A quick fix

'At-risk' prisoners are being issued with a take-home pack of a drug to help them recover if they overdose. Will this trial scheme save lives or could it encourage risky behaviour among addicts? Mark Gould reports
Kylie Reed, a doctor, trains drug users at St Mungo's homeless hostel to use naloxone
Doctor Kylie Reed works with drug users at St Mungo's homeless hostel, including training them in using the injector packs. Photograph: Teri Pengilley

The bleak statistics show that around 3,000 deaths every year in the UK are due to drug overdose, with 1,058 death certificates in 2007 giving the cause of death as injecting heroin or morphine. And the most at-risk group are newly released prisoners with a history of injecting. In the first four weeks of freedom, they are seven times more likely to die of an overdose than other heroin users.

In an attempt to address the problem, 5,600 prisoners with a history of injecting will take part next month in a £1m trial in which, come their release date, half of them will be issued with "take-home" packs containing one-shot injectors of naloxone. Giving addicts free access to naloxone - a cheap antidote to heroin that is almost free of side-effects and is regularly administered by paramedics and in accident and emergency units - could lead to a significant reduction in overdose deaths and become part of national drug treatment policy.

After promising trials, the homelessness charity St Mungo's also wants to offer naloxone to injecting users in its hostels and on the streets.

However, there are concerns that giving addicts what they might regard as an insurance policy against an overdose could simply reinforce addictive behaviour, and could therefore increase the death toll.

The "take-home" trial hopes to answer these questions and cut overdose deaths by 28% in the first 12 weeks after release. The ultimate aim would be a reduction of between 150 and 200 deaths a year.

Chemical receptors

Naloxone, injected into arm or leg muscle, blocks the chemical receptors in the brain of the person who has overdosed, quickly restoring consciousness. If the dose wasn't big enough the user would simply fall back into unconsciousness. Depending on the dose, the effect lasts for around 20 minutes, so the trial stresses that an ambulance must be called immediately, as dragging someone back into consciousness and instant, chemically induced cold turkey can make them distressed, agitated and, potentially, violent.

While it must be prescribed by a doctor for a named patient, naloxone is one of the few drugs classed as "exempt", meaning that, in an emergency, anyone - a carer, or member of the family or fellow user - could give a life-saving injection, or the named patient could give the injection to someone else who has overdosed.

The trial, funded by the Medical Research Council, is being run from 25 prisons in England and Scotland. On release, prisoners will receive a pouch containing a pre-loaded syringe of naloxone hydrochloride, information illustrating injection sites, and a pre-paid reply card about their drug use. Families and carers will also receive training in overdose awareness and how to administer the drug.

In the control group, prisoners and families will receive all the same information about harm and overdose awareness, but no naloxone. This group will model in effect what is current best practice in some, but not all, prisons.

Naloxone is non-addictive and usually does no harm even when given in error, so it seems a "no-brainer", according to Max Parmar, who is running the MRC trial. He says: "It looks very promising, but it's not as simple as that, especially when you are talking about changing behaviours of injecting drug users."

He adds: "It's entirely possible that we will save lives, but it may be that we do nothing except waste NHS and prison service time and money. Signing up to the scheme means lots of people need to be involved.

"We could do more harm than good. What if a peer or carer isn't there to give the injection, or doesn't feel comfortable doing it? What if [users], having a failsafe to protect from overdose, get into more risky behaviour?"

If the trial is successful, and gets approval from the Department of Health (DH), the prison service and the Ministry of Justice, it could become part of UK release procedure for some 56,000 at-risk inmates.

"Take-home" kits have been used with apparent success by several community drug teams in England and Scotland. The DH welcomed the MRC trial, but added that its own, independent reviews of such community schemes, concludes that effectiveness is "largely anecdotal".

Last year, St Mungo's issued naloxone to residents of one of its hostels in London. The drug was used six times and there were no overdose deaths. However, there are no reliable figures to compare the situation before the trial.

Gayle Jones, one of St Mungo's managers, says: "Naloxone gives addicts more control over their habit, and it can become part of treatment and aid recovery."

She wants to extend the scheme to all hostels, and to its outreach and needle exchange schemes to target the many thousands who are not aware there is an antidote to an overdose.

But Parmar cautions: "To see the benefits in the community, you would need to study thousands of people to see if it saved one life, as there isn't that same level of risk of [fatal] overdose as in the weeks just after release from prison."

Ettore is 51 and has injected heroin for more than 20 years. He looks emaciated and says he has kidney disease, diabetes and circulation problems. He knows all about overdose and the effects of naloxone, as someone who has used it both on himself and to save a friend. He has lived in St Mungo's hostel in south London for two years and has been revived from overdose twice - once a couple of months ago.

The right dose

He says: "OD is like having a heart attack. You feel hot, you feel cold, your arms and face tingle." After the naloxone, he says, "you wake up and feel like a normal person, only like you are speeding. It [the amount of naloxone needed to revive a person] depends on how much heroin you had and what it was cut with, and also on the dose of naloxone. Paramedics give you a big dose, but the dose here is smaller, so you might need two or three."

When he revived his friend, it took under a minute. "We had a hit together," he recalls. "My friend was lying on the bed and I saw his face had turned purple. I got him up and put his arm over my shoulder and started walking him around to try to wake him up. It didn't work, so I injected him in the arm. He woke up in 40 seconds. I never fix on the street, always with a friend. That way they can help you."

With a small bag of heroin costing £10 and offers of three for £25, Ettore explains that dealers maximise profits by adding other substances that can dilute or even negate the effects of naloxone. The latest trend is for adding tranquillisers or buprenorphine, a morphine substitute used in treatment. Naloxone is not an antidote to these drugs, so it adds to the complexity of treating an unconscious patient.

Ettore believes that naloxone should be freely available, especially to newly released prisoners. "You come out of jail and your body is not used to heroin, so a little fix will knock you over," he says.

But he also provides ammunition for those who say that making it freely available will encourage drug use. "Why not take it before you have a fix?" he asks. "But you would need a lot, because some people in here have seven fixes a day."

Emily Finch, an addiction psychiatrist from South London and Maudsley NHS foundation trust, who prescribes to St Mungo's residents, is confident that naloxone is safe and hopes the MRC trial saves lives.

She would like to see all 4,000 or so injecting users in treatment on her patch carrying naloxone, and for it to be prescribed to families so that they are part of the treatment process. She says: "I'd like to see it become as normal as one of those kits that kids who are allergic to peanuts carry around."

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