The NHS is failing to provide life saving Naloxone at the point of release from prison in the majority of prisons

Those leaving prison having had an opiate problem are seriously at risk of having a life threatening overdose or dying as a result of one. Both Public Health England and the Government have been clear in their recommendation that all local areas need to have appropriate Naloxone provision in place. However, prisons have so far failed to implement provision at the point of release across much of the prison estate. This is putting lives at risk.

Blenheim workers have found it is rare for any of our service users to be released from prison having been provided with Naloxone, medication which is literally life-saving in the case of overdose.

Public Health England’s strategy to reduce drug related deaths identifies discharge from prison as the point of maximum risk of overdose and maintaining contact with treatment services as the key intervention to stem the rise in drug related deaths. Naloxone is the emergency antidote for overdoses caused by heroin and other opiates/opioids (such as methadone, morphine and fentanyl).The main life-threatening effect of heroin and other opiates is to slow down and stop breathing. Naloxone blocks this effect and reverses the breathing difficulties.


Read more in Blenheim’s report – ‘Failure by Design and Disinvestment: the Critical State of Custody-Community Transitions


The NHS is responsible for provision of treatment services in prison including Naloxone but refuses to take a national view. At one point the NHS even argued that as the prisoner would use Naloxone outside of the prison it was not their responsibility and each local authority should arrange to fund, provide, and negotiate arrangements with prisons for the supply of Naloxone at the point of release. To expect them to do this with more than one hundred prisons is something that anyone can see is ludicrous. Currently the NHS says it is for local NHS areas to decide.

It has proved difficult to get NHS England to provide clarity about what is going on as they are reluctant, or unable to do so when asked. Below are a couple of responses given to questions by Grahame Morris MP that will have been prepared by officials for the Government’s response.

Question – To ask the Secretary of State for Health and Social Care, how many and what proportion of prisoners with a history of opioid misuse were provided with Naloxone when released from prison in the latest year for which information is available; and from which prisons those prisoners were released.

Reply in May 18 – “Information on how many prisoners are provided with naloxone when released from prison in England is not currently available. This data is due to be published in 2019”

Question – To ask the Secretary of State for Health and Social Care, if he will bring forward legislative proposals to make the supply of the opioid-overdose antidote Naloxone to all at-risk prisoners upon their release a mandatory requirement for prisons.

Reply – “Naloxone has a vital role in saving lives and the Government is committed to widening its use in England.”

There is no national programme that mandates the supply of Naloxone for at-risk prisoners on their release, and the Government does not have any plans to bring forward legislation to make this a mandatory requirement for prisons.

The commissioning of substance misuse treatment for prisoners is the responsibility of health and justice commissioning teams in 10 of NHS England’s area teams, supported by a central health and justice team. The Government expects commissioners and providers of substance misuse services in prisons and in the community to work together closely in respect to prisoners being released from custody to ensure seamless transfers of care.

So according to NHS England they have not got a clue about what is happening and their best estimate is they may know in 6 months time. Or as I suspect, they are putting off releasing the information and will do so for the foreseeable future. How long does it take to ask prisons the following three questions?

  1. Are you providing Naloxone at point of release?
  2. Are you providing Naloxone and overdose training?
  3. How many Naloxone kits have you given out?

Well let me try and help them out a bit. There are currently at least 36 prisons in England and Wales claiming to give out naloxone on release, a low percentage. There may also be others that I and my sources are unaware of, however just because someone at a prison says they are providing Naloxone it doesn’t mean they are handing out many or any kits. Whilst not an English or Welsh example, in Scotland, where all prisons are supposed to be providing Naloxone at the point of release, the position is depressing. In one prison in the last year only 24 kits had been handed out and in another none had been handed out. Operational difficulties are often cited as the reason for this, a common excuse which covers most prison failures.

On the NHS website it says:

  • NHS England Health and Justice teams commission to the ‘principle of equivalence’ which means that the health needs of a population constrained by their circumstances are not compromised and that they receive an equal level of service as that offered to the rest of the population.
  • NHS England health and justice commissioning supports effective links with Clinical Commissioning Groups (CCGs) and Local Authorities to support the delivery of social care within secure settings and the continuity of care as individuals move in and out of them.

The failure to provide naloxone at point of release, along with the breakdown in continuity of care (documented in response after response to the ACMD in relation to custody to community transitions) demonstrate a clear failure to live up to the statements above. I am starting to wonder how much stigma and prejudice underlies this failure. I am sure diabetics requiring insulin do not suffer the in the same way.

So to recap, why does Naloxone at the point of release matter? There is an international evidence base about the high risk of overdose and death of opiate using prisoners, in particular in the period immediately post-release. A recent large scale Norwegian study¹ examined the deaths of all prisoners in the first six months of their release over a fifteen year period (1 Jan 2000 to 31 December 2014); the sample comprised 92,663 prisoners released a total of 153,604 times. The study found that overdose was the most common reason for death at every time period within the first six months post-release.

During the first week post-release, overdose deaths accounted for 85% of all deaths, with accidents accounting for 6% and suicide for 3%. Overdose deaths peaked during the first days post-release, and thereafter declined gradually during the first month post-release. During the second week post-release, the total number of deaths approximately halved (versus first week), with overdose deaths accounting for 68% of all deaths. During weeks 3–4 and months 2–6, overdose death accounted for 62% and 46% of all deaths, respectively.

The authors suggest that the high proportion of overdoses in the immediate period following incarceration might reflect prison settings where released inmates typically have a history of heroin or opioid use, and may also be particularly high in settings where polydrug injection is a common mode of administration. For several years, Norway, like the UK, has been ranked as one of the European countries with the highest rates of overdose mortality, often explained by high rates of injecting drug use and an ageing polydrug-using population.

Recent UK research² also found that the first week following prison release was the period of highest risk of mortality with drug-related deaths the main cause.

By now it will come as no surprise when I say we do not have an accurate figure of the number of drug-related deaths of recently released prisoners in England and Wales.

Please NHS, help sort this out and start preventing these needless deaths.


Read more about Blenheim’s campaign here


References

¹Anne Bukten, Marianne Riksheim Stavseth, Svetlana Skurtveit, Aage Tverdal, John Strang & Thomas Clausen (2017) High risk of overdose death following release from prison: variations in mortality during a 15‐year observation period. Addiction Volume112, Issue 8 August 2017 Pages 1432-1439.

² Phillips, H. Gelsthorpe, L. & Padfield, N. (2017) Non-custodial deaths: Missing, ignored or unimportant. Criminology and Criminal Justice 

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The tip of the iceberg

We have just seen the highest drug related deaths figures ever; these figures record deaths from drug poisoning, but services providers know that this is just the tip of the iceberg. There is an alarming increase in the numbers of people dying in treatment as a result of chronic ill health.

An aging population of people with drug and alcohol problems are becoming unwell and often receive a poor service from the NHS in relation to their wider health needs because they struggle to navigate an increasingly complex treatment system and are often treated as undeserving by both our health system and local authorities that are under extreme financial pressure.

Imagine that you are living with a completely treatable infection, that left untreated, can cause a life changing illness (for some ultimately death) and the health service said you had to wait until you developed this life threatening related illness before they would treat you. You would rightly be outraged.

This is precisely what is happening to those who have hep C despite a range of new highly effective NICE approved treatments, with few side effects, that offers a cure for hep C. Only 3-4% of people a year currently get treatment. Unless you have a hep C related illness e.g. cirrhosis you are unlikely to be treated and even then it will have to be serious enough. Many of those with hep C who are not deemed ill enough to deserve treatment do not have their condition adequately monitored.   Sadly many GP’s tell me that they monitor those with hep C who appear to be in reasonable health but then suddenly get ill very quickly, with often fatal consequences.

This discrimination happens because around 90% of those with hep C contracted it via injecting drug use. Although many will have contracted hep C many years ago and have moved away from substance misuse they are often treated with suspicion. They are perceived as unreliable patients on whom expensive treatments are not to be wasted. Alongside this those most at risk of spreading hep C to others are seen as chaotic and thus undeserving or unsuitable.

Naloxone is a drug that saves lives by temporarily reversing the effects of opioid drugs. It costs £18 or less per pack and is recommended by the ACMD, WHO, Public Health Ministers and PHE who actively support its wide provision to those at risk of opioid overdose. Despite this many local authorities, including Liverpool, are still refusing to allow treatment providers to distribute it, denying people access to a life saving tool at a time when we are seeing a significant jump in opiate related overdose deaths. Some years ago Liverpool hosted an international harm reduction conference recognising its historical place in the history of harm reduction in drugs services.

In 2014, (after over 34 years of working in the drug, alcohol and criminal justice sectors, and as Blenheim celebrated 50 years of social action) I committed both Blenheim and myself to do everything in our power to ensure that the worlds best evidenced based treatment system was not destroyed by dogma, localism and cuts to public sector finances. Whilst recovery and ending dependency are hugely important we believe harm reduction is equally as important. Some of our sector’s best work is the daily interventions to keep people alive until they are ready to change.

I was concerned then about disinvestment by local authorities in the drug and alcohol treatment sector to fund a wide range of other equally important and underfunded public health priorities. The subsequent cuts and impending disinvestment have exceeded even my most pessimistic view of the future. We face a return to a post code lottery of underfunded services, ill prepared for the next wave of alcohol and drug dependency or to support those in often chronic ill health.

This year, 2016-17, we are seeing a 30% reduction in funding for drug and alcohol services with local authorities facing often impossible challenges, in the current financial climate, in meeting even their statutory responsibilities. With the ring fence coming off the public health grant and its abolition following the proposed introduction of Business Rate Retention, it will become increasingly difficult for local authorities to justify spending on drug and alcohol services when they cannot adequately fund services they are mandated to deliver. There is an urgent need to make the provision of a full range of drug and alcohol treatment services a statutory responsibility for local authorities.

To quote Collective Voice, an organisation part funded by Blenheim along with other large providers:

“Recent reduction in heroin use has been concentrated amongst the under-30s leaving behind a drug treatment population who are increasingly in frail health because of the cumulative impact of decades of drug addiction, problem alcohol use, poor diet, fragile mental health, and smoking. This leaves them significantly more vulnerable than their age would indicate and places a significant burden on mainstream NHS clinical services.

“Despite this, drug and alcohol treatment is not a natural priority for local authorities, the NHS or public health professionals. This places this area of activity at particular risk from the negative consequences of the proposed replacement of the ring-fenced Public Health Grant with a system of business rate retention.

“Drug and alcohol treatment provides for an unpopular and marginalised population seen by local electors, and politicians as undeserving, particularly in comparison to alternative service user populations such as children and the elderly. Without someone in local systems to champion the agenda there is a continuing risk of deprioritisation and disinvestment.”  

There is growing evidence that local politicians feel that drug and alcohol treatment is an NHS function rather than a local authority public health function. Many are already uncomfortable at the proportion of PHE funding to local authorities that is currently spent on drug and alcohol provision.

At Blenheim we work with a wide range of organisations and government departments to fight for drug and alcohol services and to ensure people in treatment aren’t discriminated against. In doing so we are supported at Westminster, by many hard working politicians from all major parties, who help us hold Government to account.

Shocked and saddened by drug related deaths figures for 2014

At the DAAT conference in early September 2015 I heard the drug related death figures for 2014. Despite having warned people they would be worse than the previous year I was shocked and deeply saddened. I have waited to write this blog to get my thoughts together.

Last year I was shocked by the inaction of Government and many Local Authorities to the 2013 figures.

I was going to talk about the Naloxone Action Group, positive action by the Department of Health, questions in Parliament and early day motions on naloxone. I was going to talk about the fact that since the 2013 drug related death figures came out, I and so many others have worked to try and understand what is happening and the cause.

Personally I believe that increased heroin purity, poor heath and financial pressures on the drug treatment system are key factors in increasing drug related deaths. I also believe that action to increase naloxone availability in England will avert a significant proportion of these deaths. Without naloxone the figures would already have been, in my view, significantly higher.

However the 2014 figures are shocking to me, every death represents a person, perhaps a father or grandmother, certainly someone’s child, grief and the waste of a life. I picture the funerals as a silent rebuke to do more. The figures are the highest since records began.

As you read the statistics below, from the Office of National Statistics, take time to consider the people the figures represent.

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Heroin and morphine deaths rise by two-thirds in the past 2 years.

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Within England, the North East has the highest mortality rate from drug misuse, London the lowest.

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2014 registrations show drug related deaths reaching the highest level since records began.

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Majority of heroin deaths were among the 30-49 year old age groups.

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Males were over 2.5 times more likely to die from drug misuse than females.

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Two issues seemed important to understand after the 2013 figures and they remain the same after the 2014 set. Firstly what is causing the rise in deaths? And secondly what is being done to prevent them?

A naloxone summit, hosted by Blenheim, bought together a campaign for a national naloxone programme in England. Through a FOI request we discovered the true extent of under provision of naloxone with only 32% of local authorities in England saying Naloxone was available. We formed the Naloxone Action Group England to ensure the regulations were changed, to ensure effective guidance was produced, and to ensure provision of naloxone across England. We got MPs to ask a range of questions in Parliament and gained support for an early day motion, sponsored by amongst others the current leader of the opposition Jeremy Corbyn and signed by the current Shadow Chancellor, John McDonald. This was not a party political issue; the EDM was also supported by current Conservative Minister Tracey Crouch. In total 32 MPs signed up to support wider naloxone availability.

Letters to the Minister from the Drug Alcohol and Justice Parliamentary group, chaired by Lord Ramsbotham secured firm assurance that the Government would make the changes recommended by ACMD to make naloxone more widely available from October this year.

Sadly, at the Naloxone Action Group we believe around 50% of local authorities continue to fail to provide naloxone. We will do a further FOI this year.

Meetings at Chatham House with senior officials revealed clear evidence that entering and leaving drug treatment and/or prison are particularly dangerous times for overdose and death. Thus pressure to leave treatment early and failure to adequately manage transfer of those with drug problems from residential settings could seriously endanger lives.

A drug related death summit held at the beginning of this year, hosted by Drugscope, Public Health England (PHE) and the Local Government Association, examined what might be causing the rise and to look at what might be done to reduce overdose deaths in future years. The attendees included policy makers from across government, commissioners, clinical and service provider leaders, and service user representatives.

The key messages from the summit were:

  • The availability of accurate, timely and easily accessible data is important in order to make the appropriate adjustments to policy and practice in order to reduce drug-related deaths;
  • The majority of drug misuse deaths still involve opiates, in particular heroin and methadone;
  • Being in contact with a treatment service would appear to be a significant protective factor for drug-related deaths;
  • Services and practitioners should pay attention to the elevated risk for those in treatment who are regularly overdosing, are drinking excessively, live alone in temporary accommodation or are homeless, or as a result of smoking-related diseases have compromised respiratory systems;
  • Policy makers and commissioners should think about providing timely and accurate alerts to drug users who are not in the treatment system – including drug users who don’t use opiates;
  • Commissioners and services should look at how they could supply naloxone more widely in the community to ensure those vulnerable to heroin overdose (including those not in treatment), their families, peers and carers are able to access the medicine.

Over the last year we have seen PHE nationally, clearly assert the need for action to reduce drug related harm and publish significant guidance on naloxone and reducing drug related deaths. However, at a time when drug related deaths are at their highest ever level, to cut £200million from Public Heath funding to local authorities is truly outrageous.

I am still ashamed to live in a country where things like the PHE £200 million cut happen at a time of evident need and many local authorities look the other way as people die as a result of the negligent failure to follow guidelines and supply naloxone.