Stakeholder perceptions and operational barriers in the training and distribution of take-home naloxone within prisons in England

Abstract

BackgroundThe aim of the study was to assess potential barriers and challenges to the implementation of take-home naloxone (THN) across ten prisons in one region of England.MethodsQualitative interviews deploying a grounded theory approach were utilised over a 12- to 18-month period that included an on-going structured dialogue with strategic and operational prison staff from the ten prisons and other key stakeholders (n = 17). Prisoner perceptions were addressed through four purposive focus groups belonging to different establishments (n = 26). Document analysis also included report minutes and access to management information and local performance reports. The data were thematically interpreted using visual mapping techniques.ResultsThe distribution and implementation of THN in a prison setting was characterised by significant barriers and challenges. As a result, four main themes were identified: a wide range of negative and confused perceptions of THN amongst prison staff and prisoners; inherent difficulties with the identification and engagement of eligible prisoners; the need to focus on individual prison processes to enhance the effective distribution of THN; and the need for senior prison staff engagement.ConclusionsThe distribution of THN within a custodial setting requires consideration of a number of important factors which are discussed.

“Once I’d done it once it was like writing your name”: Lived experience of take-home naloxone administration by people who inject drugs

“…Many participants referred either directly or indirectly to administering the whole naloxone dose at once which sparked a range of negative reactions from the recipient including acute withdrawal and aggressiveness. The potential for naloxone administration precipitating acute withdrawal has been noted in other studies (Neale and Strang, 2015;Worthington et al, 2006;Wright et al, 2006) and has been cited as a possible barrier to PWID using naloxone for peer administration (Sondhi et al, 2016;Sporer and Kral, 2007;Worthington et al, 2006;Wright et al, 2006). Although few participants in this study reported personal experiences of acute opiate withdrawal, their experiences of witnessing it in others to whom they had given naloxone were often distressing.…”

Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone

“…The reasons "done with drugs" and "encourages abuse" arose in our study population, mirroring concerns elsewhere that THN kits with syringes could increase risky behavior or trigger opioid use relapses. [15][16][17] Nevertheless, THN program participation has been associated with decreased (rather than increased) high-risk opioid use. [29] Both patients accepting and refusing THN mentioned thoughts of suicide or not caring whether they overdosed.…”

“…In non-ED settings, factors contributing to refusals include reluctance to give injections, fear of triggering additional drug use, and inappropriate minimization of OD risk. [15][16][17][18][19] Conversely, patients are motivated to accept THN if they feel they can help others, [17,19,20] if they have had an OD themselves, [18] or if they know a peer with THN. [21] To improve quality and reach of ED THN distribution and education, it is crucial to gain greater understanding of reasons influencing THN refusal or acceptance in ED patients.…”

A mapping review of take-home naloxone for people released from correctional settings

“…Only one study focused on non-prisoners (Sondhi, Ryan, & Day, 2016). This study by Sondhi et al, also conducted across ten English prisons, employed qualitative interviews to assess the attitudes of prison-based healthcare staff and substance misuse service staff, along with naloxone suppliers and strategic leads for NHS England toward prison-based THN programs.…”

“…Several of the recent studies within this review have begun shifting the focus of research toward aspects of program implementation and highlight gaps in this knowledge. Sondhi's evaluation of barriers to program implementation from the perspectives of prisoner and non-prisoner stakeholders has revealed a need to understand prison processes, explore implementation of training at different time points in an inmate's sentence, and engage prison staff of varying levels of seniority in order to address barriers to implementation such as identifying and recruiting eligible prisoners for training and disseminating THN kits (Sondhi et al, 2016;Sondhi, 2016). These variables may differ between settings and local assessment is likely to be required before design and implementation of a THN program.…”