Implementation of Systematic Programs of Overdose Training at Drug Treatment and Prevention Centres in Catalonia,

Transcription

1 Implementation of Systematic Programs of Overdose Training in Catalonia Implementation of Systematic Programs of Overdose Training at Drug Treatment and Prevention Centres in Catalonia, Albert Espelt 1,2,3 ; Xavier Major 4 ; Oleguer Parés-Badell 1 ; Sonia Carvajal 4 ; Carmen Vecino 1 ; Laia Gasulla 4 ; Marina Bosque-Prous 1 ; M. Teresa Brugal 1 Abstract Death due to overdose is a leading cause of death among people aged 15 to 44. Among drug users, there is a general lack of understanding of the risk factors that can lead to overdose and how to act when witnessing one. Thus, the Department of Drug Prevention and Care of the Catalan Government and the Public Health Agency of Barcelona have designed and deployed systematic training programs to increase understanding of overdose among drug users in Catalonia. The aim of this article is to describe these systematic programs of overdose training, and present data collected between 2009 and These programs have been successfully implemented in the majority of harm reduction centres, treatment centres and therapeutic communities in Catalonia. To date, training programs involving 4,828 drug users and 907 professionals have been conducted since the implementation of this strategy. 1 Introduction Death due to overdose is a leading cause of death among people aged 15 to 44 years. In this age group, it was the main cause of death among men and the second in women in Barcelona in 2011, with a mortality rate of 9 and 3.2 per 100,000 person-years, respectively (Agència de Salut Pública de Barcelona 2013). Almost a third of overdose deaths are caused by cocaine, while the remaining two thirds are caused by opiods (Bernstein/Bucciarelli/ Piper/Gross/Tardiff/Galea 2007). 1 Agència de Salut Pública de Barcelona. 2 Departament de Piscobiologia i Metodologia de la Universitat Autònoma de Barcelona. 3 CIBER de Epidemiologia y Salud Pública. 4 Departament de Salut de la Generalitat de Catalunya. Implementation of Systematic Programs of Overdose Training in Catalonia

2 84 3 Praxis in Europa Overdoses can be fatal or non-fatal. Thus, not only can overdoses be avoided, but also death can be avoided in individuals who have overdosed. Each year, between 9 and 22% (see Brugal/Barrio/Regidor/Royuela/Suelves 2002, Darke/ Ross/Hall 1996, Gossop/Griffiths/Powis/Williamson/Strang 1996) of heroin users suffer at least one non-fatal overdose (see Brugal/Barrio/Regidor/Royuela/Suelves 2002, Darke/Ross/Hall 1996, Gossop/Griffiths/Powis/Williamson/Strang 1996), whereas it varies from 3 to 9% in cocaine users, depending on the administration route (Kaye/Darke 2004). At any rate, overdoses can be prevented by taking their risk factors and behaviours into account, and can be reversed using simple measures when they do occur. Between 2 and 6% of all overdoses result in the death of the person, with this percentage depending on the population studied (Darke/Ross/Hall 1996, Darke/Mattick/Degenhardt 2003, Neale 2003, Espelt/Barrio/Álamo-Junquera et al. 2015). Among drug users, there is a general lack of understanding of the risk factors that can lead to overdose and how to act when witnessing one. We previously reported that young heroin users in Madrid, Seville and Barcelona had little knowledge of how to prevent an overdose (Neira-Leon/Barrio/Brugal/Ballesta/ Bravo et al. 2006), and that 29% of users at Harm Reduction Centres in Catalonia in 2008 were not able to give more than two reasons or actions for preventing overdoses or helping a person suffering an overdose. This poor level of understanding may be due to the lack of information programs and courses on this topic, which is supported by the fact that 73% of users of Harm Reduction Centres in Catalonia in 2008 reported that they had never attended an overdose prevention course (Sarasa-Renedo/Espelt/Folch/Vecino/Majó/ Castellano et al. 2014). Heroin overdose prevention and assistance programs have been effective in increasing understanding among intravenous drug users in various settings (Seal/Thawley/Gee/Bamberger/Kral/Ciccarone et al. 2005, Tobin/Sherman/ Beilenson/Welsh/Latkin 2009, Wagner/Valente/Casanova/Partovi/Mendenhall/ Hundley et al. 2010). Even in San Francisco, where users did not generally appear to apply the knowledge acquired from overdose programs, intravenous drugs users were very positive about participating in the prevention programs (Seal/Downing/Kral/Singleton-Banks/Hammond/Lorvick et al. 2003). At the beginning of the last decade, overdose prevention and harm reduction programs were developed in the Can Tunis neighbourhood of Barcelona in response to the high mortality from overdose in this area (Illundain 2006). However, these programs were not systematic and did not cover the entire city. Subsequently, due to the high number of injectors and growing evidence on the effectiveness of these programs, a systematic overdose prevention and assistance program was implemented throughout Catalonia in 2009.

3 Implementation of Systematic Programs of Overdose Training in Catalonia The aim of this article is to describe these systematic programs of overdose training, which were promoted by the Department of Drug Prevention and Care of the Catalan Government and Public Health Agency of Barcelona, and to present data collected between 2009 and Overdose Programs 2.1 Systematic overdose prevention programs in Catalonia Systematic overdose prevention programs are individual or group courses that are carried out regularly, and have been deployed throughout the Catalan network of drug prevention and treatment centres (i.e. harm reduction centres, drug treatment centres and therapeutic communities) since Currently, we are seeking to incorporate hospital detoxification and dual pathology units. In order to conduct systematic intervention, it is necessary that all centres have a protocol and a staff member responsible for implementing the program. Moreover, an annual meeting is held with these individuals to assess the implementation process and to establish annual coverage goals. Simultaneously, face-to-face and online training programs are offered to professionals at all centres. In addition, the protocol indicates that each centre must hold a clinical or scientific session about the program. 2.2 Aims of overdose prevention programs in Catalonia The main objectives of the overdose prevention programs are: 1) to reduce the number of opioid and psychostimulant overdoses; and 2) to reduce overdose mortality. The programs aim first to improve understanding of risky situations associated with drug overdose and how to prevent them, and second to improve the skills required to identify an overdose and knowledge of how to act when witnessing an overdose. 2.3 Target population of overdose prevention programs in Catalonia The main target population of these programs is users of opioid and pyschostimulant. However, the programs are also offered to relatives or friends who live with drug users, and people who may come into contact with

4 86 3 Praxis in Europa them at work. All persons registered for each program must give written informed consent, commit to attending the entire program, and not consume substances during the program. 2.4 Methodology of the Program Sessions and Materials The training program consists of a course, which can be conducted individually or in groups. Participants are trained in the various risk situations that can lead to overdose, emphasizing the personal risks of each user and recommending individual strategies to prevent overdoses. They also work on how to identify an overdose, and actions to perform when witnessing a cocaine or heroin overdose. This final section of the course is a practical exercise, with a role-playing game in which users come into contact with the material to be used and the problems that may arise. During the course, symptoms of overdoses of depressant drugs (focusing on heroin) and stimulating drugs (focusing on cocaine), and actions that may be taken are explained separately. Users understanding is evaluated at both the beginning and end of the course. Group courses are held mostly in harm reduction centres, and include about five participants. Individual sessions are mainly held in treatment centres, and are performed when a preliminary assessment of the user is needed to address their personal risk factors. These individual sessions can also be done in the street, but then the contents must be simplified and they must be focussed on the person s status. This training is facilitated by a short guide on counselling for heroin and cocaine overdose (Table 1). Increasingly, people opt for more flexible training that is adapted to individual circumstances in order to reach the most at-risk users, many of which are unable to attend formal courses. Once training is completed, participants complete a short questionnaire to assess whether they have acquired a basic understanding of overdose prevention and assistance, including the characteristics and use of naloxone. Participants who pass the test receive a naloxone kit (Figure 1) that allows them to act in case of a heroin overdose. The kit includes: two 1ml bottles of naloxone (0.4mg/ml), two retractable syringes, 1 pair of gloves, a protective mask for basic life support, two antiseptic wipes, and a prospectus. Thus, users become part of the naloxone program and must notify the centre of any use or loss of this substance. They are also given a card identifying them as an

5 Implementation of Systematic Programs of Overdose Training in Catalonia Overdose Health Agent, valid for 1 year (Figure 2), with the aim the users reassess their knowledge once a year, and undergo reinforcement training, if necessary. This reinforces their knowledge, and considers any difficulties that may be experienced by users. Figure 1. Naloxone kit

6 88 3 Praxis in Europa Personnel The courses are taught by two professionals with experience in overdose treatment and communication with users of intravenous drugs. In all cases, one is a health professional (doctor or nurse) and the other is a social worker. They receive an information manual on the prevention and treatment of overdoses (Majó/Illundain/Valverde 2009), a guide containing key points (Table 2), a slide presentation to use during the course, and a video 1 as support material, which addresses all of the issues that they have to deal with. Each centre must assign a 1 sobredosi/

7 Implementation of Systematic Programs of Overdose Training in Catalonia person responsible for the program and another in charge of its clinical aspects. Both functions can be served by the same professional, although in this case the person must be a doctor or a nurse. Each centre has some freedom to adapt itself to the general protocol, i.e. professionals in each centre can decide whether they do individual or group training, where the courses will be held, etc. The reason for this flexibility is that the program intends to be close to the personnel, to involve them in training strategies to identify the problem, to encourage them to suggest solutions and recommendations, and to take part in deploying the actions using contents and formats that they find acceptable. Thus, a key requirement is that each centre establishes an annual plan for training.

8 90 3 Praxis in Europa Evaluation and Incentives Throughout the learning process, participants in the overdose courses are evaluated three times. The course begins with an evaluation that is useful for the organisers to establish areas of lack of knowledge or specific skills in each group, and to compare participants knowledge before and after the course. At the end of the course, therefore, participants knowledge and behaviour related to opioid and psychostimulant overdose are evaluated, in order to decide whether they can receive the naloxone kit and the Overdose Health Agent card (Figure 2). The card identifies users who are experts in overdose, and allows them to obtain a reward of 5 to 10 for having taken part in the course. The evaluation is informally repeated a year later. If a lack of knowledge or skills is detected, the person can repeat the course. Figure 2. Overdose Health Agent card 3 Methods We performed a descriptive study, which had the following aims: a) to describe how to conduct overdose prevention training programs; b) to analyse the number of professional and users that have received overdose training in Catalonia; and c) to show the number of naloxone kits that have been delivered thanks to the overdose training program. This analysis included all participants in the overdose training program offered at harm reduction centres, treatment centres and therapeutic communities in Catalonia between 2009 and For each type of centre, we calculated the number of trained professionals, the number of trained users and the number of naloxone kits delivered.

9 Implementation of Systematic Programs of Overdose Training in Catalonia Results In Catalonia, there are 26 harm reduction centres, 64 treatment centres, and 17 therapeutic communities, 100% (26), 36% (23) and 88% (15) of which applied the overdose prevention training program in 2013, respectively. This program was introduced in harm reduction centres in March 2009, in therapeutic communities in 2010, and in treatment centres in January During the period , 508 professionals and 2,049 drug users were trained in harm reduction centres. In total, 4,383 naloxone kits were delivered, i.e. more than one naloxone kit for each user trained. However, in 2012 more than 30% of users trained at harm reduction centres did not receive the kit (Table 3). Regarding treatment centres, 168 professionals and 981 patients were trained between 2011 and 2013, and 987 naloxone kits were delivered (Table 4). Finally, 231 professionals and 1,798 users were trained at therapeutic communities between 2010 and 2013, although naloxone kits were not distributed at these centres (Table 5).

10 92 3 Praxis in Europa 5 Discussion Systematic overdose training programs have been successfully implemented in the majority of harm reduction centres, treatment centres and therapeutic communities in Catalonia. These training programs have reached 4,828 users and 907 professionals, allowing them to increase their knowledge on overdose-risk situations associated with drug use and how to prevent them. In addition, these courses have provided the participants with tools such as cardiopulmonary reanimation and the naloxone kit, which may prevent death in case of overdose (Baca/Grant 2005, Dietze/Cantwell/Burgess 2002). Finally, the courses have helped many professionals maintain more direct and constant contact with drug users. Systematic overdose training programs are structured, formal and, generally programmed interventions. The materials used have facilitated good maintenance over time, guaranteeing the sustainability of the program and ensuring re-evaluation of users knowledge at least once a year. The cost of the program is minimized by using the centres existing infrastructure since these workshops are self-managed by the centres and the professionals who work there. Thus, the only direct cost of the program is the naloxone kit (~ 6/ kit) and the replacement of bottles and syringes ( 1.3/bottle naloxone). Thus, the total cost of implementation was 31, for the period (~5,000 /year), dedicated exclusively to the naloxone kits. However, the total deployment of the courses includes other expenses, as follows for the period : specific personnel (103,607 ), graphic material (34,591 ), mannequins (2,787 ) and user incentives (20,000 ). Specific costs for personnel do not include those for personnel from the Department of Drug Prevention and Care of the Catalan Government or Barcelona Public Health Agency, who managed the design and implementation of the entire program.

11 Implementation of Systematic Programs of Overdose Training in Catalonia During the design of the training program, support material for professionals was assessed using a test designed ad hoc. However, self-management of these courses carried some difficulties, such as lack of time to carry them out within working hours, or the lack of necessary infrastructure in some centres. Some users had difficulty in keeping scheduled appointments or were reluctant to attend courses, especially in harm reduction centres. When were performed in groups, the sessions were very long, and some users may not have been able to follow them. Thus, it is important to develop short, flexible, individual sessions, and we also recommend the introduction of peer training. These two changes would allow us to reach more users, especially those with higher risk of acute poisoning. Since overdose is one of the leading causes of death in men aged 15 to 44 years in Barcelona, it is essential to act in people who may be exposed. Overdose training programs can be implemented in different contexts, using existing resources and with little extra cost for the services offered to drug addicts. Since overdoses are preventable and reversible if treated properly, it is essential to increase understanding and skills of users and other actors, in order to help when assisting others. It is also important that all centres systematically assess the individual overdose risk of each patient, and include the results of this evaluation in their medical record. There are also moments in the addiction treatment process in which risk of overdose is higher and, thus, preventive interventions are essential at these times. Many professionals often have little awareness of the importance of developing measures of risk detection and overdose prevention, especially those in centres designed to treat addiction, whereas those in harm reduction centres are usually more aware. Centres focused on abstinence-oriented treatment should prioritize this intervention, since the loss of tolerance is one of the most important risk factors for overdose. Moreover, we have also observed groups of patients who are less aware of their overdose risk. We also believe that a formal evaluation of the intervention is needed. It is important to know whether there is real improvement in users knowledge and skills, and if the overdose training courses meet their objectives. The proportion of the material provided to users that is finally used when they witness an overdose, or an increase in the number of emergency calls from people witnessing an overdose are indicators of the proper functioning of this systematic program. Moreover, it will be important to assess the possibility that this overdose prevention program can have harmful side effects, such as the security offered by the use of naloxone, which may increase the dose of heroin consumed or reduce the number of calls to emergency services when witnessing an overdose.

12 94 3 Praxis in Europa Finally, we were unable to provide naloxone kits to all users who attended the overdose training program, especially in therapeutic communities, mainly because treatment centres that are focused on abstinence consider being offered a naloxone kit while in treatment to be contradictory. One of the greatest advantages of the overdose training program is that it has reached a large proportion of users. In this regard, a recent study (Arribas-Ibar/ Sánchez-Niubò/Majó/Domingo-Salvany/Brugal 2014) found that 43.5% (95% CI: 37-49%) of drug users in Catalonia have participated in an overdose prevention course. This percentage differs depending on whether the patients were in treatment (32.1%), in therapeutic communities (35.2%), or users of harm reduction centres (66.7%). Given these percentages, it is needed to promote systematic overdose prevention programs in treatment centres and therapeutic communities. Moreover, it could be advisable to deploy this program in prisons, since drug users have a higher risk of a drug-related death once they are released (Bird/Hutchinson 2003). Acknowledgements Part of this paper was supported by the Spanish Network on Addictive Disorders [grant numbers RD06/0001/1018 and RD12/0028/0018]. Staf f from the Xarxa d Atenció a les Drogodependències de Catalunya (Catalan Drug Care Centres Network). References Agencia de Salut Pública de Barcelona (2013): Agencia de Salut Pública. La Salut a Barcelona Online: pdf [ ]. Arribas-Ibar/Sánchez-Niubò/Majó/Domingo-Salvany/Brugal (2014): Coverage of overdose prevention programs for opiate users and injectors: a cross-sectional study. In: Harm Reduct J 11(1): 33. Baca/Grant (2005): Take-home naloxone to reduce heroin death. In: Addiction 100(12): Bernstein/Bucciarelli/Piper/Gross/Tardiff/Galea (2007): Cocaine- and opiaterelated fatal overdose in New York city, In: BMC Public Health 7: 31. Bird/Hutchinson (2003): Male drugs-related deaths in the fortnight after release from prison: Scotland, In: Addiction 98(2): Brugal/Barrio/Regidor/Royuela/Suelves (2002): Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration. In: Addiction 91(3):

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