improve local dissemination of GNP publicity materials (e.g. through busy
dispensing pharmacies or GP surgeries) and generic overdose prevention information and
training.

Recommendation 3: Ensure GNP training supports the Glasgow Addiction Services (GAS)
treatment contract for service users.
Despite drug overdose being a consequence of acute intoxication, often involving “street” heroin,
service users must sign the GAS treatment contract which asks them to agree to their
prescription “being withheld if I am intoxicated.” This sanction may prevent service users
(current/future) from taking part in GNP training or requesting a THN re-supply if they perceive it
as jeopardising their treatment.

The treatment sanction may also result in missed opportunities to address hidden risks, such as
non-fatal overdose, and offer effective interventions such as relapse prevention or addressing
sub-optimal Methadone dosage.

Any GAS treatment contract amendment must ensure a synergy between further GNP
developments and service users receiving safe and effective drug treatment and support.
Potential conflicts or tensions between future GNP development and treatment services could be
lessened by offering THN re-supply through local pharmacies. Future trainees should also be
reassured that there would be no sanctions if they accessed training or sought THN supply/re-
supply.

Recommendation 4: Strengthening future GNP training design

It is striking that all overdose casualties that received Naloxone had not taken part in the GNP
training. There are opportunities for GNP trained drug users/carers to actively encourage these
at-risk users to attend the training, seek Naloxone or enrol in drug treatment, if relevant. There is
also a need to ensure that future GNP trainees notify significant others that they have Naloxone
including where it is kept and how it is used.

The low numbers calling an ambulance following overdose re-emphasises the need to consider

49
other training approaches that continue to stress the importance of dialling 999. It is important to
prevent a sub-group developing a false sense of security that may overlook a "secondary
overdose" involving drugs such as methadone.

Recommendation 5: There may be merit in re-visiting current emergency service

protocols for responding to drug overdose.
GNP training has had a positive impact on trainees’ confidence and knowledge in recognising
and managing overdose. The findings also challenge negative stereotypes by showing a
willingness to preserve life. In all 10 cases where Naloxone was administered, witness drug
users sought a response from the casualty with the majority using appropriate interventions.
Interestingly, six out of the 10 drug users that reported using Naloxone did not call an ambulance.
Reported reasons included a perceived fear of police attendance, child protection sanctions or
losing their tenancy.

There may be opportunities to build upon the evident willingness to preserve life. For example,
by reconsidering the need for police to routinely attend all 999 calls to a drug overdose.
Established protocols in parts of England (such as Nottinghamshire, Greater Manchester and
Leicestershire) limit police attendance at the scene of an overdose only when there is a death, a
child at risk or a threat of violence. These protocols might be further explored alongside the
wider outcomes of the forthcoming national study on reducing drug users’ risk of overdose
commissioned by the Scottish Government.

Recommendation 6: Future GNP developments should be linked to ongoing monitoring

and evaluation.
Any strategic decisions to develop the GNP should be linked to further on-going monitoring and
evaluation to ensure the programme is achieving its aims and objectives. This could involve
developing expertise links with the National Forum on Drug-related Deaths in Scotland or
creating dialogue with other Naloxone programmes work, such as the randomised UK trial
involving recently released prisoners which begins soon.

50
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Bennett, GA and Higgins, DS (1999) ‘Accidental overdose among injecting drug users in Dorset,
UK’, Addiction, Vol. 94, No. 8, pp 1179-1190

Bigg D. Chicago experience with take-home Naloxone. BMJ 2001 (19 October).

Brand, B. Exploration of Take Home Naloxone HCl (THN) Administration in Glasgow – a

report prepared on behalf of Glasgow City Addictions Planning Implementation
Subgroup on the Monitoring and Prevention of Drug-Related Deaths. (2006)

Brewer, C. (2006) Letter: Emergency Naloxone for heroin overdose Naloxone is not the only
opioid antagonist BMJ;333:754-755 (7 October), doi:10.1136/bmj.333.7571.754-b

Byrne, A. (2006) Letter Emergency Naloxone for heroin overdose Over the counter availability
needs careful consideration, BMJ ;333:754 (7 October), doi:10.1136/bmj.333.7571.754

Dollery C, ed. Therapeutic drugs. Edinburgh: Churchill Livingstone, 1991.

General Register Office for Scotland, Drug Related Deaths in Scotland 2006, GROS (2007)

Glasgow City Addiction Planning & Implementation Group, Drug Deaths Monitoring and
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Graham C, McNaugton G, Alastair I, Cassells K. Take home Naloxone for opiate addicts. BMJ
2001; 323:934 (20 October).

Hay, G., Gannon, M., McKeganey, N., Hutchinson, S. and Goldberg, D. (2005) Estimating the
National and Local Prevalence of Problem Drug Misuse in Scotland. Edinburgh: Information and
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Heather N, Wodak A, Nadelmann E, O'Hare P, ds. Drug use and harm reduction: from faith to
science. London: Whurr, 1993:3-20.

Hill, D., Chicago Study Visit: Chicago Recovery Alliance Report (2006)

Join Together Harm reduction cuts OD deaths in San Francisco. (4 November2005).

McGregor, C, Darke, S, Ali, R and Christie, P (1998) ‘Experience of non-fatal overdose among
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pp 701-711

National Forum on Drug-related Deaths in Scotland Annual Report 2007

http://www.scotland.gov.uk/Publications/2007/12/17095935/14

Perry, S. & Mackintosh, G. Glasgow Naloxone Programme – Instructor Manual. (2007)

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Pollini, RA, McCall, L, Mehta, SH, Celentano, DD, Vlahov, D and Strathdee, SA (2006)
‘Response to overdose among injection drug users’, American Journal of Preventative Medicine,
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Scott, G., Thomas, S., Pollack, H., Ray, B. Observed Patterns of Illicit Opiate Overdose Deaths in
Chicago, 1999–2003 Journal of Urban Health. 2007 March; 84(2): 292–306.

Scottish Advisory Committee on Drug Misuse: Working Group on Drug Related Deaths. Report
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Scottish Government (2007) Review of Methadone in Drug Treatment: Prescribing Information

and Practice. 23 July. http://www.scotland.gov.uk/Publications/2007/06/22094632/0

Simini, B. Naloxone supplied to Italian heroin addicts. Lancet 1998; Vol. 352 (19 Sept).

Sporer KA. Strategies for preventing heroin overdose. BMJ 2003; 326: 442-444 (22 February).

Strang J, Farrell M. Harm minimisation for drug users: when second best may be best first. BMJ
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Strang J, Best, Man, Noble and Gossop. Peer initiated overdose resuscitation: fellow drug users
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52
 Annex 1: Reported Naloxone Use

Case One - Male Casualty

The respondent (male drug user) had just moved into a new house and invited his friend home -
it was ‘giro’ day. The male who overdosed had used alcohol and Diazepam but may have taken
other drugs, although the respondent was not sure about this.

The respondent went to change his friend’s wound dressings and warned him not to use
anything but when he returned into his living room, his friend had used heroin and overdosed.

Actions and outcomes

His friend was unconscious and could not be roused. The respondent performed basic
life support and put his friend in the recovery position.

He administered Naloxone 0.4mg in his friend’s thigh twice.

He did not phone for an ambulance because he feared this would jeopardise his new
accommodation. However, he made his friend stay overnight to ensure he did not go
over again.

The friend came round and was reportedly very appreciative that the respondent had
revived him.

The respondent did not take his Naloxone pack back to the Glasgow Drug Crisis Centre
(GDCC).

Verification

The above overdose description, actions and outcomes were reported to a GDCC staff
member by the respondent who administered the Naloxone.

The study researcher made various unsuccessful attempts to contact the respondent for
further information via two letters requesting an interview and through GDCC staff.
Unfortunately, there has been no response to these requests to date.

53
 Case Two - Male Casualty

The respondent (male drug user) reported receiving a phone call from the female partner of the
male overdose casualty. The respondent was asking to come to the male casualty’s house. The
overdose casualty and female partner had been using heroin that had not been cut by the usual
source and was purer in quality than they were used to. By the time the male respondent arrived
at their house the overdose casualty had ‘just gone blue’.

Actions and outcomes

The respondent gave 30 heart compressions and mouth to mouth

He administered Naloxone 0.4mg and repeated the above procedures.

As the overdose victim came round he vomited ‘violently’.

The respondent reported not having the opportunity to ring for an ambulance as the
house was ‘raided’ by the police and he was removed from the premises.

According to the respondent the police were unaware of the Glasgow Naloxone
Programme pilot and called the Glasgow Drug Crisis Centre (GDCC) to confirm he was
legally in possession of Naloxone.

The casualty survived this reported incident.

Verification

The second reported use was recorded by a GDCC staff member and followed up with a
telephone interview by SDF researcher.

NB: As previously reported in the main body of this report (Section 3:6), the emergency
services (police and ambulance) have provided a different version of events that seriously
contest this reported event.

54
 Case Three - Male Casualty

The respondent was a nurse at the Glasgow Drug Crisis Centre (GDCC). A male service user,
with a history of chaotic drug and alcohol use and in poor physical health, presented at the
GDCC for assessment late on a Saturday night. He was heavily under influence of alcohol,
heroin & Diazepam, according to his friend. The service user was found outside the GDCC
building lying on the ground and could not be roused. He was taking approximately three
breaths per minute which were very shallow. His pulse was slow and weak.

Actions and outcomes

The GDCC nurse carried out two rescue breaths and 30 chest compressions while their
colleague phoned for an ambulance. Cardio-pulmonary resuscitation (CPR) was carried
out three times.

Subsequently, Naloxone 0.4 mg was administered with no obvious result.

CPR and Naloxone administration was continuously repeated.

Overall, GDCC staff had to administer Naloxone 2mg i.e. five injections of Naloxone
0.4mg.

He eventually came round and left the premises against GDCC staff advice.

The requested ambulance had not arrived by the time the service user left. Therefore,
the emergency services were contacted and informed of the situation and what had
happened.

No complications resulted from the administration of Naloxone.

Verification

Reported by GDCC staff member

Follow up telephone interview by SDF researcher.

55
 Case Four - Female Casualty

The receptionist at the Glasgow Drug Crisis Centre (GDCC) notified colleagues that a 23 year
old female was found lying face down. This female casualty was a known heroin and Diazepam
user (both street bought and prescribed) with a history of epilepsy. She had recently been
released from prison (four or five days previous) after serving nine months.

She was brought into the GDCC by two males, one of whom had taken part in the Naloxone
training programme and was the first reported person to administer Take-Home-Naloxone.

Actions and outcomes

GDCC staff put her in the recovery position and asked the receptionist to call an
ambulance straight away. They also summoned the GDCC duty nurse and despite
speaking to the female casualty they could not get a response.

Staff agreed that Naloxone should be administered and the duty nurse injected Naloxone
0.4 mg into the female’s thigh. There was a 30 second delay before she came round.

She then had a reported epileptic seizure lasting two minutes. The staff attributed this to
an insufficient supply of Diazepam and anticonvulsant medication, ‘Epilim’.

Once revived, she became aware of what was happening and recognised GDCC staff.
They sat her in a chair and despite wanting to leave, the staff insisted she stayed. They
took her to a room and supervised her for two and half hours after which time she left.

The ambulance was cancelled as the female did not want it to attend.

The GDCC staff booked her a place in the 218 Project (14 bedded residential drug
service for women in Glasgow) for the next day but she left this project shortly after
attending.

Verification

Reported by GDCC staff member.

Follow up telephone interview by SDF researcher

56
 Case Five - Male Casualty

The male casualty was in his early to mid 30s and had been using heroin for the first time after a
ten day period of abstinence from all substances. The incident occurred in temporary supported
accommodation.

The respondent (a male opiate user living in a city centre hostel) received a telephone call asking
for assistance.

When he arrived at his friend’s house the overdose casualty was unconscious and was not
responding to attempts to rouse him. His breathing was reportedly ‘bad’ and his skin was grey
and turning blue.

Actions and outcomes

The male respondent reported that there was ‘a lot of panic’ but he managed to check the
person’s breathing and pulse then placed him in the recovery position.

He then administered Naloxone 0.4 mgs.

The overdose casualty came round after a ‘few seconds’ and there were no reported
complications.

An ambulance was not called to the event as there were concerns that calling it may have
had negative repercussions vis-à-vis their accommodation.

NB: This male respondent is alleged to have used Naloxone on a second occasion. This
event is not recorded as it has not been possible to contact the respondent.

Verification

Reported by GDCC staff member.

Recorded by GDCC staff member

57
 Case Six - Male Casualty

The respondent had been out drinking with the overdose casualty, a 29 year old homeless male.
They went back to the respondent’s house and prepared three £10 bags of heroin for injection.
The male overdose casualty went into the bathroom and injected into his groin. The respondent
was in the living room at the time and said: “He was taking his time, about 10-15 minutes passed.
I was gouching but it was dead quiet so I shouted on him.”

The respondent shouted again but there was no reply. He went to the bathroom to check. He
also pointed out that the overdose casualty often ‘falls over’ when injecting heroin.

Actions and outcomes

The respondent tried to rouse the casualty by shaking his shoulders, attempting to lift him
and rubbing his knuckles on the casualty’s chest (as shown in the GNP training). The
casualty’s face was ‘cold & damp’.

At this point, the respondent realised he had overdosed and put the person in the
recovery position, performed CPR and mouth to mouth.

He phoned an ambulance and “remembered the Naloxone”. He injected 0.4mg in to the
upper thigh and reported no complications. He also felt ‘quite confident’ about using it but
asked if witnesses could give more than 0.4mg to bring the casualty around quicker,
which would ‘help stop/reduce panic’.

The respondent did not go back for a Naloxone re-supply at the time of interview because
he said he did not know how to get it replaced: “Even though I’d used it and had it used
on me I didn't think about it but that's the frame of mind I was in when using. I thought you
had to have a serial number or identifier.”

Verification
• Reported by GDCC staff member
• Face-to-face interview with SDF researcher

58
 Case Seven – Two Male Casualties

This joint incident occurred in the Grampian region and involved two male overdose casualties
(Male OC1 and Male OC2).

Male OC1 was unconscious and breathing.

Male OC2 had stopped breathing and his lips and fingertips were ‘blue’ (cyanosis).

Both causalities were found behind a pub by a female respondent (drug user). She ‘assumed’
they had both overdosed as there was ‘no sign of an assault’ and it was an area ‘notorious’ for
drugs

The only female drug user involved in giving Naloxone, she completed the training and received
the Naloxone pack two weeks before this incident.

Actions and outcomes

The respondent prioritised’ her actions and first checked to see if both were breathing.

Male OC1 was put into the recovery position by the respondent.

Male OC2 was unresponsive so the respondent asked her friend to inject this casualty with
Naloxone 0.4mg and then call an ambulance.

Male OC2 also received chest compressions from the respondent while her friend gave
mouth-to-mouth.

Both rescuers were ‘debating’ giving Male OC2 another Naloxone injection when the
ambulance arrived.

Grampian police sought confirmation of the Naloxone programme as OC2 had died.

The police confirmed OC2 had predeceased the Naloxone injection by suffering from a fatal
opiate overdose.

OC1 survived this incident.

The respondent did not seek a re-supply of Naloxone, at the time of interview.

Verification

Reported by Grampian Police Officer

Follow up telephone interview by SDF researcher

59
 Case Eight – Male Casualty

The respondent was in a friend’s house smoking cannabis while three companions were injecting
heroin. A male, in his early thirties, overdosed immediately following the injection. According to
the respondent the casualty was unresponsive and ‘went a funny colour’.

Actions and outcomes

The respondent performed Cardio-pulmonary resuscitation (CPR)

He then injected Naloxone 0.8mg into the casualty’s leg i.e. two injections of Naloxone
0.4mg.

An ambulance was not called as the casualty came round after a ‘few minutes’ and the
respondent stated he did not want the police there. There were no complications reported.
The respondent did not replace his Naloxone as he still had a clean needle and some
Naloxone left in the syringe. He said ‘I’ll go once I use this spike.’

Verification

Follow up telephone interview by SDF researcher

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 Case Nine – Male Casualty

The overdose incident happened in what was described by the respondent as a ‘shooting gallery’
- five people were present. The overdose casualty was a male in his late forties and a long-term
heroin user. The casualty was sat on the floor and the respondent noticed his lips were ‘going
blue’.

Actions and outcomes

The respondent kicked the casualty and spoke to him but there was no response.

No-one else was checking on the casualty so the respondent took control and pulled the
casualty to the centre of the floor.

The respondent checked his breathing which was alright but according to the respondent
the casualty’s heart beat was slow which was why he decided to put him in the recovery
position.

He administered Naloxone 0.4 mg into the casualty’s thigh.

The casualty was revived after five minutes and stated that they did not want an ambulance
- the respondent reported staying with the casualty for four hours.

The respondent reported that the other witnesses present did not want an ambulance
called because of the potential police presence.

The respondent stated that if he had to administer a second dose of Naloxone to the
casualty, then he would have called an ambulance.

The respondent reported going back to the GDCC for a Naloxone re-supply.

Verification

Follow up telephone interview by SDF researcher

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 Case Ten – Male Casualty

The respondent was with his brother at a dealer’s house. The brother bought two £10 bags of
heroin and injected into his groin in the house. The respondent said his brother had recently
completed a prison sentence and he thought this was the first time his brother had injected since
he had been released. The overdose casualty had also taken Methadone 60mg that morning.
According to the respondent his brother ‘went over’ immediately following the heroin injection.
The dealer was in a ‘panic’.

During the interview the respondent repeatedly mentioned that he had lost two siblings and an
in-law through drug use and he ‘wasn’t going to let [his] brother die.’

Actions and outcomes

The respondent tried to get a response but the casualty’s ‘eyes were rolling’ and he was
‘changing colour’.

He administered Naloxone 0.4mg into the thigh with the overdose casualty reviving after
three to four minutes.

An ambulance was not called because the casualty was ‘alright’ but the respondent stayed
with him that night and made sure his brother did not take any more drugs.

He went back to the GDCC to get his Naloxone pack replaced.

Verification
• Reported by GDCC staff member

Face-to-face interview by SDF researcher

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 Case Eleven – Male Casualty

The respondent received a telephone call form the overdose casualty’s partner. The casualty
was a 40 year old male heroin user and occasional injector.

Actions and outcomes

The respondent asked the partner to check the casualty’s breathing and immediately went
to their house which is 10 minutes from his own accommodation.

When he arrived, he put the overdose casualty into the recovery position, ensured the
airways were clear and injected Naloxone 0.4mg into the thigh.

The respondent said he used Naloxone because he knew the casualty was a heroin user
and he ‘wanted to cover [his] bets’.

An ambulance was not called as the casualty did not want one (there were children in the
house).

The respondent reported the casualty was annoyed at being brought round; he thought he
had fallen asleep. The casualty said he had a ‘wee bit of a sore head’ but he went to work
that night.

The respondent has a needle phobia and said he thought about the orange fruit which he
had practised injecting with at the training session. He said it was an ‘automatic reaction’
and went into what he described as ‘robot mode’.

The respondent did not go back to get his Naloxone replaced as he is in recovery and is
not ‘in the company of injectors’. He said that he disposed of the Naloxone box once he
used it but was uncertain as to whether he needed to return the used box in order to get it
replaced.

Verification
• Reported by GDCC staff member

Follow up telephone interview by SDF researcher

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Appendix 2: Naloxone Hydrochloride - Pharmacological Information

Naloxone is a drug used to counter the effects of opioid overdose, for example heroin or
morphine overdoses. It works on the central nervous system and counteracts life-threatening
depression of the respiratory system. The drug is marketed under various trademark names e.g.
Narcan.

Naloxone is most commonly injected intravenously for fast action. The drug acts after about two
minutes and its effects may last about 45 minutes. It can also be administered via intramuscular
or subcutaneous injection and usually lasts about 20 minutes.

In this evaluation study, the standard adult dose was Naloxone 0.4mg with each pre-filled syringe
containing Naloxone 2mg/2ml (i.e. equivalent to five standard doses)

Caution has been advised in administering Naloxone to those with cardiovascular disease or
receiving cardiotoxic drugs. Large dosages of the drug may precipitate acute drug withdrawal on
those with a physical dependence on opioids. Side-effects are rare but may include nausea and
vomiting, tachycardia and fibrillation.

It is not to be confused with Naltrexone which is another opioid receptor antagonist used to treat
dependence rather than an emergency overdose.

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Appendix 3: Consent Forms and Questionnaires

EVALUATION GLASGOW’S PILOT NALOXONE PROJECT INFORMATION SHEET

Scottish Drugs Forum

93 Mitchell Street, Glasgow

Scottish Drugs Forum (SDF) is conducting an evaluation of the pilot Naloxone project in Glasgow. The
aims of the evaluation are to:

• Evaluate the Naloxone training sessions

• Identify individuals overdose experience and awareness
• Evaluate individuals use of Naloxone during overdose events
• Identify potential training improvements or changes

We would like to ask you questions relating to the

• Naloxone training sessions

• Overdose awareness
• Personal and witnessed overdose
• Experience of using Naloxone

The information you provide will be passed on to the SDF research officer who will write a report on the
results, which will be provided to the

• Naloxone Pilot Steering Group

• Glasgow City Council’s Addictions Planning and Implementation Group
• Glasgow City Council’s Drug Related Death Monitoring and Prevention Working Group
• Greater Glasgow and Clyde Drug Action Team

The information you provide in the questionnaire is completely confidential and nothing in the
report will identify individuals.

You are free to refuse to take part or withdraw from the evaluation at any time. You are also free to choose
not to answer any particular questions. This will not affect your right to use/receive any service/s, nor will
your care/treatment be affected in any way.

The information you provide will be used only for the purpose of the evalaution and no information
that could identify you will be shared with anyone else.

If you require further information regarding the evaluation please contact:

April Shaw, Scottish Drugs Forum, 91 Mitchell Street, Glasgow

Or telephone April at 0141 221 1175

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 EVALUATION GLASGOW’S PILOT NALOXONE PROJECT

CONSENT FORM

Scottish Drugs Forum

93 Mitchell Street, Glasgow

• I have read, understood and have a copy of the evaluation information sheet
• I have been able to discuss the evaluation and ask questions about it.
• I understand that I can withdraw from the evaluation at any time, without having to give a reason
and that this will not affect my right to attend any service.
• I understand that any information about me will be kept confidential.
• I understand that any information I provide will be used for evaluation/reporting purposes but that
any such information will remain anonymous and will not identify me.

Agreed Yes No

Initials ____________________________________

Date __________________________

Thank you for agreeing to take part in this evaluation

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