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SUBSTANCE MISUSE PROGRAMME

Harm Reduction Database

Wales:

Take Home Naloxone

2017-18

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About Public Health Wales Public Health Wales exists to protect and improve health and wellbeing and reduce health

inequalities for people in Wales. We work locally, nationally and internationally, with our partners

and communities.

The Substance Misuse Programme works to address both the current and emerging public health

threats in Wales and in line with the overarching strategic objective to ‘reduce health inequalities,

and prevent or reduce communicable and non-communicable disease, wider harms and

premature death related to drugs and alcohol’.

Substance Misuse Programme

Public Health Wales Number 2 Capital Quarter Tyndall Street

Cardiff CF10 4BZ

Tel: 02920104496 www.publichealthwales.org/substancemisuse

Acknowledgements: Public Health Wales would like to thank all those that contributed to the Harm Reduction Database Wales: Naloxone service users, their families, friends and carers, Naloxone staff and all provider organisations including specialist substance misuse services, Criminal Justice services including Prisons, Police, DIP and IOIS and specialist housing and hostel/homelessness service providers. Published: Drew Turner, Gareth Morgan and Josie Smith, Substance Misuse Programme, Health Protection Division, Public Health Wales, 2018.

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Contents

1 EXECUTIVE SUMMARY ...................................................................................................... 5

2 THN USED IN FATAL/NON-FATAL DRUG POISONING EVENTS ......................................... 7

2.1 Outcome of drug poisoning events ...................................................................... 7

2.2 The recipient and administrator of THN............................................................... 8

2.3 Setting of opioid poisoning events ....................................................................... 8

2.4 Follow-on care ...................................................................................................... 9

2.5 Role of THN kit holder ........................................................................................ 10

2.6 Demographics of THN kit holders ....................................................................... 10

3 THN DISTRIBUTION ......................................................................................................... 14

3.1 Sites supplying THN Following ............................................................................ 14

3.2 Individuals supplied with THN ............................................................................ 14

3.3 Number of kits provided ..................................................................................... 15

4 INDIVIDUALS SUPPLIED WITH THN FOR THE FIRST TIME ............................................... 16

4.1 Number of unique individuals ............................................................................ 16

4.2 Role of person supplied with THN ...................................................................... 16

4.3 Coverage of THN ................................................................................................. 17

4.4 Demographics of individuals newly supplied with THN ..................................... 18

5 RE-SUPPLY OF THN ......................................................................................................... 21

5.1 Reason for re-supply ........................................................................................... 21

6 SUPPLY OF THN BY HEALTH BOARD / AREA PLANNING BOARD (APB) AREA................. 22

7 THN DISTRIBUTION - PRISON VS. COMMUNITY ............................................................. 25

8 APPENDICES 8.1 Background ......................................................................................................... 26

8.2 What is THN? ...................................................................................................... 26

8.3 Harm Reduction Database Wales (HRD) ............................................................ 26

8.4 Data definitions .................................................................................................. 27

8.5 Data recorded on HRD – Naloxone..................................................................... 28

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25,767

Estimated opioid

users in Walesa

19,159 Total Take Home

Naloxone kits issued

in Wales (since July

7,674 Unique individuals

supplied THN

8,377 THN re-supply

events

2,186

Reported uses

of THN during

25

Fatalities

11,813 Estimated opioid

injectors in contact with

NSP services in Wales b

a Data mining Wales: The Annual Profile of Substance Misuse in Wales, Health Protection Division, Public Health Wales

(2017). Available at:: http://www.wales.nhs.uk/sitesplus/888/page/72998 b Harm Reduction Database Wales: Needle and Syringe Programmes, Health Protection Division, Public Health Wales (2018), Available at: http://www.wales.nhs.uk/sitesplus/888/page/72998

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1 Executive Summary

The supply of ‘Take Home Naloxone’ (THN) was initiated in 2009 as a harm reduction tool used to

prevent fatal opioid poisonings. This report provides data on the provision of THN kits from 57

registries across Wales as recorded on the Harm Reduction Database Wales (HRD) during the period

1st April 2017 to 31st March 2018.

Key findings:

Since 1st July 2009, 19,159 THN kits have been issued to 7,674 unique individuals in Wales – this

includes 9,094 kits to new individuals and 10,065 kits as re-supply following the use, loss, or

expiry of previous kits

A total of 4,120 THN kits were issued (supplied and re-supplied) in Wales during 2017-18 – a

reduction of 9 per cent on the previous year

During 2017-18, a total of 1,372 new individuals were supplied with THN and 1,689 existing THN

kit holders were re-supplied. Amongst those new individuals receiving THN, 25 per cent were

listed as family / partner / carers or professionals working with people at risk of opioid poisoning

THN used in fatal/non-fatal drug poisoning events:

Since 1st July 2009 THN has reportedly been used during 2,186 drug poisoning events

THN was reportedly used in 533 drug poisoning events during 2017-18. There were 470 reported

non-fatal drug poisonings compared to less than 5 recorded as fatal

In 87 per cent of cases, THN was administered to a third party rather than to the THN kit holder,

and 62 per cent of all reported drug poisoning events occurred within a private residence

Follow-on care (ambulance) was requested in only 49 per cent of all cases where THN was used

in a drug poisoning event, representing a four percentage point decrease on the previous year

New individuals issued THN - Demographics:

Of those newly supplied with THN (n=1,451): the mean age was 38 years (ages ranged from 17-

70 years), 7 per cent of THN kits were issued to ‘young people’ (under 25 years), and 31 per cent

were female

Re-supply of THN:

There was a 4 per cent increase in kit re-supply events in Wales (n=2,503) when compared to the previous year. ‘Kit Lost’ accounted for 62 per cent of reasons for re-supply

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Recommendations

1. Services should work to raise awareness and actively encourage all individuals taking and especially injecting opioids, particularly within private residences, to adopt simple harm reduction steps3 to prevent fatal drug poisonings. Specific advice should include:

Always carry THN kit with you

Do not inject alone

It is safer to use in sight of others. If insistent on injecting out of sight, let someone know where you are going, leave the door unlocked and make sure the door cannot be blocked

Ensure there is someone present capable of identifying and responding to a potential drug poisoning event – have THN kit to hand and let others know where it is

Adopt a ‘designated smoker’ approach - where one individual smokes a small amount rather than injects so that they are better able to respond in the event of a drug poisoning

2. Research is required to establish the reasons behind the decrease in follow-on care /

requesting paramedic attendance following an opioid poisoning event. A campaign to reverse this trend should then be developed nationally.

3. In 2017-18, a total of 5,052 individuals reporting opioid use attended specialist NSP

substance misuse services, of which 3,580 attended regularly. All of these individuals should have THN, along with their close contacts. Provision of THN should be scaled up to ensure coverage amongst all relevant specialist substance misuse service users.

4. In addition to those attending specialist NSP services, 57 per cent of individuals who

report injecting opioids only access NSP services through community pharmacy services. This is especially true in more rural communities. It is recommended that the provision of THN is extended into community pharmacies alongside specialist services to ensure maximum coverage.

5. Service providers should continue to work with those returning for re-supply in order to

discuss and identify methods of THN safer storage to prevent erroneous reporting of ‘Kit Loss’ and where possible, work towards reducing stigma in reporting non-fatal drug poisoning events.

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2 THN used in fatal/non-fatal drug poisoning events A key feature of the take home naloxone (THN) module on the Harm Reduction Database Wales

(HRD) is the ability to record, when an individual is re-supplied, if the previously supplied THN kit

was used in a drug poisoning event. However, as all data is self-reported, use of a THN kit in opioid

drug poisonings is potentially under-reported.

From 1st April 2017 to 31st March 2018, there were 533 recorded incidences in Wales where THN

was used in a drug poisoning event, a 9.5 per cent reduction from the previous year, where 589

incidences were recorded. Over the same period, there was a 3.1 per cent reduction in the number

of unique individuals reporting using their THN kit in a drug poisoning event.1 This is the first year

where the number of recorded uses of THN in a drug poisoning event has dropped after

consecutive year on year increases since the program began formally in 2011-12.

2.1 Outcome of drug poisoning events

As shown in Figure 1, the majority of drug poisoning events where THN is used have a recorded

outcome of non-fatal drug poisoning. In 2017-18:

Less than one per cent of THN events were reported as fatal drug poisonings

88.2 per cent (n=470) of recorded events were non-fatal

11.1 per cent (n=59) had no outcome recorded

Since 2009 there have only been 25 known fatal drug poisonings recorded on the HRD where THN was used

compared to 1,965 recorded as non-fatal drug poisoning events.

Figure 1 - Number of reported uses of Take-home Naloxone (THN) by outcome 2009-10 to 2017-18

1 Date of drug poisoning event is taken as the date of re-supply.

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2.2 The recipient and administrator of THN

Take-home Naloxone can help prevent a fatal opioid drug poisoning. In 2017-18, the recipient of

THN was known in 505 opioid poisoning events (94.7 per cent) reported on the HRD. Of these:

87.1 per cent (n=440) THN was administered to a third party other than the individual

provided with the kit, the ‘THN kit holder’.

Where THN was provided to a third party:

- the THN kit holder administered THN in 79.8 per cent (n=351) of drug poisoning events

- 6.4 per cent (n=28) were administered by a professional (including hostel staff)

- 10.9 per cent (n=48) were administered by a friend, partner or family member

- An administrator was not recorded for 3 per cent (n=13) of events

In the remaining 12.9 per cent of events (n=65), THN was administered to the THN kit holder

by a third party, of which:

- 50.8 per cent (n=33) were administered by friends, partners or family

- 26.2 per cent (n=17) were administered by a professional

- The person administering the kit was not recorded in the remaining 23.1 per cent

(n=15) of events

2.3 Setting of opioid poisoning events

To reduce future fatal and non-fatal poisonings it is important to recognise and identify the

common settings of opioid poisoning events to better identify appropriate interventions and

targeting of services.

In 2017-18, 94.7 per cent (n=505) of drug poisoning events on the HRD had a setting of opioid

poisoning recorded. Figure 2 shows the proportion of opioid poisoning events where THN was used,

by setting over the last 4 years. A private residence remains the most common setting, reported for

62 per cent of events in 2017-18, a figure similar to previous years. However, the percentage of

events where THN was reported being used in a public place has increased for the last four years,

from 22 per cent in 2014-15 to 29 per cent in 2017-18. This could be due to improved reporting of

drug poisoning events in public places due to an increase in ‘first responder’ schemes implemented

in some services in Wales. There has also been a decrease in the proportion of uses of THN within a

hostel setting, from 19.6 per cent in 2014-15 to 8.5 percent in 2017-18. This may be as a result of

increased use of Synthetic Cannabinoid Receptor Agonists (SCRAs) rather than opioids amongst

hostel residents (Huggard Centre, Cardiff, personal communication July 2018).

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Figure 2 - The proportion of THN events by setting 2014-15 to 2017-18

Whilst THN has proven to be effective where reported, a substantial proportion of fatal drug

poisonings still occur within a private residence.2 Qualitative research has indicated a number of

high risk practices continue resulting in delays in potentially life-saving actions including; using

alone, using with individuals too intoxicated to respond or using in a difficult to access location. 3

2.4 Follow-on care

Details of follow-on care were recorded for 90.5 per cent (n=484) of opioid drug poisoning events. A

summary of the actions taken can be found below in Table 1.

Table 1 – Follow-on care reported for drug poisoning events on the HRD, 2014-15 to 2017-18

Where recorded, paramedic teams were called to attend 49.3 per cent of cases (n=239) where use

of THN was reported, a reduction from 52.8 per cent in the previous year. The individual was taken

to hospital in 24.3 per cent (n= 118) of events, also a reduction compared to the previous year, 27.1

per cent in 2016-17. This is of concern as the data indicate that in 2016-17, the number of opioid

2 Public Health Wales (2017), Harm Reduction Database: Fatal and Non-Fatal Drug Poisonings 2017. Available at: www.publichealthwales.org/substancemisuse

3 Holloway, K. & Hills, R. (2017). A Qualitative Study of Fatal and Non-Fatal Overdose Among Opiate Users in South Wales

2014-15 2015-16 2016-17 2017-18

Ambulance called 148 274 292 239

No further action 0 25 60 63

Person refused hospital 58 90 82 58

Person taken to hospital 90 159 150 118No ambulance called 97 135 261 245

No follow on care recorded 12 24 36 49

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related drug poisoning hospital admissions were at the highest levels recorded in the last decade

(2017-18 figures pending). 4

Figure 3 – Proportion of drug poisoning events recorded on the HRD with details of follow on care, 2014-15 to 2017-18.

2.5 Role of THN kit holder

Following changes to the Human Medicines Act (Amendment) (No.3) Regulations (2015), THN could

be issued to carers, family and relevant professionals alongside those at risk of an opioid poisoning.

In 2017-18, 91.6 per cent (n = 483) of individuals reporting having used THN in an opioid drug

poisoning event were considered the person ‘at risk’, 3.2 per cent (n=17) were family or carers and

6.2% (n=33) were professionals. This highlights the importance of continuing to provide THN to

individuals considered ‘at risk’, as well as their close contacts.

2.6 Demographics of THN kit holders

The following demographics refer to unique individuals, whose THN kit was used during a fatal or

non-fatal opioid poisoning event. Understanding the demographic profile of those individuals

whose kit has been used supports services to identify potential ‘first-responders’ who may prevent

future fatal drug poisonings.

The demographic data presented focus exclusively on individuals who are themselves at risk of an

opioid poisoning event. Those who report being carers, family or professionals are not included.

4 Public Health Wales. Data Mining Wales: Annual Profile of Substance Misuse in Wales 2016-17. Available at:

http://www.wales.nhs.uk/sitesplus/documents/888/FINAL%20profile%20for%20substance%20misuse%202016-17%20%282%29.pdf

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These demographics are not representative of individuals who have experienced an opioid

poisoning as THN is often used on a third party not the individual supplied with the kit.

Table 2 Demographics of at risk individuals who used their THN kit in a drug poisoning event, 2014-15 to 2017-18

2.6.1 Gender and age profile

In 2017-18, the most common age groups were 35-39 and 40-44 years, each representing 22.3 per

cent of individuals. As shown in Figure 4 and Figure 5, females tend to be younger than males.

Table 3 – Number of ‘at risk’ individuals who used their THN in a drug poisoning event by age group and gender, 2014-15 to 2017-18

2014/15 2015/16 2016/17 2017/18

Percentage female 34% 34% 34% 33%

Median age 34 36 37 38

Age range 18-57 19-57 21-59 22-60Percentage under 25 8% 5% 3% 3%

Percentage in non-stable housing 16% 14% 10% 10%Percentage with no fixed abode 19% 34% 40% 36%

Percentage White Welsh/British 96% 94% 96% 93%

2014-15 2015-16 2016-17 2017-18Female 109 164 217 191

Under 25 12 19 12 9

25-29 38 23 21 25

30-34 30 53 77 52

35-39 18 22 37 45

40-44 5 27 33 31

45-49 2 10 23 19

50 + 4 10 14 10

Male 148 269 372 342

Under 25 7 7 10 7

25-29 22 34 55 33

30-34 37 64 68 58

35-39 38 71 88 74

40-44 25 48 72 88

45-49 12 30 50 43

50 + 7 15 29 39

Total 257 433 589 533

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Since 2014-15 the median age of ‘at risk’ THN kit holders has increased by 4 years from 34 in 2014-

15 to 38 in 2017-18. The proportion of individuals who are under the age of 25 has declined from

7.4 per cent in 2014-15 to 3 per cent for the years 2016-17 and 2017-18. The proportion of female

‘at risk’ individuals using THN has decreased over the four year period from 42.4 per cent in 2014-

15 to 35.8 per cent in 2017-18.

Figure 4 - Age distributions of ‘at risk’ females who reported using THN in an opioid drug poisoning event

Figure 5 - Age distributions of ‘at risk’ males who reported using THN in an opioid drug poisoning event

2.6.2 Ethnicity

Ethnicity was reported by 72 per cent (n=386) of individuals who had used THN during a drug

poisoning event in 2017-18. Where reported, 93 per cent (n=357) were either White Welsh or

White British. The most common ethnicities other than White Welsh/British were White Irish (1 per

cent) and Mixed: White & Black African (1 per cent).

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2.6.3 Housing status

Housing status was recorded for 64 per cent (n=349) of individuals using THN during a drug

poisoning event. Over 54 per cent (n= 185) of individuals lived in secure accommodation. For the

remaining 46 per cent, 10 per cent (n= 69) reported as living in non-secure housing and 36 per cent

(n=126) reported having no fixed accommodation.

2.6.4 Risk behaviour

Risk behaviour was reported for 78.4 per cent (n= 418) of individuals who used their THN in a drug

poisoning event. Where reported, poly-drug use was identified as the primary risk factor by 81.3

per cent (n=340). Recent release from prison was reported by 9.8 per cent (n=41) of individuals, 4.6

per cent reported having recently left detox/rehab and 4.3 per cent were new opiate users.

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3 THN distribution

3.1 Sites supplying THN Following

The number of sites distributing THN within Wales has increased year on year (see Figure 6) from 11 when

the program began in 2009 to 57 in 2017-18. Since the amendments to the Human Medicines Act

Regulations in 2015, THN can be provided by all services commissioned in the provision of drug treatment

rather than only by named qualified professionals, resulting in an increase in the number of services in which

THN can be provided as well as the number of individuals with easy access to THN.

Figure 6 - Time series of sites distributing THN, number of unique individuals (100s) accessing THN and number of THN kits provided (100s), 2014-15 to 2017-18

3.2 Individuals supplied with THN

Since the 1st July 2009, 7,676 unique individuals have been supplied THN over a total of 16,051

supply events. A total of 2,896 unique individuals were supplied with THN in 2017-18, an increase of

4.7% compared to the previous year. This continues the year on year increase since the program

began. However, it is the smallest annual increase observed since 2012-13.

In 2017-18 there were 1,372 individuals supplied with THN for the first time (down from 1,451 in

the previous year) and 2,504 instances where an individual was re-supplied with a new THN kit (up

from 2,405). It is expected, as the proportion of individuals who use opioids carrying THN increases,

there will be less individuals newly trained and more re-supply events.

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21

3028

32

38

43

5457

3.1 4.7

9.7 10.3

18.0

27.9

31.9

44.941.2

2.9 4.3

8.3 9.011.4

13.4

18.5

27.7 29.0

2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

Number of Sites Kits provided (100s) Unique clients (100s)

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Table 4 – Number of sites, unique indiviuals and THN kits provided by year, 2009-10 to 2017-18

3.3 Number of kits provided

Since 2009, 19,159 THN kits have been provided. In 2017-18, 4,120 kits were provided by services, a

reduction of 9 per cent compared to the previous year. This may be explained by the introduction

of 5 dose Prenoxad injection® kits in services over 2016-17, replacing the single dose ‘Welsh kit’.

The Prenoxad injection® kits were introduced so that multiple doses could be provided on occasions

where one dose may be insufficient to reverse the opioid poisoning or when more time is needed

for follow-on care, without the need to carry multiple kits. In 2017-18, over 99 per cent of the kits

provided were Prenoxad ®kits.

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4 Individuals supplied with THN for the first time

4.1 Number of unique individuals

The number of new unique individuals supplied with THN in Wales decreased by 5.4%, from 1,451

in the previous year to 1,372 in 2017-18. A total of 7,676 unique individuals have been supplied

THN since the program began.

Figure 7 - Number of new unique individuals supplied with THN by year, 2009-10 to 2017-18

4.2 Role of person supplied with THN

The amendments to the Human Medicines Act Regulations in 2015 have provided opportunities for

a wider range of individuals to be issued THN, including friends and carers of people at risk and

professionals or volunteers who are potentially more likely able to respond in an opioid drug

poisoning event.

In 2017-18, a quarter of new individuals supplied with THN were either family or carers of an ‘at

risk’ individual (9.5 per cent, n = 130) or professionals (15.1 per cent, n = 207), representing

marginal increases from the previous year. The number of new unique ‘at risk’ individuals provided

with THN in 2017-18 remains comparable with recent years with 1,035 individuals provided with

THN kits in 2017-18, as shown in Figure 8.

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Figure 8 – Number of unique individuals supplied by role, 2009-10 to 2017-18.

4.3 Coverage of THN

Whilst provision of THN throughout Wales continues to grow, prevalence estimates of populations

at risk of an opioid poisoning highlight that saturation still has not been achieved. Estimates of

problem drug use indicate that there are approximately 25,767 opioid users5 in Wales (including all

methods of use i.e. smoking, injecting etc. Activity data on individuals accessing Needle and Syringe

Programmes (NSP) across Wales indicates that for 2017-18 there were 11,813 unique opioid users

attending NSP services of which 6,395 were attending on a regular basis.6,7 Further work will need

to be undertaken to establish an estimate of coverage of THN among the at-risk population once

the estimates of problematic drug users (including both opioid injectors and non-injectors) for

2017-18 have been published.

In 2017-18, a total of 5,052 individuals reporting opioid use attended specialist substance misuse

services, of which 3,580 attended regularly. All of these individuals should have THN, along with

their close contacts. The NSP report also indicates that 57 per cent of individuals who report using

opioids only access NSP services through community pharmacy services. This is especially true in

more rural communities such as Hywel Dda University Health Board and Betsi Cadwaladr University

Health Board where over 90 per cent of all NSP transactions occur in a community pharmacy.

Currently THN is only available in specialist substance misuse services and not community

pharmacies. It is therefore recommended that the provision of THN is extended into community

pharmacies alongside specialist services to ensure maximum coverage.

5 Public Health Wales (2017): Data Mining Wales: The Annual Profile for Substance Misuse 2016-17 6 Harm Reduction Database Wales, Health Protection Division, Public Health Wales (2017) 7 Attended NSP at least twice in between 1st April 2017 – 31st March 2018

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4.4 Demographics of individuals newly supplied with THN

This section explores the demographics of individuals who have been newly supplied with THN in

2017-18. It focuses exclusively on individuals who are themselves ‘at risk’ of a drug poisoning event.

Those who report being carers, family or professionals have been excluded.

Table 5 – Demographics of individuals newly supplied THN, 2014-15 to 2017-18

2014/15 2015/16 2016/17 2017/18

Percentage female 27% 29% 31% 31%

Median Age 35 36 37 38

Age Range 16-67 16-70 17-74 17-70

Percentage under 25 9% 7% 7% 7%

Percentage in non-stable housing 10% 10% 11% 11%

Percentage with no fixed abode 21% 27% 24% 23%

Percentage White Welsh/British 95% 90% 92% 91%

4.4.1 Gender and age profile

Of the 1,133 unique ‘at risk’ individuals newly supplied with THN, 31 per cent were female and the

median age was 38. This is higher than the proportion reported by the NSP report for 2017-18

which indicated that just under 20% of individuals regularly accessing NSP services are female. The

proportion of newly supplied individuals who are female has been steadily increasing each year

since 2014-15, from 27 per cent to 31 per cent in 2017-18.

Table 6 – Number of individuals newly supplied THN by gender and age, 2014-15 to 2017-18

2014-15 2015-16 2016-17 2017-18Female 232 303 542 537

Under 25 31 41 53 35

25-29 51 49 100 72

30-34 58 76 116 100

35-39 36 57 99 104

40-44 25 31 78 72

45-49 16 20 40 71

50 + 15 29 56 83

Male 624 755 909 832Under 25 62 42 56 58

25-29 94 88 97 102

30-34 119 160 153 121

35-39 132 169 209 179

40-44 107 133 171 148

45-49 64 88 102 112

50 + 46 75 121 112

Other 0 0 0 3

Total 1712 2116 2902 2741

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The median age of ‘at risk’ individuals newly supplied with THN has also increased from 35 in 2014-

15 to 38 years in 2017-18. The most common age group overall was 35-39 years accounting for 23

per cent. This remains consistent with the previous year. The most common age group for females

is younger with 23 per cent being in the 30-34 years age group. The age distributions are shown in

Figure 9 and Figure 10.

Figure 9 Age distributions of females newly supplied with THN, 2014-15 to 2017-18

Figure 10 - Age distributions of males newly supplied with THN, 2014-15 to 2017-18

0%

5%

10%

15%

20%

25%

30%

16-17 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

Female 2014-15 2015-16 2016-17 2017-18

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4.4.2 Ethnicity

Ethnicity was recorded for 26.2 per cent (n=359) of individuals who have been newly supplied.

Where reported, 91.1 per cent (n=381) were either White Welsh or White British. The most

common ethnicity other than White Welsh/British were White - Other (3 per cent, n=14).

4.4.3 Housing status

Housing status was reported for 22.7 per cent (n=312) of newly supplied ‘at risk’ individuals. Since

2014-15, data completeness for this data item has substantially declined. In 2017-18, 77.3 per cent

of newly supplied individuals did not have a housing status recorded.

Where reported, 23.4 per cent (n= 73) reported having no fixed address. A further 11.5 per cent

reported living in non-stable housing and 65.0 per cent reported living in secure housing.

4.4.4 Risk behaviour

Amongst ‘at risk’ individuals newly supplied with THN, a risk behaviour was recorded for 67 per cent

(n=695). Of which, the majority, 69 per cent (n=482), reported poly-drug use as their primary risk

behaviour. A further 12 per cent (n=81) reported being a new opioid user, which is higher than the

6 per cent of opioid injectors accessing NSP who were identified as new initiates.8 For the remaining

individuals, 12 per cent reported recently leaving detox or rehab (n=85) and 7 per cent (n=47)

reported being recently released from prison.

8 An injecting career of 36 months or less

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5 Re-supply of THN Individuals who carry THN are able to collect replacement or additional kits from services. In 2017-

18, 2,503 re-supply events took place across Wales, involving 1,689 unique individuals. Compared

to 2016-17, this is a 4 per cent increase in the number of re-supply events and an 11 per cent

increase in the number of unique individuals re-supplied.

Including those newly supplied, in 2018-17, 79 per cent (n=2,277) of individuals provided with THN

were supplied with THN once in 2017-18. A further 14 per cent (n=407) were supplied twice and 7

per cent (n=212) were supplied three or more times. These figures are consistent with previous

years as shown in Figure 11.

Figure 11 – Percentage of individuals accessing services multiple times during one year, 2014-15 to 2016-

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5.1 Reason for re-supply

A reason for re-supply was provided for 100 per cent of re-supply events. The most common

response provided at a re-supply event for each of the last four years was “Kit lost”, recorded for 52

per cent (n=1296) of events in 2017-18. A further 21 per cent (n= 533) stated they had used their

previous THN kit in a drug poisoning event. This proportion has decreased from to 31 per cent in

2015-16. It is currently not possible to evidence how many of the kits issued may have been used in

opioid poisoning events and not reported as such.

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Figure 12 – Percentage of resupply events where a reason for resupply was provided.

In 21 per cent of re-supply events, the reasons recorded was ‘kit was out of date’, an increase from

16 per cent in 2016-17. The THN kits have a shelf life of approximately 24 months post

manufacture. Although it is encouraging that more individuals are returning to services to renew

their THN kits, services should still actively seek out individuals with expired kits.9 Furthermore,

those who have not been re-provided with additional THN kits in the last two years are encouraged

to collect a new Prenoxad Injection® kit which will be fully effective in the event of an overdose.

6 Supply of THN by Health Board / Area Planning Board (APB) area

To compare the number of kits provided by APB, European age standardised rates (EASR) per

100,000 population have been calculated for all unique and newly supplied individuals (Table 7,

Table 8, Figure 13 and Figure 14).

Cardiff and Vale University Health Board (CVUHB) provided the highest provision of THN with an

EASR of 147.9 individuals per 100,000 population, followed by Abertawe Bro Morgannwg University

Health Board (ABMUHB) with 139.5 individuals per 100,000 population. These figures could have

been slightly inflated by the presence of the three prisons within these Health Board / APB areas.

An increase in the EASR of unique individuals per 100,000 population has been observed in all other

health boards except for Hywel Dda University Health Board, where figures remained comparable

with the previous year.

As reported earlier, the number of new individuals who have been supplied with THN has dropped

across Wales. The Wales-wide EASR has decreased from 50.4 individuals per 100,000 population in

2016-17 to 47.3 in 2017-18. However, increases in EASR of new individuals per 100,000 population

were observed Cwm Taf and Hywel Dda University Health Boards in each of the last 3 years.

9 Report 304 on the report suite on the HRD-Take home Naloxone Module

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Table 7 – Number of sites, unique individuals and THN kits provided by Health Board/APB area, alongside European age standardised rate (EASR) of unique individuals supplied with THN per 100,000 population, 2014-15 to 2017-181011

Figure 13 - EASR of unique individuals provided with THN by Health Board/APB area, 2014-15 to 2017-18

10 Calculated using on mid-year population estimates (ONS, 2015 ,2016 & 2017) 11 Includes prisons located within the Health Board area

Health Board Sites provding THNUnique individuals

2017-18No of Kits EASR 2014-15 EASR 2015-16 EASR 2016-17 EASR 2017-18

Abertawe Bro Morgannwyg 11 12 700 1018 98.4 111.4 146.3 139.5

Aneurin Bevan 10 471 618 38.5 42.8 82.2 86.0

Betsi Cadwaladr 7 384 446 28.1 28.4 49.6 63.6

Cardiff and Vale11 8 718 975 58.5 123.2 151.6 147.9

Cwm Taf 7 259 378 16.6 60.2 78.0 92.1

Hywel Dda 6 272 371 33.1 41.5 84.3 85.3

Powys Teaching 5 87 111 33.1 14.5 58.2 85.8

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Table 8 - European age standardised rate (EASR) of new individuals supplied with THN per 100,000 population, 2014-15 to 2017-18 10

Figure 14 - EASR of new unique individuals provided with THN by Health Board/APB area, 2014-15 to 2017-18

10 Calculated using on mid-year population estimates (ONS, 2015, 2016 & 2017)

11 Includes prisons located within the Health Board area

Health Board

New Unique

individuals

2017-18

EASR 2014-15 EASR 2015-16 EASR 2016-17 EASR 2017-18

Abertawe Bro Morgannwyg 11 256 62.9 61.1 65.5 50.7

Aneurin Bevan 233 21.3 21.1 42.4 41.9

Betsi Cadwaladr 253 17.8 20.3 32.8 41.5

Cardiff and Vale11 288 38.2 70.4 71.0 58.3

Cwm Taf 131 11.2 36.0 42.5 47.0

Hywel Dda 146 21.5 22.7 49.3 44.3

Powys Teaching 35 26.9 7.9 22.6 35.3

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7 THN distribution - Prison vs. Community

Following release from prison, opioid users are at increased risk of fatal and non-fatal drug

poisoning. Currently there are six male-only prisons located within Wales, three of which currently

provide THN to individuals identified at risk upon release. A recently opened prison in North Wales,

HMP Berwyn, began to provide THN to prisoners on release from April 2018 and as such their data

are not included in this report. Two further prisons, located in England identified as housing Welsh

residents, also provide THN.

In 2017-18, a total of 763 supply events (19.7 per cent of all supply events) occurred in a custodial

setting, an increase from 14.2 per cent from 2014-15. Since implementation in Wales in 2009, THN

has been supplied to either new individuals or as a re-supply within a custodial setting on 2,437

occasions. During this time 986 unique individuals received THN for the first time on release from

custody.

In 2017-18, THN kits were provided to 586 unique individuals, an increase of 9 per cent compared

to 2016-17. Of these, 174 individuals received THN for the first time, 12.7 per cent of all new

supplies recorded on the HRD in 2017-18. This demonstrates that the prison estate continues to

remain an important asset to ensuring the supply of THN to new individuals throughout Wales.

Table 9 – Number of re-supply events in Wales in a custodial setting, by site and year

Site 2014-15 2015-16 2016-17 2017-18

Gwent Police 0 0 54 41

HMP Cardiff 85 152 305 256

HMP Eastwood Park 0 0 116 201

HMP Parc 81 38 26 12

HMP Stoke Heath 0 0 0 2

HMP Swansea 85 141 154 251

Total 251 331 655 763

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8 Appendices

8.1 Appendix I: Background

In July 2009 the Take Home Naloxone (THN) pilot project was launched by Welsh Government (WG)

in selected areas of Wales. The key aim of the project was to reduce drug-related deaths in Wales.

In addition, the project aimed to promote harm reduction and to improve the health and social

wellbeing of drug users. The evaluation report is available at:

http://wales.gov.uk/about/aboutresearch/social/latestresearch/naloxoneproject/?lang=en

Full national implementation of THN projects throughout Wales was approved by WG in May 2011.

Full reports indicating the provision of THN throughout Wales from 1st July 2009 – 31st March 2017

can be obtained from:

www.publichealthwales.org/substancemisuse

8.2 What is THN?

Naloxone is a competitive opioid antagonist and has been commonly named a ‘Heroin Antidote’. It

works by temporarily binding to opioid receptors in the brain and body and counteracting the

effects of opioids. This has been proven to bring a patient experiencing poisoning through opioid

use to consciousness in minutes following administration, thus restoring breathing and preventing

fatal poisoning. The effects of Naloxone last approximately 20 minutes following administration and

follow-on care is vital to ensure the prevention of subsequent poisoning. What Naloxone does is

provide time prior to the arrival of emergency services and follow-on care.

Further information and publications available at: www.naloxonesaveslives.co.uk

8.3 Harm Reduction Database Wales (HRD)

HRD Wales is a web-based data collection system used to record a range of activity related to harm

reduction interventions, including needle and syringe provision and reduction of opioid deaths

through THN.

From 1st April 2012 the ‘HRD – Naloxone’ module was implemented to record THN-related activity.

A back population exercise was also completed to ensure that all of the data from the pilot project

and first year of implementation was securely stored on the HRD. This development allows the

recording of all unique individual activity relating to the training and issue of THN, and provides

clinicians with the ability to obtain live data relating to THN activity. For each individual accessing

services, the database allows the recording of: referral to THN services, completion of training

sessions (recognising overdose and how to use THN) and details relating to the supply and re-supply

of THN. Details surrounding the type of information recorded are outlined in Appendix I.

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8.4 Data definitions

This report details the THN activity data recorded on the HRD from 1st April 2017 to 31st March

2018. During this period THN training and distribution was recorded on the HRD by 54 registries

throughout Wales. This includes statutory/voluntary substance misuse services, homelessness

hostels, and public/private sector prisons (see Table 7 for details).

Table 7: List of sites where THN training and supply has been recorded since 1st April 2016 – 31st March

2017

Data relating to re-supply and poisonings

The data contained within the subsequent section 3 - THN used in fatal/non-fatal opioid poisoning

events reflects only the information provided by those individuals who have returned for THN re-

supply. Currently there is no method of recording data relating to the use of THN should the client

not present for re-supply.

ABUHB - Young persons service Gwent Police

BCUHB SMS - Denbighshire HMP Cardiff

BCUHB SMSS - Flintshire HMP Eastwood Park

BCUHB SMS - Wrexham HMP Parc

BCUHB SMS - Ynys Mon HMP Stoke Heath

BCUHRT - Central - LD09 HMP Swansea

BCUHRT - East - CX07 Huggard Centre

BCUHRT - West - PE08 Kaleidoscope - Brecon

CAU - Cardiff Kaleidoscope - Llandrindod

CDAT - Aberystwyth Kaleidoscope - Newtown

CDAT - Carmarthen Kaleidoscope - Welshpool

CDAT - Merthyr Tydfil Kaleidoscope - Ystradgynlais

CDAT - Mountain Ash OIS - Cwm Taf

CDAT - Pembroke Dock OIS Bridgend

CDAT - Pontypridd OIS Cardiff and Vale

Newlink Wales - Bridgend OIS Neath

DDAS Carmarthenshire OIS Swansea

DDAS Ceredigion RISMS

DDAS Pembrokeshire Solas Cardiff

Barod Merthyr Tydfil Taith - Barry

Barod - Swansea Taith - Cardiff

GDAS - Blackwood TEDS

GDAS - Caerphilly UHW ED

GDAS - Citadel WCADA - Bridgend

GDAS - Monmouthshire WCADA - Neath

GDAS - Newport WCADA - Port Talbot

GDAS - Torfaen WCADA - Swansea

GSSMS

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8.5 Data recorded on HRD – Naloxone

Client Details:

The ‘client details’ section is a profile of an individual’s demographic and health status information (as indicated by the individual) for each person accessing THN services, and includes: Demographics including – ethnicity, housing status

Referral details including – non fatal poisoning (NFP) history, risk behaviour that lead to referral, current engagement in substance misuse services

Onward referrals – details of referrals to other specialist health and social care services offered to the client by staff issuing THN and training. This section allows the recording of referrals declined as well as accepted by the client.

Naloxone training:

This section records information relating to the training provided to the client in administering THN,

recognising opioid poisoning, and basic life support/CPR. Training is delivered to every client prior

to the initial issue of THN, and a refresher session is delivered on a yearly basis. The training section

is completed during every event where training is delivered to a service user, their family/friends, or

a working professional. This enables service users to evidence completion of training prior to being

issued THN. Details contained within this section include date of training, date of next training due,

trainer’s details and training elements provided.

Consent:

Prior to the issue of THN, every client is required to complete an online consent form where they

declare no knowledge of adverse effects to THN, that satisfactory information and training was

provided in the use of THN, that they will adhere to appropriate use of THN and the equipment

issued and that their information may be stored on the HRD.

Naloxone supply/re-supply:

The supply/re-supply section contains details for all kits issued to the client, and is split into the following sections:

Supply/re-supply including – date of supply, batch number, expiry date, name of prescriber

Reason for re-supply including – batch recall, confiscated by the police, kit lost, out of date, used for poisoning

Who was supplied & additional detail including – individual THN was supplied to, details of follow-on care, outcome of poisoning (if applicable), free text box to record additional information