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

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 UKP 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 UKP 10 and offers of three for UKP
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."