Naloxone from Hospital to Home. Improving access to take-home naloxone (THN) on discharge from acute medical care in Scotland

Problem to be addressed and rationale for undertaking the proposed research
In 2015, the WHO reported 450,000 global deaths due to drug use, with 167,750 directly associated with drug use disorders (UNODC, 2018). Scottish rates of drug-related death (DRDs) continue to rise year on year, with over 900 deaths in 2017, the highest ever recorded annual total. Between UK nations, Scotland's DRD rate sits at approximately 175 per million deaths, compared to 66.1 in England and Wales (ONS, 2017). Of the 934 DRDs in Scotland in 2017, opioids were implicated in 87% of these, consistently remaining the most prominent cause of DRDs (NRS 2018). High risk times for opioid related deaths (ORDs) are periods following abstinence including post prison release, post detoxification or residential rehabilitation, and post hospital discharge, likely due to lowered opioid tolerance (Strang et al 2014).
Naloxone is a short-acting opioid receptor antagonist which reverses the potentially fatal effects of opioid overdose (White & Irvine, 1999). It has no obvious potential for abuse and maintains a good safety profile (Strang et al, 2013). The National Naloxone Programme (NNP) aims to contribute to a reduction in ORDs in Scotland through provision of take-home naloxone (THN) to those at risk for the purposes of peer administration. The NNP involves training in overdose risk awareness, emergency management with resuscitation and intramuscular naloxone administration. Naloxone is provided to opioid users, family members or service workers, for use in witnessed overdose situations to allow emergency services time arrive and instigate further treatment (McAuley et al, 2012). Research indicates THN programmes can improve overdose-related knowledge, administration techniques and have a strong association with overdose survival (McDonald & Strang 2016). The recently updated Scottish drug and alcohol strategy (Scottish Government 2018) recognises the importance and impact that harm reduction measures can have, and specifically highlights the requirement to provide naloxone to all those at risk of ORD.
To date, the NNP has had significant success in tackling post prison release ORDs via provision of, and training in, use of naloxone prior to liberation; 3.5% of ORDs were four weeks post release in 2016 and 4.4% in 2017, compared to 9.8% in the five years prior to NNP implementation (NNP Monitoring Report 2017/18). Unfortunately, Scottish post hospital discharge ORD levels have increased; 11% of ORDs observed within four weeks post hospital discharge in 2017, compared to 9.7% in the five years preceding the NNP (NNP Monitoring Report 2017/18). Thus, whilst there has been an important effect on post prison ORDs, there has been no impact on post hospital rates. Lack of recognition of heightened overdose risk after discharge is likely to be a contributing factor (Bird et al, 2017). Many at risk of opioid overdose do not routinely engage with specialist drug treatment services which has been the main route to accessing naloxone thus far. In addition, due to inaccessible healthcare and perceived stigma from those working in primary care services, many people who use opioids delay seeking help until a health problem becomes severe and they are forced to use emergency services (Ayres et al, 2012). A natural access point for naloxone distribution is therefore acute medical care. The policy profile of this critical issue is now high yet there is a need for robust practical strategies to ensure utilisation of naloxone to its full potential.